Skills over pills? A clinical gastroenterologist’s primer in cognitive behavioral therapy for irritable bowel syndrome

ABSTRACT

Introduction

Irritable bowel syndrome is a common, painful, and often disabling GI disorder for which there is no satisfactory medical or dietary treatment. The past 10 years have seen the development and validation of a number of psychological treatments of which CBT is arguably the most effective based on two recently conducted multiple site trials from two investigative teams in the UK and USA.

Areas covered

The purpose of this review is to describe the principles, processes, procedures, and empirical basis supporting CBT and distinguish it from other psychological treatments available to clinical GE whose patients suffer from refractory IBS.

Expert opinion

The efficacy of CBT in treating refractory IBS patients is well established but there is limited understanding of why it works and for whom it is most beneficial. Further, its availability is generally limited to tertiary care settings which may undermine its value proposition if improved self-management is not accompanied by other health-care efficiencies. Systematic efforts to increase both the efficiency of CBT and the way it is delivered (e.g. digital therapeutics, integration into primary care) is critical to optimizing CBT’s potential and reducing the public health burden IBS imposes.

KEYWORDS:

• IBS treatment
• chronic pain
• cognitive behavioral therapy
• psychotherapy
• digital therapeutics
• behavioral intervention
• FDA

Article highlights

• IBS is a complex GI disorder for which there are no satisfactory medical or dietary treatments. Psychological treatments particularly cognitive behavioral therapy is a class of treatment with the strongest empirical support in relieving GI symptoms.

• The purpose of CBT is to teach cognitive (different ways of thinking) and behavioral (different ways of responding) to stimuli that trigger GI symptoms via dysregulation in neuroenteric axis.

• CBT has been found effective if delivered face to face, telephonically, web-based, or in a minimal therapist contact. Unlike medications, treatment gains persist after treatment ends.

• Low-intensity CBT has a relatively low cost making it both more affordable and more disseminable than one-to-one clinic-based psychological treatments that are lengthy and resource intensive

• The active ingredient of CBT is unknown although some combination of cognitive change in how patients process information about threat cues and non-specific factors (quality of relationship, expectancy of improvement) seem important.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One reviewer would like to disclose that they are involved with the ACTIB trial and they are a beneficiary of a license agreement for a digital product used in that trial. The other peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.