Why Consider Psychological Problems?
I have irritable bowel syndrome, a medical problem. Sure, I’ve had it a while, but why should I think about ‘psychological problems’? I’ve got enough to deal with.
Dealing with irritable bowel syndrome (IBS) takes a lot of effort and is demanding. Anyone with irritable bowel syndrome knows this and will admit that it can be emotionally stressful and draining. Did you know that about half of all people attending hospital clinics with irritable bowel syndrome have an additional significant psychological problem such as anxiety or depression?
Psychological problems are probably no more common in people with irritable bowel syndrome than in the general population. Nevertheless, most people with irritable bowel syndrome will readily admit that their irritable bowel syndrome symptoms are worse during times of psychological pressure. So there is a link between having irritable bowel syndrome and a person’s psychological state.
What sort of psychological symptoms are associated with irritable bowel syndrome?
Many different psychological symptoms are associated with irritable bowel syndrome. These are determined by the interaction between the individual’s personality and the irritable bowel syndrome. Some are common and occur in all shades of severity. These include anxiety, depression, loss of confidence, loneliness, secrecy and withdrawal, and acute embarrassment.
Remember that you’re not alone. Psychological disorders are very common in the general population. Up to 1 in 4 women and 1 in 8 men will suffer from a major depression at some time in their life. Many more will have less severe mood disorders. And anxiety problems are even more common. Having any of these feelings does not mean that you have that disorder – feeling depressed, for example, does not mean that you therefore have a formal depressive illness.
Can anxiety cause gastrointestinal symptoms?
Gastrointestinal symptoms are very common in anxiety. The most common symptom is a dry mouth. Nausea and vomiting also occur and may be the dominant feature. The large bowel can also be disturbed, with diarrhoea or constipation. These symptoms occur due to activation of the autonomic nervous system (the automatic, unconscious part of the nervous system that controls the internal organs). They are usually associated with other physical manifestations of anxiety such as a cold sweat, a tremor and palpitations.
Do you think I’m a hypochondriac?
It is normal to worry about illness from time to time. Some people worry more than others, and they then worry that they will be seen as a hypochondriac. A short-lasting preoccupation with the fear of having a disease is fairly common. It usually occurs following a major life event, or when a person has experience of death or disease in a family member or friend. It is said to occur in over 70% of medical students at some time in their training!
What do doctors mean by the term ‘hypochondriasis’?
In hypochondriasis, the fear of disease persists for months and years. People with this condition focus on thoughts about having a disease and constantly seek medical attention, but fail to be reassured by negative findings. Although fearful of disease, they rarely follow advice for a healthy lifestyle. They are more concerned with convincing the doctor that their illness is genuine. Unlike people with a serious illness, and most of those with irritable bowel syndrome, people with hypochondriasis utterly reject any suggestion of an emotional element to their illness.
Do you think I’m depressed?
Depression is so common, either as a primary problem or as a consequence of other problems, that it should always be considered. Most people know when they are depressed. They recognise that they are sad and acknowledge that this sadness is out of proportion to their situation. They may recognise irritability, frustration, worry, loss of libido, insomnia and fatigue as part of their depression. Gastro intestinal symptoms are also common and include loss of appetite, weight loss and an alteration in bowel habit. Sometimes these physical complaints come to predominate. People may not recognise them as part of a depression, or may attribute the depression to the physical symptoms. There is then a fruitless quest for a physical cause, which serves only to exacerbate the worry and frustration.
How can I tell if my abdominal symptoms are due to depression, or if I’m just frustrated by my continuing symptoms?
Depression is usually worse in the morning and lifts towards evening. It usually disturbs sleep with insomnia and early morning wakening, but it can occasionally cause excess sleep and sleepiness. By contrast, irritable bowel syndrome rarely disturbs sleep even though many irritable bowel syndrome patients complain of fatigue. It is not known whether fatigue in irritable bowel syndrome is part of the syndrome or part of an associated depression.
