Psychologist develops cognitive therapy book for IBS patients

Psychologist develops cognitive therapy book for IBS patients
Melissa Hunt

Irritable bowel syndrome, a condition affecting up to 10 percent of the population, often occurs alongside anxiety and depression. But most interventions for IBS focus on reducing gastrointestinal symptoms through medication or elimination diets rather than tackling psychological issues that may be a factor.

Melissa Hunt, an associate director of clinical training in the Department of Psychology at the University of Pennsylvania, now seeks to change that with her new self-help workbook, which uses cognitive behavioral therapy to treat patients with IBS.

According to Hunt's randomized, controlled clinical trial, recently published in Cognitive Therapy and Research, patients who followed the workbook show statistically and clinically significant decreases in symptom severity.

"We saw huge improvements in quality of life and that people were able to maintain their gains over time," Hunt says. "We believe this approach could be effective for a significant fraction of people who suffer from IBS."

Hunt, a trained cognitive behavioral therapist, became interested in the psychological underpinnings of GI problems while treating patients with anxiety and panic disorders.

"I started noticing that a lot of my patients presented with GI symptoms," Hunt says. "Then I discovered that many of these patients had also been diagnosed with IBS."

Patients who suffer from IBS often experience "visceral hypersensitivity," or acute awareness and anxiety about sensations in their gut.

"This leads them to catastrophize the pain, what it means about their health, what it means for them professionally and socially," says Hunt. "And catastrophizing causes patients to engage in a huge amount of avoidance behavior, avoidance of particular foods, social gatherings, long car rides, movie theaters. You can imagine how this impacts a person's quality of life."

Hunt's self-help workbook for IBS was inspired by an earlier successful trial in which she placed a modular treatment protocol online and gave therapeutic feedback to users via email. While Hunt was encouraged when she saw improvements in patients' symptoms and quality of life following this therapist-guided intervention, she also knew that there simply aren't enough cognitive behavioral therapists for all IBS sufferers to receive such attention.

"I realized what we really needed was a completely stand-alone self-help treatment," Hunt says. "If a substantial number of people with IBS can work through these exercises on their own, that would make treatment more accessible to millions."

To find out if this was the case, Hunt designed a workbook that covers psychoeducation about IBS, relaxation techniques and tailored specifically to IBS sufferers. Patients are taught to identify specific catastrophic beliefs and engage in behavioral experiments to test and overcome them.

For instance, an IBS patient may believe that getting up to use the bathroom during a movie will be extremely annoying to other movie patrons. To test this belief, the patient would be encouraged to go to a movie theater, sit in the back and observe how many patrons get up during the movie and how others react.

Hunt then set out to test the book's efficacy in a controlled clinical study. Hunt randomly allocated 60 volunteer patients to either the workbook group or a waitlist control group. All patients were evaluated at the outset of the experiment and six weeks following the start of intervention, at which point the waitlist group was crossed over to the treatment. Both groups were evaluated again three months after treatment.

Patients who completed the workbook reported statistically significant decreases in symptom severity and increased quality of life. These results were explained in part by decreased catastrophic thinking and visceral sensitivity.

"Overall, I was really pleased that the book seemed to 'speak' to people and that many people were able to work through the exercises and get a lot of benefit from them on their own," Hunt says. "The whole reason I wrote the book and then tested it is that I want effective, empirically supported treatment for IBS to be available to the many people who don't have access to a trained cognitive-behavioral therapist."

Although Hunt saw a fair amount of attrition over time, attrition rates in her study were comparable to other Internet-based, self-directed interventions.

"We think this means our results are more representative 'real world' users," Hunt says. "We wanted to know how successful this intervention is going to be for the general population who might be interested in it."

Hunt's book is unusual among self-help workbooks, very few of which have been tested through clinical trials. It's also a departure from most other self-help books for GI symptoms, which often encourage to avoid particular foods. Hunt's book strongly encourages graded exposure to feared foods and situations.

"Paradoxically, GI symptoms tend to get a lot better when people stop worrying about them and trying to avoid them," Hunt says. "We want people to start going out into the world again and living their lives, to stop avoiding situations they think will be terrible."


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