Functional gastrointestinal disorders (FGID) are conditions in which people complain of symptoms for which no organic cause can be found. They affect up to 20% of western populations (Sandler 1990, Drossman et al 1993) with recent evidence suggesting they are equally common in the Third World (Spiller 2005). Although FGID are frequently presented in primary care and account for approximately half of the gastroenterologists’ workload (Thompson 2006), they are considered challenging by many doctors. This is not surprising as FGID is characterized by multiple recurring physical symptoms in the absence of known structural or biochemical cause. Additionally, sufferers have a higher prevalence of emotional problems and traumatic life events than healthy subjects or patients with organic disease (Creed 1999, Douglas & Drossman 1999). Time restrictions, together with lack of training or motivation to elicit psychosocial concerns have caused frustration, misunderstanding and compromised doctor–patient relationships (Toner et al 1998). Diagnostic pathways have added to the problem. FGID were traditionally diagnosed by excluding organic pathology which resulted in multiple consultations, excessive investigations, over-prescribing and a disproportionate utilization of healthcare resources (Jones et al 2007). Describing functional disorders by what they are not rather than what they are, e.g. ‘we can’t find anything wrong with you!’ suggests that the doctor does not believe the patient when he/she complains of physical symptoms and impaired quality of life. The difficulty in establishing a positive diagnosis and poor response to conventional treatment serve to erode the patient’s confidence in the medical profession (Talley et al 1995).

Over the last three decades, this unsatisfactory situation has been addressed by the formulation and development of the Rome criteria (Thompson 2006). Specialist teams meet in Rome to develop and update positive diagnostic criteria and treatment recommendations for FGID. The latter can be reliably diagnosed using these criteria providing there are no ‘alarm’ features indicative of organic disease (Spiller 2005).

This chapter will focus on irritable bowel syndrome (IBS) and functional dyspepsia as they are the most commonly reported FGID (Box 13.1). However, at REAL Wellbeing (a charitable organization situated in Northern England), patients with functional dyspepsia and other functional GI disorders usually present with a diagnosis of IBS with reference to upper GI tract problems and predominant bowel habit (diarrhoea or constipation predominant). For the purpose of this chapter, it can be assumed that IBS is a blanket term for FGID with treatment adapted to individual need. The symptomatology of IBS will be described, followed by a brief explanation of the therapeutic content of dynamic psychotherapy, cognitive-behaviour therapy and gut-directed hypnotherapy. Selected research demonstrating the efficacy of these approaches is outlined together with suggested reasons for their effectiveness in IBS. The main focus of the chapter will be a national study which assessed the feasibility of the provision of group therapy in routine care using a standardized treatment protocol (Taylor et al 2004a). Congruent with most studies, the latter is reported from the quantitative perspective, so in order to establish which elements of the programme were the most effective and valued the greatest by participants, a post-intervention qualitative evaluation will be discussed. As treatment-seeking IBS patients are predominantly female, this study additionally allows the experiences of male sufferers to be expressed. The therapists’ views are also presented. The chapter will conclude with recommendations for education, training and development.

BOX 13.1 Classification of functional gastrointestinal and bowel disorders (excerpts from the Rome II criteria)

I Gastrointestinal disorders

A. Functional dyspepsia

B. Dysmotility-like dyspepsia

C. Unspecified (non-specific) dyspepsia

II Bowel disorders

A. Irritable bowel syndrome (IBS)

B. Functional abdominal bloating

C. Functional constipation

D. Functional diarrhoea

E. Unspecified functional bowel disorder

(Cited in Jones et al 2007.)

DEFINITION, SYMPTOMS AND TREATMENTS

IBS describes a collection of symptoms causing muscle spasm and irritation in the lower gastrointestinal tract. The three central symptoms of IBS are abdominal pain, bloating and disordered bowel habit (classical IBS). Atypical IBS refers to patients with just one or two of the central symptoms (Whorwell 1987). Many additional gastrointestinal (GI) symptoms are reported such as early satiety, nausea, vomiting, indigestion, heartburn, gastro-oesophageal reflux, anal pain and incomplete evacuation. Patients also report a wide range of non-gastrointestinal symptoms, including headaches, lethargy, musculoskeletal, gynaecological and urological problems. Standard medical intervention is targeted towards symptom reduction, including antispasmodic, diarrhoeal/laxative, acid suppressant, antidepressant medication, etc. Some patients respond to exclusion diets and others to probiotics. There is increasing evidence, however, suggesting the pathophysiology of IBS is multifactorial, with environmental issues, gender, visceral sensitivity, gut flora alterations and psychosocial stressors all playing a part. Symptoms are thought to be associated with altered 5-HT transmission and central processing of noxious stimuli (Jones et al 2007, Clark & DeLegge 2008). Treatment can only be effective if the complex relationship between these factors is acknowledged and addressed. Assessment and treatment, therefore, needs to integrate gut function with psychosocial issues (Levy et al 2006). Research into dynamic psychotherapy, CBT and hypnotherapy has provided ample evidence of efficacy in IBS.

