Journal of Psvchosomrir
Research. Vol. 35, No. 415, PP. 461-469.
1991. 0
Printed an Great Britain.
BEHAVIOURAL
PSYCHOTHERAPY
cm-3999191 $3.00f.cQ 1991 Pergamon Press plc
IN THE TREATMENT
OF
IRRITABLE BOWEL SYNDROME ROSLYN H. CORNEY,* RUTH STANTON,* ROBERT NEWELL,* ANTHONY CLARE* and PETER FAIRCLOUGH~ (Received
3 July 1990; accepted
in revised form 28 November
1990)
Abstract-The irritable bowel syndrome is a highly prevalent condition whose underlying aetiology is not understood. While many patients respond to a combination of gastrointestinal antispasmodics, bulking agents and dietary manipulation [ 11, controlled clinical trials have suggested that the benefit is only marginal and is due mainly to the large placebo effect found in this condition, which has been calculated to range between 54 and 8 1% [2-41. Associations between the syndrome and psychological and social stresses suggest, however, that treatment involving a systematic approach to the management of symptoms may hold out real therapeutic possibilities. In the current study, 42 IBS patients were randomly allocated to either medical treatment or to behavioural psychotherapy with a nurse therapist. They were assessed initially and at 4 and 9 months. There was a general improvement over the 9 months on a number of physical and psychological symptoms measured. However, no differences were found between treatment groups except for changes in two avoidance scores. A significant correlation was found, however, between improvement in the bowel symptoms of IBS (stomach pain and diarrhoea) and improvement in the psychological symptoms measured by the Clinical Interview Schedule, suggesting a close interrelationship between the two.
INTRODUCTION THE IRRITABLE bowel syndrome (IBS) consists of altered bowel habit, abdominal pain and gaseousness, each of which are present to a variable degree, and is without any recognized organic gastrointestinal pathology 151.A recent review 131concluded that the syndrome and its variants affect up to 15% of the general population [61and accounting for about half the referrals to specialized gastrointestinal clinics 17, 81. There is no consensus amongst clinicians and researchers concerning the underlying cause of this syndrome. Organic causes which have been suggested include abnormal motor activity of the intestinal tract 19, 101 abnormal gut hormone, secretion and sensitivity 1111 and diet [121. However, many studies have indicated that psychological factors are important and that patients with this syndrome are more neurotic, depressed or anxious than others [13, 141. However, it is difficult to know whether such depression is of the transient mild type seen in a high proportion of those in chronic pain, or is a form of classical affective disorder warranting and benefitting from antidepressant treatment [31. The uncertainty concerning the extent to which organic and psychological factors are operating in IBS is reflected in the variety of treatments employed and the lack of clarity regarding their precise efficacy [2-41. However, long term studies of natural history or follow up, have generally shown lower remission rates, the majority of patients have intermittent symptoms with the length of time during which they
* Department of Psychological Medicine, St Bartholomews Hospital, London E.C. 1A 7BE, U.K. t Department of Gastroenterology, St Bartholomews Hospital, London E.C.lA 7BE, U.K. Address all correspondence to: Dr R. H. Corney, Senior Lecturer, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 BAF, U.K. 461
