The Role of Stress in Symptom Exacerbation Among IBS Patients
Edward B. Blancharda, Jeffrey M. Lacknerb, James Jaccardc, Dianna Rowella, Ann Marie Carosellab, Catherine Powellb, Kathryn Sandersa, Susan Krasnerb and Eric Kuhna
aCenter for Stress and Anxiety Disorders, University at Albany-SUNY, Albany, NY, USA
bUniversity at Buffalo, State University of New York, Buffalo, NY, USA
cDepartment of Psychology, Florida International University, Miami, FL, USA
Received 30 June 2006; revised 9 June 2007; accepted 16 October 2007. Available online 24 January 2008.
Over 200 treatment-seeking irritable bowel syndrome (IBS) patients completed 4 weeks of daily prospective measures of stress and gastrointestinal symptoms as well as retrospective measures of stress (life events over 12 months, hassles over 1 month). We also obtained the stress measures on 66 nonill controls. Irritable bowel syndrome patients report more frequent hassles than controls and a greater stress impact than controls. Using structural equation modeling, we found that the data were consistent with a model of robust autocorrelation effects of both week-to-week gastrointestinal (GI) symptom indices (r=.84) and stress indices (r=.73), as well as strong concurrent effects of stress on IBS symptoms (r=.90) and vice versa (r=.41). The data also were consistent with a model where there were effects of stress in Week t upon GI symptoms in Week t+1 and t+2, but they were mediated through the concurrent week effects and/or autocorrelation effects. There were no statistically significant independent pathways from stress in Week t to GI symptoms in Week t+1 or t+2. Thus, there is more support for a reciprocal relation between stress and symptoms than there is for a causal relation.
Keywords: Irritable bowel syndrome; Stress; Stress and irritable bowel syndrome
Corresponding author. Center for Stress and Anxiety Disorders, University of Albany-SUNY, Albany, NY, USA.
Published in: Journal of Psychosomatic Research, Volume 64, Issue 2, February 2008, pp. 119-128.
Cognitive Behavioral Treatment of
Irritable Bowel Syndrome
Dennis Tirch and Cynthia L. Radnitz, Ph.D.
Fairleigh Dickinson University, Teaneck, NJ
Veterans Affairs Medical Center, Bronx, NY
I. Description of Treatment
Irritable Bowel Syndrome (IBS) is a functional disorder of the gastrointestinal (GI) tract for which no evidence of lesion or disease can be found. Prevalence estimates of IBS in the general population range from 7 to 17% (Drossman, Sandler, McKee, & Lovitz, 1982; Whitehead, Winget, Fedoravicius, Wooley, & Blackwell, 1982). Individuals with this condition experience a variety of symptoms including abdominal pain, extreme abdominal tenderness, diarrhea, constipation, bloating, belching, nausea, and flatulence. Thus far, pharmacological interventions have proven relatively interventions have proven relatively inefficient in treating this disorder (Blanchard & Malamood, 1996). However, a number of different psychological therapies have been demonstrated to be more effective in treating IBS than regular medical treatment or symptom monitoring (Blanchard, 1993). Compelling evidence of the effectiveness of cognitive behavioral therapy (CBT) has been found among reports of successful psychological interventions for IBS.
A number of studies have revealed that many patients seeking treatment for IBS may also suffer from an anxiety disorder or mood disorder (Blanchard, Scharff, Schwarz, Suls, & Barlow, 1990; Walker et al., 1990). Hence, it has been suggested that treatment methods which focus on the cognitive dimensions of an anxiety problem may address underlying processes which bring about the manifestation of physiological IBS symptoms (Blanchard, 1993; Greene & Blanchard, 1994).
The Albany Multicomponent Behavioral Therapy Program for IBS employs techniques drawn from a CBT perspective to address both the GI symptoms of IBS and the hypothesized anxiety and/or affective disturbances which may underlie the disorder (Blanchard, 1993). In this treatment protocol, a CBT regimen is conducted for twelve weeks, with sessions held twice weekly during the first eight weeks. Before beginning treatment, therapists instruct patients in how to monitor IBS symptoms using a diary form. Patients monitor GI symptoms during a pre-treatment assessment phase and throughout treatment in order to gauge improvement. During initial treatment sessions, therapists impart educational information about bowel functioning, answer questions about IBS, and reassure patients that their symptoms are not "all in their heads." This is intended to countermand the tendency for some IBS patients to identify with the sick role. At the same time, patients receive training in progressive muscle relaxation (Bernstein, & Borkovek, 1973) using an adaptation of the procedure described in Blanchard & Andrasik (1985). Later in the treatment regimen thermal biofeedback is conducted where patients are taught to warm their hands, a response which serves to dampen peripheral nervous system arousal. Both the relaxation and biofeedback are designed to provide patients with greater control of their physiological responses to stress. Home practice of these techniques is emphasized, and patients are provided with tools to conduct these procedures at home. An audiotape is used to assist in relaxation sessions, and a small thermometer is employed to facilitate the practice of thermal biofeedback.