DYNAMIC PSYCHOTHERAPY

Dynamic psychotherapy owes much to Freud’s identification of the unconscious mind and ego defence mechanisms such as repression. Rarely complete, repression manifests itself into psychological symptoms or psychosomatic disorder. Although modern, brief focussed methodology is used; today, the aim is the same, i.e. to facilitate self-understanding by means of therapeutic regression, enabling the patient to relinquish the defence and adopt more adaptive behaviours.

In an early randomized controlled trial, Guthrie et al (1991) found that patients who had received exploratory dynamic psychotherapy demonstrated a superior reduction in IBS symptoms, improved quality of life and reduction in healthcare costs compared with usual medical treatment. This finding was supported in a more recent study. Creed et al (2003) randomly assigned patients with severe IBS to one of three conditions, i.e. eight sessions of individual dynamic psychotherapy; 20 mg daily of antidepressant medication (paroxetine), or standard medical care. Three months after the intervention, outcome measures (SF-36) demonstrated superior improvements in the physical aspects of health-related quality of life in both psychotherapy and paroxetine conditions compared with treatment as usual. At the 12-month follow-up, psychotherapy only was associated with significantly reduced healthcare costs compared with standard medical care.

COGNITIVE BEHAVIOUR THERAPY

Cognitive behaviour therapy (CBT) describes clinical problems as disorders of thought and feelings. As behaviour is controlled by thought, the most effective way to change maladaptive behaviour is to change the underlying maladaptive thinking (Beck 1993). The relationships between thoughts, feelings, behaviours and GI symptoms are explored, using techniques of cognitive restructuring to produce lasting change. CBT combines techniques such as cognitive approaches with stress management, pain management, assertiveness training and relaxation to provide a multi-component intervention (Toner 2005).

Trials of cognitive therapy have shown symptomatic and psychological improvement, compared with a similar period of daily symptom monitoring (Greene & Blanchard 1994). Additionally, when combined with behavioural techniques, improvements of bowel symptoms were sustained for 4 years (Neff & Blanchard 1987). In a large-scale (n = 431) randomized trial, Drossman et al (2003) found CBT to be more effective than attention placebo control.

When CBT was applied to groups, clinical improvements were greater than either attention placebo or standard care controls (Toner et al 1998), waiting list controls (Payne & Blanchard 1995) or support and symptom monitoring (van Dulmen et al 1996).

GUT-DIRECTED HYPNOTHERAPY

Hypnotherapy is described elsewhere in this book (see Ch. 1). Gut-directed hypnotherapy (GDHT) however, is hypnosis targeted towards the gut. In a seminal study, Whorwell et al (1984) randomly assigned 30 patients with severe refractory IBS to seven sessions of GDHT; seven sessions of supportive discussion plus placebo medication; or waiting list controls. Hypnotherapy patients demonstrated the greatest improvement in pain, bloating and bowel habit, disturbance with no relapse after 3 months. Improvement was maintained at later follow-up sessions (Whorwell et al 1987).

Further research has demonstrated economic benefits for hypnotherapy. Patients who received GDHT visited their doctors less frequently. Some returned to or obtained work, thus reducing sickness benefit claims (Houghton et al 1996, Gonsalkorale et al 2003). Reduced medication following hypnotherapy has also been reported (Koutsomanis 1997, Gonsalkorale et al 2003).

Recent studies with medium- to long-term follow-up supports the success of GDHT in adults (Gonsalkorale et al 2002, 2003, Barabasz & Barabasz 2006), and in children (Vlieger et al 2007). Group hypnotherapy is equally effective (Harvey et al 1989, Taylor et al 2004a).

WHY ARE PSYCHOLOGICAL THERAPIES BENEFICIAL IN FGID?

There is increasing evidence that IBS is a multifactorial disorder of brain–gut function. Cognitive and emotional areas of the brain modify gut motility and visceral sensitivity (Toner 2005, Clark & DeLegge 2008). Psychological distress, past traumatic experiences and recent stressors affect mood and alter gut function (Levy et al 2006). Motility abnormalities, in turn, have psychological consequences, e.g. fear of going out due to rectal urgency, fear of intimacy due to pain, food phobia, embarrassment due to wind, fear of upsetting loved ones and so on. The poor response to pharmacology, therefore, is not surprising.

Dynamic psychotherapy helps the patient to identify the relationship between past and present traumas/stressors. Similarly, CBT explores the relationship between thoughts, feelings, behaviours and GI symptoms. By adjusting cognitions and behaviour, patients are enabled to develop more adaptive ways of managing IBS and improving quality of life (Toner 2005). Cognitive change has also been demonstrated in hypnotherapy by restructuring IBS-related thoughts (Gonsalkorale et al 2004). Additionally, hypnosis has adjusted the sensory and motor component of the gastrocolonic response in IBS (Simren et al 2004) and reduced rectal sensitivity and pain sensitivity (Lea et al 2003). Palsson et al (2002), however, found rectal pain thresholds, rectal smooth muscle tone and autonomic functioning, measured before and after treatment, were unaffected by hypnotherapy. These workers argue that the latter improves IBS symptoms by reducing emotional distress and somatization. The mechanism underpinning the clinical efficacy of hypnotherapy is not yet understood but there is evidence to indicate that gastrointestinal physiology can be altered by hypnosis (Whorwell et al 1992, Whorwell 2009), similar hypotheses exist for CBT (Lackner et al 2007).

