Test your knowledge and learn more about Irritable Bowel Syndrome by taking our Knowledge Questionnaire.
I. Background Information, Epidemiology
Q1. It is estimated that between 10% and 20% of adults in the US have IBS.
True or False?
The Answer is True
IBS is the most commonly diagnosed gastrointestinal condition, accounting for 12% of all visits to a primary care doctor. IBS often starts in late adolescence and is characterized by flare ups and remissions throughout the life span. Stress and major life events often precede the onset of chronic bowel symptoms.
The symptoms of IBS can deeply affect a person's quality of life. IBS is second only to the common cold as a cause of absence from work and school. Twenty eight percent of all visits to GI doctors are for symptoms related to IBS.
Q2. Patients with IBS visit the doctor twice as often as the average patient primarily to address symptoms related to IBS.
True or False?
The Answer is False
Most of the health care visits that people with IBS make are not for their bowel problems. In one study researchers reported that IBS patients had twice as many doctor visits compared to other patients in the same HMO, but they found that 78% of the additional visits were to address problems other than IBS. In addition to gastrointestinal symptoms, many people with IBS also have symptoms and disorders that are not related to intestinal function. These include skin rashes, headache, frequent and/or difficult urination, fatigue, trembling hands, sleeping difficulties, unpleasant taste in the mouth, jaw pain, back pain, and shortness of breath, among others.
Q1. Which group of symptoms/disorders is LEAST associated with IBS?
- Chronic fatigue syndrome and fibromyalgia
- Anxiety, depression and headaches
- Ulcerative colitis, Crohn´s Disease and bowel cancer
- Frequent urination, back pain and chronic pelvic pain
The correct answer is C: ulcerative colitis, Crohn’s Disease and bowel cancer
In a recent study, IBS patients had a higher frequency of almost half of all non-GI diagnoses in a comparison of patients with and without the disease. For instance, it is estimated that fibromyalgia (a disorder characterized by muscle pain, stiffness and tiredness) occurs in up to 28-65% of patients with IBS, chronic fatigue syndrome in 14% of IBS patients, temporomandibular joint disorder in 16-25% and chronic pelvic pain in 35% of IBS patients.
However, IBS does not cause intestinal bleeding, inflammation or any other bowel diseases such as Crohn's disease, ulcerative colitis or bowel cancer. Over time, less than 5 percent of people originally diagnosed with IBS will be diagnosed with some other gastrointestinal condition.
Whitehead WE, Palsson O, Jones Kr. "Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?" Gastroenterology. 122(4): 1140-56, 2002.
Jones KR, Palsson OS, Levy, RL, et al. "Comorbid disorders and symptoms in irritable bowel syndrome (IBS) compared to other gastroenterology patients." Gastroenterology. 120:A66, 2001.
Q2. Which symptoms are NOT associated with IBS?
- Blood in the stools
- Weight loss
The correct answers are D (Blood in the stools) and F (Weight loss)
Patients with IBS can present with a wide variety of symptoms, both intestinal and throughout the body. The classic gastrointestinal symptoms of IBS are chronic or recurrent abdominal pain or cramps in the lower abdomen that may be severe; changes in bowel habits such as diarrhea, constipation or alternation between the two; and gas and bloating. Symptoms commonly occur after a meal, may be worsened by emotional stress, and are often relieved by a bowel movement.
Blood in the stool is not a symptom of IBS. Bloody stools often indicate an injury or disorder in the upper or lower digestive tract such as peptic ulcers, gastritis, colon polyps, colon cancer, inflammatory bowel diseases, diverticulosis and hemorrhoids, among others.
Significant weight loss is also not a symptom of IBS and may be the result of another problem such as Crohn's Disease, ulcerative colitis, gastric ulcers, cancer and a wide variety of other non-gastrointestinal causes. Both blood in the stool and weight loss require evaluation by a healthcare professional in order to make an accurate and sound diagnosis.
III. Diagnosis of IBS
Q1. Which of the following can confirm a diagnosis of IBS?