People who are depressed often lose or gain weight. Surprisingly, despite the physical symptoms, weight is usually stable in irritable bowel syndrome.
You should consider talking to your partner, friends or close colleagues. They may have noticed changes in your mood and behaviour that were not obvious to you. Often, you can’t be sure whether you are depressed, frustrated or both. Indeed, it may not really matter. If there is a significant depressive element to your illness, you should consider treatment. It is sometimes worth trying antidepressants even on just a suspicion of depression.
STRESS
What is stress?
The everyday experience of stress is easily identifiable and occurs when you have too much to do and too little time or money to do what is actually required. Essentially, the demands on you outstrip your internal supply of resources. irritable bowel syndrome can be worsened by stress and can contribute to a stressful situation. The manifestations of stress can therefore be noticed in physical, behavioural and cognitive (thought) terms.
What are the physical effects of stress?
In physical terms, stress involves the co-ordinated response of the nervous system and the endocrine (hormone-secreting) system to prepare the body for unusually extreme activity. This has been termed the ‘fight or flight’ response.
The heart rate speeds up to deliver more blood to the muscles, breathing becomes faster to obtain more oxygen, and blood is diverted away from the gut, the kidneys and the skin to favour the muscles. The nervous system slows the gut down. Hormones such as adrenaline and cortisol (a steroid) are released and serve to stimulate the muscles and arouse the brain. The body gears itself up to run, fight or think rather than digest and excrete. In some people, the start of the stress response leads to an urge to defecate or pass urine.
Transient physical, emotional or psychological stress is perfectly normal and healthy. But stress that goes on for a prolonged period of time is thought to result in problems. The gut may be deluged with messages to slow down or speed up. The normal regulatory systems may be unable to make the fine adjustments necessary for normal function, and the gut may overreact to minor stimuli with severe reactions.
What are the behavioural effects of stress that may show up in irritable bowel syndrome?
The behavioural response to stress and irritable bowel syndrome may, for example, involve spending a lot of time getting to know the location of toilets, or avoiding going out altogether. Some people eat less; some people drink more alcohol. These responses may themselves cause yet more stress, leading to a vicious circle of stress–behavioural change–more stress, which ultimately depletes the person’s resources until something has to give.
What is the cognitive response to stress in irritable bowel syndrome?
The word ‘cognitive’ refers to the thoughts, beliefs and attitudes that colour our emotions and behaviour. For example, needing to use the bathroom in the middle of an important meeting can be awkward for most people. How you think about this situation can make all the difference. You could, for example, see the trip to bathroom as a chance for a break, or a rethink, and come back to the meeting re-energised.
Unfortunately, many people with irritable bowel syndrome will be thinking negatively about themselves – ‘My bowel is letting me down again, Why can’t I hold on?’, for example. What is worse is going on to assume that the other people at the meeting will also interpret your bathroom break negatively. It can destroy your confidence and exacerbate your stress if you feel that other people will think there is something wrong with you, that you can’t handle the situation, that you’re a failure, and so on.
This is how the cognitive response to an irritable bowel syndrome problem increases a person’s misery. And it is one area in which psychological therapy can help. You may not be able to control your need to visit the bathroom, but you can learn to understand and control your cognitive response.
What’s the relationship between emotional feelings and the physical aspects of irritable bowel syndrome?
It’s essentially a vicious circle. The original cause of the irritable bowel syndrome may be a mixture of physical and psychological factors. In some people, emotional problems can be transformed in the mind into physical symptoms because that is the safest way of dealing with them. The irritable bowel syndrome then becomes a useful ‘final common pathway’ for both factors, physical and psychological.
But having irritable bowel syndrome is a stressful experience and can lead to very powerful feelings and other psychological problems. These experiences may be felt directly or may themselves be transformed into physical conditions and then become part of the irritable bowel syndrome. For example, the irritable bowel syndrome may be in part caused by depression, but it is also a depressing condition to have.
