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IBS and Mind-body Medicine
By Yoon Hang "John" Kim, MD, MPH, and Nola Daniel CNC, DIHom. Dr. Kim is director and Ms. Daniel is a homeopathic practitioner and nutrition counselor at Georgia Integrative Medicine in Tyrone, GA; they report no financial relationship to this field of study.
Irritable bowel syndrome (IBS) is a complex condition characterized by abdominal pain and discomfort associated with altered bowel habits in the absence of specific organic pathology. IBS is among the most prevalent gastrointestinal (GI) motility disorders.1 Prevalence estimates for IBS range from 3% to 20%, with most estimates in North America ranging from 10% to 15%.2
IBS-related symptoms are often chronic and bothersome, negatively affecting patients' quality of life related to activities of daily living, social relationships, and productivity at work or school.3 IBS also puts a heavy economic burden on patients, employers, and the health care system, resulting in more than $10 billion in direct medical costs and an estimated $20 billion in indirect costs through work absenteeism and reduced productivity each year.4
IBS and Women's Health
Women are affected by IBS more often than men with the ratio of 2:1 in the community setting and the ratio of 3:1 to 4:1 in the tertiary care setting.2 Among women, IBS is most prevalent during menstruation years, with symptoms being most severe during post-ovulatory and premenstrual phases. Studies have found that more than 50% of patients seeing a gynecologist for lower abdominal pain have IBS.5 Women with IBS are more likely than women with other bowel symptoms to ultimately be diagnosed with endometriosis. Women with IBS are three times more likely to receive a hysterectomy than women without IBS.6
IBS and Conventional Treatment
Conventional treatments of IBS target relief of symptoms, including dietary therapy, antispasmodic agents, antidiarrheal agents, and antidepressant and anti-anxiety medications. Some of the new medications target selective serotonin receptor subtypes such as 5-HT3 antagonists and 5-HT4 agonists.7 In 2005, Quartero et al published the results of a systematic review on bulking agents, antispasmodic, and antidepressant medication for the treatment of irritable bowel syndrome.8 The authors concluded that the evidence for efficacy of drug therapies for IBS was weak and that there was no clear evidence of benefit for antidepressants or bulking agents. In 2007, Evans et al published the results of an updated systematic review on the use of tegaserod, a partial 5-HT4 agonist for treating IBS with chronic constipation features.9 The authors concluded that tegaserod improved the overall symptoms of IBS and improved the frequency of bowel movements in those with chronic constipation. However, the authors stated that the clinical importance of these modest improvements was not clear due to lack of data on quality of life.
IBS and Complementary and Alternative Medicine
Given the absence of a cure and the adverse effects of many medications, patient with IBS often utilize complementary therapies. It is estimated that up to 50% of IBS patients turn to complementary and alternative medicine therapies for help.10 Common herbs for treating IBS include peppermint oil for antispasmodic properties, ginger for enhancing motility, and fennel for reduction of bloating.11 Other approaches include the use of system-based traditional healing including Chinese medicine, naturopathy, and homeopathy.
The evidence for using CAM for treating IBS is still being formulated. Many of the studies testing CAM modalities appear to suffer from poor quality. In 2006, Hussain and Quigley published the results of a systematic review of CAM for treating IBS.10 The major conclusion called for improvements in the quality of clinical trials. In 2006, another group, Lim et al, published the results of a systematic review on the effectiveness of acupuncture for treating IBS.12 The authors ruled that no conclusion could be made based on the basis of poor quality of studies.
In 2006, Liu et al published the results of a systematic review of traditional herbal therapies for treating IBS.13 In this study, authors found 75 randomized controlled trials, involving 7,957 participants with irritable bowel syndrome meeting the inclusion criteria. The authors concluded that Tibetan herbal medicine Padma Lax and traditional Chinese formula Tongxie Yaofang showed significant improvement of global symptoms. However, the authors also recommended that the results be interpreted with caution due to poor quality of the studies. The commonality of the studies indicates relative poor quality of evidence in the form of randomized clinical trials and call for more clinical studies with rigorous design.
In 2009, Shen and Nahas published an article reviewing the use of complementary and alternative medicine for treating IBS.14 The article confirmed an encouraging trend of an increasing level of evidence. The authors concluded that soluble fiber improves constipation, peppermint oil alleviated IBS symptoms, and probiotics showed overall benefit in improving global symptoms.