- Analysis of gut bacteria
- Barium enema
- There are no confirmed diagnostic tests for IBS
The correct answer is D: There are no confirmed diagnostic tests for IBS
IBS itself is not a disease, as no abnormality of the bowel can be identified by standard medical tests. Rather it is classified as a functional disorder, or a "syndrome," because it is caused by a problem with how the intestines actually work.
IBS affects the movement of stool and gas through the colon and the way in which fluids are absorbed. When stool remains in the colon for a long time, too much water is absorbed from it, and it becomes hard and difficult to pass. When spasms push the stool through the colon too fast for the fluid to be absorbed, diarrhea results. Spasms may cause gas to become trapped or stool to collect in one area, making it unable to move through the colon as normal. When these disturbances occur, people experience symptoms of abdominal pain, bloating, diarrhea and/or constipation.
Currently no specific diagnostic tests exist for IBS such as x-rays or blood tests, although tests may be used to eliminate other diagnoses. Because there is no readily identified physiologic marker, it has been necessary to rely on the patient's symptoms for diagnosis. The diagnostic criteria used at this time are the Rome II criteria, developed by a consensus of experts. The basic criteria include at least 3 months of continuous or intermittent abdominal discomfort or pain associated with disturbed defecation (altered stool frequency, consistency or passage such as straining, urgency, mucus and bloating).
IV. Causes of IBS
Q1. Between 7% and 31% of patients with IBS report an episode of gastroenteritis (an infection of the stomach and intestines) before the onset of IBS symptoms
True or False?
The answer is True
Bacterial gastroenteritis is a risk factor for developing irritable bowel syndrome. It has been documented that after an episode of bacterial gastroenteritis, at least one patient in 14 will develop the classical features of IBS. Women are at a higher risk for developing post-gastroenteritis IBS as well as those who experience a long period of diarrhea. In a 2003 study involving 128 IBS patients, results showed that IBS and functional diarrhea occurred frequently in patients six months after bacterial gastroenteritis. In addition, the proportion of patients with a functional gastrointestinal disorder was maintained between 3 and 6 months, suggesting that the symptoms are likely to be long lasting.
Parry SD, Stansfield R, Jelley D, et al. "Does bacterial gastroenteritis predispose people to functional gastrointestinal disorders? A prospective, community-based, case-control study." The American Journal of Gastroenterology. 98(9): 1970-1975, 2003.
Q2. Patients who have received antibiotic therapy for gastroenteritis are less likely to develop IBS symptoms.
True or False?
The answer is False
Patients who have received antibiotic therapy are more likely to develop IBS symptoms. This leads one to question whether antibiotic therapy per se may also be a risk factor for the development of IBS.
It has been suggested that following antibiotic therapy certain micro-organisms are allowed to flourish in the gut due to the reduction in the amount of Lactobacillus and Bifidobacteria, helpful bacteria normally found in the intestines that may decrease abdominal bloating and flatulence in people with IBS.
Nobaek S, Johansson ML, Molin G, et al. "Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome." American Journal of Gastroenterology. 95(5): 1231-8, 2000 May.
Q3. Possible causes of IBS include which of the following:
- Bacterial infections, fungal infections or intestinal parasites
- Chronic low-grade inflammation
- Food sensitivities and food allergies
- Imbalance of the bacteria in the gut (too little Bifidobacteria and overgrowth of enterobacteriacae)
- All of the above
The correct answer is E: All of the above
While no one knows what causes IBS, it is clear that symptoms cannot be traced to a single organic cause. Research suggests that persons with IBS seem to have intestinal tracts that are more sensitive and reactive than usual to a variety of things, including certain foods and stress.
Because food intolerances occur frequently in patients with IBS, it has been suggested that the development of IBS may be related to food sensitivity or allergy. The best way to detect an association between symptoms of IBS and food sensitivity is to eliminate certain food groups systematically (a process called an elimination diet), which is usually best done under the supervision of a health care professional such as a doctor or nutritionist. It usually takes at least one to two weeks without a specific food group to determine if IBS symptoms are positively affected.