462
R. H. CORNEY et al.
were asymptomatic being relatively short 1151, although some studies suggest a better long term outcome [ 11. Recently, several studies have been published suggesting that psychological treatments may be particularly effective in IBS. Svedlund and colleagues 1161 reported that dynamically oriented short term individually orientated psychotherapy was significantly more effective than conventional medical treatment in reducing somatic symptoms. Whorwell and his colleagues 1171 randomly allocated 30 patients to treatment with either hypnotherapy, psychotherapy or placebo and reported that hypnotherapy treated patients showed a dramatic improvement in all features whereas psychotherapy treated patients showed a significant improvement in bowel pain but not in bowel habit. However, inferences from this study must be tentative as only simple measures of outcome were used, length of follow up was brief and the same therapist conducted both treatments. A number of uncontrolled studies have used stress management techniques or biofeedback training in the treatment of IBS, all showing positive results 118-231 other workers have compared treatments, Giles found that behavioural psychotherapy was the most effective in reducing the frequency of loose bowel movements, while a combined treatment approach of behavioural therapy and biofeedback was superior with relieving symptoms associated with IBS 1241. Whitehead found that stress management produced no change in bowel motility but that pain decreased significantly. Patients in his biofeedback group showed the opposite response 141. Bennett and Wilkinson 1251 compared cognitive-behavioural interventions with medical management. Both groups reported a decrease of symptoms, but the cognitive-behavioural group showed less anxiety at follow up. The dearth of controlled clinical trials (especially those with follow up assessments over 6 months) in the psychological treatment of IBS is striking particularly in the light of the prevalence of this disorder and the generally unsatisfactory response of these patients to diet and pharmacological management. The aim of this present study was (a) to establish whether a stress management package is superior in effectiveness to conventional medical management in the treatment of IBS and (b) to establish whether psychiatric ill health and social dysfunction are factors which predict the therapeutic response of IBS sufferers to the two treatments. METHOD Patients suffering from IBS were recruited from out-patient attenders at the Department of Gastroenterology at St Bartholomews Hospital and from St Mark’s Hospital, London. For inclusion in the study, the following criteria were met: 1. Abdominal pain that fits no other disease pattern and/or non-bloody diarrhoea and/or constipation with discomfort. 2. Symptoms present for over 6 months. 3. Normal sigmiodoscopy and rectal biopsy (if diarrhoea was a complaint). 4. Alteration in bowel habit. Patients also had to be willing to be included in the clinical trial and accept either treatment, thus patients unable to attend for weekly therapy had to be excluded. Patients were initially assessed by an independent researcher using the following measures. (a) A structured interview covering demographic data, current medical history, medical treatment, current medication and family history of illness. (b) The Clinical Interview Schedule. the CIS [261, and instrument designed to detect the presence of psychological disorders in community samples. The instrument includes measures of depression of mood somatic symptoms, disturbances of sleep, concentration, memory, and cognition, anxiety, phobias,
Behavioural
psychotherapy
in IBS treatment
463
obsessional and compulsive thoughts and behaviour and depersonalization. The CIS score takes into account the subjects’ description of the frequency, duration and severity of symptoms in the past week but subjects are also rated on manifest abnormalities by the interviewer according to their appearance and conduct during the interview. Subjects having a score of 13 or more points were deemed to be a ‘case’ which means that they would be considered to be ill if examined by a psychiatrist. ‘Non cases’ had scores of 12 points or less. (c) The following questionnaires and rating scales: (1) The 30 item General Health Questionnaire, the GHQ [271, used to assess recent mental health. This questionnaire completed by the patient is designed to dichotomize subjects into probably ‘cases’ of psychiatric ill-health, (GHQ positive) if examined by a psychiatrist in an outpatient clinic and those who would probably be deemed ‘non cases’ (GHQ negative). (2) The Social Problem Questionnaire [281 measuring presence or absence of social problems. (3) Three rating scales to measure the frequency, severity and duration of pain experienced in the last month (on an eight-point scale). (4) A number of rating scales to measure avoidance of specific activities on an eight-point scale ranging from ‘no avoidance’ to ‘total avoidance’. Subjects rated their avoidance of each activity when IBS symptoms were present or when they were absent. (5) Visual analogue scales recording symptom severity over the previous 7 days. Patients were then randomly allocated by a research assistant to one of two groups. The control group were referred back to the gastroenterology department for conventional medical treatment and the experimental group were referred to a nurse behaviour therapist for treatment. Outcome was assessed at 4 and 9 months after entry into the study using the same instruments. The clinical interview schedule, however. was only administered at the 9 month reassessement. Patients referred to medical treatment were seen in the out-patients department (ranging from 1-4 appointments) and treated using explanation, reassurance, a variety of medications, antispasmodics, bulk laxatives, dietary advice. Those referred to the behaviour therapist were mostly seen at weekly intervals for 6 to 15 one-hourly sessions and followed up every three months post treatment. An assessment was made of each patient’s behaviour and its contribution to the presenting symptoms. Patients were given general information about the complaint and any mistaken ideas were elicited, discussed and modified. Patients who avoided situations or activities were encouraged to re-enter them by rehearsing them with the therapist. Bowel retraining techniques [291 were used to establish normal bowel habit and patients were encouraged to refrain from going to the lavatory in response to pain. Patients were given advice on pain management techniques along the lines advocated by Fordyce [301. Two-way repeated measures analyses of variance were performed on a number of variables to investigate differences in outcome between the two treatment groups. Analyses of covariance were also performed for this purpose with initial scores being the covariate. The dependent variables on which repeated measures analysis of variance were performed were: (a) Individual scores on the visual analogue scales at 0, 4 and 9 months and the total score (obtained by adding the scores together). (b) Individual pain scores at 0, 4 and 9 months and the composite pain score obtained by multiplying severity, duration and frequency of pain. (c) Individual scores obtained on the Clinical Interview Schedule at 0 and 9 months and the total clinical score obtained. (d) Individual avoidance scores at 0, 4 and 9 months. Analyses of covariance were performed on the scores obtained on the General Health Questionnaire and Pearson correlation coefficients were used to calculate associations between the change scores of physical and psychological symptoms.
