Cognitive Behavioral Treatment of Irritable Bowel Syndrome

Dennis Tirch and Cynthia L. Radnitz, Ph.D.

Fairleigh Dickinson University, Teaneck, NJ
Veterans Affairs Medical Center, Bronx, NY

Reprinted from:
Tirch, D. & Radnitz, C. L. (1997). Cognitive behavioral treatment of irritable bowel syndrome. The Clinical Psychologist, 50(1), 18-20.

I. Description of Treatment

Irritable Bowel Syndrome (IBS) is a functional disorder of the gastrointestinal (GI) tract for which no evidence of lesion or disease can be found. Prevalence estimates of IBS in the general population range from 7 to 17% (Drossman, Sandler, McKee, & Lovitz, 1982; Whitehead, Winget, Fedoravicius, Wooley, & Blackwell, 1982). Individuals with this condition experience a variety of symptoms including abdominal pain, extreme abdominal tenderness, diarrhea, constipation, bloating, belching, nausea, and flatulence. Thus far, pharmacological interventions have proven relatively interventions have proven relatively inefficient in treating this disorder (Blanchard & Malamood, 1996). However, a number of different psychological therapies have been demonstrated to be more effective in treating IBS than regular medical treatment or symptom monitoring (Blanchard, 1993). Compelling evidence of the effectiveness of cognitive behavioral therapy (CBT) has been found among reports of successful psychological interventions for IBS.

A number of studies have revealed that many patients seeking treatment for IBS may also suffer from an anxiety disorder or mood disorder (Blanchard, Scharff, Schwarz, Suls, & Barlow, 1990; Walker et al., 1990). Hence, it has been suggested that treatment methods which focus on the cognitive dimensions of an anxiety problem may address underlying processes which bring about the manifestation of physiological IBS symptoms (Blanchard, 1993; Greene & Blanchard, 1994).

The Albany Multicomponent Behavioral Therapy Program for IBS employs techniques drawn from a CBT perspective to address both the GI symptoms of IBS and the hypothesized anxiety and/or affective disturbances which may underlie the disorder (Blanchard, 1993). In this treatment protocol, a CBT regimen is conducted for twelve weeks, with sessions held twice weekly during the first eight weeks. Before beginning treatment, therapists instruct patients in how to monitor IBS symptoms using a diary form. Patients monitor GI symptoms during a pre-treatment assessment phase and throughout treatment in order to gauge improvement. During initial treatment sessions, therapists impart educational information about bowel functioning, answer questions about IBS, and reassure patients that their symptoms are not "all in their heads." This is intended to countermand the tendency for some IBS patients to identify with the sick role. At the same time, patients receive training in progressive muscle relaxation (Bernstein, & Borkovek, 1973) using an adaptation of the procedure described in Blanchard & Andrasik (1985). Later in the treatment regimen thermal biofeedback is conducted where patients are taught to warm their hands, a response which serves to dampen peripheral nervous system arousal. Both the relaxation and biofeedback are designed to provide patients with greater control of their physiological responses to stress. Home practice of these techniques is emphasized, and patients are provided with tools to conduct these procedures at home. An audiotape is used to assist in relaxation sessions, and a small thermometer is employed to facilitate the practice of thermal biofeedback.

In the course of the twelve week treatment, patients receive cognitive therapy using procedures described by Holroyd & Andrasik (1982) which were derived from work conducted by Meichenbaum (1977), Beck and Emery (1979) and Ellis (1962). Cognitive distortions and attributions which serve to cause or exacerbate the negative experience of stress, and subsequent GI symptoms, are addressed. Initially patients record stressful events and resulting cognitions and behavior in a diary. Gradually, they are taught to employ rational self-talk to disrupt maladaptive cognitive patterns. In the final step, they learn to identify core negative constructs underlying their automatic thoughts, and how these constructs are related to their IBS symptoms, in effect developing their own case formulation. In cases where patients report anxiety and/or depression, addressing cognitions may help alleviate these conditions, and in turn, lead to relief of IBS symptoms.

II. Summary of Studies Supporting Treatment Efficacy

In a review of studies conducted to date, Blanchard and Malamood (1996) found that CBT regimens had been empirically replicated and were equivalent or superior to routine medical care. Accordingly, in eight of twelve studies analyzed by Blanchard and Malamood (1996), CBT based IBS treatment methods were employed successfully.