There is growing evidence that low-grade inflammation in the lining of the gastrointestinal tract may play a role in the development of certain kinds of IBS. Another explanation is that people who develop IBS may have poorer defense mechanisms to combat infections or other pathologies of the gut. An important area for future study will be to clarify the relationship between inflammation, stress and IBS symptoms.
Another theory being studied is that overgrowth of bacteria in the small intestines might cause IBS in some patients. Bacterial overgrowth is associated with bloating, pain and diarrhea. Only if bacterial overgrowth in the small intestines is diagnosed should IBS patients be treated with antibiotics to reduce these symptoms.
Drossman DA. "Bacterial Overgrowth in IBS." The UNC Center for Functional GI & Motility Disorders.
. Last accessed 4/19/05.
It is known that stress and anxiety have a number of effects on the intestine. While these can likely cause a worsening of IBS symptoms, they are probably not the cause of symptoms. Nevertheless, addressing psychosocial problems forms an important part of the treatment approach to IBS. Ongoing stress can make IBS resistant to treatment. There is increasingly sound data that supports the use of antidepressant medication and a variety of mind/body treatments for patients with more severe forms of IBS.
Murray CD, Flynn J, Ratcliffe L, Jacyna MR, et al. "Effect of acute physical and psychological stress on gut autonomic innervation in irritable bowel syndrome." Gastroenterology. 127(6): 1695-703, 2004.
Q4. Which food is NOT implicated in worsening of IBS symptoms in some patients?
- Refined sugars
- Complex carbohydrates such as whole grains, brown rice, buckwheat and millet
The correct answer is F: complex carbohydrates
Milk, wheat, eggs, citrus, corn, refined sugars and fat are the most frequently identified problem foods for IBS.
Dietary factors play an important role for many patients with IBS. Although patients rarely have a true food allergy, food intolerance is quite common. Some studies have reported that most people with IBS have food sensitivities and that gas production and IBS symptoms decrease when the offending foods are avoided. Research shows, however, that many patients are not aware of all of their food triggers. One way to help manage IBS is to use a diary to identify the factors that trigger attacks.
Another way to evaluate which foods might trigger IBS symptoms is to avoid those foods and then reintroduce them into the diet. However, elimination diets are difficult and arebest done in partnership with a healthcare practitioner. Positive responses to elimination diets range from 15% to 71%.
Atkinson W, Gurney R, Sheldon TA, Whorwell PJ. "Do food elimination diets improve irritable bowel syndrome? A double blind trial based on IgG antibodies to food." Gastroenterology. 2003; 124:A29. [Abstract #198]
Jones VA, McLaughlan P, Shorthouse M, et al. "Food intolerance: a major factor in the pathogenesis of irritable bowel syndrome." Lancet. 2(8308):1115-7, 1982
Parker TJ, Naylor SJ, Riordan AM, et al. "Management of patients with food intolerance in irritable bowel syndrome: the development and use of an exclusion diet." Journal of Human Nutrition and Diet. 8:159-66, 1995.
V. Treatment Strategies
Q1. The use of anti-inflammatory medications is part of the standard treatment for IBS.
True or False?
The answer is False.
One theory on the cause of IBS is low-grade chronic inflammation. Data from animal studies show that even mild inflammation can lead to persistent changes in gastrointestinal nerve and smooth muscle function. Studies show that after an acute gastrointestinal infection, about one third of individuals develop lasting symptoms comparable to IBS. Because most of this data is still preliminary and will need confirmation by larger research studies, taking anti-inflammatory drugs such as cortisone or nonsteroidal anti-inflammatories is not warranted at this time.
However, there are natural strategies to help reduce chronic inflammation that may be helpful. These include:
- Reducing pro-inflammatory foods such as tea, coffee, alcohol, excess salt, meat and dairy products, and foods prone to causing intolerances (especially wheat and dairy products).
- Increasing anti-inflammatory foods such as oily fish like herring, salmon and sardines and black, blue and purple fruits
- Using supplements that have an anti-inflammatory effect such as ginger, fish oil, glucosamine and bromelain.
Q2. The use of antiobiotics is recommended for all cases of IBS.
True or False?