RESULTS
Initial features
of the patient groups
Forty-two patients were found to fulfill the entry criteria, were willing to enter into the trial and lived close enough to the hospital to commit themselves to weekly sessions with the therapist. Twenty-two were allocated to the experimental group and 20 to the control groups. Only one patient (in the experimental group) was unable to be traced for the follow-up assessments. The demographic features of these patients are shown in Table I. There were no significant differences between the two groups on any of the initial variables measured. Three-quarters of the patients in the study were women. Their ages ranged from 19
R. H. CORNEY et al.
464
to 73 yr. Half were aged under 30 yr. Forty-three per cent were classified according to the occupation of the head of household in social class 1-2, 37% in class 3 and 20% in class 4-5. The patients were generally highly educated, 33% had taken a degree course, and an additional 20% had had some training after leaving school. TABLE
I.--INITIAL
DEMOGRAPHIC
DETAILS
Behavioural
Medical
psychotherapy
treatment
Sex Male
6 16
15
22
20
9 10 3
4 8 8
22
20
12 8 2
5 14
22
20
14 5 3
11
22
20
Female
19-25 26-40 41-73 Marital
BY GROUP
5
Status
Single Married/cohabiting Other
Work Full/part time paid work Housewife/unemployed/retired Student
7 2
The visual analogue scales included a number of commonly experienced symptoms of IBS plus a number of symptoms of affective disorder, namely, anxiety, depression and irritability (Table II). No one symptom had been experienced by all 42. patients in the last 7 days. However, stomach pain was experienced by 90% in this period. TABLE
II.-PERCENTAGE
OF SUBJECTS SCALES
Symptoms Feeling sick Stomach Diarrhoea Constipation Bloatedness Appetite loss Pain when opening Backache Headache Irritability Depressed Anxious Worrying Tiredness Sleep loss
bowels
WITH
MEASURING
VARIOUS
SYMPTOMS
SCORES ON IN
LAST
THE
VISUAL
ANALOGWE
7 DAYS
No symptoms (0)
Slight to moderate (l-10)
Moderate to severe (11-20)
50.0 9.5 38.1 35.7 28.6 57.2 42.8 35.7 45.2 26.2 33.3 19.0 45.2 21.5 45.2
26.2 28.6 28.6 28.6 28.6 19.0 28.6 28.6 31.0 40.5 33.3 50.0 26.2 33.3 28.6
23.8 61.9 33.3 35.7 42.8 23.8 28.6 35.7 23.8 33.3 33.3 31.0 28.6 45.2 26.2
Those symptoms only rated by one third or less of patients are not included in this table. This included symptoms of vomiting, breathlessness, palpitations, faintness, crying and feelings of panic.
Behavioural
psychotherapy
465
in IBS treatment
In addition to the other physical symptoms commonly associated with IBS, high proportions of patients had experienced severe symptoms of irritability, depression, anxiety, tiredness and sleep loss in the past 7 days. The psychiatric scores of the two groups are shown in Table III. Over 50% of the two groups had one or more social problems. These problems were wide ranging, work difficulties being mentioned by 2 1% of the whole sample, financial by 17 % , housing by 12 % and marital/sexual relationship problems by 14%.
