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

Cognitive Behavioral Therapy

This is a structured form of psychotherapy that is usually conducted individually but can be administered in group format. The treatment usually consists of a course of 6–12 sessions that focus on the present situations in which symptoms occur rather than the patient's history. CBT is based on the theory that maladaptive thoughts are the causes of psychological symptoms such as anxiety and depression, which in turn cause or exacerbate physical symptoms. An example would be a patient who believes that eating in a public place will always cause them to have diarrhea and other embarrassing symptoms (a catastrophizing maladaptive thought), which might lead the patient to both avoid social interactions (selfdefeating behavior) and to become anxious when dining in a restaurant. The anxiety and autonomic arousal caused by this maladaptive thought may actually trigger diarrhea. The therapist aims to help the patient recognize maladaptive thoughts and self-defeating behavior patterns that are adversely affecting life functioning, symptom experience, and mental well-being. Therapy tasks commonly include increasing awareness of the association between stressors, thoughts, and symptoms; examining and correcting irrational beliefs; countering automatic negative thoughts; observing and problem-solving factors that exacerbate symptoms; and identifying and adopting alternative, more effective coping strategies to handle challenging life situations and deal with gastrointestinal symptoms. In between therapy visits, patients are typically asked to complete homework assignments related to the treatment tasks. It should be noted that the relative emphasis on individual treatment components varies a lot. Some interventions that fall under the general umbrella of CBT are mostly or exclusively either cognitive or behavioral in nature (ie, they either focus on changing thought patterns or on learning and practicing healthy behavior patterns).

CBT has been studied more than any other form of psychological intervention for FGIDs in RCTs. Thirty RCTs have been published (Supplementary Table 1) comparing CBT with other interventions. The majority of these trials (18 studies) were conducted on adults with IBS. Outcomes for CBT treatment were compared with control groups receiving usual medical care or on waiting lists for the treatment, antidepressant or antispasmodic medication, placebo or active psychological interventions such as supportive therapy, education, or stress management/stress reduction treatment. This substantial body of empirical studies shows that CBT is an effective therapy for improving IBS. In all but 3 trials, the CBT arms showed superior outcomes. In the positive trials, gastrointestinal symptoms were almost uniformly found to be significantly reduced after treatment, sometimes substantially more than in comparison groups. For example, Payne and Blanchard[13] randomized 34 patients to 8 weeks of cognitive therapy, a self-help support group (which controlled for "placebo" or expectancy effects), or a waiting list group. Cognitive therapy patients showed an average of 67% reduction in the composite bowel symptom score after treatment, compared with 31% reduction in the support group and only 10% in the waiting list subjects. Improvement was fully maintained at 3-month follow-up. Although most studies have not included follow-up longer than 3 months after treatment, there is evidence that therapeutic benefit of CBT for IBS can last 8 months to 2 years after treatment termination.[14–16] In addition to gastrointestinal symptom improvement, quality of life and emotional well-being are often documented to improve significantly from such treatment as well.

CBT has also proved to be a reliably effective therapy for the treatment of functional chest pain and recurrent abdominal pain in children (Supplementary Table 1), both of which are conditions for which no good pharmacologic therapy exists.

Five RCTs on noncardiac chest pain all found superior outcomes for patients assigned to CBT compared with control groups, with 4 of them showing the treatment to be effective in reducing the pain problem[17–20] and the fifth (which used the shortest course of treatment, only 3 sessions) finding only an effect on quality of life.[21] Especially noteworthy is the study by Spinhoven and et al,[20] who assigned 69 patients to CBT, paroxetine, or usual medical care. The CBT patients had a greater reduction in pain than both the medication and usual care groups, and only the CBT group showed reduction in heartfocused anxiety after treatment (even though paroxetine is often used to treat anxiety problems).

Six RCTs have tested CBT for recurrent abdominal pain in children. In such treatment, parents and children are commonly treated together. Again, all the trials have found CBT to lead to better outcomes (diminished pain), with CBT generally leading to longer-term pain reduction and higher rates of elimination of pain compared with control groups.

A noteworthy recent development in the field of CBT for FGIDs is testing of mostly or entirely self-administered CBT, with minimal involvement of clinicians or staff. The Internet, printed manuals, or personal digital assistants serve as the principal mode of therapy delivery, and this addresses the important limitation of lack of CBT therapists in many geographic areas. Seven such randomized trials (identified with an asterisk in Supplementary Table 1) have been reported so far, mostly in IBS treatment. All of them show that this method of delivering CBT leads to superior outcomes compared with the control conditions. Moreover, the largest RCT ever conducted on psychological treatment for FGID, a multicenter National Institutes of Health–funded trial with estimated enrollment of 480 IBS subjects,[22] is currently evaluating the potential of self-administered CBT further. Even though such cost-effective therapy is not yet generally available, the consistently positive findings to date suggest that a very inexpensive and easily accessible form of effective CBT may be on the horizon for IBS and perhaps other FGIDs.

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