Psychological aspects and psychotherapy of inflammatory bowel diseases and irritable bowel syndrome in children.
ABSTRACT Despite holistic approach to psychosomatic medicine, gastroenterological disorders (GI) tend to be categorized broadly into "functional" and "organic". Major GI illnesses are Inflammatory bowel diseases (IBD) include ulcerative colitis and Crohn's disease. Both are chronic, with remissions and relapses over the years while irritable bowel syndrome (IBS) is a common, often disabling functional gastrointestinal disorder.
A literature review was performed using the National Library of Medicine PubMed database, including all resources within the period 1991-2008, additional references were found through bibliography reviews of relevant articles.
Psychological problems: Higher scores of neuroticism, depression, inhibition, and emotional instability, are typical for many patients with chronic diseases and nonspecific for chronic gastroenterological disorders. Patients with chronic gastrointestinal disorders have impaired health-related quality. Psychological treatments: There have been few adequate psychological treatment trials in IBD. These achieved lower demands for health care rather than a reduction of anxiety or depression. Psychotherapy with chronic gastrointestinal disorders could lead to improve the course of the disease, changing psychological factors such as depression and dysfunctional coping and improving the patient's quality of life.
There seem to be "risk patients" in whom psychosocial components have a bigger influence on the course of disease than in other patients; and those would probably benefit from psychotherapeutic treatment. Psychological treatments help patients manage the psychological distress which worsens bowel symptoms and quality of life.
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ABSTRACT: Psychological interventions can be effective treatments for patients with medical illnesses such as inflammatory bowel disease (IBD). However, there are barriers to their widespread implementation such as lack of therapists, high costs, stigma, and poor accessibility in remote areas. Computerised psychological interventions can overcome these barriers. The aim of this study was to measure and compare the preferences of IBD patients for computerised versus face-to-face psychological interventions. One hundred and two IBD patients were given a support willingness questionnaire which measured their willingness and confidence to participate in computerised and face-to-face psychological interventions as well as the number of sessions they would be willing to participate in. IBD patients were more likely to want to take part in a computer based than face-to-face intervention (45.5% versus 16.8%, p=0.045). Furthermore, IBD patients were willing to participate in more sessions of computerised than face-to-face intervention median (5 vs. 3.5, Z=3.93, p<0.001). Younger females had a significantly higher acceptability of a computerised intervention than older females (χ(2)(1)=6.77, p=0.009) but the same was not found for males. Duration of disease was not associated with willingness to participate in an intervention. IBD patients appear more willing to participate in a computerised than face-to face psychological intervention. Future studies should attempt to study the effectiveness of computerised psychological interventions in IBD.Journal of Crohn s and Colitis 12/2013; · 3.39 Impact Factor
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ABSTRACT: Psychological factors such as personality traits may affect the adjustment capacity and Quality of Life (QOL) in Ulcerative Colitis (UC) patients. Type D personality has some similarities with general personality traits of UC patients. The aims of this study were to compare NEO personality profile and type D personality between healthy normal group and UC patients; and to determine the possible relationship between type D personality and QOL in UC patients. The sample of study comprised of 58 UC patients and 59 healthy control subjects (from their family members). All participants were requested to fill out NEO-FFI, Type D personality (Ds14) Scale and WHO-Quality of Life Questionnaire. The findings indicated that UC patients scored higher in neuroticism (P<0/01); lower in extraversion (P<0/01) and openness (P<0/05) than healthy controls but their differentiation were not significant in agreeableness and conscientiousness. The findings showed that 59% of UC patients and 33% of the control subjects had type D personality; and the differences in frequency of type D between the two groups were significant (P<0/05). The mean QOL scores of type D personality in UC patients was significantly lower than patients without type D personality (F= 7/55, P<0/01). Type D personality could better predict QOL of UC patients than NEO dimensions. Differences were observed between UC patients and their healthy family members, in terms of personality factors. Type D personality may be regarded as an important factor that may bring about some adverse effects in QOL among UC patients.Journal of research in medical sciences 10/2012; 17(10):898-904. · 0.68 Impact Factor
