I offer an approach to these patients that 1) emphasizes a diagnostic evaluation that uses positive symptom criteria and that is limited to avoid unnecessary studies; 2) provides key questions that help the physician understand the psychosocial contributions to the illness; 3) optimizes patient and physician satisfaction and adherence to treatment; and 4) provides information about psychological referral and treatment. These observations and recommendations add to existing knowledge of the physiologic features of these disorders and their specific treatments [1]. Furthermore, the concepts and techniques presented here can be applied to patients with other chronic and painful disorders, such as fibromyalgia, headache, back pain, and genitourinary pain.

Diagnostic Evaluation

Because a functional gastrointestinal disorder is by definition "... a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities" [2-4], it cannot be diagnosed through endoscopic, radiologic, or laboratory studies. Furthermore, even though these disorders share certain physiologic characteristics (such as abnormal motility and visceral hypersensitivity) that are associated with symptom generation [5], the findings are not specific for diagnosis, and the clinician has limited ability to evaluate them in practice. Finally, given that these disorders occur frequently in the population [6] and in clinical practice [2] and that they are not life-threatening, a conservative diagnostic approach is recommended. Figure 1 shows the diagnostic strategy discussed below, which relies heavily on the clinical history, a limited diagnostic evaluation, and early symptomatic treatment that includes symptom monitoring and reassessment.

View larger version (23K): [in this window] [in a new window]   Figure 1. A diagnostic strategy for evaluation of patients with functional gastrointestinal disorders.

Symptom-Based Diagnosis

Recent efforts have led to the development of a symptom-based diagnostic classification system for the functional gastroenterologic disorders (known as the "Rome" criteria) that is similar to classification systems used in psychiatry [7] and rheumatology [8]. A positive diagnosis made using symptom criteria helps reduce the tendency to order studies to "rule out" other disease. Table 1 lists the functional gastrointestinal disorders recently proposed by the Rome multinational working committees of gastroenterologic investigators [1]. The diagnostic criteria for each disorder were established through review of the literature and group consensus [5, 9]. (Table 2 and Table 3) list the criteria for the irritable bowel syndrome and functional dyspepsia, two of the more common conditions. In all cases, diagnosis is made after an appropriate evaluation is done to exclude other medical disorders.

Identifying Symptom Subgroups

Once the diagnostic criteria are fulfilled, the physician may need to consider whether there are symptom subgroups that require different diagnostic and treatment approaches. For example, the irritable bowel syndrome may be diarrhea-predominant, constipation-predominant, or both. Certain diagnostic studies (such as biopsy of the small or large intestine to exclude small-bowel malabsorption or microscopic colonic inflammation) or treatments (such as loperamide) might be ordered when diarrhea is predominant but are not indicated when constipation is predominant. Similarly, as shown in Table 3, functional dyspepsia has been subclassified into "ulcer-like" and "dysmotility-like" dyspepsia. Although some controversy exists about whether these two subgroups are pathophysiologically distinct [26], physicians tend to differentially choose endoscopic evaluation and H₂-blocking agents for ulcer-like dyspepsia and to order a solid-phase gastric emptying study or a prokinetic agent (such as cisapride or metaclopramide) for dysmotility-like dyspepsia.

Other Clinical Factors

Several additional factors need to be considered when planning a diagnostic strategy: the duration and severity of symptoms and their changes over time (their "trajectory"), demographic features, the referral status of the patient, and cost. For example, a young patient visiting a family physician because of short-lived and relatively mild lower abdominal cramping and diarrhea is likely to receive a limited evaluation, if any, and to be followed expectantly. In comparison, an older patient referred to a gastroenterologist with similar but progressive symptoms is likely to receive a colonoscopy. Concurrent psychosocial difficulties will affect the ways in which symptoms are reported and the patient's ability to cope with symptoms, and in some cases these difficulties may be the primary basis for the symptoms (as in the somatization disorder). However, they do not protect the patient from other serious medical conditions. The clinician must appraise the relative contributions of psychosocial and medical factors when selecting the best diagnostic strategy.