PSYCHOLOGICAL TREATMENT
The primary cause of irritable bowel syndrome may not be a psychological illness. But there is often an important psychological element that exacerbates and prolongs the problems and makes the symptoms more difficult to deal with. The treatment approaches to these psychological elements differ in terms of how far they call upon the individual to be engaged in the treatment and the psychological ‘depth’ that is potentially reached. Treatments that can be less demanding on the person include informal discussion with the family doctor and the use of medication. Those requiring more involvement are well described by cognitive behavioural therapy and psychoanalytic psychotherapy.
What do you mean by ‘informal psychological treatment’?
Informal psychological treatment’ occurs whenever you discuss your problems with someone. The process of putting the problems into words and expressing them to other people may give you a better sense of perspective on the situation and make you feel less burdened. Talking with your doctor will hopefully bring more authoritative reassurance, along with education and perhaps some useful ideas and possible other treatments. Many doctors will use some of the cognitive and behavioural techniques described below, without calling them this, as part of their normal consultation.
What aspects of a consultation with the doctor are psychologically helpful?
Allowing people to describe in detail what for them may be very embarrassing problems is the first part of a successful consultation. This is followed by the reassurance from someone who knows. Part of the reassurance involves ‘making a diagnosis’, giving the disease a name and so ‘legitimising’ the symptoms.
But what if the doctor can’t give a reassuring diagnosis?
It may not be possible at the first consultation for the doctor to be completely reassuring. For example, a test may be required to check for cancer. Some people will immediately think that there is a cancer there and will go on to imagine the very worst. In this situation, it can be useful for the doctor to be completely up front with the possible diagnosis rather than to offer bland reassurance that will not be believed. People may respond better to a simple statement of facts, for example, ‘Yes, we are going to perform a colonoscopy to check for cancer, but the chance of finding it is only about 1 in 10.’
Some people will insist on thinking the worst. For them, describing the worst-case scenario may help as what they would otherwise imagine is invariably worse. There are other people who really do not want to know. This can be a conscious or unconscious decision. It is a kind of pretending that there is nothing wrong; this is called ‘denial’. It can be a useful psychological protection mechanism, and most of the time it turns out that there was nothing at all to worry about. To my mind, ‘denial’ should be respected by the doctor as far as possible. Unfortunately, the current emphasis by the medical regulatory authorities and lawyers on fully ‘informed consent’ for procedures sometimes makes this difficult and can lead to unnecessary anxiety.
Can the doctor–patient consultation for irritable bowel syndrome go wrong?
Even the most experienced, sympathetic and knowledgeable doctor will have an unsuccessful consultation from time to time in which both parties will come away feeling unhappy. Discussions about diseases that have no clear cause or solution take considerably more time than those dealing with usually ‘simple’ problems such as stomach ulcers. Appointment systems cannot cater for this discrepancy, especially as on many occasions the diagnosis isn’t known when the appointment is booked.
People find it helpful to talk about their symptoms in detail and at length, but doctors often diagnose by pattern recognition and ‘know’ the diagnosis early on in the consultation. The doctor will want to ask specific questions to confirm or deny this prospective diagnosis, but the person with the condition may want to go on talking about symptoms that the doctor now considers irrelevant. The doctor’s priority is to look for serious disease; the individual may be confident that he or she has irritable bowel syndrome and just want advice on symptom management. The doctor may feel that the problem is at least partly psychological; the person may feel that his or her physical symptoms are not being taken seriously. So the two of them can continue to annoy each other for the whole consultation.
These are just a few of the potential problems that can occur when going to see the doctor about irritable bowel syndrome. If there were a really effective medical treatment for irritable bowel syndrome, people would find it easier to forgive their doctors. Unfortunately, this is not yet the case.
WHAT ABOUT MEDICATION?
Antidepressant treatment is discussed in the section on pain. It is one of the most useful treatments for irritable bowel syndrome. Pain may be reduced even if there is no depression, and the improvement may occur with low doses within just a few days.