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ABSTRACT: Ulcerative colitis and Crohn's disease, commonly known as inflammatory bowel disease (IBD), draw attention from specialists of various disorders, including gastroenterology, psychiatry, and radiology. The involvement of a cortical influence in the brain-gut axis as well as the interaction of the hypothalamic-pituitary-adrenal axis and the peripheral nervous system provide an initial explanation of the psychological symptoms associated with IBD. The involvement of structures the limbic system, such as the anterior cingulate cortex, the prefrontal cortex, and the amygdala, paves the way for the discovery of the mechanisms underlying depression depression, anxiety, alexithymia, personality traits, and other psychological impairments following the onset of IBD. Psychiatric therapy in IBD patients is almost as important as the gastroenterological approach and consists of pharmacological treatment and psychotherapy. Neither of the available psychiatric treatment methods is considered the golden standard because both methods have side effects, and psychotropic medication can provoke the worsening of IBD symptoms. Thus, both approaches must be applied with awareness of the possibility of side effects. We suggest that psychiatrists and gastroenterologists work together to reach a consensus on IBD therapy to ensure success and to reduce side effects and relapse to the lowest possible rates.World Journal of Gastroenterology 04/2014; 20(13):3552-3563. · 2.55 Impact Factor
Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2010 Dec; 154(4):307–314.
© J. Prasko, D. Jelenova, V. Mihal
PSYCHOLOGICAL ASPECTS AND PSYCHOTHERAPY OF INFLAMMATORY
BOWEL DISEASES AND IRRITABLE BOWEL SYNDROME IN CHILDREN
Jan Praskoa, Daniela Jelenovaa*, Vladimir Mihalb
a Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, Czech
b Department of Paediatrics, Faculty Medicine and Dentistry, Palacky University and University Hospital Olomouc
Received: April 29, 2010; Accepted: July 21, 2010
Key words: Inflammatory bowel disease/Crohn’s disease/Ulcerative colitis/Irritable bowel syndrome/Quality of life/
Psychological problems/Cognitive behavioral therapy
Backround. Despite holistic approach to psychosomatic medicine, gastroenterological disorders (GI) tend to be
categorized broadly into “functional” and “organic”. Major GI illnesses are Inflammatory bowel diseases (IBD) include
ulcerative colitis and Crohn’s disease. Both are chronic, with remissions and relapses over the years while irritable
bowel syndrome (IBS) is a common, often disabling functional gastrointestinal disorder.
Methods. A literature review was performed using the National Library of Medicine PubMed database, including
all resources within the period 1991–2008, additional references were found through bibliography reviews of relevant
Results. Psychological problems: Higher scores of neuroticism, depression, inhibition, and emotional instability, are
typical for many patients with chronic diseases and nonspecific for chronic gastroenterological disorders. Patients with
chronic gastrointestinal disorders have impaired health-related quality. Psychological treatments: There have been few
adequate psychological treatment trials in IBD. These achieved lower demands for health care rather than a reduction
of anxiety or depression. Psychotherapy with chronic gastrointestinal disorders could lead to improve the course of
the disease, changing psychological factors such as depression and dysfunctional coping and improving the patient’s
quality of life.
Conclusions. There seem to be “risk patients” in whom psychosocial components have a bigger influence on
the course of disease than in other patients; and those would probably benefit from psychotherapeutic treatment.
Psychological treatments help patients manage the psychological distress which worsens bowel symptoms and quality
In the 21st century a bio-psycho-social model of dis-
ease is being appraised. This implies an appreciation
that genetic and early environmental factors may shape
an individual’s predisposition to disease, on which bio-
logical, psychological, and social variables may determine
the onset and subsequent course of a clinical disorder1.
