INTEGRATED CARE IS BEST FOR IBS
The world leaders in IBS research have come together and published a review paper on behavioural and diet therapies in integrated care for the IBS patient.
The diet therapy part of the study reviews the low FODMAP diet as a treatment option in an integrated care model, supporting its use as an evidence based dietary therapy. This summary will not delve into the LFD specifically as this has been done before but rather on the psychotherapy side of integrated care and what options exist for the IBS patient.
“Integrated care is becoming the rule not the exception” in IBS treatment
IBS is a chronic condition of diverse pathogenesis.
It is well known that IBS patients experience reduced quality of life. This arises from a combination of symptoms generated in the gastrointestinal tract but also centrally in the form of fatigue, insomnia, depression and anxiety to mention just a few.
The traditional Western management model which is not collaborative fails to deliver results and patient dissatisfaction is high
There is however now compelling research to support a team based collaborative care model where patients have access to dietitian and /or a behavioural therapist along with the clinician.
Most convincing research was an unblinded randomized study (MANTRA study) of 188 patients where a gastroenterologist led integrated, multidisciplinary care model showed significally improved clinical outcomes (84% in integrated care vs 57% in standard care) quality of life, psychological health and cost effectiveness.
Lets look at some of the behavioural therapies that work:
Research and efficacy data is limited but growing in this field.
The Gastrointestinal behavioural therapies available can be divided into 2 primary pathways:
Ascending Gut – Brain Pathway
This treatment focusses on reinterpreting benign sensations from the gut that could trigger maladaptive cognitive or affective process in the brain.
Various techniques exist with varying levels of evidence (Table 1 of the study, refence at end).
IBS patients have been shown to have heightened sympathetic nervous system arousal, lower heart rate variability and higher levels of circulating stress hormones – these can all lead to mechanical and chemical stimulation of the colon and activation of the emotional motor system. Under real or perceived stress these patients perceive normal gut signals as painful. IBS patients also have a reduced thickness of the prefrontal cortex. This limits their ability to ignore gut sensations, they are more susceptible to visceral hypersensitivity, attentional bias and hypervigilance.
The following therapies in various ways are able to reverse or decrease the effect of these mechanisms:
- Gut directed hypnotherapy
- Gastrointestinal CBT
- Mindfullness based stress reduction programmes
- Psychodynamic interpersonal psychotherapy – best for early trauma , personality characteristics (neuroticism and alexithymia – (inability to recognize or describe one’s own emotions)).
Descending Brain-Gut Pathway
Here gastrointestinal symptoms occur in response to cognitive and affective triggers that arise from fear of symptoms, lack of acceptance of disease or external environment stressors.
IBS patients demonstrate a reduced activity in the limbic system which is the emotional response network of the brain. This can result in ineffective down regulation of the gut signals and amplification of abdominal pain. Abnormalities of the emotional response system is common in depression and anxiety which often occurs alongside IBS.
There could also be reduced grey matter density and an altered resting state. This has been associated with cognitive errors in “pain catastrophizing” and “negative prediction overestimation” in some chronic conditions similar to IBS.
Good research exists for:
- Gastrointestinal Cognitive Behavioural Therapy , which includes acceptance based therapies that aim to focus on living a meaningful balanced life in spite of chronic pain.
- Gut directed hypnotherapy where the focus is on normalising the pain threshold.
It is important to stress that the success of behavioural therapy in IBS rests on the clinicians relationship with their patient and their ability to select the right patients for the right treatment routes.
WHO WOULD RESPOND BETTER TO BEHAVIOURAL THERAPY
Please read the full paper by clicking on this link.