TABLE III.-CLINICAL
GHQ status GHQ -ve GHQ fve
(not a case)* (a case)*
Clinical Interview Schedule Not a case (O-12)* A case (13+)*
MT
Total sample
9 13
8 12
17 25
22
zi
42
7 13
14 18
20
22
(US) 7 1.5 22
* See text regarding
SCORES
BP
“caseness”
Over 40% of patients showed moderate to marked avoidance of a including work, travelling, activities when symptoms were present, sexual intercourse, domestic and leisure activities, eating certain food or others. Avoidances were generally less frequent when symptoms were
number of socializing, eating with absent.
Results of treatment Although a number of analyses were conducted (details in the method section) no significant differences between the two groups were found except for two avoidance scores. These were for the avoidance of certain foods and the avoidance of domestic activities, both when symptoms of IBS were present. For these two scores, the experimental group made significantly more improvement (Table IV). TABLE IV.-CHANGES
IN AVOIDANCE SCORES
BP Group Mean
Avoidance of specific Initial 4 months 9 months Avoidance of domestic Initial 4 months 9 months
SD
95 %
foods* (when symptoms 5.89 3.36 4.27 3.26 3.60 1.53 3.78 3.79 1.86 -
MT Group Confidence intervals present) 7.52 5.0 5.51
tasks** (when symptoms present) 3.0 2.87 0.95 5.05 1.4 2.50 0.39 3.19 2.2 3.05 0.02 4.38
Mean
SD
95 %
Confidence intervals
5.7 5.9 6.4
3.51 3.21 3.08
4.06 4.40 4.96
-
7.34 7.40 7.84
3.0 2.4 5.4
2.36 1.84 2.32
1.31 1.09 3.74
-
4.69 3.71 7.06
* Significant time by group effect p = 0.004; significant time effect p = 0.030. ** Significant time by group effect p = 0.048; significant time effect p = .047.
466 Overall
R. H. CORNEY changes
over
et al.
time
The group as a whole, however, were found to have improved over the 9 months (Table V). Changes were significant for a number of dependent variables including the VAS symptom scores for stomach pain, constipation, headache and irritability (all p
Research. Vol. 35, No. 415, PP. 461-469.
1991. 0
Printed an Great Britain.
BEHAVIOURAL
PSYCHOTHERAPY
cm-3999191 $3.00f.cQ 1991 Pergamon Press plc
IN THE TREATMENT
OF
IRRITABLE BOWEL SYNDROME ROSLYN H. CORNEY,* RUTH STANTON,* ROBERT NEWELL,* ANTHONY CLARE* and PETER FAIRCLOUGH~ (Received
3 July 1990; accepted
in revised form 28 November
1990)
Abstract-The irritable bowel syndrome is a highly prevalent condition whose underlying aetiology is not understood. While many patients respond to a combination of gastrointestinal antispasmodics, bulking agents and dietary manipulation [ 11, controlled clinical trials have suggested that the benefit is only marginal and is due mainly to the large placebo effect found in this condition, which has been calculated to range between 54 and 8 1% [2-41. Associations between the syndrome and psychological and social stresses suggest, however, that treatment involving a systematic approach to the management of symptoms may hold out real therapeutic possibilities. In the current study, 42 IBS patients were randomly allocated to either medical treatment or to behavioural psychotherapy with a nurse therapist. They were assessed initially and at 4 and 9 months. There was a general improvement over the 9 months on a number of physical and psychological symptoms measured. However, no differences were found between treatment groups except for changes in two avoidance scores. A significant correlation was found, however, between improvement in the bowel symptoms of IBS (stomach pain and diarrhoea) and improvement in the psychological symptoms measured by the Clinical Interview Schedule, suggesting a close interrelationship between the two.
