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Rapid Responses: Rapid Responses published:
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Tricyclic antidepresants in IBS.
- Mohammad Shaikhani (27 May 2007)
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Psychotherapy for IBS
- Anne Ward (29 May 2007)
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Support for IBS as a positive diagnosis
- William Cayley (29 May 2007)
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Hypnotherapy for IBS.
- James Paul Pandarakalam (31 May 2007)
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Short-term Psychodynamic Psychotherapies for IBS
- Allan A Abbass (13 June 2007)
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Mohammad Shaikhani, Consultant physician Sulaimanyah-Iraqi Kurdistan 0532
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From my daily practise in managing patients with IBS, I feel that even patients with constipation-predominant IBS benefit from TADs as patients with diarrhea-predominant IBS,keeping in mind that the mechanism of action is raising the pain trehold or the teshold for sensing symptoms. Thanks. Competing interests: None declared |
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Anne Ward, Consultant Psychaitrist in Psychotherapy South London and Maudsley NHS Foundation Trust SE5 8AZ
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An RCT (Guthrie, 1993, BJPsych) showed the efficacy of Interpersonal Therapy (psychodynamic, based on Hobson's model - not the IPT of Weissman) was effective in women with Irritable Bowel Syndrome. This needs to be mentioned alongside CBT. Competing interests: My specialty is psychodynamic psychotherapy |
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William Cayley, Assistant Professor University of Wisconsin School of Medicine and Public Health
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Thank you to Dr Hayee and Dr Forgacs for pointing out that it is actually more therapeutically helpful to patients to quickly make a POSITIVE diagnosis of IBS and minimize un-needed testing. While some physicians may see diagnostic testing as a way to avoid “missing something”, research actually demonstrates that among patients meeting criteria for IBS who do not have alarm symptoms, the risk of other underlying pathology is very low. Specifically, a Meta-analysis of 6 studies found that the prevalence of other diseases among patients meeting IBS criteria was: Colitis/inflammatory bowel disease = 0.5% - 1.0%, Colorectal cancer = 0% - 0.5%, Celiac disease = 4.7%, Gastrointestinal infection = 0% - 1.7%, Thyroid dysfunction = 6%, Lactose malabsorption = 22% - 26%. Furthermore, endoscopy, ultrasound, and barium studies only detected organic disease in approximately 1% of patients, CBC and chemistries were unhelpful. (1) It is still important, however, to remember that patients with red flags should have a more thorough diagnostic evaluation: weight loss, evidence of bleeding, signs of infection, those older than 50 years at the onset of symptoms. (1) Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review. Am J Gastroenterol. 2002 Nov;97(11):2812-9. Competing interests: None declared |
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James Paul Pandarakalam, Consultant psychiatrist St Helens North CMHT, St Helens WA 9 3DA
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I.B.S. is considered as a brain-gut dysfunctional syndrome by hypnotherapists and several studies have impressively documented the value of hypnotherapy for this condition. Gastrointestinal conditions seem to be stress –related illnesses. These conditions are associated with the possible involvement of several other emotional factors such as repressed hostility and anger that may be responsive to hypnotherapy 1. Whorwell’s study group noticed long term (mean 18months) follow up response rates on 50 patients with 95% success with classical cases, 43% with atypical cases, and 60% with cases exhibiting significant psychopathology 2. They also found that patients over age 50 responded poorly (25% success), but patients below the age of 50 with classical irritable bowel syndrome were 100% successful. Even though it is not clear whether IBS is caused by stress, it is certain this condition is worsened by stress. The mechanism of the working of gut- directed hypnotherapy is enigmatic but it may change the way the brain modulates gut activity: under hypnosis gut sensitivity is reduced. References 1.Walker, B.B. (1983) Treating stomach disorders can we reinstate regulatory processes? In R. Hozl & W.E. Whitehead (Eds), Psychopathology of the Gastrointestinal Tract: Experimental & Clinical Applications. New York; plenum, pp209-233 2.Whrwell, P.J., Prior, A., & Faragher, E.B. (1984) Controlled trial of hypnotherapy in the treatment of service refractory irritable bowel syndrome. Lancet, 2, 1232-1233 Competing interests: None declared |
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Allan A Abbass, Associate Professor and Director of Education 8203- 5909 Veterans Memorial Lane, Halifax, NS, B3H 2E2
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To the Editor: I wish to thank Drs Hayee and Forgacs for their review of treatment of IBS and to add information about some recent developments, assessment methods and treatment alternatives for this condition. First, the authors called the method Guthrie et al studied “Cognitive Behavioral Therapy (CBT)”. In fact it is a variety of short term psychodynamic/ interpersonal therapy with different theory, technique and objectives than CBT. Short-term Psychodynamic Psychotherapies (STPP) have been shown efficacious in treating IBS now in randomized controlled trials including one for Refractory IBS (1) and one for Severe IBS (2). The technique has also been shown efficacious in reducing somatic symptoms in both short and long-term follow-up in a recent Cochrane review. (3). A current review (Abbass, Kisely and Kroenke, in preparation) has found over 20 studies of STPP for a broad range of somatic conditions including IBS, dyspepsia, ulcer disease, movement disorders, dermatitis, pelvic pain, chronic pain, headaches, rheumatoid disease, coronary heart disease and other common conditions. These cost-effective and non-toxic treatments need to be covered in reviews such as this and given more attention in mainstream medical literature including the BMJ. A further issue is that some forms of STPP have built in methods to directly diagnose emotional factors and their relative contribution to symptoms such as IBS. (4) Thus, it is possible to directly diagnose these factors versus to have to speculate about them or only to diagnose by the assumptive “rule out” method. Since these interview methods exist, Medicine is behooved to update itself about these relatively non-invasive diagnostic techniques which can save both the patient and the system undue suffering. Sincerely Yours, Allan Abbass References: 1. Guthrie, E., Creed, F., Dawson, D., & Tomenson, B. (1993). A randomised controlled trial of psychotherapy in patients with refractory irritable bowel syndrome. British Journal of Psychiatry, 163, 315-321. 2. Creed F L F, Guthrie E, Palmer S, Ratcliffe J, Read N, Rigby C, et al. The Cost Effectiveness of Psychotherapy and Paroxetine for Severe Irritable Bowel Syndrome. Gastroenterology. 2003;124(124):303-317, 3. Abbass AA, Henderson J, Kisely S., Hancock JT. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database Syst Rev. 2006; Oct 18;(4):CD004687 4. Abbass A. Somatization Diagnosing it sooner through emotion- focused interviewing. Journal of Family Practice. 2005;54 (3) 215-24. Competing interests: None declared |
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