Physical Examination

The physical examination serves primarily to exclude other diagnoses. However, the "laying on of hands" also provides a foundation for the physician's later reassurance of the patient.

Limited Diagnostic Screening

Unless the clinical data (for example, occult blood in the stool, significant weight loss, or abnormal physical findings) suggest the possibility of other disorders, the diagnostic studies ordered on the first visit should be limited. The choice depends on the nature and severity of symptoms and the other clinical factors enumerated above. Thus, the physician might order stool examination and sigmoidoscopy for colonic symptoms but might consider only a therapeutic trial for upper gastrointestinal symptoms. This approach is supported by studies of the irritable bowel syndrome [27-29] that indicate a missed diagnosis rate of less than 5% in patients who were followed for up to several years.

Initiation of Treatment and Reassessment

By the end of the first visit, the physician should consider initiating symptomatic treatment and should plan to reevaluate the clinical response in 3 to 6 weeks. This is the key to the conservative diagnostic approach: The physician is able to reevaluate the patient's clinical condition and the diagnostic strategy on the basis of information obtained at two or more points in time. The use of a symptom diary (see below) during this observation period can help by providing prospective information on the nature and progress of the symptoms and their associations with stressors or environmental factors.

Psychosocial Assessment: Key Clinical Questions

Twelve key questions can be asked during the first visit to help determine the biopsychosocial nature of the condition and to help plan possible psychological referral or treatment.

1. Is the Pain Acute or Chronic?

Chronic pain is more strongly influenced than acute pain by higher brain centers or enhanced visceral sensation, so it is less likely that tissue pathology will be found with chronic pain. Thus, although acute pain is more likely to be associated with a single specific cause related to tissue damage, chronic pain has multiple, behavioral contributions. Acute pain is associated with physiologic arousal (such as tachycardia and diaphoresis) and anxiety, whereas chronic pain is associated with no arousal; the patient may even seem withdrawn or depressed [30].

For acute pain, peripherally acting analgesics and narcotics work well, and treatment includes rest. Recovery is expected after treating or removing the nociceptive source. For chronic pain, peripherally acting analgesics are not often helpful, narcotics are usually contraindicated, and treatment frequently involves increased physical activity and behavioral or psychopharmacologic treatment. Because recovery is rare, patients must learn to cope. However, with refractory pain, "sick-role" behavior can also be seen, in which the patient makes unconscious efforts to maintain the illness state.

2. Is There a Pain History?

Is this the only episode of significant pain, or does the patient have a long-standing history of painful gastrointestinal or other symptoms? Patients with frequent symptom episodes and visits to physicians for problems such as "gastroenteritis," back pain, headache, and dysmenorrhea communicate a long-standing pattern of somatic sensitivity, pain behaviors, or both. This gives a poorer prognosis for recovery.

3. Is the Pain Associated with Altered Gut Physiology?

Patients with intermittent pain that is typically brought on by eating, stress, or menses; that is associated with change in bowel function; or that is relieved by defecation or vomiting have a functional gastrointestinal disorder (such as the irritable bowel syndrome, functional dyspepsia, or functional constipation) [4, 13]. In these patients, the pain is related to changes in gut physiology that respond to treatments directed at the gut (such as cisapride [31, 32] and anticholinergic agents e). Conversely, constant pain not associated with changes in gastrointestinal function (such as chronic functional abdominal pain [13]) is modulated by higher brain centers; thus, gut-acting agents are not helpful. Treatment involves behavioral methods, psychopharmacologic methods, or both.

