Controversies in Management: Psychological treatment is essential for someBMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6969.1647 (Published 17 December 1994) Cite this as: BMJ 1994;309:1647
- Francis Creed
- Department of Psychiatry, Rawnsley Building, Manchester Royal Infirmary, Manchester M13 9WL, professor of community psychiatry.
Strong evidence exists that the irritable bowel syndrome has an important psychological component. Firstly, about half of patients with the irritable bowel syndrome in a hospital clinic have psychiatric disorder when assessed by research criteria.1 This is two or three times greater than the prevalence among patients with organic gastrointestinal conditions such as peptic ulcers or inflammatory bowel disturbance and healthy controls (<20%),1 suggesting a strong association between the irritable bowel syndrome and psychological disorder. Although anxiety, depression, and sexual problems might be the consequence of persistent abdominal symptoms, they are not found to the same extent in patients with organic diseases that also lead to persistent abdominal symptoms.2 The anxiety and depression might explain attendance at the hospital rather than the occurrence of the symptoms,3 4 but people attending hospital also have much worse intestinal symptoms than people with the irritable bowel syndrome in the community, and the anxiety almost certainly exacerbates the pain and bowel dysfunction.5
Role of stress
Secondly, two thirds of patients with the irritable bowel syndrome have experienced a severe social stress such as bereavement, marital separation, or major argument leading to a broken family relationship before the onset of the abdominal symptoms. This compares with about a quarter of patients with organic disease and healthy controls.6 The pattern of social stress before the onset of the irritable bowel syndrome is similar to that preceding deliberate self harm, where precipitating stress is well recognised.
Even in patients with no overt anxiety or depression, onset of the irritable bowel syndrome is still preceded by stressful life events. Not all studies have confirmed this result, but these negative studies have measured life events before attending a clinic rather than before the onset of symptoms and have often used inadequate measures of life events.
Success of psychological treatment
Thirdly, patients with the irritable bowel syndrome attending the clinic for the first time have been randomly allocated to group stress management or pharmacological treatment.7 Although the short term response was similar, at six month follow up patients randomised to psychological treatment showed a significantly better response, with patients receiving drugs having returned to their initial symptom level. This result strongly suggests that the core problem is a psychological disturbance.
About 15% of patients with the irritable bowel syndrome do not respond to routine treatment with bulking agents, antispasmodics, and support. Most such patients respond to dynamic psychotherapy or hypnotherapy,*RF 8-10* and the reduction of bowel symptoms closely follows the reduction in psychological symptoms, indicating a clear link between the two.10
In their original description of the irritable colon, Chaudhury and Truelove observed that patients who had no history of dysentery before the onset of bowel symptoms but who did have evidence of psychological problem had the worst two year outcome.11 Their case examples indicated that such patients might recover when their circumstances changed. A middle aged man developed symptoms during a marital separation; they cleared when he successfully remarried. A teenage girl with lifelong bowel problems improved greatly when she left home and the conflicts with her parents ceased.
Evidence of a motility disorder
The evidence for a motility disorder is less convincing.12 The normal motility pattern of the gut is extremely variable, and abnormal motility patterns seem poorly related to a patient's experience of symptoms. In addition, the motility patterns of patients with the irritable bowel syndrome cannot satisfactorily be separated from those of psychoneurotic patients presenting to the psychiatrist,13 suggesting that psychological disturbance might cause the abnormal bowel motility patterns as well as the bowel symptoms. Although changed visceral sensitivity has been shown in the irritable bowel syndrome, the only treatment that has been shown to change the sensitivity and improve symptoms is hypnotherapy.14
In the United States the irritable bowel syndrome is the commonest condition presenting to gastroenterologists. Half of the gastroenterologists working in academic settings use “personal psychosocial support,” for at least three quarters of these patients. Yet there still seems to be a reluctance to recognise the importance of the role of psychological factors in the aetiology or exacerbation of the irritable bowel syndrome in Britain except at a few centres.
The reasons for this are currently being examined by a joint working group of the Royal Colleges of Physicians and Psychiatrists. Most gastroenterologists do not have training which enables them to feel confident in handling the emotional side of the patients they treat. In addition, the environment in medical outpatient clinics is oriented toward investigations for organic disease and not conducive to private interviews in which the doctor can explore psychological problems that might cause or exacerbate symptoms. Some gastroenterologists are prejudiced against acknowledging the importance of psychological factors in their patients, presumably as a result of the organic bias of medical training.
Increasing recognition of the importance of psychosocial factors in the aetiology of the irritable bowel syndrome would lead to more satisfactory treatment. Such treatment might follow that described by Rumsey,7 in which small groups of patients met for six weekly sessions to understand the nature of the disorder and the role of stress; to learn the techniques of progressive muscle relaxation and problem solving; and to be taught the importance of diet, fitness, and long term strategies. Although pharmacological treatment seems to help in the short term, any patient who has persistent symptoms should be considered for psychological treatment. This seems to produce better long term results,10 15 presumably because of the importance of underlying psychological problems in the syndrome.
Commentary: try dietary modification first
Reading these two articles it is difficult to believe that the authors are writing about the same condition. It seems clear that the irritable bowel syndrome is just what it says it is: a syndrome rather than a single pathophysiological entity. It would be interesting to know if those people with demonstrable abnormalities of gut motility also have a history of emotional stress or whether there are at least two essentially separate types of patient with the irritable bowel syndrome. Most people with these symptoms are going to present to general practitioners rather than gastroenterology specialists. Advising dietary modification is simple and inexpensive and can usefully be attempted in everybody. Those who do not respond and who seem to have a definite precipitating factor could then be considered for psychotherapeutic intervention.—PETER C RUBIN, professor of therapeutics, University of Nottingham