Cognitive behaviour therapy and relaxation training for Irritable Bowel Syndrome

1
Cognitive behaviour therapy and relaxation
training for Irritable Bowel Syndrome

• Philip Boyce
• University of Sydney
• Westmead Hospital
• President RANZCP

World Psychiatric Association Athens March 2005
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Thanks to

• Professor Nick Talley Professor of Medicine
• Belinda Balaam Clinical psychologist
• Gemma Gilchrist Clinical psychologist
• Natasha Koloski Psychologist
• George Truman Psychologist
• Sanjay Nandurkar Gastroenterlogist

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Irritable Bowel Syndrome

• Common
• Disabling
• Costly
• Medical treatments for IBS not always successful
• Psychological treatments intuitively evident

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Rome II Diagnostic criteria for Irritable Bowel
Syndrome

• Relieved with defecation and/or
• Onset associate with a change in frequency of
  stool and/or
• Onset associated with a change in form
  (appearance of stool)

At least 12 weeks, which need not be
consecutive, in the preceding 12 months of
abdominal discomfort or pain that has two of
three features
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Additional symptoms to support the
diagnosisSymptoms present 1 in 4 defecations or
days

• Abnormal stool frequency (gt3/day or lt3/week)
• Lumpy/hard or loose/watery stool
• Straining, urgency or feeling of incomplete
  evacuation
• Passage of mucus
• Bloating or feeling of abdominal distension

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Psychosocial correlates ofIrritable Bowel
Syndrome
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Psychosocial correlates ofIrritable Bowel
Syndrome
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Rationale for psychologictherapies for IBS

• Biopsychosocial model of interaction between
  emotion and gut function in IBS

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• Early Life
• Genes
• Environment

• Psychosocial
• Factors
• Life stress
• Psychological state
• Personality style
• Coping
• Social support

CNS
ENS

• Physiology
• Motility
• Sensation

• IBS
• Symptom
• Experience
• Behaviour

• Outcome
• Medications
• Consultations
• Disability
• Quality of life

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Aims of psychological therapy for IBS

• Break the negative feedback loop between emotion
  and gut function to reduce IBS symptoms.
• Reduce the psychological factors that maintain
  the presence of IBS symptoms and inappropriate
  consulting behaviour.

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• Early Life
• Genes
• Environment

• Psychosocial
• Factors
• Life stress
• Psychological state
• Coping
• Social support

Psychological Interventions
CNS
ENS
CBT

• Physiology
• Motility
• Sensation

• IBS
• Symptom
• Experience
• Behaviour

• Outcome
• Medications
• Consultations
• Disability
• Quality of life

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Review of the evidence for psychological
therapies for IBS

• 14 Controlled studies
• 8 studies found psychological treatment superior
  to control group
• 5 studies found psychological treatment equally
  as effective as control group
• (60 symptom reduction)
• 1 study - results not clear

(Talley, Owen, Boyce Patterson, 1996)
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Psychological Treatments for Irritable Bowel
Syndrome

• Cognitive and behavioural treatments
• psychoeducation
• Dynamic psychotherapy
• Hypnotherapy

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Cognitive Behaviour Therapy

• First developed by Beck for the treatment of
  depression based on the premise that
• Depressive (dysfunctional) thoughts lead to a
  depressed mood.
• Negative cognitive triad depressed view of
• The self (low self-esteem)
• The world (helplessness)
• The future (hopelessness)
• When depressed, people engage in maladaptive
  behaviours and do not use behaviours to improve
  mood

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Cognitive Behaviour Therapy

• Treatment aims to
• Challenge maladaptive thoughts and replace them
  with more realistic thoughts
• Encourage healthy behaviours to over come the
  amotivation associated with depression
• CBT now used for many conditions, especially
  anxiety disorders
• Parallels between IBS and panic disorder

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Cognitive-behavioural therapy

• Consists of a range of techniques designed to
  alter patients responses by teaching them to
  change the way they think and react to certain
  events (eg. IBS)
• Behavioural strategies to overcome abnormal
  illness behaviours (e.g. avoidance)

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Hypothesized maintaining mechanisms in
hypochondriasis
Trigger (information, event, illness, image)
Perceived threat
Apprehension
Interpretation of body sensations and/or signs
as indicating severe illness
Checking behaviour and reassurance seeking
Increased focus on body
Physiological arousal
Preoccupation with perceived alteration/abnormalit
y of bodily sensations/state
(Salkovskis, 1989)
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Studies of CBT for Irritable Bowel Syndrome
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Studies of CBT for Irritable Bowel Syndrome
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Pilot Study of CBT for Irritable Bowel Syndrome

• AIM
• Examine the effectiveness of a structured
  cognitive behaviour therapy in reducing the
  symptoms, or symptom severity, in IBS.
• 10 subjects (8 female, 2 male)

(Boyce, Greenstock, Talley, Rose, 2000)
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Pre- and post-treatment scores of frequency of
bowel symptoms and associated distress and
disability on the BSSQ
Pre-treatment Post-treatment

Score

p lt 0.05 p lt 0.01
Distress Subscale
Frequency
Disability
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Pre- and post-treatment scores on subscales of
the SF-36
Pre-treatment Post-treatment



Score


p lt 0.05 p lt 0.01
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Randomised controlled trial

• Cognitive Behaviour Therapy (CBT)
• Relaxation training (RT)
• Routine Clinical care (RCC)
• Funded by the National Health Medical Research
  Council

