• About 15% of patients with routine IBS do not respond to routine treatment… most such patients respond to dynamic psychotherapy [ or hypnotherapy].
• The reduction of bowel symptoms closely follows the reduction in psychological [ discomfort ] indicating a clear line between the two.
• There seems to be a reluctance to recognize the importance of psychological factors in the etiology or exacerbation of IBS in Britain except in a few centers.

• Evidence suggests that several brief psychotherapy sessions or supportive counseling early in the course of the disease lead to greater improvement in symptoms, more satisfaction with care, and quicker return to normal activities.
• Of greater importance [is that] this improvement when compared with that of a control group, is sustained one year after this extra effort.
• Klein concluded that "not a single [pharmaceutical] agent provides conclusive evidence of effectiveness in the global treatment of IBS.

• Psychological treatments are increasingly used in IBS.
• Three ways in which they are effective. 1) relating symptoms to specific stress conditions. 2) help with psychosocial problems. 3) decrease of anxiety and tension.
• Psychological treatments should be reserved for patients who do not respond to first line standard medical treatment.
• Findings [are that] psychotherapy groups significantly improved (in comparison to) controls on abdominal pain, bowel dysfunction, and mental symptoms.
• Differences were apparent at three months and maintained at one year.

• IBS is not caused by anxiety. But symptoms are more likely when anxiety is present.

• In terms of quality of life and with the exception of general health, IBS patients showed as great or greater impairment as patients with congestive heart failure, on all scales.
• Neuroticism and psychological distress were correlated with life measures.
• IBS non consulters exhibited less psychological distress than IBS patients

• ...an increase in overall symptom severity is likely to precede an increase in severity of commonplace stresses.
• this relationship was stronger than that of hassles preceding symptoms.

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• Studies conclude that psychiatric illness was present in 50% of IBS clinic attenders therefore a definite association [ exists] between functional abdominal pain and psychiatric illness.
• Untreated anxiety and depression impair response to conventional treatments whereas in some patients psychiatric treatment might improve symptoms.
• Some of these patients unless psychiatrically treated, never get better.

• None of the drugs in the treatment of IBS have been uniformly effective Psychotherapy combined with medical treatment has been substantially more effective than routine medical care.

• At the time of their initial illness patients who subsequently developed IBS symptoms had higher scores for anxiety, depression, somatization than those who returned to normal function

• When compared with IBD patients, the IBS patients in this study had significantly higher prevalence rates of lifetime major depression, current panic disorder, somatization disorder, generalized anxiety disorder and agoraphobia, as well as childhood rape and molestation.
• Patients with IBS, despite the absence of serious organic disease, had levels of disability in physical, emotional, family, social and occupational functioning comparable with those of patients with a serious organic gastrointestinal disease...(they) perceived significantly more distress... than patients with IBD.
• These findings suggest that psychological distress plays a fundamental role in the ongoing adjustment that patients make to physical symptoms, and that the treatment of comorbid psychiatric disease in patients with both IBD and IBS is an important goal in the longitudinal care of patients with gastrointestinal symptoms...
• these findings suggest that attention to beliefs about illness and disability, psychosocial factors such as prior history of abuse, and the evaluation and treatment of concurrent psychiatric disorders may be essential factors in the successful treatment of patients with either IBS or IBD.

• No uniformly successful treatment exists for IBS
• Overall 40-60% of patients with IBS who seek medical advice have psychological symptoms of depression, anxiety or both..

• A Prevalence of IBS of 29% in major depression [diagnosis ]and 37% in generalized anxiety disorders as compared to 11% in the healthy control group..... IBS is a generic expression of global psychopathology.

Patients were only selected if their symptoms had not improved with standard medical treatment over the previous three months.

• At three months ( of psychological medical and relaxation treatment) the treatment group showed significantly greater improvement than the controls ( medical treatment only ) on both gastroenterologists', and patients', ratings of diarrhea and abdominal pain, but constipation changed little.
• Good prognostic factors [for psychotherapeutic treatment ] included overt psychiatric symptoms and intermittent pain exacerbated by stress...

• Although there is no rigorous data to support such an approach, treatment of IBS is probably best accomplished by a comprehensive and individualized blend of patient education, support, and psychotherapy, as well as by the pharmacologic treatment of selected symptoms at appropriate times.

• With the same symptom severity recent IBS patients show less severe psychological symptoms and have a better outcome at 18 month follow up
• Those with short symptom duration and fewer psychological symptoms have a better prognosis than patients with longer histories and associated psychological distress.
• Psychiatric diagnoses such as anxiety, depression and neuroticism are common in patients with chronic abdominal discomfort who seek medical attention. In contrast, patients who have not consulted a physician but who report IBD symptoms have a similar number of psychiatric diagnoses as the general population. ( The implication here is... treat the psychological symptom and the level of seeking relief will decrease.)

• The substantial lack of difference between the two groups of patients leans in favor of a major role of psychological disturbance in these patients. The close affinity between nerves and mast cells in the gastrointestinal tract can account for a direct influence of the central nervous system on intestinal motility through smooth muscle control, Thus making it conceivable that psychological stress can provoke motility disturbances by a direct release of mast cell mediators.

• ...Can we not have an interactive model where psychological and biological factors both play an important part? Mayer has pointed to recent evidence to support such a model in both inflammatory and functional bowel disorders.

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• In our recent studies IBS patients who sought medical advice had significantly higher anxiety and depression scores than individuals with similar symptoms who had not consulted. Sixty percent had fulfilled diagnostic criteria for major depression, anxiety disorder and dysthymia.
• ... Hypnotherapy and psychotherapy are both of value in the management of IBS.

• Comparing patients seeking treatment for dysthymia and a general clinic population seeking a variety of other treatments the authors found an incidence of IBS symptoms in 59.32% of the experimental group versus 1.85% in the control group.
• Patients with dysthymia were more likely to report symptoms of back pain and weakness, as well as a personal history of bowel disease.
• Future studies need to address whether treatment of primary psychiatric illness leads to an improvement or resolution of the symptoms of IBS.

• To date no single therapy for IBS has proven satisfactory.
• A critical review of randomized controlled trials in patients with IBS concluded that no therapy has been shown superior to placebo.