Review
Identifying effective techniques within psychological treatments for irritable bowel syndrome: A meta-analysis☆

https://doi.org/10.1016/j.jpsychores.2014.12.009Get rights and content

Highlights

  • •

    Psychological interventions for IBS improve symptoms and psychological well-being.

  • •

    Improvement of psychological distress was associated with IBS symptom improvement.

  • •

    More intervention sessions were associated with improvements in IBS symptom outcomes.

  • •

    8 techniques were associated with improvements in both symptom and well-being outcomes.

Abstract

Objectives

Psychological interventions can alleviate the symptoms of irritable bowel syndrome (IBS) and psychological distress commonly reported among IBS sufferers. However, the theoretical underpinnings and intervention techniques used by such interventions vary considerably. This study aimed to identify which theoretical approaches and techniques lead to greater improvements in IBS symptoms and psychological well-being within psychological interventions for IBS.

Methods

Outcome data were extracted from 48 randomized controlled trials testing psychological treatments for IBS. Theoretical intervention targets and intervention techniques of each study were identified. Cumulative effect sizes were calculated for pain, bowel dysfunction, composite symptom scores, psychological distress, and health-related quality of life. Comparative analyses contrasted the effect sizes of studies which included each intervention technique to those which did not.

Results

Cumulatively, interventions significantly improved all outcomes, with effect sizes (Hedges' g) ranging from 0.32 to 0.64. Interventions which stated a theoretical intervention target, prompted self-monitoring of symptoms and cognitions, provided tailored feedback linking symptoms and cognitions, utilized problem solving or assertiveness training and provided general support had greater effects upon symptom and well-being outcomes than interventions which did not (all P < .05). Across all studies, improvements in psychological distress were associated with improvements in composite symptom scores (P < .01).

Conclusions

This study identifies a set of techniques associated with improvements in IBS symptoms and psychological well-being in existing interventions, and provides initial evidence for the link between improvements in psychological distress and IBS composite symptom scores. These findings can aid the development and refinement of psychological treatments for IBS.

Introduction

Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder characterized by abdominal pain and associated bowel dysfunction [1], and has a prevalence rate of around 12% within the European Union and North America [2], [3], [4]. For some patients, IBS leads to high rates of health care utilization, absenteeism and lower productivity [2], and where these factors are present, IBS symptoms are often refractory to standard drug treatments for pain and bowel dysfunction [5]. IBS also leads to reduced health-related quality of life (HRQoL) [6], and between 50% and 90% of IBS patients have mental disorders including generalized anxiety disorder, social phobia and major depression [7], [8]. The links between reduced quality of life, psychological comorbidity and absenteeism is in part due to avoidance of behaviors such as traveling, physical activity, sexual activity and certain foods believed to aggravate symptoms [9]. These patterns may be perpetuated by maladaptive cognitions, catastrophizing and visceral hypersensitivity [10].

As a result, a number of approaches to therapy for IBS target improvements in psychological outcomes in addition to symptoms. Additionally, some approaches and treatments theorize that improvement in psychological outcomes is integral to improving gastrointestinal (GI) symptoms [8]. A recent meta-analysis indicates that treatment with either anti-depressant medications or psychological therapies leads to nearly identical improvement rates among IBS patients (relative risks of .66 and .67 respectively) [11]. Despite this, very little research has examined the mechanisms by which the treatment effects of psychological therapies are achieved, and in addition, the magnitude of the relationships between improvements in anxiety and depressive symptoms and improvement in IBS symptoms have not been explored.

Within psychological therapies for IBS, cognitive therapy, cognitive behavioral therapy, relaxation, psychodynamic, mindfulness and gut-directed hypnosis models have all been examined [12], [13], [14], [15]. While there is reported efficacy for each of these approaches, psychological treatments which have the same treatment labels (e.g. cognitive therapy) may not be comparable. For instance, one type of cognitive therapy may hypothesize that improving depressive symptoms will improve IBS outcomes, whereas another may posit that reductions in visceral hypersensitivity are key to alleviating IBS symptoms. Furthermore, even if two types of therapy target the same intermediate theoretical predictors, they may utilize different techniques to achieve treatment gains. And to further complicate matters, two treatments with different labels may actually target the same intermediate theoretical constructs and utilize the same intervention techniques. It is therefore vitally important to identify and understand the active ingredients of psychological therapies in order to develop interventions which optimize treatment efficacy while minimizing delivery time and cost. New effective treatments might be developed based on a set of techniques which are associated with more successful interventions. While it has been argued that the specific ingredients of psychological therapies do not predict IBS outcomes [16], this has not been investigated quantitatively.

Thus, this meta-analysis of randomized controlled trials testing psychological interventions for IBS will use meta-regression to examine the relationship between improvements in psychological distress and improvements in IBS symptoms. It will also identify the most commonly used techniques within psychological interventions for IBS, and provide cumulative effect size estimates for symptoms (pain, bowel dysfunction and composite symptom scores) and psychological well-being (psychological distress and health-related quality of life) outcomes. Finally, comparative analyses will examine which characteristics of psychological interventions for IBS are associated with greater improvements in both IBS symptoms and psychological well-being outcomes.