The answer is False
Small bowel bacterial overgrowth is a relatively common condition that can cause symptoms suggestive of IBS, especially bloating and distension. Physicians can test for this condition by giving the patient a lactulose hydrogen breath test to assess the presence of small intestinal bacterial overgrowth and can treat it appropriately with antibiotics when it is found. In these cases, eradication of bacterial overgrowth should decrease the symptoms of diarrhea, bloating and abdominal pain. However, antibiotics should only be prescribed when there is definite evidence of small bowel bacterial overgrowth because antibiotic therapy can also cause an imbalance of intestinal flora. Bacterial overgrowth does not yet appear to be confirmed as the primary cause of IBS in the majority of IBS cases. It is not known what percentage of patients with IBS shows a positive lactulose hydrogen breath test and therefore would benefit from antibiotic therapy. Unfortunately it can be difficult to find physicians who are familiar with and able to perform this particular diagnostic test and patients may have to be persistent to locate someone in their area.
Thompson WG, Longstreth G, Drossman DA, et al. "Functional bowel disorders and functional abdominal pain." In: Drossman DA, et al. Rome II: The functional gastrointestinal disorders, 2nd edition. Degnon Associates, McLean, Va, 2000. Pp 351-432.
Q3. Probiotics are often used to limit the growth of harmful bacteria and promote the growth of beneficial bacterial in the intestines.
True or False?
The answer is True.
The normal colon contains billions of harmless bacteria, some of which may actually promote the health of the bowel. Probiotics are dietary supplements containing these friendly bacteria that can aid in the breakdown of proteins and fats in food and help in the absorption of vitamins, minerals and amino acids. They can also help boost the immune system and prevent or reduce the growth of harmful bacteria like salmonella. Probiotics have been used as part of a therapeutic regimen for problems such as yeast infections, constipation, bloating, irritable bowel syndrome (IBS), and lactose intolerance.
The results of 12 studies on the use of probiotics for IBS in 1,371 patients show some benefit with the use of a single strain or combination of bacteria including lactobacilli, bifidobacteria, and enterococcus fecalis among others. Fructo-oligosaccharides (FOS) may be added to acidophilus pills. FOS are carbohydrates that are not digestible by humans, but serve to help the beneficial bacteria grow.
O'Mahony L, McCarthy J, Kelly P, et al. "Lactobacillus and bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles." Gastroenterology. 128(3): 541-51, 2005 Mar.
Q4. Fecal bacteriotherapy is a very new and controversial therapeutic approach that has been reported to improve IBS constipation in small case studies.
True or False?
The answer is True
Fecal bacteriotherapy uses the complete normal human intestinal flora as a therapeutic probiotic mixture of living organisms administered through colonic infusion via enema. It has shown success in the treatment of IBS and chronic constipation in small case series and warrants further study. At the present time, however, it is probably not possible to receive fecal bacteriotherapy outside a research setting.
Borody TJ, Warren EF, Leis, SM, et al. "Bacteriotherapy using fecal flora: toying with human motions." Journal of Clinical Gastroenterology. 38(6): 475-483, 2004.
Q5. Integrative IBS care focuses on nutrition, supplementation, exercise, mind-body medicine and other holistic interventions to the exclusion of the use of medications.
True or False?
The answer is False.
An integrative approach seeks to work with the body's natural potential for healing while also making appropriate use of modern medicines. It pays attention not only to the physical body but also to the mental, emotional and spiritual aspects of the individual. It looks at one's total lifestyle to assess which factors are adding to distress and what can better further healing. Because of this holistic view, an integrated approach to IBS may incorporate various therapeutic approaches. These include:
Nutritional approaches: diet, supplements and herbs
Medications: address different symptoms of IBS. These include:
- Antispasmodic agents such as dicyclomine and Hyoscyamine sulfate can
relieve intestinal cramps or spasms
- Antidiarrheal agents such as Imodium and Lomotil can reduce diarrhea
- Anti-depressants such as paroxetine, amitryptyline, and desipramine can help with pain, diarrhea and depression by reducing intestinal transit and gut sensitivity
- Bulking agents such as bran and psyllium can help with constipation by increasing stool size and transit time through the colon
- Osmotic laxatives can act as stool softeners for constipation
- Serotonin-related medicines such as Tegaserod--which can help lessen constipation in women--and Alosetron-- which is being studied for severe diarrhea-can help with bowel symptom.