4. What is the Patient's Understanding of the Illness?

All patients hold certain perceptions about their illnesses and have expectations for treatment: their "cognitive schema" or belief system [34, 35]. If their beliefs are realistic and consistent with physician expectations, a mutually acceptable treatment plan is likely. However, many patients referred to medical centers have unrealistic beliefs about cause and treatment and are not satisfied by negative findings or the physician's reassurance. For example, the patient's belief that "there must be a medical (that is, ‘organic’) explanation for this pain" leads to continued medical consultations, hypervigilance to bodily sensations, and increased anxiety and arousal when no "cause" is found. A perpetual state of anxiety, physiologic arousal, and sensitivity to pain ensues, which only confirms (from the patient's perspective) the evidence for a physical cause.

By trying to understand the patient's belief system (see below), the physician can provide more relevant information and develop a negotiated treatment plan. If this is not done, the patient will remain dissatisfied with the care and continue to seek new diagnostic tests and treatments. Questions to ask include the following: What do you think is causing your symptoms? What are your concerns or fears about your illness? What do you hope I will be able to do for you? [36].

5. Does the Patient Accept That Stress May Play a Contributing Role?

Perhaps because of childhood experiences relating to illness [37-39], some patients with gastrointestinal pain deny or minimize the role of psychological factors, even though the influence of these factors is evident to the physician. Consider a young child who wakes up on the day of a dreaded examination with the psychophysiologic effects of anxiety: tachycardia, abdominal pain, and diarrhea. If the parent keeps the child home from school to stay in bed and watch television, then relief from the stress of the examination is obtained through the reinforcement of illness behavior. Through repeated similar episodes, the child will inappropriately learn to communicate psychological distress and obtain symptom relief through physical complaints. But if the parent states, "You have a tummy ache; maybe you're upset about something ... . Let's talk about it," the underlying emotional distress is acknowledged and the verbal communication of these feelings is encouraged. Features that distinguish patients with the irritable bowel syndrome from those with irritable bowel who have not been to physicians are the former's tendency to deny or minimize the psychological effect of stressful life events [40]; inability to recognize or acknowledge existing mood disturbances, such as depression [41]; and high levels of social conformity (for example, what is socially accepted) [42]

6. Is There Abnormal Illness Behavior?

Is the pain reported with urgent demands that "... you must do something now"? Or does the patient accept some personal responsibility for treatment? The way in which symptoms are perceived, reported, and acted on is designated "illness behaviors" [43]. The diagnostic features of "abnormal" illness behavior [44] include 1) symptoms or disability disproportionate to detectable disease [for example, always rating the pain as "10" on a 0 to 10 scale of severity]; 2) a relentless search to validate the presence of disease; 3) placement of responsibility for health care with the physician; 4) a sense that one is entitled to be cared for by others; and 5) adoption of the "sick role" and efforts to avoid health-promoting behaviors. Abnormal illness behaviors require behavioral interventions by the physician or mental health professional to improve the clinical outcome.

7. What is the Family's Involvement?

For the most part, the family's involvement with the illness is associated with emotional support and is oriented toward recovery and health. However, in dysfunctional situations, intrafamilial stresses are not well managed, and undue attention paid to illness may serve to stabilize family stress [45]. Thus, when family tensions arise, the afflicted adult or child may focus on the illness to divert attention from the family distress, and this may affect later symptom reporting [46].

The physician may observe this condition when spouses or parents overindulge the patient, assume undue responsibility for the management of the condition ("enmeshment" or absent boundaries), or act as the "spokesperson" for the patient when communicating anger at the physician (for example, for not doing enough). When family difficulties are suspected, physicians should ask the family members how they perceive and respond to the patient's illness and should observe the family's behavior in the patient's presence. When healthy and supportive behaviors are present, the family members can be recruited to help the patient toward recovery. However, if family dysfunction is observed, counseling may be indicated. Referral can be presented as a way to help the family develop better coping strategies.

8. How Does the Disorder Affect Daily Function?

With chronic pain, diagnostic and treatment decisions are determined by the effects the pain has on the patient's health-related quality of life. Thus, more treatment efforts are needed if the pain is associated with decreased social activity or the inability to work than when the patient can maintain daily activities. The physician can simply ask about the effect of the illness on daily physical, psychological, and social activity.