A number of studies have empirically validated the efficacy of both the Albany Multicomponent Behavior Therapy Program and its constituent elements (Blanchard, Schwarz, & Neff, 1987; Blanchard, Greene, Scharff, & Schwarz-McMorris, 1993; Greene & Blanchard, 1995; Neff & Blanchard, 1987; Payne & Blanchard, 1995; see Blanchard, Schwarz, et al., 1992 for an exception). Studies of the cognitive component seem especially promising. In successive trials using two different therapists, cognitive therapy was shown to be superior to both symptom monitoring and self-help support (Greene & Blanchard, 1994; Payne & Blanchard, 1995). In this condition 75-80% of patients achieved at least a 50% reduction in composite symptom scores. Other studies of the Albany Multicomponent Behavior Therapy program have shown that results were maintained at two years follow-up (Blanchard, Schwarz, & Neff, 1987) and that comparable results can be obtained when treatment is administered in a small group format (Blanchard & Schwarz, 1987).

III. Clinical References

Blanchard, E. B. (1993). Irritable bowel syndrome. In R.J. Gatchel & El. B. Blanchard (Eds.). Psychophysiological Disorders (pp. 23-62) Washington, DC: American Psychological Association

IV. Resources for Training

Those interested in detailed information concerning training opportunities in the Albany Multicomponent Behavioral Treatment Program for IBS should contact

Dr. Edward B. Blanchard
Center for Stress and Anxiety Disorders
The University at Albany-SUNY
1535 Western Avenue
Albany, NY 12203

V. References

Beck, A. T., & Emery, G. (1979). Cognitive therapy of anxiety and phobic disorders. Philadelphia: Center for Cognitive Therapy.

Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxation training. Champaign, IL: Research Press.

Blanchard, E. B. & Andrasik, F. (1985). Management of chronic headache: A psychological approach. Elmsford, NY: Pergamon Press.

Blanchard, E. B., Greene, B., Scharff, L., & Schwarz-McMorris, S. P. (1993). Relaxation training as a treatment for irritable bowel syndrome. Biofeedback and Self-Regulation. 18, 125-132.

Blanchard, E. B., & Malamood, H. S. (1996). Psychological treatment of irritable bowel syndrome. Professional Psychology: Research and Practice, 27, 241-244.

Blanchard, E. B., Scharff, L., Payne, A., Schwarz, S. P., Suls, J., & Malamood, H.S., (1992). Prediction of outcome from cognitive-behavioral therapy of irritable bowel syndrome. Behaviour Research and Therapy, 30, 647-650.

Blanchard, E. B., Scharff, L., Schwarz, S. P., Suls, J. M., & Barlow, D. H. (1990). The role of anxiety and depression in the irritable bowel syndrome. Behaviour Research and Therapy, 28, 401-405.

Blanchard, E. B., & Schwarz, S. P. (1987). Adaptation of a multicomponent treatment program for irritable bowel syndrome to a small group format. Biofeedback and Self-Regulation, 12, 63-69.

Blanchard, E. B., Schwarz, S. P., & Neff, D. F. (1988). Two-year follow-up of behavioral treatment of irritable bowel syndrome. Behavior Therapy, 19, 67-73.

Blanchard, E. B., Schwarz, S. P., Taylor, A., Berreman, C., & Malamood, H. S., (1992). Two controlled evaluations of multicomponent psychological treatment of irritable bowel syndrome. Behaviour Research and Therapy, 30, 175-189.

Drossman, D. S., Sandler, R. S., McKee, D. C., & Lovitz, A. J. (1982). Bowel patterns among subjects not seeking health care: Use of a questionnaire to identify a population with bowel dysfunction. Gastroenterology, 83, 529-534.

Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.

Greene, B., & Blanchard, E. B., (1994). Cognitive therapy for irritable bowel syndrome. Journal of Consulting and Clinical Psychology, 62, 576-582.

Holroyd, K. A., & Andrasik, F. (1982). A cognitive-behavioral approach to recurrent tension and migraine headache. In P. E. Kendell (Ed.). Advances in cognitive-behavioral research and therapy (Vol. 1, pp. 275-320). San Diego, CA: Academic Press.

Meichenbaum, D. (1977). Cognitive behavior modification: An integrative approach. New York: Plenum.

Neff, D. F. & Blanchard, E. B. (1987). A multicomponent treatment for irritable bowel syndrome. Behavior Therapy, 18, 70-83.

Payne, A., & Blanchard, E. B. (1995). A controlled comparison of cognitive therapy and self-help support groups in the treatment of irritable bowel syndrome. Journal of Consulting and Clinical Psychology, 63, 779-786.

Walker, E. A., Roy-Byrne, P. P., & Katon, W. J. (1990). Irritable bowel syndrome and psychiatric illness. American Journal of Psychiatry, 147, 565-572.

Whitehead, W. E., Winget, C., Fedoravicius, A. S., Wooley, S., & Blackwell, B. (1982). Learned illness behavior in patients with irritable bowel syndrome and peptic ulcer. Digestive Diseases and Sciences, 27, 202-208.

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