Psychotherapy in irritable bowel syndrome. A controlled outcome study.

Abstract

ABSTRACTPsychotherapy in the treatment of irritable bowel syndrome. A controlled outcome study. By Jan Svedlund, Department of Psychiatry, Sahlgren's Hospital, University of Göteborg, Sweden. Thesis defended 20th May, 1983.Problem: The irritable bowel syndrome (IBS) often becomes a chronic relapsing condition despite medical treatment. The influence of psychological factors on the course of the disorder has been recognized, but has had little influence on treatment. The aims of the study were to compare the effectiveness of routine medical treatment with combined medical treatment and psychotherapy, to elucidate mechanisms of therapeutic action and to find prognostic factors.Method: 101 IBS‐outpatients with at least one year of complaints were randomly aallocated to two treatment groups. All patients received the same medical treatment. The patients in one group (n=50) were given dynamically oriented short term psychotherapy in addition. The psychotherapy was administered in one‐hour‐sessions weekly during three months and limited to ten sessions. Assessments were made by independent raters, and by self‐ratings on three occasions, at intake before assignment to treatment group, three months later after the psychotherapy course and after a one year follow up. Changes in the severity of symptoms, social adjustment and coping ability with problems focused in the therapy were the main criteria of outcome.Results: The patients in both groups improved during treatment but after three months there was a significantly greater improvement in favour of the psychotherapy group. The difference became still more pronounced one year later as the psychotherapy group showed further improvement while the control group showed some deterioration. Global ratings of severity by independent raters showed that almost half of the patients in the psychotherapy group had improved at follow up versus ten per cent in the control group. According to patients' self‐ratings two thirds had improved in the psychotherapy group versus 40 percent in the control group. The self‐confidence and coping ability had also improved significantly more among patients receiving the combined treatment. Confounding factors such as differences in drug treatment, extra‐therapeutic life events, treatments not included in the study, changes in smoking and drinking habits and drop‐out rate did not contribute to the different outcomes. The combined treatment approach was applicable to a large proportion of the IBS‐patients. Patients with a periodic course were more suitable for psychotherapy and patients with a need for achievement were more suitable for medical treatment only. Patients displaying reactivity during therapy were more successful in the handling of focused problems. Suitability for insight‐oriented psychotherapy was more related to coping ability than to symptomatic improvement.Conclusions: Medical treatment gives a short term symptomatic improvement in IBS. By combining medical treatment with psychotherapy the outcome can be essentially improved, not only in short term but also in the long run. The major mechanism of action is probably the acquisition of more effective ways of coping with emotional problems. The result is in agreement with a psychosomatic approach, from which can be stated that treatment is more effective and rational if it considers both somatic and psychological aspects of a disorder, and lends added support to the concept of a psycho‐physiological basis for IBS.