9. What Is the Reason for the Visit or Referral?

With chronic pain, it is better to address the reasons for the current visit than to explore the original bases for the pain, which are often multiple and complex. Reasons for the visit may include increased concern about having a serious disease (perhaps as a result of a recent death in the family), recent stressors, worsening of functional status, a hidden agenda (for example, to obtain narcotics, disability, sick-role privileges, or the legitimization of illness to family or coworkers), exacerbation of psychiatric disturbance ("comorbidity"), or any combination of these.

A physician may initiate a referral because of concern that a diagnosis is being overlooked, because a colonoscopy or other procedure is needed to complete an evaluation, because additional treatment recommendations are needed, or because the patient needs to be reassured. The specialist should clarify the reason for the visit by questioning the patient (for example, "You've had these symptoms for a while ... . What led you to come to see me at this time?"), reviewing the chart, and communicating directly with the referring physician.

10. Is There a Concurrent Psychiatric Diagnosis?

Treatable psychiatric disorders such as anxiety, depression, somatization, alcoholism, and drug dependency can be diagnosed through psychological referral or through the use of standardized psychiatric symptom criteria as published in the Diagnostic and Statistical Manual of Mental Disorders [7].

11. Is There a History of Psychosocial Trauma?

Unresolved losses (such as the death of a parent or spouse) or personally meaningful operations (such as hysterectomy, ostomy, abortion, or stillbirth) may produce symptom exacerbations soon after or on the anniversaries of these events [47, 48]. Similarly, a history of physical or sexual abuse contributes to persistent pain, refractoriness to treatment, and increased referral rates [49, 50]. The reasons for this are many and may relate to the consequences of the trauma on increasing awareness of bodily sensations, the resultant development of personality disturbances, poor coping strategies, or physiologic effects on pain threshold [50, 51]. Patients do not usually volunteer this type of information [49], so physicians need to consider this possibility in high-risk patients: those with chronic, unexplained, or refractory symptoms. Obtaining this information furthers an understanding of the illness condition and may lead to improvement through psychological intervention.

12. What Are the Patient's Psychosocial Resources?

Psychosocial factors that promote health need to be identified. For example, the availability of social networks, such as family, church, recreational clubs, and community organizations help to buffer the adverse effects of stress on medical illness and are associated with improved outcome [52]. Patients with good social support have a better sense of control over their illnesses and report lower stress levels than do those without social support [53]. Coping, defined as "efforts, both action-oriented and intrapsychic, to manage (that is, master, tolerate, minimize) environmental and internal demands and conflicts, which tax or exceed a person's resources" [54], is another mediating psychosocial factor that helps to reduce stress and improve the medical condition.

An Approach to Patient Care

Effective management is based on a sound patient–physician relationship. With chronic functional gastrointestinal disorders, certain traditional approaches interfere with this relationship. Examples [55] include 1) "Don't worry, there's no serious pathology" [this invalidates the patient who knows it is serious]; 2) "I'd like to order a few tests to be sure there's no problem ... but I believe they'll be normal" [this raises doubts about the physician's confidence and competence]; 3) "Your problem is due to stress" [this statement leads to an adversarial situation if the patient holds beliefs to the contrary]; and 4) "The studies show that you have a functional problem" (patients will reject vague diagnoses made dismissively and may later claim that no information was given about the condition).

Establishing an Effective Patient-Physician Relationship

1. Acknowledge the Pain

By acknowledging the reality and distress associated with the pain, the physician provides empathy. Empathy involves showing an understanding of the patient's experience by sharing and communicating that experience while maintaining an objective and observant stance [56]. An empathic statement would be "I can see how difficult it has been for you to manage with your pain." However, the physician must feel empathy, because patients judge it more by nonverbal communications, such as posture, voice tone, and facial expressions, than by statements. Empathic behaviors improve patient satisfaction and adherence to treatment and reduce adversarial behaviors [56].