INTRODUCTION THE IRRITABLE bowel syndrome (IBS) consists of altered bowel habit, abdominal pain and gaseousness, each of which are present to a variable degree, and is without any recognized organic gastrointestinal pathology 151.A recent review 131concluded that the syndrome and its variants affect up to 15% of the general population [61and accounting for about half the referrals to specialized gastrointestinal clinics 17, 81. There is no consensus amongst clinicians and researchers concerning the underlying cause of this syndrome. Organic causes which have been suggested include abnormal motor activity of the intestinal tract 19, 101 abnormal gut hormone, secretion and sensitivity 1111 and diet [121. However, many studies have indicated that psychological factors are important and that patients with this syndrome are more neurotic, depressed or anxious than others [13, 141. However, it is difficult to know whether such depression is of the transient mild type seen in a high proportion of those in chronic pain, or is a form of classical affective disorder warranting and benefitting from antidepressant treatment [31. The uncertainty concerning the extent to which organic and psychological factors are operating in IBS is reflected in the variety of treatments employed and the lack of clarity regarding their precise efficacy [2-41. However, long term studies of natural history or follow up, have generally shown lower remission rates, the majority of patients have intermittent symptoms with the length of time during which they
* Department of Psychological Medicine, St Bartholomews Hospital, London E.C. 1A 7BE, U.K. t Department of Gastroenterology, St Bartholomews Hospital, London E.C.lA 7BE, U.K. Address all correspondence to: Dr R. H. Corney, Senior Lecturer, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 BAF, U.K. 461
462
R. H. CORNEY et al.
were asymptomatic being relatively short 1151, although some studies suggest a better long term outcome [ 11. Recently, several studies have been published suggesting that psychological treatments may be particularly effective in IBS. Svedlund and colleagues 1161 reported that dynamically oriented short term individually orientated psychotherapy was significantly more effective than conventional medical treatment in reducing somatic symptoms. Whorwell and his colleagues 1171 randomly allocated 30 patients to treatment with either hypnotherapy, psychotherapy or placebo and reported that hypnotherapy treated patients showed a dramatic improvement in all features whereas psychotherapy treated patients showed a significant improvement in bowel pain but not in bowel habit. However, inferences from this study must be tentative as only simple measures of outcome were used, length of follow up was brief and the same therapist conducted both treatments. A number of uncontrolled studies have used stress management techniques or biofeedback training in the treatment of IBS, all showing positive results 118-231 other workers have compared treatments, Giles found that behavioural psychotherapy was the most effective in reducing the frequency of loose bowel movements, while a combined treatment approach of behavioural therapy and biofeedback was superior with relieving symptoms associated with IBS 1241. Whitehead found that stress management produced no change in bowel motility but that pain decreased significantly. Patients in his biofeedback group showed the opposite response 141. Bennett and Wilkinson 1251 compared cognitive-behavioural interventions with medical management. Both groups reported a decrease of symptoms, but the cognitive-behavioural group showed less anxiety at follow up. The dearth of controlled clinical trials (especially those with follow up assessments over 6 months) in the psychological treatment of IBS is striking particularly in the light of the prevalence of this disorder and the generally unsatisfactory response of these patients to diet and pharmacological management. The aim of this present study was (a) to establish whether a stress management package is superior in effectiveness to conventional medical management in the treatment of IBS and (b) to establish whether psychiatric ill health and social dysfunction are factors which predict the therapeutic response of IBS sufferers to the two treatments. METHOD Patients suffering from IBS were recruited from out-patient attenders at the Department of Gastroenterology at St Bartholomews Hospital and from St Mark’s Hospital, London. For inclusion in the study, the following criteria were met: 1. Abdominal pain that fits no other disease pattern and/or non-bloody diarrhoea and/or constipation with discomfort. 2. Symptoms present for over 6 months. 3. Normal sigmiodoscopy and rectal biopsy (if diarrhoea was a complaint). 4. Alteration in bowel habit. Patients also had to be willing to be included in the clinical trial and accept either treatment, thus patients unable to attend for weekly therapy had to be excluded. Patients were initially assessed by an independent researcher using the following measures. (a) A structured interview covering demographic data, current medical history, medical treatment, current medication and family history of illness. (b) The Clinical Interview Schedule. the CIS [261, and instrument designed to detect the presence of psychological disorders in community samples. The instrument includes measures of depression of mood somatic symptoms, disturbances of sleep, concentration, memory, and cognition, anxiety, phobias,