Section snippets

Literature search strategy

This meta-analysis included only randomized controlled trials of psychological therapies for IBS, and was conducted in line with the PRISMA statement [17]. In May 2013, a literature search was performed using the online databases PubMed, PsycInfo, Web of Science, Google Scholar and Science Direct. The abstracts, titles and keywords were searched for the following terms to specify participants, interventions, comparisons, outcomes and study designs (PICOS) of interest: ‘irritable bowel syndrome’

Identification of studies

In total, 6837 records were recovered through a database search and 20 were identified through searching the bibliographies of previous meta-analyses in this area. Of these, 6483 were excluded based on title alone. The abstracts of the remaining 374 records were screened, of which 285 were excluded. The full-texts of the remaining 89 articles were screened. After this procedure, a total of 45 articles reporting on 48 studies were included in the meta-analysis. One article [26] included two

Discussion

As a whole, the psychological interventions included here had significant small to medium [24] effect sizes on symptom and psychological well-being outcomes, with the largest effects evident on composite symptom reduction scores (g = 0.64; 95% CI 0.49–0.79). As composite scores measure overall symptom improvement, this medium effect size is noteworthy, as it indicates that psychological treatments have the capability to improve the full range of IBS symptoms.

Compared with the cumulative effect

Conclusion

Cumulatively, psychological interventions for IBS have small positive effects on pain, bowel dysfunction, psychological distress and health-related quality of life, and medium effect sizes on composite IBS symptom indices. Within this set of studies, interventions that state their proposed working mechanisms (as recommended by Michie and Prestwich [18]) seem to more effectively improve outcomes. In addition, eight treatment techniques, when included in psychological treatments for IBS, seem to

Source of funding

None.

Conflict of interest statement

We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.

The following are the Supplementary data related to this article.

. List of excluded studies at full text stage and reason for exclusion.

. Behavior change techniques per study.

References (93)

  • D a Drossman et al.

    Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders 1. 1This study was registered with ClinicalTrials.gov (Trial registry no. NCT00006157)

    Gastroenterology

    (2003)
  • E Guthrie et al.

    A controlled trial of psychological treatment for irritable bowel syndrome

    Gastroenterology

    (1991)
  • MM Heitkemper et al.

    Self-management for women with irritable bowel syndrome

    Clin Gastroenterol Hepatol

    (2004)
  • I Heymann-Mönnikes et al.

    The combination of medical treatment plus multicomponent behavioral therapy is superior to medical treatment alone in the therapy of irritable bowel syndrome

    Am J Gastroenterol

    (2000)
  • MG Hunt et al.

    Brief cognitive-behavioral internet therapy for irritable bowel syndrome

    Behav Res Ther

    (2009)
  • L Keefer et al.

    The effects of relaxation response meditation on the symptoms of irritable bowel syndrome: results of a controlled treatment study

    Behav Res Ther

    (2001)
  • JM Lackner et al.

    Self-administered cognitive behavior therapy for moderate to severe irritable bowel syndrome: clinical efficacy, tolerability, feasibility

    Clin Gastroenterol Hepatol

    (2008)
  • B Ljótsson et al.

    Internet-delivered exposure and mindfulness based therapy for irritable bowel syndrome—a randomized controlled trial

    Behav Res Ther

    (2010)
  • DF Neff et al.

    A multi-component treatment for irritable bowel syndrome

    Behav Ther

    (1987)
  • S Oerlemans et al.

    Intervening on cognitions and behavior in irritable bowel syndrome: a feasibility trial using PDAs

    J Psychosom Res

    (2011)
  • J Svedlund et al.

    Controlled study of psychotherapy in irritable bowel syndrome

    Lancet

    (1983)
  • A Vollmer et al.

    Controlled comparison of individual versus group cognitive therapy for irritable bowel syndrome

    Behav Ther

    (1998)
  • JA Glombiewski et al.

    Psychological treatments for fibromyalgia: a meta-analysis

    Pain

    (2010)
  • RL Levy et al.

    Psychosocial aspects of the functional gastrointestinal disorders

    Gastroenterology

    (2006)
  • M Jones et al.

    Pathways connecting cognitive behavioral therapy and change in bowel symptoms of IBS

    J Psychosom Res

    (2011)
  • DA Drossman et al.

    Alterations of brain activity associated with resolution of emotional distress and pain in a case of severe irritable bowel syndrome

    Gastroenterology

    (2003)
  • DD Price et al.

    Widespread hyperalgesia in irritable bowel syndrome is dynamically maintained by tonic visceral impulse input and placebo/nocebo factors: evidence from human psychophysics, animal models, and neuroimaging

    Neuroimage

    (2009)
  • M Eccles et al.

    Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings

    J Clin Epidemiol

    (2005)
  • H Hazlett-Stevens et al.

    Prevalence of irritable bowel syndrome among university students

    J Psychosom Res

    (2003)
  • K Wolitzky-Taylor et al.