Despite the holistic approach to psychosomatic medi-
cine, gastroenterological disorders tend to be categorized
broadly into “functional” and “organic”. This has some
advantages and many disadvantages. The distinction helps
facilitate research into the psychological factors that are
important in the etiology, presentation, and outcome of
the “functional” disorders. The research has been multi-
disciplinary and has led to a clear conceptualization of
the biopsychosocial model in gastroenterology2. This is
important because such disorders comprise approximately
half of all new patients seen by gastroenterologists. The
most prominent disadvantage of the functional and or-
ganic division is the apparent reinforcement of dualistic
thinking; for example peptic ulcer, previously regarded as
a psychosomatic condition, is now regarded as a purely
biological one, and psychosomatic aspects tend to be
ignored3. Another problem is some gastroenterologists
falsely equate functional with psychiatric, and may give
the impression complaints based on a demonstrable ab-
normality (e.g. by gastroscope visualization) are “real,”
whereas other complaints may be dismissed as they turn
out to be only functional and are the responsibility of a
psychiatrist or of the patients themselves. Since the mid-
1990s, a symptom-based classification of the functional
gastrointestinal disorders, the “Rome” criteria, has been
developed4. This is similar in concept to the DSM5, and
the use of these two schemas has greatly aided research
into the psychological aspects of functional gastrointes-
tinal disorders6. Such a classification has caused much
discussion among gastroenterologists who are accustomed
to making diagnoses on the basis of observable pathologi-
IBD include ulcerative colitis and Crohn’s disease.
Both diseases are chronic, with remissions and relapses
over the years. Symptoms include diarrhea, abdominal
cramps, pain, weight loss, and bleeding from intestines.
Both biological and psychological factors are independ-
ent determinants of impairment in patients IBD. IBS is a
J. Prasko, D. Jelenova, V. Mihal
common, frequently disabling functional gastrointestinal
disorder whose full range of symptoms (abdominal pain/
discomfort with altered bowel habits such as diarrhea
and/or constipation) is generally unresponsive to conven-
tional therapy. The few effective medications developed
specifically for IBS have either been withdrawn or severely
restricted in response to concerns about safety, creating
an urgent need to develop behavioral self management
treatments that could train patients to adopt effective
strategies for relieving symptoms unresponsive to avail-
able dietary or pharmacological agents.
A few years after Crohn’s disease was firstly describ-
ed7, speculations about psychosomatic etiology/influences
arose and these were discussed in the same way as ul-
cerative colitis8. As a result, researchers tried to identify
typical personality traits, specific conflict constellations
and/or psychiatric abnormalities in the case of IBDs but
these failed in consistency and specificity.
STRESS AND INFLAMMATORY BOWEL
Psychosomatic research hypothesized some psycho-
social factors could help trigger relapses. An increased
stress appears to facilitate disease reactivation. IBDs can
be affected by stress9,10. Stress modulates colonic motility11
and it influences the endocrine and immune system which
are mediators of the inflammatory process. The disease
activity in IBDs might be affected by stress-related factors
(vasoactive intestinal protein, tumor necrosis factor α)12.
Elevated stress levels or life events increased the relapse
risk in patients with ulcerative colitis13. IBS and IBDs
have significantly greater stress burdens than controls10
and higher levels of psychiatric distress, alexithymia and
somatosensory amplification14. Unlike short-term stress,
the perception of chronic stress appears to increase the
risk of exacerbation of ulcerative colitis13.
Active IBD is significantly related to impaired psycho-
logical functioning across a range of domains, whereas
inactive disease is not15. IBDs in remission had similar
psychological well-being to the non-inflammatory bowel
disease community sample. In Crohn´s disease patients,
well-being was comparable regardless of whether remis-
sion was surgically or medically induced16.
In the Canadian Community Health Survey (sam-
ple size of 132,947 Canadians) the IBDs (4,441 partici-
pants) were more likely to experience fair or poor general
health17. IBS patients reported higher levels of stress and
poorer mental health than IBDs. When IBS or IBD coex-
isted with another chronic condition, active participation
at home and at work was significantly more likely to be
IBS is also associated with several other conditions,
notably other bowel disorders, chronic fatigue syndrome,
and fibromyalgia18,19. The presence of untreated psychiat-
ric disorder predicts a poor outcome20.