2. Don't Overreact

Some patients develop controlling or overdependent relationships, are demanding (they may want narcotics or disability, for example), or are adversarial. They may lead physicians to do unnecessary diagnostic studies or to overmedicate [57]. By realizing that these behaviors are part of the patient's condition, overresponses are avoided, and techniques can be implemented to reduce these behaviors [58]. It sometimes helps to "tune in" to inner thoughts and reactions ("What is it about this patient's behavior that makes me feel frustrated?") and use that information to maintain composure ("Don't just do something ... stand there" [59]).

3. Educate

Patient education involves 1) eliciting the patient's understanding of the condition; 2) addressing any unrealistic concerns the patient has; 3) explaining the nature of the symptoms in a way that is consistent with the patient's belief system; and 4) checking the patient's understanding of what was discussed.

It is important to legitimize the condition. I find it helpful to explain that functional gastrointestinal pain is a true disorder related to abnormal gut motility, sensation, or both. Symptoms can be modified by dietary or hormonal factors (including menses), activity, and stress. I explain how motility and visceral hyperalgesia contribute to pain symptoms. It helps to use a diagram Figure 2 to review how, through the gate-control theory [60, 61], the brain can modify this experience through descending central nervous system inhibitory pathways. I give examples of how intense concentration (for example, when playing sports) can "close the gate" and how psychological distress (such as hassles at work or losing a loved one) "opens the gate," increasing pain. If possible, I refer to similar experiences that the patient reported previously. Finally, I indicate that the best treatment involves attending to both the gut (for example, with antimotility agents or diet) and brain (perhaps by using behavioral techniques and pharmacologic agents to reduce stress or increase control over symptoms).

View larger version (63K): [in this window] [in a new window]   Figure 2. Descending inhibitory pathway for pain control. Diagram shows the inhibitory effect of the descending corticofugal pathway on pain control.

4. Reassure

All patients need to be reassured because they fear serious disease or surgery and because their conditions impose helplessness and dependency. To offer reassurance, the physician should first elicit the patient's worries and concerns and respond to them clearly and objectively. For example, to a patient with the irritable bowel syndrome who is concerned about cancer because of a family history, the physician might say "I can understand your concern about the possibility of cancer. However, the symptoms you have and the results of the studies are typical for the irritable bowel syndrome, and this does not turn into cancer. If new symptoms develop, I'll be available to address them with you. When you reach age 50, even if you don't have symptoms, we'll also begin a screening program to prevent the development of cancer." Reassurance given before the studies are done or in a perfunctory manner (for example, "Don't worry, everything's fine") undermines the patient's sense of the physician's commitment and competence.

Developing a Treatment Plan

5. Set Reasonable Treatment Goals

Unrealistic treatment goals, such as to cure, are not likely to be fulfilled [47, 62] and should be addressed with the patient. I state that, as with arthritis, it is possible to improve symptom control and daily function even without cure. This requires a shared plan of care between patient and physician (which helps diminish the belief that the physician should provide all the answers).

6. Help the Patient Take Responsibility: The Symptom Diary

Patients with chronic disorders need to take responsibility for their health care. I show my interest in this approach by encouraging patients to keep a symptom diary for several weeks [63]. The diary I use has five entry columns: 1) for the date and time when symptom exacerbation occurs; 2) for the description and severity [on a scale of 1 to 10] of the symptoms; 3) for any factors antecedent to or associated with the symptom exacerbation [such as diet, activity, menses, and stressful experiences or thoughts]; 4) for emotional responses [such as anger, sadness, or anxiety]; and 5) for thoughts and cognitions (such as "I can't deal with this any longer" or "This one wasn't so bad ... . I'll get over it"). I ask the patients to record their entries and to review and summarize their findings in writing at the end of the evaluation period.