Mind-body therapies: these self-awareness and self-regulating techniques help to manage symptoms of IBS
Exercise and physical activity: can help to decrease feelings of depression and anxiety
Manual medicine: including massage, chiropractic and osteopathy, among others, can help to reduce the effects of stress and may have a balancing effect on the nerves that supply signals to the intestinal tract
Homeopathy: a unique therapeutic system that prescribes individualized remedies to relieve the characteristic mental and physical signs and symptoms of IBS
East Asian Medicine: This traditional system of medicine provides a comprehensive integrative approach to IBS through the use of herbs, acupuncture and moxibustion, tui na (massage and acupressure), Qi Gong (mind-body exercise) and dietary therapy
Q6. Dietary changes that may help manage IBS symptoms include:
- Avoiding gas-forming foods such as cabbage, broccoli and beans
- Avoiding caffeine and alcohol
- Increasing dietary fiber
- Avoiding dairy, fried and fatty foods
- Increasing water intake
- All of the above
The correct answer is F: All of the above
Dietary changes can help many people with IBS manage their symptoms. Fiber reduces constipation by softening the stool, making it easier to pass. The recommended daily intake of fiber is 20 to 35 grams for healthy adults. It is best to gradually introduce high-fiber foods into your diet. Good sources of fiber include whole-grain bread and cereals, fruits, vegetables, and beans. Dried plums, prune juice, ground flaxseed, and water also help loosen bowels.
Some people use bulking agents, commonly known as fiber supplements, to treat IBS with constipation. These supplements may increase bowel movement, but they do not appear to help with other IBS symptoms such as abdominal pain, discomfort, and bloating. In fact, extra doses of fiber may worsen abdominal pain, bloating, and discomfort in some people with IBS.
In general it is recommended that coffee, carbonated drinks, and alcohol be avoided. They can slow the passage of stool, as can refined foods such as chips, cookies, and white rice.
Dairy products can cause digestive problems due to their lactose and fat contents and the proteins they contain including whey and casein. In some people the high fat content causes colon spasms and diarrhea. In others, the proteins, lack of fiber, and low water content can lead to severe constipation. If the body can't easily digest lactose, it remains in the intestines and interferes with normal intestinal bacteria, leading to cramps, gas, bloating and diarrhea. Dairy products include milk, cream, butter, yogurt, cheese, and ice cream, among others.
Sulfur-containing vegetables such as onions, garlic, leeks, asparagus, broccoli, brussel sprouts, cauliflower and cabbage can produce additional gas in the digestive tract, which can trigger bouts of IBS.
Q7. Various herbal teas and supplements can be used for different IBS symptoms.
The one that has been shown to be most effective is:
- Blackberry tea
The correct answer is C: Peppermint
The most studied herbal medicine with the greatest evidence of a positive effect is enteric-coated peppermint oil. Peppermint oil has been shown to reduce gas production, ease intestinal cramping, and soothe irritation. It has been reported to help relieve symptoms of IBS in two analyses of controlled trials. Studies of peppermint oil have typically used enteric-coated capsules that supply 0.2-0.4 ml of peppermint oil taken three times per day.
In one study, the combination of 90 mg of peppermint oil plus 50 mg of caraway oil in enteric-coated capsules taken three times per day led to significant reduction in IBS symptoms. The same combination has compared favorably to the drug cisapride (Propulsid®) in reducing symptoms of IBS. Whole peppermint leaf is also used either alone or in combination with other herbs to treat abdominal discomfort and mild cramping that accompany IBS.