INFLAMMATORY BOWEL DISEASES
AND QUALITY OF LIFE
Physical complaints as well as mental problems can
adversely affect a patient’s quality of life (QOL), as proved
in studies of patients with ulcerative colitis and Crohn’s
disease21,22. The number of patients with chronic func-
tional gastrointestinal disorders is increasing and con-
sequently the prevalence of psychiatric disorders. It is
widely recognized that people with IBD have impaired
health-related QOL20,23, but recent studies emphasized
concurrent anxiety and depressive and panic disorders
as major causes of this impairment24,25. In dyspepsia, psy-
chological distress is a better predictor of health-related
QOL than the severity of the dyspepsia26. In IBS factors
predicting health-related QOL are a combination of psy-
chiatric disorders (depressive, panic, or neurasthenia) or
symptoms (easily fatigued and low in energy) and severe
bowel symptoms, notably pain24.
Health-related QOL is impaired in IBS and dyspepsia
sufferers compared with healthy controls25,27. A recent
thorough study found how the degree of somatization me-
diates the negative effect of anxiety and depression on the
physical component score of the Medical Outcomes Scale
SF-36 (limitations on daily life imposed by the illness,
associated bodily pain, and impaired physical function-
ing)25. The relation between impaired health-related QOL
and subjects with IBS and dyspepsia can be explained by
psychological factors. The depression reduction in the
patients undergoing psychological treatments was associ-
ated with improved health related QOL24.
In clinic studies, especially at tertiary care centers,
there has been found an association between sexual and
physical abuse and functional gastrointestinal disorders,
but findings are not consistent28,29. A high rate of reported
childhood abuse is not unique to patients with functional
gastrointestinal disorders because similar high rates are
also reported by patients with other chronic or recurrent
painful functional conditions, such as pelvic pain, head-
aches, and fibromyalgia30,31. Since a history of abusive
experiences is closely related to poor health outcomes
(severe abdominal pain, marked impairment of function-
ing, and frequent visits to the doctor), there might be an
association with concurrent psychiatric disorder rather
than with history of abuse23.
IBD RELATED PSYCHOLOGICAL AND
There are high levels of psychiatric disorders across
diagnostic groups such as IBS, functional dyspepsia, func-
tional abdominal pain, and noncardiac chest pain32,33.
Anxiety is more prominent in first-time attenders with
IBS, but depression seems to be more prominent in
those with chronic symptoms and a long period without
remission34,35. The group of patients with gastrointesti-
nal symptoms as a part of their panic disorder, may be
an atypical group of functional gastrointestinal disorder
Psychological aspects and psychotherapy of inflammatory bowel diseases and irritable bowel syndrome in children
patients36. IBDs have a higher prevalence of anxiety and
depressive disorders than the general population, but a
lower prevalence of these disorders than patients with
functional bowel disorder5. The rate (21 – 35%) is similar
to the one found in other patients with chronic physical
illness37. Depressive disorder appears to be more common
in older patients and in those with a previous history of
In a cross-sectional clinic-based study included pa-
tients with recent onset of both peptic ulcer and IBD39
only 16% had define psychiatric disorders but a further
32% had subthreshold psychiatric disorders. A recent
onset of nonspecific symptoms of tension, worry, and ir-
ritability together with mild mood disorders was common
in these patients with recent onset IBD or peptic ulcer.
Two prospective clinical studies of patients with IBD
appear to produce conflicting results. During a 6-month
follow-up period, one study found a strong association
between change in disease activity and anxiety level and a
weaker association with depressive symptoms40. Changes
in disease activity seemed to lead to changes in anxiety
and depression. Beck Depression Inventory scores at base-
line predicted number and timing of relapses during an
18-month follow-up period41.
The presence of additional gastrointestinal symptoms
(defecation, bloating, altered bowel habit) is associated
with the greatest impairment of health-related QOL of all
patients with IBD42. Thus, the relationship between psy-
chiatric disorders and IBD is unclear. Some investigators
suggested a possible vulnerability of certain patients with
IBD to develop a psychiatric disorder due to experiences
that are independent of the disease process (e.g., child-
hood victimization and abuse) (ref. 43).
Many authors report psychiatric disorder only in close
relationship with increased disease activity, suggesting
that the former may be a consequence of disease activ-
ity44. A population-based linkage study identified contacts
with psychiatric services for 5 years before and 5 years
after the initial diagnosis of IBD in a total population
of more than 2 million people during 36 year period45.