FORMAL PSYCHOLOGICAL TREATMENT
Cognitive behavioural therapy (CBT)
What is cognitive behavioural treatment?
This is a treatment provided by psychologists using cognitive (thinking) and behavioural (action) techniques. The cognitive approach assumes that how we think and interpret our experiences affects our emotions and general well-being. Thoughts come before feelings. In other words, having negative thoughts makes us feel worse, whereas positive thoughts can make us better.
The behavioural approach puts the emphasis on what we actually do rather than what we think or feel. Put simply, if we behave normally, we will be normal. If we behave like an invalid, we will be an invalid.
What does a case using CBT ‘look like’?
Here’s one. Mrs A was a very busy woman. It wasn’t easy being a wife and mother as well as holding down a job. On top of all that, she also had irritable bowel syndrome. Mrs A had never really been sure when it had developed, but it had become another aspect of her already busy life that she had had to manage. Her husband was supportive as long as it didn’t interfere too much in their lives and as long as she kept the details about her irritable bowel syndrome down to a minimum.
One day, while rushing around the shops, Mrs A suffered an attack of irritable bowel syndrome. It was so bad and urgent that she very narrowly avoided having a major accident, but she found herself in the ladies toilet with soiled underwear and a faintly soiled skirt. She was really embarrassed and upset. She confided in her best friend and, after a heart-to-heart, her friend suggested that perhaps she should find some professional help.
Mrs A approached her family doctor, who referred her to the clinical psychology service in her area. Mrs A went on to meet Miss T for a consultation, and they agreed to an initial contract of 12 hourlong sessions.
Mrs A initially needed to keep a detailed diary of her daily activities, her bowel motions, her experience with her irritable bowel syndrome symptoms, what she thought when these occurred and how she felt during every day. In her meetings with Miss T, the two of them would discuss the diary entries to a level of detail that surprised Mrs A, but it was an aspect of the treatment that she quickly embraced.
This approach was very enlightening for Mrs A. She realised that she expected herself to pass a stool at the beginning of every day and that the stool had to clear her bowel entirely. If these two beliefs were not confirmed by events, Mrs A tended to think that she would then have an attack of irritable bowel syndrome, so she felt pressured, lacked confidence and restricted going out so that she only went to places where she had easy access to a toilet. So, in her morning routine, Mrs A sat on the toilet straining for long periods to try and prevent all this happening.
Miss T was able to help Mrs A challenge her own thoughts and try and find evidence to back them up. Encouraged, Mrs A found out that it was not necessary to empty her bowel every day. She learned that the feeling of an incomplete motion was very common in irritable bowel syndrome and did not signify an ongoing attack. She did not therefore need to strain on the toilet. More importantly, by examining and talking about the evidence in her diary, Mrs A was able to identify what pattern of bowel motion was normal for her and therefore begin to plan her working day and movements to accommodate this.
As the sessions progressed, Mrs A became increasingly able to notice how thoughts that were self-deprecating often flashed through her mind. She learnt how to identify these and then ask herself for evidence of whether or not these were correct. Her confidence and sense of control increased. As a result, whether an episode of irritable bowel syndrome occurred or not had less devastating consequences for her.
Interestingly, in the course of the 12 sessions, Miss T noted how Mrs A would often make huge, overwhelming conclusions based on very meagre evidence. On the first occasion, Mrs A seemed to conclude that she had cancer because she felt pain that kept coming back and did not seem to be helped by any treatment. As a result, she felt extremely anxious for long periods of time. Miss T helped Mrs A to evaluate the evidence that was available, such as the length of time she had felt the pain, which was in fact several years, the intermittent nature of the pain, which did not suggest a problem there all the time, the absence of other factors such as weight loss, and the length of time that Mrs A had thought she had had cancer. Given all this, if Mrs A did have cancer, she should have been dead by then.