Although generally not well studied, various herbal capsules, powders, teas and supplements have been used to improve IBS symptoms. These include the following categories:
- Carminatives to reduce gas and spasms: peppermint, ginger, fennel, German chamomile, caraway, artichoke leaf extract
- Bitter Tonics to promote digestion by improving the acidity of stomach secretion and protein digestion, thereby increasing gastric emptying: Gentian root, goldenseal and angelica
- Fiber supplements (bulking agents) to improve constipation: linseed (dried ripened seed of flax), psyllium, wheat bran (if there is no sensitivity to gluten)
- Osmotic agents for constipation: cascara, senna and aloe
- Anti-diarrheal agents: blackberry tea, blueberry tea and raspberry tea
- Constipation - Padma Lax (Tibetan herbal formula)
Madisch A, Heydenreich CJ, Wieland V, et al. "Treatment of functional dyspepsia with a fixed peppermint oil and caraway oil combination preparation as compared to cisapride." Arneimittlforschung . 49:925-32, 1999.
VI. IBS and the Mind-Body Connection
Q1. Many people who meet criteria for IBS also have anxiety and/or depression.
True or False?
The answer is True.
Approximately half of IBS patients who seek medical attention have a co-existing psychological diagnosis. The most common diagnoses are generalized anxiety disorder and depression. Many IBS patients have negative early life experiences and heightened anxiety about their health. This suggests that many patients would be helped by focusing not only on IBS symptoms but also on psychological factors.
Q2. Patients who have not been helped by traditional medical interventions are also resistant to psychological treatments.
True or False?
The answer is False.
Many of the studies on non-pharmacological approaches to IBS (such as psychotherapy, biofeedback and hypnotherapy) use a sample of patients who have not responded to conventional medical care, and many of these studies demonstrate positive results. Approximately 15% of IBS patients do not improve with standard medical therapy (dietary modification, conventional pharmacological interventions and reassurance). Psychological treatments are usually reserved for these patients who are not improving and those who relapse despite an initial response to medical treatment. These non-pharmacological alternatives may be helpful for patients who have not seen sufficient results from standard medical care as well as those who are interested in exploring mind/body techniques for the management of their IBS symptoms.
Q3. Tricyclic antidepressants are often given to patients with IBS because:
- IBS patients almost always experience depression that should be treated
- Antidepressants block the activity of nerves responsible for gut motion and help to reduce pain
- Antidepressants affect the kinds of foods that patients eat
- IBS patients often have a strong placebo response to taking a medication
The correct answer is B: Antidepressants block the activity of nerves responsible for gut motion and help to reduce pain.
Antidepressants can be a helpful therapy for IBS patients whether or not they also experience a mood disorder. A favorable effect was found in a meta-analysis of 11 studies using antidepressants for functional gastrointestinal disorders. Research trials have demonstrated that a certain class of antidepressants, namely tricyclic antidepressants, seems to have the effect of reducing gut sensations and altering the experience of pain. The underlying mechanism is not known but it might be because they reduce sensitivity of peripheral nerves or cause alterations in the brain. Based on research trials, tricyclic antidepressants are recommended for patients with severe diarrhea-predominant IBS, because constipation is a potential side effect of this type of pharmacotherapy. A different class of antidepressants, Selective Seratonin Reuptake Inhibitors (SSRI), is sometimes prescribed for IBS patients who primarily experience constipation. The doses of antidepressants administered for IBS tend to be lower than the doses used to treat depression. Physicians prescribing antidepressants for this purpose should be familiar with appropriate dosages for IBS.
Jackson JL, O'Malley PG, Tomkins G, Balden E, Santoro J, Kroenke K. Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis. American Journal of Medicine. 108:65-72, 2000.
Q4. Which symptom is least likely to be helped by psychological treatments?
- Abdominal pain
- Co-occurring conditions such as depression, anxiety, pain or sleep disorders
The correct answer is C: Constipation
Psychological therapies have been a part of the treatment of IBS for a long time. Most experts agree that the research supports the use of psychological interventions for reducing abdominal pain and diarrhea as well as for conditions that tend to occur with IBS such as depression, anxiety, pain or sleep disorders.
