Clinical Review Clinical review

Psychological approach to managing irritable bowel syndrome

BMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39199.679236.AE (Published 24 May 2007) Cite this as: BMJ 2007;334:1105
  1. Bu'Hussain Hayee, specialist registrar,
  2. Ian Forgacs, consultant physician
  1. Department of Gastroenterology, Kings College Hospital, London SE5 9RS
  1. Correspondence to: I Forgacs ian.forgacs{at}kcl.ac.uk
  • Accepted 11 April 2007

“It is more important to know what sort of person has a disease than to know what sort of disease a person has.” Hippocrates

The medical management of patients with irritable bowel syndrome is often unsatisfactory. Doctors are still taught that irritable bowel syndrome is a diagnosis of exclusion, and patients readily sense that they are being told that nothing is really wrong with them. Many people soon come to appreciate that the range of medical treatments available is limited in both scope and efficacy. The mood of negativity, once established, is difficult to dispel.

Summary points

  • Irritable bowel syndrome is believed to result from a variety of biological and psychosocial factors

  • Irritable bowel syndrome is not a diagnosis of exclusion; a positive diagnosis can usually be made

  • The usual medical treatment is often highly unsatisfactory; if psychological factors seem important, these should be dealt with

  • Tricyclic antidepressants and some selective serotonin reuptake inhibitors are of value in improving symptoms

  • Cognitive behaviour therapy has a strong evidence base for its effectiveness

  • Gut directed hypnotherapy is an effective treatment and is especially suitable for more severely affected patients who might be prepared to travel to specialist centres

Current medical treatment includes drugs that alter intestinal motility—such as antispasmodics, 5-hydroxytryptamine antagonists, antidiarrhoeals, and laxatives—and dietary changes, including fibre supplementation and identification of food intolerances.1 Response may vary, but the failure rate of these “physical” treatments is high, which may lead to the conclusion that irritable bowel syndrome has a strong psychological component. A diagnosis of exclusion has been made—again with negative, rather than positive therapeutic, connotations.

Although many doctors are aware that antidepressants have been used in irritable bowel syndrome, they seem reluctant to prescribe such agents, not least because suggesting this as a valid option to patients who are clearly not depressed …

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