Both depression and anxiety were more prevalent during
the year before diagnosis of ulcerative colitis compared
with the control population. There was no similar excess
of anxiety or depression before the diagnosis of Crohn’s
disease. However, both anxiety and depression were much
more common in the year immediately following diagno-
sis of Crohn’s disease and ulcerative colitis. The excess of
anxiety or depression during the year subsequent to the
diagnosis of IBD might be due to a reaction to the diagno-
sis of IBD, it could also result from the use of medication
(steroids). These are impressive results, especially because
this study included psychiatric patients only; though many
people with anxiety and depressive disorders would not
go to see a psychiatrist.
Important personality factors in ulcerative colitis were
neuroticism and locus of control, while in Crohn’s disease
there was social conformity/desirability together with neu-
roticism46. IBDs often have high level of dependence on
others and low levels of hostility and aggression47. Unlike
patients with a high level of dependence on others, people
with internal locus of control are generally less distressed
in stressful situations, which might be associated with
better disease-specific QOL48. In contrast, hostility and
other aggressive personality traits might have a negative
impact on the QOL. In adolescents with IBD, hostility is
related to higher level of subjective illness, and hostility is
generally related to poor health habits and interpersonal
TO PEOPLE WITH IBD
The suspected connection between psychological fac-
tors and relapses leads to the question whether psycho-
therapy would be beneficial to IBDs. There have been a
few adequate psychological treatment trials in IBD. Of
these, lower demands on health care were achieved rather
than a reduction of anxiety or depression. Psychotherapy
with IBDs could improve the course of the disease, reduce
psychological factors such as depression and dysfunction-
al coping and better the quality of life. Ten studies were
conducted on the effects of psychotherapeutic treatment
of patients with IBD50. In all studies, patients received
conservative therapy and, simultaneously, the psychother-
apy was used as a supplementary treatment. The studies
presented two main approaches of psychotherapy:
1. Psychodynamic therapy (including psychoanalysis and
2. Behavioral therapy (predominantly stress management
training). Psychodynamic therapy addresses more un-
derlying problems and conflicts, and the behavioral
therapy addresses more specific problematic cogni-
tions and dysfunctional behavior.
STUDIES INVOLVING PSYCHODYNAMIC
The first study regarding the effectiveness of psycho-
therapy for ulcerative colitis was conducted 50 years ago51,
but unfortunately, it was methodologically poor-quality.
The effects of supportive psychotherapy on the course
of the disease and coping skills in patients with Crohn’s
disease were investigated in 1987 (ref.52). The scores for
depression and anxiety decreased significantly during the
13 months while the study was being conducted. There
were no differences in regard to most of the somatic data.
The effect of psychodynamic psychotherapy on
patients with Crohn’s disease was investigated in
a randomized, multicenter study53. The psychotherapeutic
intervention consisted of psychodynamic psychotherapy
(26 sessions) and autogenic training (17 sessions). After
2 years, a relapse has not been experienced by 23% of
the control group and 30% of the therapy group. 29% of
the control group and 17% of the therapy group had to
undergo surgery. The therapy group had better somatic
data than the control group but not significantly so. After
1 year, the scores for depression, anxiety, quality of life,
and psychological symptoms did not differ significantly,
J. Prasko, D. Jelenova, V. Mihal
but mostly were within the normal range. In another
study, the scores for maladaptive coping decreased sig-
nificantly over the course of treatment in patients with
IBD who underwent 20 weekly sessions of supportive-
expressive group psychotherapy covered emotion-evoking
issues and discussions about disease related topics (such
as self-image, stigma, and conflict with health care profes-
COGNITIVE BEHAVIORAL THERAPY
Cognitive behavioral therapy (CBT) is a time limited,
structured, problem focused, and prescriptive therapy
based on two central underlying assumptions:
1. Symptoms are acquired (learned) and reflect specific
skills deficits in domains of cognitive and behavioral
2. Teaching and rehearsing skills for modifying maladap-
tive behaviors and thinking patterns can remediate
these deficits which, in turn, relieve symptoms.