Cognitive-behavioral treatment, dynamic (interpersonal) psychotherapy, hypnotherapy and stress management/relaxation seem to be effective in reducing abdominal pain and diarrhea (but not constipation), anxiety and other psychological symptoms. Improvement may relate to changes in GI physiology, improved coping strategies, or in the interpretation of signals from the gut. Greater benefit may be expected in patients whose symptoms worsen in relation to stress, who have associated symptoms of anxiety or depression, symptoms of a relatively short duration, and intermittent rather than chronic pain. No one psychological treatment seems superior, and future studies are needed to determine the relative effectiveness of these treatments for various subgroups of IBS patients.
Q5. Which of the following psychological interventions have been shown to lead to the greatest long-term reductions in IBS symptoms?
- Dynamic psychotherapy
- Stress management
- Cognitive-behavioral therapy
The correct answer is C: Hypnotherapy
The strongest follow-up data on IBS treatments come from hypnotherapy studies. Results suggest that treatment gains from hypnotherapy are maintained for at least five years. One benefit of psychological treatment is that patients learn skills and develop insight that can be beneficial to patients on an ongoing basis, whereas the effect of drugs produces temporary improvement in symptoms that may return once the drug is discontinued.
Blanchard, Edward B. Long-term follow-up of psychological treatments for irritable bowel syndrome. In Blanchard, Edward B. (2001). Irritable bowel syndrome: Psychosocial assessment and treatment. (Pp. 309-314). Washington, DC, US: American Psychological Association. xi, 1-373 pp.
Q6. Hypnotherapy has been shown to be helpful for patients with IBS because hypnotherapy:
- Encourages patients to ignore their symptoms, especially their pain
- Patients, while in a state of relaxation, are taught to assert control over gut function and imagery
- Patients simply enter a very deep state of relaxation that can be achieved through any other relaxation strategy
- Patients are given an opportunity to explore the psychological reasons why they have IBS
The correct answer is B: Patients, while in a state of relaxation, are taught to assert control over gut function and imagery.
Hypnotherapy is a unique treatment in which patients are guided into a relaxed trance state and become open to therapeutic suggestions for healing and change. Relaxation and pain management can be important parts of hypnotherapy treatment, but the focus of hypnotherapy for IBS is on exerting control over gut function. Well-designed studies have been conducted on the topic. When compared to psychotherapy, hypnotherapy has been shown to have a more significant impact on IBS symptoms. In this type of "gut directed" hypnotherapy, patients are guided through images related to bowel functions, (such as the analogy of a flowing river) and use hand placement to elicit abdominal warmth and an increased sense of control over gut function.
Q7. By promoting deep states of relaxation, meditation can help to reduce symptoms of IBS.
True or False?
The answer is True.
Research has demonstrated that a meditation technique called The Relaxation Response, which was developed by Dr. Herbert Benson in 1975, can offer relief for patients with IBS symptoms. In one small study, patients were assigned to either a six-week meditation regimen or a six-week symptom monitoring waitlist. At the end of three months, researchers noted significant improvements in flatulence, belching, bloating, and diarrhea in the meditation group. Constipation symptoms also improved, but not to the same degree as the other symptoms. Other conditions such as headache, insomnia, anxiety and worry also improved. A follow-up study found that pain and bloating, which tend to be especially distressing symptoms, remained improved after a one-year follow-up period.
The Relaxation Response is an easy to learn meditation technique. Patients assume a comfortable position and silently repeat a word or phrase while passively disregarding everyday thoughts that arise. This technique is described on The Mind Body Medical Institute web site at http://www.mbmi.org/pages/mbb_rr2.asp
Keefer L, Blanchard EB. The effects of relaxation response meditation on the symptoms of irritable bowel syndrome: results of a controlled treatment study. Behaviour Research and Therapy. 39(7): 801-11, 2001.
Q8. Biofeedback is useful to patients with IBS because it uses visual and auditory cues to teach patients to alter bodily responses.
True or False?
The answer is True.
According to the Biofeedback Certification Institute of America, "Biofeedback is a group of procedures for learning control over physiological responses with the help of electronic instruments and the services of a certified biofeedback professional." In biofeedback, physiological processes normally outside of a patient's awareness (such as temperature or heart rate) are sensed by instruments that provide visual and auditory feedback to the patient. In IBS, biofeedback can measure changes in skin conductivity, brain waves, bowel sounds and rectal distention. Patients ultimately learn techniques of mental and physical relaxation in order to gain control over underlying bodily processes.