When patients return for follow-up visits, I ask what they found and what could be done to modify the symptoms. Many patients are surprised that they can easily identify exacerbating factors (such as fat in the diet, excess caffeine, and psychological stressors) that are amenable to treatment. One patient, while attending a concert, noted that his abdominal pain worsened as he became panicky about having an accident in the theater. However, the pain abated when he realized that he knew exactly where the bathroom was and that he could get there in plenty of time. By noting that the symptoms could be predictably modified by his thoughts, he felt more in control and was eager to enter a cognitive-behavioral treatment program.

Some patients do not effectively assume this responsibility, and this will be evident from the diary. If the patient "forgot" to keep the diary, did not enter much information, or wrote concrete statements without addressing stressors or emotional responses, I know that a psychological treatment approach is unlikely to help because the patient won't "buy in" to this type of treatment. I accept the patient's inability or unwillingness (at the time) to take an active role, and I reduce efforts to intervene psychologically. I still offer hope that the patient may eventually obtain better control over the symptoms, and I focus more on pharmacologic treatments and continued medical support.

7. Base Treatment on the Severity and Nature of the Symptoms and the Degree of Disability

Patients with mild symptoms and little disability usually require reassurance, education, and dietary or lifestyle changes. Moderately severe symptoms require pharmacologic or behavioral treatments [15]. The predominant symptom helps to determine the best medication (loperamide for diarrhea, fiber for constipation, anticholinergic agents for pain). If pain is the primary problem, it helps to determine whether the pain occurs in relation to changes in gut function, which would indicate the need for a medication directed at the gut (such as an antimotility drug). If the pain is continuous, severe, and unrelated to changes in gut function, psychoactive medications for central analgesia (such as tricyclic antidepressants or serotonin-reuptake inhibitors) are indicated. Psychological treatments (see below) seem to work best with patients who have intermittent pain episodes of moderate severity (as with classic irritable bowel syndrome) and when patients can relate symptom exacerbations to psychological distress. They are less helpful for chronic, unremitting pain [15, 64, 65].

8. Negotiate Treatment

To obtain adherence, patient and physician must agree on the treatment. This is done after adequate evaluation and with the patient's full understanding of the condition. The physician should ask about the patient's personal experiences with, understanding of, and interest in various treatments and then provide choices (not directives) consistent with the patient's beliefs. Simply stated, if the patient doesn't believe that stress exacerbates symptoms, then stress reduction techniques will not work. However, if the treatment options can be related to the patient's symptom experience, the patient will be more accepting. For example, if the diary indicates that symptoms are clearly related to tension states or daily hassles at work, a relaxation method could be recommended. If the patient recognizes maladaptive or "catastrophizing" cognitions (for example, "I have no control over this ... . It will never end"), cognitive-behavioral treatment can help the patient feel more in control when symptoms occur.

It is important to help the patient understand the benefits of antidepressant medication. First, I ask about the patient's experiences with and concerns about this type of treatment. Patients who are reluctant to take this medication have predictable responses: It was tried, usually briefly, and did not work; it produced side effects and was quickly discontinued; the patient does not want "mind-altering" pills or medication that controls him or her; or the patient doesn't have a psychiatric problem (what would friends and family say?).

By eliciting these concerns, the physician can reframe the patient's understanding to increase interest in the treatment. Using the previously mentioned diagram Figure 2, I explain that antidepressants are central analgesics—not just drugs for psychiatric conditions—that increase the release of neurotransmitters that facilitate descending inhibitory pathways (see inset, Figure 2). They thereby "close the gate" at the spinal cord level and block pain transmission from the gut to the brain. I might also mention that these medications work in doses lower than those used for psychiatric disorders. However, full doses can be used if the symptoms have led to depressive symptoms that can further lower the pain threshold. I then indicate that it takes several weeks for these medications to work, so stopping therapy early (this may have been done previously because of side effects) has no benefit. I mention that most side effects diminish after a few days or can be reduced by temporarily lowering the dosage. I offer to be available to discuss the side effects if they occur, and I also suggest (because of concerns about "mind altering") that the medication be tried for a few weeks and then re-evaluated. The decision to continue therapy remains with the patient. In this way, the medication is presented to reduce pain, the physician provides support and guidance about dosage, and the patient feels in control of the treatment.