Inevitably, methodological criticism has been directed towards this literature in terms of sample size, lack of parallel comparisons with other treatments, inadequate control conditions, failure to identify primary vs secondary outcome measures, etc. (Toner 2005, Whitehead 2006, Wilson et al 2006). Nevertheless, systematic reviews to assess the quality of research into psychological treatments have indicated that these interventions are effective in reducing IBS symptoms compared with pooled controls (Lackner et al 2004). Indeed, hypnotherapy for IBS has recently been included in the NICE (2008) guidelines for primary care commissioning.

WHAT ABOUT THE PATIENT?

IBS is much misunderstood in general society and often equated with psychological disorders. Patients, especially women, often feel their embarrassing problems are trivialized and may suffer in silence for many years (Toner et al 1998, Toner 2005), adding social isolation to their difficulties. Better results may be obtained by combining hypnotherapy with CBT (Kirsch et al 1995, Schoenberger 2000) and, because of the many and diverse problems associated with IBS, a combined treatment programme would offer enhanced management. It is important for therapists and patients to work in collaboration to elicit problems and empower changes that are meaningful to the patient. CBT techniques are usually borrowed from approaches to treat anxiety and depression rather than using specific treatment protocols for IBS. Furthermore, studies reported from the quantitative framework may restrict understanding of the individual patient’s and therapist’s interpretation of events. As a consequence, they limit the opportunity to refine interventions more specifically to meet the needs of an individual. Only one study reported the experiences of women who received CBT for IBS (Toner et al 1998). Although treatment-seeking patients are predominantly women, little is known about men’s experiences of treatment (Spiller 2005). Additionally, the results of randomized controlled trials are infrequently implemented in clinical practice (Haines & Jones 1994). Indeed, many doctors still insist on exhaustive medical investigations before they are prepared to diagnose IBS (Jones et al 2007). Moreover, facilities providing routine psychological care for this patient population are rare.

Some of these issues were addressed by ELIHC. Taylor et al (2004a) assessed the feasibility and short-term effectiveness of combined group CBT, hypnotherapy and education. The treatment protocol was standardized in a session-by-session manual and tested in a pilot group. Thereafter, 13 therapists delivered the programme to 23 different groups. A total of 158 patients (120 females, 38 males) completed group therapy.

The intervention consisted of 3-hourly sessions over a 16-week period. The initial 1.5 h consisted of CBT specific to IBS (Greene & Blanchard 1994). This focussed principally on the exploration of how certain cognitions and behaviours can influence IBS symptoms and associated psychosocial distress. Negative automatic thoughts were challenged and task-orientated assignments practised to induce greater coping abilities and the reduction of psychological and gastrointestinal symptoms. Following a short refreshment break, the educational element was delivered. This included the pathophysiology of IBS, the physiology of emotion, pain and hyperventilation, the nature of catastrophizing/perfectionistic thought, life-events, diet and the effects of multiple medical consultations and the influences of these factors on IBS. The final 20 min consisted of gut-directed hypnotherapy. After induction of hypnosis and ego-strengthening suggestions, patients were asked to place their hands on the abdomen and generate feelings of warmth and comfort in this area. This was followed by suggestions of symptom reduction and personal control over bowel function, reinforced by guided imagery (Whorwell et al 1984). Patients with upper gut problems used appropriate visualization to facilitate gastric emptying. Patients were encouraged to take responsibility for their disorder and to practise cognitive restructuring, learned coping skills and gut-directed hypnotherapy on a daily basis. Symptom and thought monitoring diaries were provided, together with standardized hypnotherapy tapes to facilitate the process. An action plan was completed at the 10th session for the purposes of self-assessment and future goal setting. During the course of the intervention, patients joined a guided walk with available public conveniences, in order to overcome incontinence phobias and encourage social interaction.

On completion of the intervention, participants completed a semi-structured qualitative questionnaire. Therapists provided detailed written reports for each session conducted. A thematic content analysis reflecting both patients’ and therapists’ perceptions were undertaken (Taylor et al 2004b).

Quantitative measures indicated a low attrition and high attendance rate, emphasizing the acceptance of the intervention. Outcome measures demonstrated highly significant improvements in both gastrointestinal and psychosocial symptoms. This suggests that combined psychotherapy and hypnotherapy is a feasible method for helping large numbers of patients with IBS, by providing them with advanced coping skills. Since this was a study of feasibility conducted in a lay setting, we did not include a control group. The results could therefore be susceptible to regression to the mean, though data on the natural history suggest that even with medical treatment, IBS is a chronic condition that in most patients can last for many years (Heaton & Thompson 1999).