While biofeedback's effectiveness for IBS symptoms is not yet scientifically established, results merit further research. In a small controlled trial of bowel sound biofeedback, patients with diarrhea-predominant IBS listened to their bowel sounds with a stethoscope placed on their abdomen, and were reinforced for successfully either increasing or decreasing the sounds. Patients' symptoms improved when compared to the symptom monitoring control group.
More recent approaches to treating IBS use biofeedback as an aid to teaching relaxation or combine biofeedback with cognitive therapy approaches in a multi-component treatment program.
Blanchard, Edward B. Psychological treatment of irritable bowel syndrome. In Blanchard, Edward B. (2001). Irritable bowel syndrome: Psychosocial assessment and treatment. (Pp. 157-181). Washington, DC, US: American Psychological Association. xi, 1-373 pp.
Q9. In cognitive behavioral therapy for IBS, the focus of treatment is on:
- Understanding and analyzing the root causes of the maladaptive patterns
- Using hypnotherapy techniques to explore thoughts and behaviors
- Exploring unconscious reasons for particular behaviors
- Focusing on the here and now to control current symptoms
The correct answer is D: Focusing on the here and now to control current symptoms
In cognitive behavioral therapy (CBT), the focus is on dealing with current issues, problems and behavioral patterns rather than exploring past experiences in great detail. Treatments can focus on either thoughts or behaviors or both. Techniques used in CBT include relaxation, guided imagery, skills training, homework assignments, changing internal dialogues, and correcting illogical thought patterns. CBT treatment for IBS often includes education about IBS, monitoring of thoughts and emotions and how they might be related to IBS, testing assumptions, stress management including training in relaxation strategies, and planning activities. Cognitive therapy can help patients change anxious and catastrophic interpretations of their symptoms that negatively impact their lives (such as "I'm so worried about being incontinent that if I leave my house it will be a disaster").
A number of studies have been conducted on cognitive behavioral therapy for IBS, but research to date is not yet conclusive. CBT may be especially appropriate for patients who are very distressed by their symptoms, believe that psychological factors may play a role in their problems, and are willing to be active participants in treatment.
Q10. Relaxation strategies that can be helpful for patients with IBS include:
- Progressive Muscle Relaxation
- Deep Breathing
- Body Scan
- All of the above
The correct answer is E: All of the above
Relaxation can be an important part of IBS management, as stress is often a trigger for IBS flare-ups. Learning to relax can reduce frequency of flare-ups and can help patients manage the anxiety they have in response to their symptoms. Relaxation training is included in many stress management programs and is a component of other psychological interventions including cognitive behavioral therapy, hypnotherapy and biofeedback. Relaxation can be used as a coping skill when in a stressful situation and can also be practiced to prevent stress from having a damaging effect on the body.
Stress management was compared to conventional therapy in a randomized, controlled trial with 35 patients with IBS. Patients in the stress management program received an average of six 40-minute sessions with a physiotherapist during which they were educated about the nature of their symptoms and their relationship to stress and were taught relaxation exercises. Two thirds of those in the stress management program found the program effective in relieving symptoms and experienced fewer attacks of less severity. This benefit was maintained for at least 12 months. Only a small number of those in the conventional therapy group experienced any relief.
There are many relaxation strategies that can be effective.
- Progressive muscle relaxation is a technique whereby patients tense and then release each muscle group in the body. The created muscular tension allows for a greater degree of relaxation once the muscle is released.
- There are many different meditation techniques, all of which help patients calm their mental chatter and experience the relaxation response. Two popular forms of meditation are transcendental meditation and mindfulness meditation.
- Deep breathing encourages patients to use diaphragmatic breathing rather than shallow chest breathing; shallow breathing is a common indicator that the stress response has been activated. Conscious deep breathing can promote overall physiological relaxation.
- In a body scan, patients mentally scan each part of their bodies to notice where they might be holding excess tension, with the increased awareness leading to enhanced relaxation.