9. Know Your Limitations

Because the functional gastrointestinal disorders are so complex, treatment of them requires a multidisciplinary approach. The physician with a busy practice must set reasonable time limits and must recognize when management is best shared with mental health professionals. Patients who demand more time than required often have strong dependency needs, and these are better handled by scheduling brief, regular appointments of fixed duration. It is also important for the physician to maintain an ongoing relationship with the patient.

Referral and Psychological Treatments

Psychological Difficulties Requiring Referral

Referral for behavioral consultation and treatment might be needed for psychological difficulties such as 1) certain psychiatric diagnoses, such as major depression [66, 67] or panic disorder [68], that could respond to psychological or psychopharmacologic treatment; 2) a history of abuse that comes to light during consultation and that interferes with adjustment to the illness [49, 50, 69-71]; 3) impairment in health-related quality of life (such as daily function) associated with increased health care visits [15, 72]; 4) somatization [73], in which multiple symptoms lead to frequent consultations and ineffective treatments; and, rarely, 6) certain personality disorders (such as factitious, borderline, or multiple personality disorder) associated with interpersonal difficulties that interfere with the patient–physician relationship [58, 74-76].

Referral to a Psychologist or Psychiatrist

Patients may be reluctant to see a psychologist or psychiatrist because they lack knowledge of the benefits of referral or because they feel stigmatized and view the referral as evidence of a psychiatric rather than a physical problem. Also, if the referral is made without assurance of continued medical care, the patient may see the referral as a rejection by the medical physician ("The workup is negative, it must be nerves").

It helps if the physician clearly explains that the mental health professional is a member of a treatment team involved in the patient's overall management. For example, "I have a colleague, Dr. X, who sees many of my patients with these symptoms, and we find that her treatment can help us with your care." For patients who do not associate stressors with symptom exacerbation, the physician should indicate that psychological treatments also help to reduce the psychological distress engendered by the symptoms. Furthermore, the psychiatrist might also recommend a pharmacologic agent to help control pain. Continued medical care is essential and can consist of regular visits for ongoing treatment of symptoms, occasional visits for reassessment, or no scheduled visits but continued availability as the need arises.

Types of Psychological Treatments

Several types of recommended psychological treatments are indicated below. Although the results of the few treatment trials are compelling, methodologic limitations for some of the treatments require additional well-designed studies to confirm the findings. Furthermore, there are no comparative data to determine which treatments are superior or which are better for certain patient groups or bowel conditions. For the present, the physician should identify a mental health professional to help in the choice of treatment; this identification should be made on the basis of patient requirements, available resources, and the experience of the therapist. The physician's role is to help motivate the patient to work on the treatment as part of an overall plan of care.

1. Cognitive-Behavioral Treatment

Cognitive-behavioral treatment involves identifying maladaptive thoughts, perceptions, and behaviors and using this information to develop new ways to increase control of symptoms. The symptom diary can be used to show that abdominal sensations are triggered by stressors, lead to negative cognitions (such as fear of dying, fear of cancer, or feelings of hopelessness or lack of control), or both. The therapist then uses this information to develop exercises that "reframe" maladaptive thoughts. At least six controlled studies [77-82] have shown favorable results for cognitive or behavioral techniques, or both, in the treatment of the irritable bowel syndrome.

2. Stress Management

This is usually done in groups of five to eight persons for whom education and relaxation techniques are provided. After 4 months of follow-up, one 6-week group-treatment program was shown to be superior to treatment with a phenothiazine-tricyclic combination (Motival) in terms of reduction of anxiety, depression, pain, and bloating [83].