Specific technical components of CBT protocols
typically include: (a) information on stress and its rela-
tionship to IBS; (b) self monitoring of antecedent and
consequent events associated with IBS flare ups; (c)
problem solving strategies around stressors that aggravate
symptoms; (d) muscle relaxation exercises for cultivat-
ing lower physiological arousal and increased sense of
mastery over symptoms; (e) cognitive restructuring for
modifying faulty threat appraisals that underlie physiologi-
cal and emotional reactivity.
An overarching goal of CTB is to teach skills for pa-
tients to take proactive role in controlling symptoms,
cope with emotional unpleasantness, and improve qual-
ity of life. CBT has been found to be effective in hospital
patients with IBS, however recent trials have reported
equivocal results55,56. A number of clinical trials support
the efficacy of CBT when administered over multiple
(weekly) sessions by trained therapists in tertiary care
settings57,58 – the outcomes include improvement in key
gastrointestinal symptoms (pain, bowel dysfunction),
quality of life59, and psychological distress60. CBT has
practical limitations (high cost, shortage of adequately
trained therapists, long waiting lists, time requirements)
that hamper its clinical utility. As the “second generation”
of IBS treatments under development, it is increasingly
clear that efficacy demonstration is a necessary but not
sufficient condition of treatment viability for IBS treat-
Cognitive based models have been proposed in the eti-
ology and maintenance of IBS: these patients are hypothe-
sized to hold the faulty belief that they have an organic GI
abnormality. Based on this schema, hyperalgesia would be
a consequence of IBS61. Patients with IBS more selectively
recall words describing GI sensations than neutral words
compared to healthy controls62. A genetically predeter-
mined visceral hypersensitivity can lead to symptoms of
IBS. Patients become hypervigilant to GI sensations and
develop cognitive distortions, interpreting the sensations
as threatening. These threats increase anxiety, which in
a vicious cycle directly affects the gut, causing further
symptoms of IBS63. Both of the above hypotheses support
a cognitive behavioral theory of IBS. Psychotherapists
attempt to break the feedback loop described above by
addressing dysfunctional cognitions such as catastrophic
thinking and by decreasing overall anxiety. Due to CTB
treatment, less negative thoughts were associated with
greater amelioration of symptoms64. Unfortunately, stud-
ies of psychological treatment trials in patients with IBS
are of poor quality with small sample sizes, poor randomi-
zation or inadequate blinding19; or researchers use varying
definitions of IBS56. Nonetheless, several controlled trials
have reported CBT, or CBT-like treatment, to be effective
in patients with IBS.
No significant differences were found in a controlled
comparison of individual versus group CBT for patients
with IBS; at the end of treatment only 10% of the wait-
ing list of control patients had improved bowel symptoms
compared to 55% patients receiving individual treatment
and 64% of patients receiving group treatment65.
Individual CBT-like treatment
Individual CBT-like treatment in IBS patients was
found to be superior to a self-help support group or a wait
list control; both individual gastrointestinal symptoms and
a composite index of overall symptoms were reduced66.
The effectiveness of two stress management programs
for patients with Crohn’s disease was studied67. Fewer
complaints with fatigue, constipation, abdominal pain
and distension were expressed by patients from group “A”
(received 6 individual sessions of manualized stress man-
agement) and group “B” (received a self-directed stress
management program and relaxation training) over con-
trol group “C” (conventional medical treatment).
A special summer camp proved to be helpful for
children with IBD68. The 9–16 year old children had no
formal IBD educational classes but many informal con-
versations among the campers and between campers and
counselors about their illness. The campers participated
in leisure group activities such as swimming, basketball,
arts. The total scores for health related QOL improved,
and so did bowel symptoms scores, social functioning
scores, and treatment interventions scores.
Patients after a 2 hour patient-orientated self manage-
ment program had significantly fewer hospitalizations
than control group during 1 year follow-up69. However,
the scores for quality of life, anxiety, and depression were
not significantly different.