    Visceral sensitivity as a mediator of outcome in the treatment of irritable bowel syndrome

    Behav Res Ther

    (2012)
  • S Elsenbruch

    Abdominal pain in irritable bowel syndrome: a review of putative psychological, neural and neuro-immune mechanisms

    Brain Behav Immun

    (2011)
  • M Larauche et al.

    Stress and visceral pain: from animal models to clinical therapies

    Exp Neurol

    (2012)
  • V Deary et al.

    The cognitive behavioural model of medically unexplained symptoms: a theoretical and empirical review

    Clin Psychol Rev

    (2007)

  • Systematic review on the management of irritable bowel syndrome in the European Union

    Eur J Gastroenterol Hepatol

    (2007)
  • S Wilson et al.

    Prevalence of irritable bowel syndrome: a community survey

    Br J Gen Pract

    (2004)
  • RM Lovell et al.

    Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis

    Clin Gastroenterol Hepatol

    (2012)
  • KW Olden

    Approach to the patient with severe, refractory irritable bowel syndrome

    Curr Treat Options Gastroenterol

    (2003)
  • RB Lydiard

    Irritable bowel syndrome, anxiety, and depression: what are the links

    J Clin Psychiatry

    (2001)
  • EL Garland et al.

    Therapeutic mechanisms of a mindfulness-based treatment for IBS: effects on visceral sensitivity, catastrophizing, and affective processing of pain sensations

    J Behav Med

    (2012)
  • AC Ford et al.

    Efficacy of antidepressants and psychological therapies in irritable bowel syndrome: systematic review and meta-analysis

    Gut

    (2009)
  • SD Dorn

    Systematic review: self-management support interventions for irritable bowel syndrome

    Aliment Pharmacol Ther

    (2010)
  • JM Lackner et al.

    Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis

    J Consult Clin Psychol

    (2004)
  • WE Whitehead

    Hypnosis for irritable bowel syndrome: the empirical evidence of therapeutic effects

    Int J Clin Exp Hypn

    (2006)
  • AC Ford et al.

    Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis

    BMJ

    (2008)
  • D Moher et al.

    Preferred reporting items for systematic reviews and meta-analyses : the PRISMA statement

    BMJ

    (2009)
  • S Michie et al.

    Are interventions theory-based? Development of a theory coding scheme

    Health Psychol

    (2010)

    • Cited by (41)

    • Future of Brain–Gut Behavior Therapies: Mediators and Moderators

      2022, Gastroenterology Clinics of North America
      Citation Excerpt :

      Nevertheless, stating a purported target for an intervention and conducting studies that measure change in the both the target and the outcome to conduct mediation analysis to test the hypothesized mechanism of action is a crucial part of the development of effective psychological treatments.52 In fact, a mediation analysis found that brain–gut behavior therapies for IBS that have stated purported target are more effective than the ones who do not.53 Moreover, it seems unlikely that all purported targets that we delineate are equally important to intervene on to achieve symptom reduction in DGBI.

    • Goal Achievement and Goal-Related Cognitions in Behavioral Activation Treatment for Depression

      2019, Behavior Therapy
      Citation Excerpt :

      Numerous meta-analyses and empirical studies have highlighted the relationship between these self-regulation techniques and actualizing health behaviors in various domains (Michie, Abraham, Whittington, McAteer, & Gupta, 2009). Additionally, interventions utilizing more of these self-regulation techniques have been shown to produce greater improvements in depressive symptoms, anxiety, and well-being outcomes than interventions utilizing fewer (Henrich et al., 2015; Knittle, Maes, & De Gucht, 2010). As such, action control, action planning, and self-monitoring should continue to be emphasized within LICBT treatments involving goal-setting and goal-striving processes.

    • Behavioral and non-pharmacological management of functional gastrointestinal disorders

      2019, Clinical and Basic Neurogastroenterology and Motility

    • A comprehensive review and update on Crohn's disease

      2018, Disease-a-Month
      Citation Excerpt :

      The psychotropic medications should be reserved for those who do not respond to behavioral interventions or those who have severe psychopathology.246 Psychosocial interventions that have shown most promise for pain management include cognitive behavioral therapy (CBT), hypnosis and mindfulness techniques.247–250 CBT is a short-term, goal oriented psychotherapy treatment where the therapist teaches skills to change maladaptive thought and behavior to improve anxiety and associated bodily responses which in turn reduces a patient's focus on pain.251

    • Examining interactions of illness perceptions, avoidance behavior and patient status in predicting quality of life among people with irritable bowel syndrome

      2024, Health Psychology and Behavioral Medicine

    • Irritable bowel syndrome in adolescents

      2023, Chronic Disease and Disability: The Pediatric Gastrointestinal Tract, Second Edition. Medical and Surgical Perspectives including Infection and Pain
    View all citing articles on Scopus
    ☆

    The work was conducted at the Department of Health, Medical and Neuropsychology, Leiden University, Leiden, The Netherlands.

    1

    These authors contributed equally to the work in this study.

    View full text
    Copyright © 2014 Elsevier Inc. All rights reserved.