Behavioural
psychotherapy
in IBS treatment
463
obsessional and compulsive thoughts and behaviour and depersonalization. The CIS score takes into account the subjects’ description of the frequency, duration and severity of symptoms in the past week but subjects are also rated on manifest abnormalities by the interviewer according to their appearance and conduct during the interview. Subjects having a score of 13 or more points were deemed to be a ‘case’ which means that they would be considered to be ill if examined by a psychiatrist. ‘Non cases’ had scores of 12 points or less. (c) The following questionnaires and rating scales: (1) The 30 item General Health Questionnaire, the GHQ [271, used to assess recent mental health. This questionnaire completed by the patient is designed to dichotomize subjects into probably ‘cases’ of psychiatric ill-health, (GHQ positive) if examined by a psychiatrist in an outpatient clinic and those who would probably be deemed ‘non cases’ (GHQ negative). (2) The Social Problem Questionnaire [281 measuring presence or absence of social problems. (3) Three rating scales to measure the frequency, severity and duration of pain experienced in the last month (on an eight-point scale). (4) A number of rating scales to measure avoidance of specific activities on an eight-point scale ranging from ‘no avoidance’ to ‘total avoidance’. Subjects rated their avoidance of each activity when IBS symptoms were present or when they were absent. (5) Visual analogue scales recording symptom severity over the previous 7 days. Patients were then randomly allocated by a research assistant to one of two groups. The control group were referred back to the gastroenterology department for conventional medical treatment and the experimental group were referred to a nurse behaviour therapist for treatment. Outcome was assessed at 4 and 9 months after entry into the study using the same instruments. The clinical interview schedule, however. was only administered at the 9 month reassessement. Patients referred to medical treatment were seen in the out-patients department (ranging from 1-4 appointments) and treated using explanation, reassurance, a variety of medications, antispasmodics, bulk laxatives, dietary advice. Those referred to the behaviour therapist were mostly seen at weekly intervals for 6 to 15 one-hourly sessions and followed up every three months post treatment. An assessment was made of each patient’s behaviour and its contribution to the presenting symptoms. Patients were given general information about the complaint and any mistaken ideas were elicited, discussed and modified. Patients who avoided situations or activities were encouraged to re-enter them by rehearsing them with the therapist. Bowel retraining techniques [291 were used to establish normal bowel habit and patients were encouraged to refrain from going to the lavatory in response to pain. Patients were given advice on pain management techniques along the lines advocated by Fordyce [301. Two-way repeated measures analyses of variance were performed on a number of variables to investigate differences in outcome between the two treatment groups. Analyses of covariance were also performed for this purpose with initial scores being the covariate. The dependent variables on which repeated measures analysis of variance were performed were: (a) Individual scores on the visual analogue scales at 0, 4 and 9 months and the total score (obtained by adding the scores together). (b) Individual pain scores at 0, 4 and 9 months and the composite pain score obtained by multiplying severity, duration and frequency of pain. (c) Individual scores obtained on the Clinical Interview Schedule at 0 and 9 months and the total clinical score obtained. (d) Individual avoidance scores at 0, 4 and 9 months. Analyses of covariance were performed on the scores obtained on the General Health Questionnaire and Pearson correlation coefficients were used to calculate associations between the change scores of physical and psychological symptoms.
RESULTS
Initial features
of the patient groups
Forty-two patients were found to fulfill the entry criteria, were willing to enter into the trial and lived close enough to the hospital to commit themselves to weekly sessions with the therapist. Twenty-two were allocated to the experimental group and 20 to the control groups. Only one patient (in the experimental group) was unable to be traced for the follow-up assessments. The demographic features of these patients are shown in Table I. There were no significant differences between the two groups on any of the initial variables measured. Three-quarters of the patients in the study were women. Their ages ranged from 19