Patients with ulcerative colitis in remission par-
ticipated in 60 hour training program of “Mind-Body-
Therapy” including stress management training, exercise,
Mediterranean diet, behavioral techniques, and self-care
strategies70. Statistically significant changes were noted
only regarding the mental health scale and QOL. In con-
trast there were no differences concerning somatic data
such as disease activity, endocrine, and immune param-
Female patients with functional bowel disorders
(including IBS, functional abdominal pain, painful con-
Psychological aspects and psychotherapy of inflammatory bowel diseases and irritable bowel syndrome in children
stipation, and unspecified functional bowel disorders)
showed statistically significant benefits when treated
with CBT compared to patients treated with education
only55. Patients with comorbid depression did not appear
to benefit from CBT.
Group CBT-like treatment
Reduction of abdominal complaints was greater in
patients with IBS who received group CBT than those in
a waiting list71. Additionally, patients who received group
therapy developed a greater number of useful coping strat-
egies and less avoidant behavior. The results persisted at
2 years follow-up.
6 hours of stress management training focused on
planning techniques (time management, problem solv-
ing), communication skills, and relaxation (autogenic
training) improved the disease activity and stress index
12 sessions of group CBT consisted of psychoeduca-
tion about IBD, factors of stress creation, coping strate-
gies for disease-related and routine stress, and progressive
muscle relaxation training73. Even after 9 months of the
therapy, patients with IBD had lower scores of depression
and illness-related anxiety; in addition, female patients
had better ability to cope.
A 12 hour educational program involved general infor-
mation about anatomy, pathophysiology of IBD, therapy,
and discussions74. Higher knowledge scores and patient
satisfaction remained 8 weeks; no significant effect was
found in QOL or medication adherence.
Trials without psychotherapeutic effect
In contrast with the above findings, several trials found
no therapeutic effect of such interventions and in one
study, all patients with IBS showed significant improve-
ment in self-reported GI symptoms, regardless of treat-
ment type (CBT or relaxation training, or care as usual)56.
Outpatient behavioral therapy with IBD had similar
somatic symptoms and psychological variables to the
waiting list control group75. Most patients in the 12 hour
therapy group (including information about IBD, progres-
sive muscle relaxation, thermal biofeedback, and cognitive
coping strategies), however, found the therapy helpful in
giving them better ability to cope with the disease.
IBD patients with high anxiety scores participated in
an 8 session group training program dealing with somatic
and psychosocial factors of IBD and stress management76.
The patients were satisfied with the training, but 6 months
after the training, none of the psychological instruments
indicated a significant change.
Results of psychotherapy studies
The results of the psychotherapy studies can be sum-
marized as follows: only one study showed an (indirect)
influence of psychotherapy on the somatic course of the
illness as fewer rehospitalizations and operations 52. Most
other studies failed to show such an influence. The results
of the largest psychotherapy study were not statistically
significant53. Another studies illustrated the impact of a
stress management program on disease related symptoms
such as fatigue, diarrhea, constipation, and abdominal
pain67,72. Some studies showed that psychotherapy influ-
ences psychological factors such as depression, anxiety,
coping, and stress index52,72,73, but this could not be re-
peated in others53,74–76. Patients often believed they had
profited from the intervention53,67,72,74–76. The studies used
very different psychotherapeutic methods (individual
and group therapy, psychodynamic methods, behavior-
al therapy, relaxation therapy, and stress management
training), with more frequent use of stress management
training. Given the dearth of studies, it is not possible
to decide whether one therapy is superior to another.
Psychodynamic therapies and behavior therapy appear
to have had similar results.
Conclusion based on review of psychotherapy studies
• Psychotherapy does not affect the course of disease
itself but influences the outlook of the patients and
how they deal with their illness. Psychotherapy ap-
pears to have a positive impact on the patients’ de-
pression and anxiety and helps them cope with their
illness. Somatic effects were found only seldom and
inconsistently. In most of the studies, patients con-
sidered psychotherapeutic intervention as helpful in
coping with the illness.
• Psychotherapy seems to be ineffective in patients al-
ready in the subclinical range before the intervention,
when no further improvement is possible.
• The demand for psychotherapy varies significantly.
A questionnaire distinguish the demand for certain
types of psychological care for IBD patients (inten-
sive/professional psychotherapy, disease-oriented
counseling, and integrated psychosomatic care with
focus on the interaction of bio-psycho-social state of
the patient) (ref.77).