3. Dynamic (Interpersonal) Psychotherapy

This type of treatment proposes that psychological and physical distress is exacerbated by difficulties in interpersonal relationships [84-86]. These difficulties emerge during therapy (even, at times, with the therapist) and lead to feelings of anxiety that are understood and addressed during therapy. The psychological distress is often associated with physical symptoms, such as abdominal discomfort or diarrhea, and treatment of the psychological distress ameliorates physical symptoms. Thus, addressing the psychological issues helps the patient control the medical condition, which in turn helps to prevent recurrences of bowel symptoms. One 12-week trial using this form of treatment [86] showed that a group receiving psychotherapy had greater improvement in physical and psychological symptom scores than a supportive listening control group. Furthermore, similar benefit was later obtained in the control group, which was offered the same psychological treatment. Treatment effect was retained at 1 year of follow-up.

4. Hypnotherapy

Hypnotic induction first involves eye fixation and hand levitation techniques, which deepen the hypnotic state and increase the patient's openness to suggestion. After induction, the hypnotherapist uses progressive muscular relaxation and "gut-directed" hypnotherapy [87, 88]. For example, the patient is asked to place his or her hands on the painful part of the abdomen, to feel the warmth radiating from the hands into the abdomen, and to associate the warmth with the relief of pain and muscular spasm. Hypnosis was reported to be beneficial in patients with the irritable bowel syndrome; patients receiving hypnosis had greater reductions in bowel symptoms and greater improvement in well-being than controls or patients receiving psychotherapy [87]. This effect was maintained at 18 months [65]. Follow-up reports indicated an 85% overall success rate; poorer outcome was associated with age greater than 50 years and high levels of anxiety [65, 88]. Hypnosis was also shown to reduce colonic contractile activity [89] and to normalize thresholds for pain from distension of a rectal balloon [90].

5. Relaxation (Arousal Reduction) Training

Relaxation training attempts to help counteract the physiologic effects of stress or anxiety. Reduction in skeletal muscle tension decreases autonomic arousal, decreases subjective tension or anxiety, and may improve gut motility. Skin temperature and electrodermal biofeedback training attempt to reduce autonomic arousal directly, and autogenic training attempts to reduce smooth-muscle activity through imagery in a technique closely resembling hypnosis. Transcendental meditation and yoga aim to modify both skeletal muscle tension and autonomic arousal indirectly through cognitive focusing techniques. The most widely used arousal reduction techniques include progressive muscle relaxation training [91, 92]; biofeedback for striated muscle tension, skin temperature, or electrodermal activity [78]; autogenic training [93]; and transcendental or yoga meditation [94]. Although support exists for the effectiveness of all of these techniques for anxiety or stress reduction, only two controlled studies [95, 96] have evaluated progressive muscle relaxation training in the irritable bowel syndrome. One study [95] showed significantly fewer pain attacks and medical visits over 40 months for the active treatment group after a 6-month treatment program. The other [96] showed that half of the patients had at least a 50% reduction in gastrointestinal symptoms.

Conclusion

Top Conclusion Author & Article Info References

The care of patients with refractory functional gastrointestinal disorders is particularly challenging. Because symptoms can be severe and diagnosis is never assured, these patients are at risk for receiving unneeded and costly diagnostic studies and ineffective treatments that further erode the patient–physician relationship. Several points can be emphasized. First, the diagnostic strategy involves identifying positive symptom criteria, doing a limited screening evaluation, providing early symptomatic treatment, and monitoring the clinical course with reassessment in several weeks. Second, the psychosocial contributions to the illness and the decision for psychological referral can be evaluated through several questions during the first visit. Third, an effective patient–physician relationship can be developed by acknowledging the patient's pain, offering education and reassurance, giving the patient responsibility for the treatment, and negotiating realistic treatment goals. Fourth, psychological referral and treatment should be offered to help the patient obtain greater control over symptoms. Finally, any of several psychological treatments can be used; the choice will depend on patient requirements, available resources, and the experience of the therapist.