In the course of the twelve week treatment, patients receive cognitive therapy using procedures described by Holroyd & Andrasik (1982) which were derived from work conducted by Meichenbaum (1977), Beck and Emery (1979) and Ellis (1962). Cognitive distortions and attributions which serve to cause or exacerbate the negative experience of stress, and subsequent GI symptoms, are addressed. Initially patients record stressful events and resulting cognitions and behavior in a diary. Gradually, they are taught to employ rational self-talk to disrupt maladaptive cognitive patterns. In the final step, they learn to identify core negative constructs underlying their automatic thoughts, and how these constructs are related to their IBS symptoms, in effect developing their own case formulation. In cases where patients report anxiety and/or depression, addressing cognitions may help alleviate these conditions, and in turn, lead to relief of IBS symptoms.
II. Summary of Studies Supporting Treatment Efficacy
In a review of studies conducted to date, Blanchard and Malamood (1996) found that CBT regimens had been empirically replicated and were equivalent or superior to routine medical care. Accordingly, in eight of twelve studies analyzed by Blanchard and Malamood (1996), CBT based IBS treatment methods were employed successfully.
A number of studies have empirically validated the efficacy of both the Albany Multicomponent Behavior Therapy Program and its constituent elements (Blanchard, Schwarz, & Neff, 1987; Blanchard, Greene, Scharff, & Schwarz-McMorris, 1993; Greene & Blanchard, 1995; Neff & Blanchard, 1987; Payne & Blanchard, 1995; see Blanchard, Schwarz, et al., 1992 for an exception). Studies of the cognitive component seem especially promising. In successive trials using two different therapists, cognitive therapy was shown to be superior to both symptom monitoring and self-help support (Greene & Blanchard, 1994; Payne & Blanchard, 1995). In this condition 75-80% of patients achieved at least a 50% reduction in composite symptom scores. Other studies of the Albany Multicomponent Behavior Therapy program have shown that results were maintained at two years follow-up (Blanchard, Schwarz, & Neff, 1987) and that comparable results can be obtained when treatment is administered in a small group format (Blanchard & Schwarz, 1987).
III. Clinical References
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Drossman, D. S., Sandler, R. S., McKee, D. C., & Lovitz, A. J. (1982). Bowel patterns among subjects not seeking health care: Use of a questionnaire to identify a population with bowel dysfunction. Gastroenterology, 83, 529-534.
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Holroyd, K. A., & Andrasik, F. (1982). A cognitive-behavioral approach to recurrent tension and migraine headache. In P. E. Kendell (Ed.). Advances in cognitive-behavioral research and therapy (Vol. 1, pp. 275-320). San Diego, CA: Academic Press.
Meichenbaum, D. (1977). Cognitive behavior modification: An integrative approach. New York: Plenum.
Neff, D. F. & Blanchard, E. B. (1987). A multicomponent treatment for irritable bowel syndrome. Behavior Therapy, 18, 70-83.
Payne, A., & Blanchard, E. B. (1995). A controlled comparison of cognitive therapy and self-help support groups in the treatment of irritable bowel syndrome. Journal of Consulting and Clinical Psychology, 63, 779-786.
Walker, E. A., Roy-Byrne, P. P., & Katon, W. J. (1990). Irritable bowel syndrome and psychiatric illness. American Journal of Psychiatry, 147, 565-572.
Whitehead, W. E., Winget, C., Fedoravicius, A. S., Wooley, S., & Blackwell, B. (1982). Learned illness behavior in patients with irritable bowel syndrome and peptic ulcer. Digestive Diseases and Sciences, 27, 202-208.
Reprinted from: Tirch, D. & Radnitz, C. L. (1997). Cognitive behavioral treatment of irritable bowel syndrome. The Clinical Psychologist, 50(1), 18-20.