• There is no proof that one therapy is superior to anoth-
er. So far, there has not been a systematic comparison
between the various therapies.
• Patients with Crohn’s disease or ulcerative colitis
might respond differently to psychotherapy. Overall,
Crohn’s disease patients have more psychological com-
plaints42 which indicates a different starting position
or a mentally and physically more challenging illness.
Future studies should take this into consideration.
Overall, the existing results give no general indication
that patients with IBD should undergo psychotherapeutic
treatment. There appear to be “risk patients” in whom
psychosocial components have a bigger influence on the
course of disease than in other patients. These would
probably benefit from psychotherapeutic treatment. The
risk factors are: obvious psychopathology, especially de-
pressive symptoms, (chronic) mental stress, interaction
of stress and symptoms, dysfunctional coping techniques.
A gastroenterologist considering psychotherapy or psy-
chologist consultation for a IBD patient should ask fol-
J. Prasko, D. Jelenova, V. Mihal
1. Is the patient under a lot of stress that could possibly
2. How is the patient coping with the disease?
3. Does he or she express signs of depression?
4. Does the patient have a social support system?
Then the physician can decide, together with the pa-
tient and possibly a psychotherapist, about the most ap-
propriate type of intervention. These recommendations
are in concordance with the European evidence based
guideline on the management of Crohn’s disease, which
indicates that psychotherapy is useful in IBD patients with
psychological disorder, such as depression, anxiety, a re-
duced quality of life with psychological distress, a mala-
daptive coping with the illness78. Currently, it is not known
how or why CBT works, when it works, or how to opti-
mize it so that it renders more robust effect sizes; since
23 – 30% patients do not respond adequately to CBT55,79.
CBT needs to be extended beyond the small number of
academic facilities providing behavioral treatments into
routine practice settings where the overwhelming majority
of patients with IBS can be found. In short, developing
more simplified, powerful, accessible, and cost-effective
self management therapies depends on specifying theo-
retical change mechanisms and testing whether they are
responsible for therapeutic improvements80. Therapies
such as CBT derive their therapeutic value by reducing
comorbid psychological distress characteristic of more se-
vere IBS patients63. Psychological treatments help patients
manage the psychological distress which worsens bowel
symptoms and quality of life81. This view casts heightened
psychological distress as a driving influence of symptom
exacerbations and its reduction should be the primary
goal of psychological therapies. In other words, CBT pre-
sumably improves GI symptoms by reducing comorbid
BARRIERS TO THE TREATMENT AND
POSSIBLE EFFECTS OF INTERNET USAGE
A main barrier to CBT treatment is the acceptability
of the treatment by “nonpsychiatric” population. Patients
are likely to see a doctor’s recommendation of CBT as
a belief that symptoms are not real, but are instead im-
aginary82. Patients with “psychosomatic illnesses” often
reject any implication that psychological processes affect
their condition83. Considering the current stigma of men-
tal illness in our society today, this rejection is understand-
Web-based treatment may play an important role in
reducing this gap between demand and supply. In recent
years, Web-based approaches have been increasingly used
and Internet-delivered treatments showed to be an effec-
tive and inexpensive alternative to traditional treatments.
Web-based programs cover therapeutic approaches such
as behavioral activation, cognitive restructuring, mind-
fulness/acceptance exercises, and social skills training.
Interventions can be delivered programmatically and reli-
ably, greatly extending the numbers and types of people
who can be reached with services.
This model of irritable bowel syndrome requires both
factors to be involved, the biological (prior infection, an-
algesic consumption, and possible genetic predisposition)
and psychosocial (prior or recent severe stress, anxiety,
depression, and somatization), which represent the arche-
typal “psychosomatic” paradigm. Although the full range
of factors has yet to be worked out it is unlikely that a
wholly biological model will supersede this psychosomatic
Although the IBD has predominant physical factors,
psychological factors are recognized too, (anxiety and
depression after the diagnosis). As research methods
develop in the 21st century, the interaction between psy-
chological and biological variables will become clearer
and could lead to treatment methods adjustment, being
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