R. H. CORNEY et al.
464
to 73 yr. Half were aged under 30 yr. Forty-three per cent were classified according to the occupation of the head of household in social class 1-2, 37% in class 3 and 20% in class 4-5. The patients were generally highly educated, 33% had taken a degree course, and an additional 20% had had some training after leaving school. TABLE
I.--INITIAL
DEMOGRAPHIC
DETAILS
Behavioural
Medical
psychotherapy
treatment
Sex Male
6 16
15
22
20
9 10 3
4 8 8
22
20
12 8 2
5 14
22
20
14 5 3
11
22
20
Female
19-25 26-40 41-73 Marital
BY GROUP
5
Status
Single Married/cohabiting Other
Work Full/part time paid work Housewife/unemployed/retired Student
7 2
The visual analogue scales included a number of commonly experienced symptoms of IBS plus a number of symptoms of affective disorder, namely, anxiety, depression and irritability (Table II). No one symptom had been experienced by all 42. patients in the last 7 days. However, stomach pain was experienced by 90% in this period. TABLE
II.-PERCENTAGE
OF SUBJECTS SCALES
Symptoms Feeling sick Stomach Diarrhoea Constipation Bloatedness Appetite loss Pain when opening Backache Headache Irritability Depressed Anxious Worrying Tiredness Sleep loss
bowels
WITH
MEASURING
VARIOUS
SYMPTOMS
SCORES ON IN
LAST
THE
VISUAL
ANALOGWE
7 DAYS
No symptoms (0)
Slight to moderate (l-10)
Moderate to severe (11-20)
50.0 9.5 38.1 35.7 28.6 57.2 42.8 35.7 45.2 26.2 33.3 19.0 45.2 21.5 45.2
26.2 28.6 28.6 28.6 28.6 19.0 28.6 28.6 31.0 40.5 33.3 50.0 26.2 33.3 28.6
23.8 61.9 33.3 35.7 42.8 23.8 28.6 35.7 23.8 33.3 33.3 31.0 28.6 45.2 26.2
Those symptoms only rated by one third or less of patients are not included in this table. This included symptoms of vomiting, breathlessness, palpitations, faintness, crying and feelings of panic.
Behavioural
psychotherapy
465
in IBS treatment
In addition to the other physical symptoms commonly associated with IBS, high proportions of patients had experienced severe symptoms of irritability, depression, anxiety, tiredness and sleep loss in the past 7 days. The psychiatric scores of the two groups are shown in Table III. Over 50% of the two groups had one or more social problems. These problems were wide ranging, work difficulties being mentioned by 2 1% of the whole sample, financial by 17 % , housing by 12 % and marital/sexual relationship problems by 14%.
TABLE III.-CLINICAL
GHQ status GHQ -ve GHQ fve
(not a case)* (a case)*
Clinical Interview Schedule Not a case (O-12)* A case (13+)*
MT
Total sample
9 13
8 12
17 25
22
zi
42
7 13
14 18
20
22
(US) 7 1.5 22
* See text regarding
SCORES
BP
“caseness”
Over 40% of patients showed moderate to marked avoidance of a including work, travelling, activities when symptoms were present, sexual intercourse, domestic and leisure activities, eating certain food or others. Avoidances were generally less frequent when symptoms were
number of socializing, eating with absent.
Results of treatment Although a number of analyses were conducted (details in the method section) no significant differences between the two groups were found except for two avoidance scores. These were for the avoidance of certain foods and the avoidance of domestic activities, both when symptoms of IBS were present. For these two scores, the experimental group made significantly more improvement (Table IV). TABLE IV.-CHANGES
IN AVOIDANCE SCORES
BP Group Mean
Avoidance of specific Initial 4 months 9 months Avoidance of domestic Initial 4 months 9 months
SD
95 %
foods* (when symptoms 5.89 3.36 4.27 3.26 3.60 1.53 3.78 3.79 1.86 -
MT Group Confidence intervals present) 7.52 5.0 5.51
tasks** (when symptoms present) 3.0 2.87 0.95 5.05 1.4 2.50 0.39 3.19 2.2 3.05 0.02 4.38
Mean
SD
95 %
Confidence intervals
5.7 5.9 6.4
3.51 3.21 3.08
4.06 4.40 4.96
-
7.34 7.40 7.84
3.0 2.4 5.4
2.36 1.84 2.32
1.31 1.09 3.74
-
4.69 3.71 7.06
* Significant time by group effect p = 0.004; significant time effect p = 0.030. ** Significant time by group effect p = 0.048; significant time effect p = .047.
466 Overall
R. H. CORNEY changes
over
et al.
time
The group as a whole, however, were found to have improved over the 9 months (Table V). Changes were significant for a number of dependent variables including the VAS symptom scores for stomach pain, constipation, headache and irritability (all p
