An almost untouched area of health psychology
New book says many patients with irritable bowel syndrome could be helped by
psychological treatment, but few psychologists treat the disorder.
BY KATHRYN FOXHALL
Monitor staff
Irritable bowel syndrome (IBS) affects as many as 34 million American adults and costs almost $10 billion annually in medical care. While psychologists have much to offer in treating those people, mental health professionals "have been relatively slow to take on this disorder, especially in the United States," says psychologist Edward Blanchard, PhD, a researcher at the University at Albany, State University of New York.
To provide an avenue into work with those patients, Blanchard, who has studied the problem for almost two decades, has written "Irritable Bowel Syndrome: Psychosocial Assessment and Treatment," a 373-page book offering psychology practitioners extensive background on the problem, a discussion of what's known about its association with psychological distress and techniques for psychological treatments.
Researchers are uncertain as to what causes IBS, but it is a functional disorder of the lower gastrointestinal (GI) track: That is, patients with IBS have no structural abnormality that could cause the problem, "leaving only disordered bowel function to account for the symptoms."
The condition is probably related to the disordered movement of the colon, notes Blanchard. The major
symptoms are pain and altered bowel habits, including diarrhea or constipation, and possibly bloating, flatulence, belching, nausea and noticeable bowel sounds. A physician diagnoses the disorder when all other medical causes are ruled out.
Probably more than half of people with IBS "just live with it and never go to the doctor," says Blanchard. Of those who do see a physician, many are helped by education or dietary interventions or just "reassurance that they do not have a serious or life-threatening disease."
However, about 20 percent to 30 percent of patients who do see a physician are considered as having moderate to severe cases, and "can benefit a great deal from psychological assessment and good psychological treatment," says Blanchard.
A number of studies have found that IBS patients as a group have increased levels of psychological distress, he notes, and there is strong evidence that brief psychodynamic therapy and hypnotherapy help these patients. He also supports cognitive behavioral therapy, "as a third viable treatment alternative."
Is IBS caused by psychological distress? Although both conventional medical wisdom and most IBS patients think it is, Blanchard believes the reverse is also a possibility: that IBS patients have a higher level of stress because of the reoccurring bouts of the syndrome.
For mental health professionals, he indicates, the question is somewhat academic. One way or the other, "IBS patients who respond successfully to your psychological treatment are likely to feel twice blessed," he explains. "Not only are their GI symptoms reduced, but also their psychological state is likely to improve to a noticeable degree."
The book includes manuals on cognitive-behavioral treatment, cognitive therapy treatment and hypnotherapy treatment for IBS. But, Blanchard stresses, the manuals are not designed to teach those therapies; rather, they are designed to help practitioners who already have those skills apply them to IBS patients.
How should practitioners go about getting IBS patients into their practices? The first step is to consult with physicians who are likely seeing these patients, says Blanchard. His book includes ideas on approaching gastroenterologists and other physicians for IBS referrals, including a list of studies in prestigious medical journals on psychological treatment for IBS, which the practitioner can leave with the physician.
From his own experience, says Blanchard, a primary-care physician who has a good relationship with a psychologist will refer a patient with chronic IBS to that practitioner. That contrasts with gastroenterologists, who he finds, "don't really think about mental health referrals."
But when they think about the possibility, Blanchard finds, "gastroenterologists are pleased to refer their chronic IBS patients to psychologists, because they have little to offer in terms of consistently successful drug or surgical interventions, leaving both the patient and the physician frustrated."
And Blanchard is adamant about working closely with gastroenterologists or internists in assessing or treating IBS patients for another reason. A physician must exclude alternative diagnoses, because IBS-like symptoms can also be signs of very serious ailments, including inflammatory bowel disease, which often requires surgery and carries a high risk of cancer.
And the potential for reimbursement? Studies indicate that 50 percent to 90 percent of IBS patients have some Axis I diagnosis through which reimbursement can be sought, says Blanchard.
The book also provides practitioners with a patient questionnaire and discussions on taking an IBS history, reviews of IBS research, treatment manuals for different therapies and basic information for patients.
"Irritable Bowel Syndrome: Psychosocial Assessment and Treatment" is available for $34.95 for members, $39.95 list. To order a copy from APA Books, call (800) 364-2721.
"Gastroenterologists are pleased to refer their chronic IBS patients to psychologists, because they have little to offer in terms of consistently successful drug or surgical interventions, leaving both the patient and the physician frustrated."