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Recruitment

• Subjects recruited from
• the Nepean hospital Gastroenterology clinic
• via media appeal
• through self-help organisations
• Local General practices

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Methods

• Preliminary assessment to ascertain suitability
  for project
• Explanation of rationale for the project
• Clinical interview
• Asked to complete diary
• Baseline assessment (2 weeks following
  preliminary assessment)

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Baseline assessment

• Comprehensive history
• Assessed using the SIBS for Rome I criteria
• Psychological assessment
• Review by gastroenterologist to confirm diagnosis
• Complete baseline self-report measures
• Explanation about IBS and rationale for
  interventions
• Provide informed consent
• Randomisation

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Model for Irritable Bowel Syndrome
Genes
Psychosocial Stress
Visceral Hypersensitivity
Appraisal
Social Support Personality
IBS Symptoms
Gut function
Dysfunctional cognitions
Anxiety
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Treatment protocol

• All participants received routine medical care
• Symptom review
• Dietary advice
• Fibre supplement Metamucil
• Support

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Relaxation Training

• Relaxation training weekly (8 x 30 minute
  sessions)
• Range of relaxation strategies
• progressive muscle relaxation
• release only
• cue-controlled
• applied relaxation
• Ventilation control

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Cognitive behaviour therapy

• Manual-based treatment
• modelled on and incorporating parts of that
  produced by Andrews et al for the anxiety
  disorders
• The hypochondriasis model of Salkovskis
• Homework tasks
• Strategies used meet the aim of providing
• a broad anxiety management approach
• realistic symptom appraisal
• enhanced coping strategies
• restructuring maintaining cognitions.

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Cognitive behaviour therapy

• The nature of IBS and the digestive system
• Anxiety education and breathing retraining
• Progressive muscle relaxation
• Cognitive therapy
• Behavioural testing and graded exposure
• Problem solving and worry control techniques
• Relapse prevention.

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Measures

• Structured Interview for Bowel Symptoms (SIBS)
• Bowel Symptom Severity Scale
• Frequency
• Impairment
• Distress
• Hospital Anxiety and Depression Scale (HADS)
• SF-36

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Bowel Symptom Severity Scale Sample questions

• Over the past week on how many occasions did you
  have hard or lumpy stools when you had a bowel
  motion?
• Not at all Occasionally
  Sometime Most times Every bowel
  motion
• How distressed were you by this?
• Not at all A little bit Moderately Quite a
  bit Extremely
• How much did this interfere with your everyday
  life?
• Not at all A little bit Moderately Quite a
  bit Extremely
• Over the past week, on how many days have you had
  more than 3 bowel motions a day?
• Not at all 1 2-3 4-5 6-7
• How distressed were you by this?
• Not at all A little bit Moderately Quite a
  bit Extremely
• How much did this interfere with your everyday
  life?
• Not at all A little bit Moderately Quite a
  bit Extremely

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Sample Referrals, volunteers (n105)
R
Routine Clinical Care Control (n34)
Relaxation Training Control (n36)
Cognitive Behaviour Therapy (n35)
Lost to Followup (n13)
Lost to Followup (n10)
Lost to Followup (n4)
Primary Outcome Post-treatment (n30 88)
Primary Outcome Post-treatment (n23 64)
Primary Outcome Post-treatment (n25 71)
Lost to Followup (n9)
Lost to Followup (n10)
Lost to Followup (n7)
Secondary Outcome 12 months (n21 56)
Secondary Outcome 12 months (n18 51)
Secondary Outcome 12 months (n13 36)
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Comparison of groups at baseline
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Number of subjects at each time point
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Results

• Intent to treat analysis
• The results from the completer analysis are
  similar

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BSSS mean scores over time
Total BSSS mean score
Time (weeks)
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4
8
26
Baseline
Main effect F10.9, plt0.001 Differences between
groups F0.5, NS
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BSSS change in score from baseline Frequency
Effect Size
4
8
26
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Time (weeks)
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BSSS change in score from baseline Distress
Effect Size
4
8
26
52
Time (weeks)
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BSSS change in score from baseline Interference
Effect Size
4
8
26
52
Time (weeks)
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HAD mean scores over time
Total HAD mean score
4
Time (weeks)
8
26
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Baseline
Main effect F4.67, p0.001 Differences between
groups F0.62, NS
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HAD change in score from baseline Anxiety
Effect Size
4
8
26
52
Time (weeks)
44
SF-36Changes in score over time
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SF-36 change in score from baseline General
health
Effect Size
4
8
26
52
Time (weeks)
46
SF-36 change in score from baseline Physical
functioning
Effect Size
4
8
26
52
Time (weeks)
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SF-36 change in score from baseline Pain
Effect Size
4
8
26
52
Time (weeks)
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SF-36 change in score from baseline Social
functioning
Effect Size
4
8
26
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Time (weeks)
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SF-36 change in score from baseline Mental health
Effect Size
4
8
26
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Time (weeks)
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Conclusions

• All treatments were effective
• CBT no better than relaxation training or routine
  medical care
• The therapy was not conducted properly
• The CBT model is wrong
• Psychoeducation good clinical care are
  effective ingredients

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An approach to the management of IBS

• A detailed and comprehensive biopsychosocial
  assessment
• Explanation about IBS using a biopsychosocial
  model
• Provide a new way of understanding symptoms
  reattribution
• Appropriate treatment for anxiety disorder or MDD
• Appropriate medical management
• Dietary advice (fibre)
• Support
• Specific strategies to reduce anxiety and improve
  coping skills

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Thank you for your attention