IBS and Mind-body Medicine
Mind-body medicine represents an interdisciplinary culmination of many traditions including psychotherapy, relaxation, meditation, hypnosis, guided imagery, and spirituality. Other practices like the relaxation response and mindfulness-based stress reduction are based on meditation traditions, but focus on secular techniques divorced from the original spiritual context.15
There is an increasing understanding of IBS as more than a functional motility disorder. In this perspective, the loss of self-regulation of the brain-gut function is manifested through gut hyper-reactivity and enhanced sensitivity to various stresses.16 Brain-gut interactions are increasingly recognized in the pathogenesis of IBS, and almost half of IBS patients have comorbid psychiatric disorders.17 Individuals with IBS have increased stress perception, and chronic stress has been shown to affect IBS symptoms.18 Patients with IBS have also been shown to be hypervigilant toward bodily sensations and symptoms.19 Therefore, mind-body interventions intended to reduce stress perceptions would have a sound theoretical basis for treating IBS.
Despite the wide array of techniques available for mind-body medicine, two modalities, hypnosis and cognitive-behavioral therapy, showed the most robust level of evidence for treating IBS.
Hypnosis for Treating IBS
Therapeutic suggestions have been given to patients in a state of deep relaxation and narrow focus since the 19th century.20 In 2005, Whorwell published a review article describing the history of hypnotherapy and its role in irritable bowel syndrome.21 The article provides a case for the effectiveness of hypnotherapy in relieving the symptoms of IBS and improving quality of life of patients with IBS.
One of the notable developments in hypnosis for treating IBS is the development of more standardized protocol in the form of gut-directed hypnotherapy, which combines suggestions related to emotional well-being and intestinal health. First use of this technique was documented in a small clinical trial in 1984 by Whorwell involving 30 patients.22 The authors reported that improvements in symptoms were greater after seven weekly sessions of hypnotherapy than they were with supportive psychotherapy.
The largest trial involving gut-directed hypnotherapy was conducted by Roberts et al in 2006.23 In this study, 81 IBS patient received either five weekly sessions and a self-hypnosis audiotape to use daily or no treatment. Results showed that patients receiving hypnotherapy had a greater decline in symptom scores at three months (mean change in score on a 100-point scale, 13 in the treatment group vs. 4.5 points in the control group; P = 0.0008).
In 2006, Whitehead published the findings of a review of 11 clinical trials including five controlled trials.20 The review concluded that the literature supports the claim that hypnosis has a substantial positive impact on IBS, even for patients unresponsive to standard medical interventions. The median response rate was 87% and bowel symptoms and quality of life measures improved by about 50%.
In 2007, Webb et al published findings of a systematic review of using hypnosis for treating IBS.24 The authors found four studies including a total of 147 patients met the inclusion criteria, including the two studies mentioned above.20,23 The authors concluded that the therapeutic effect of hypnotherapy was found to be superior in the short term to a waiting list control or usual medical management for abdominal pain and composite primary IBS symptoms in patients who fail standard medical therapy. Most significantly, harmful side effects of hypnotherapy were not reported in any of the trials.
Psychological Treatments for IBS
In 2009, Zijdenbos published the results of a review of psychological treatment for the management of irritable bowel syndrome, which included the analysis of 25 studies meeting the inclusion criteria.25 The author concluded that the psychological interventions may be slightly superior to usual care or waiting list control conditions at the end of treatment. However, the author also acknowledged the clinical relevance of the slight improvement. One weakness of this study involves the term "psychological treatments," which represented a diversity of techniques.
Cognitive behavioral therapy (CBT) represents one of the psychological treatment modalities that has been most studied.26 The results are generally positive, but there are also mixed results.
In 2003, Drossman et al published the findings of the largest (n = 431 women) trial using CBT for treating IBS.27 The patients were randomly assigned to either 12 weeks of CBT or an educational control group. The results showed that 12 weekly sessions of CBT improved symptoms and quality of life over the control group (response rate to therapy, 70% vs. 37%; P = 0.001). This study illustrates clearly the benefits of CBT over education only.
In 2003, Boyce et al published the findings of a randomized controlled trial involving 105 patients with IBS.28 Patients were randomly assigned to standard care alone, standard care plus CBT, and standard care plus relaxation for one year. Patients in all three groups showed significant improvements in symptoms and quality of life. However, no differences were found in the three groups.
Mind-body therapies, especially in the form of hypnotherapy and CBT, can have a positive impact on patients with IBS. Future developments involving self-directed hypnosis using a playback device are anticipated as these units will increase access. Accessing CBT-trained therapists can have an advantage, as it may be a covered insurance benefit.
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