Psychological Treatments in Functional Gastrointestinal Disorders

A Primer for the Gastroenterologist

Olafur S. Palsson; William E. Whitehead

Disclosures

Clin Gastroenterol Hepatol. 2012;11(3):208-216. 

In This Article

Abstract and Introduction

Abstract

The functional gastrointestinal disorders (FGIDs) often show inadequate response to usual medical care. Psychological treatments can help improve functional gastrointestinal disorder patient outcomes, and such treatment should be considered for patients who have moderate or severe symptoms after 3–6 months of medical care and those whose symptoms are clearly exacerbated by stress or emotional symptoms. Effective psychological treatments, which are based on multiple randomized controlled trials, include cognitive behavioral therapy and hypnosis for irritable bowel syndrome and pediatric functional abdominal pain, cognitive behavioral therapy for functional chest pain, and biofeedback for dyssynergic constipation in adults. Successful referral by the gastroenterologist for psychological treatment is facilitated by educating the patient about the rationale for such treatment, reassurance about the diagnosis and continuation of medical care, firm doctor-patient therapeutic alliance, and identification of and communication with an appropriate psychological services provider.

Introduction

The functional gastrointestinal disorders (FGIDs) are a group of more than 20 chronic medical conditions of the gastrointestinal tract that constitute a large proportion of the presenting problems seen in clinical gastroenterology and are hard to treat effectively. For example, in a survey of 1658 patients with FGIDs in a health maintenance organization in Seattle,[1] the proportion of patients who reported that their bowel symptoms were at least somewhat better after 6 months of usual medical management was only 49% for irritable bowel syndrome (IBS), 63% for functional diarrhea, and 56% for functional constipation and functional abdominal pain. There is a clear need for supplemental interventions that can help reduce the morbidity, life impairment, and chronically high healthcare usage of the many FGID patients who remain highly symptomatic in spite of all that usual medical care approaches can offer. Psychological treatments have shown the best overall promise for that purpose to date and are gradually becoming widely accepted and recommended options for FGIDs. For example, psychological treatments are given a "strong recommendation" rating for improving global IBS morbidity in the current evidence- based position statement of the American College of Gastroenterology.[2] Similarly, the American Gastroenterological Association technical review on IBS recommends psychological treatment for moderate and severe patients, those with inadequate response to standard medical care, and patients in whom psychosocial factors clearly exacerbate symptoms.[3]

The rationale for using psychological interventions for FGIDs can be summarized as follows:

  1. Stressful life events trigger exacerbations of symptoms in many patients,[4] and traumatic life events such as sexual or physical abuse[5] are associated with an increased prevalence of IBS and other FGIDs.

  2. Comorbid psychiatric disorders such as generalized anxiety disorder and major depression are highly prevalent in FGID patients (for example, found in 50%–94% of clinical samples of IBS patients[6]), and anxiety and depression have been identified as associated with poorer outcomes for FGID patients.[7–9]

  3. The brain exerts a powerful influence over gastrointestinal pain perception, motility, and secretion. In functional dyspepsia, anxiety is correlated with lowered threshold for gastric discomfort/pain and reduced gastric accommodation,[10] and depression is associated with increased postprandial distress, nausea, and vomiting.[11] In IBS patients, stress lowers visceral pain thresholds and stimulates colonic and ileal motility.[4,12]

  4. Psychological treatments work. A large number of randomized controlled trials (RCTs) show that short courses of certain psychological interventions can markedly improve the symptoms of several FGIDs, while simultaneously enhancing emotional well-being and quality of life and sometimes reducing healthcare needs as well.

The dilemma of the clinical gastroenterologist is that he or she may be convinced that psychological treatment could help FGID patients but may not know which of the many forms of such therapies is suitable for a given disorder or how to go about making the referral. The aims of this article are to make this process easier by (1) identifying and describing the forms of psychological treatment that show evidence of effectiveness in FGIDs, (2) summarizing the empirical evidence for their effectiveness, (3) explaining how to find a suitable local provider, (4) characterizing which FGID patients should be considered for referral, and (5) describing how to make an effective referral.

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