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By Jeffrey Lackner, PsyD

Irritable bowel syndrome or IBS is the most common gastrointestinal disorder, yet pharmacologic treatment options remain unsatisfactory. The past 20 years has seen an explosion in research exploring the effectiveness of non-drug treatments for IBS. The most rigorously studied treatment is a specific psychological treatment called cognitive behavioral therapy or CBT that teaches practical skills (e.g., flexible problem solving, worry control, self-distancing through self-monitoring) for controlling gastrointestinal symptoms. Whereas most drug treatment are effective for specific GI symptoms (like constipation or diarrhea) and generally not much better than placebo pills, behavioral treatment are one of the few treatments found effective for the full range of GI symptoms for all IBS types (diarrhea predominant, constipation predominant).

…61 percent [of patients] reported symptom improvement two weeks after behavioral treatment ended compared to … 43 percent who received placebo.

In a multisite study of over 450 patients conducted at the University at Buffalo and Northwestern, we found that 61 percent reported symptom improvement two weeks after behavioral treatment ended compared to 55 percent in clinic-based treatment and 43 percent who received placebo. The treatment benefit also persisted for as long as 12 months after treatment ended. Positive findings were also found by British researchers using a different treatment protocol. The positive findings of these studies raise questions about why a non drug CBT works for physical symptoms.

…why does a a non drug CBT works for physical symptoms…

One explanation is that it works by teaching patients to reduce excessive autonomic arousal though relaxation strategies such as progressive muscle relaxation, controlled breathing, and hypnosis. The problem with this explanation is that despite the fact that it is a useful component of treatment, muscle relaxation as a standalone treatment has not proven an effective treatment for IBS. It likely works by increasing confidence in patients’ ability to self-manage symptoms and not by dampening physiological arousal. Another view is that psychological treatments work by dampening comorbid negative emotions such as anxiety and depression that characterize more severe IBS patients seen in treatment seeking settings like GI clinics. While intuitive, this explanation does not support data showing that while behavioral treatments effectively relieve GI symptoms they have little if any impact on accompanying distress symptoms. Some researchers suggest that the efficacy of psychological treatment is not due to its technical components like the skills patients learn but the quality of the relationship that forms between the patient and clinician. Relationships characterized by warmth and empathy are more likely to promote symptom relief. Again, while the therapeutic benefits of a ‘good bedside manner” is intuitive, there is no research that an empathic alliance drives IBS symptom relief. In fact, there is some evidence from research outside of IBS that a positive relationship is a consequence of symptom relief not a cause of symptom improvement. In other words, patients who “get better” regard their providers in a more positive light than those who do not improve by virtue of their symptoms getting better.

…CBT works by increasing patients’ confidence in their ability to self-manage IBS symptoms.

Two recent studies by our research group shed light on the active ingredients for why CBT works. In the first study published in the Journal of Consulting and Clinical Psychology we found that CBT works by increasing patients’ confidence in their ability to self-manage IBS symptoms. These beliefs — also called IBS self-efficacy — had a much strong and specific impact on CBT effect than patient beliefs about their symptoms like pain catastrophizing (“When I have pain I think it is terrible”) or fear of GI symptoms. We also found that the aspect of the relationship that had an impact on outcome was not the warmth or emotional bond that develops between the patient and his or her provider but whether they agreed on the tasks of treatment.

In a more recent study with Drs Mayer and Naliboff of UCLA, we were interested in cognitive flexibility as an active ingredient. Cognitive flexibility is a complex concept but basically refers to the ability to shift one’s mindset based on the situational demands one finds him/herself in. We reasoned that the multiple demands of a chronic illness like IBS –relationships, symptom fluctuations, changes in role functioning – call for a flexible mind set and CBT may work by increasing this flexibility. This may be a challenge for IBS who have a more rigid mindset. A rigid mind set is marked by a tendency to worry excessively and uncontrollably (“If only…”, “What if”) even when it is not productive, a control oriented approach to problem solving for problems that are not fixable and “core beliefs” beliefs like perfectionism. Sure enough, we found that cognitive flexibility increased from pre to past treatment in CBT but not in the placebo condition. Further, other forms of psychological flexibility did not change from the beginning to end of treatment in either the CBT or placebo condition. Understanding why treatments work is an important research goal that can tell us much about the disorders we treat and the treatment we use to treat them.

Our research suggests that IBS patients have a rigid mindset that likely disrupts brain gut interactions and generates often debilitating GI symptoms. The good news is this mind set is not fixed but can be unlearned – often quite quickly – by practical thinking skills and when this happens patients can achieve dramatic and enduring symptom relief unparalleled by other medical therapies.

Jeffrey Lackner, PsyD is Professor of Medicine at the Jacobs School of Medicine at the University of Buffalo where he is the Chief of the Division of Behavioral Medicine. He is a pioneer in the development and testing of Cognitive Behavioral Therapy (CBT) for disorders such as Irritable Bowel Syndrome (IBS).