This was all a bit of a revelation to Mrs A, who then understood that she had a tendency to come to the most catastrophic conclusions on the basis of very little evidence. She thought that this might have been linked to her experience of seeing her mother do the same, but there seemed too little time in the contract with Miss T to explore this further.
By the end of her sessions, Mrs A had learnt how to make careful observations of herself and her thoughts and to challenge those which she felt were automatic and negative. For example, in the morning she would catch herself thinking, ‘Oh dear, what a disappointing poo. I’m really going to have a bad day today’ – an automatic thought (see more on this later). Previously, this thought would not only have made her depressed and anxious, but might also even have curtailed her planned activities.
Now Mrs A had learned to question this thought by asking herself what actual evidence she had that the quality of her poo was the major determinant of the quality of her day, and to challenge this thought by purposely remembering good days that had occurred despite a ‘disappointing poo’. She gained much more control of her irritable bowel syndrome, and this appeared to lead to an overall increase in confidence in other aspects of her life. Mrs A occasionally had a bad day, but in that case she applied her method of assessing the evidence, and this undoubtedly helped her. Soon this method became automatic, and Mrs A could not imagine how she could have been so dominated by her irritable bowel syndrome before.
Put simply, what are the core ideas underlying a cognitive behavioural approach?
CBT had its origins in a treatment for depression, but it has quickly become established as a powerful, relatively short-term treatment method for a variety of problems. It assumes that behaviour is brought about by the individual’s thoughts, and that feelings are a result of these thoughts. There are different classes of thought and belief, from those which flash through the person’s mind without them noticing, to those which are so deep-rooted that they form the basis of a person’s basic identity. Most of these thoughts are outside awareness, and they develop as a result of life experience.
Psychological difficulties arise when the thoughts that flash through the mind are essentially negative and detrimental to the person themselves. These ‘negative automatic thoughts’ are never challenged but dictate an individual’s response and therefore mood. The negative automatic thoughts are in turn based on more deeply rooted assumptions that are themselves wrong. These are therefore termed ‘dysfunctional assumptions’.
CBT aims to teach individuals to notice and then challenge their own thoughts. Clients and therapists are seen as partners in this to work out exactly what is going on in the clients’ mind whenever they feel unwell and unhappy. Once identified, these thoughts need to be assessed on the basis of the available evidence and must then stand or fall. Becoming good at this is the key skill in CBT, and after a while it becomes possible to generalise across automatic thoughts and begin to identify the assumptions that these are based on.
Gradually, the individual is helped to regain control over his or her own mind in relation to the specific problem. It is not difficult therefore to understand that CBT usually works best with a well-defined difficulty rather than a sense of general malaise. Focusing on symptoms in this way may initially cause them to get worse, but they should improve as the therapy develops.
Overall, a course of CBT usually involves about 12 sessions, each lasting 50–90 minutes. Each session involves feedback from the previous session, a review of ‘homework’, identifying cognitive and behavioural factors that are maintaining the irritable bowel syndrome, devising strategies to cope with and minimise those factors, setting goals and agreeing on the next homework.
Psychodynamic psychotherapy/psychoanalysis
What does psychodynamic psychotherapy/psychoanalysis ‘look like’?
Mr B had had irritable bowel syndrome for many years and managed fairly well. He had a good relationship with his doctor and had adopted a liveand- let-live attitude towards his irritable bowel syndrome. He tolerated it and in return felt that it behaved itself and did not attack him too vigorously. He had worked all his life, was reliable and loved his wife and children. Like everyone else, he had had his fair share of disappointments, such as not being promoted at work as high as he felt he should have been, but he felt that these were more than made up for by the overall balance of his life.
One day, Mr B had an attack of irritable bowel syndrome. At first, he was not overly concerned. It had happened before and would no doubt happen again. He would just have to ride it out and manage in the way he had always done. But this attack was different. It didn’t really stop, even though it lessened somewhat, and Mr B never felt settled. It would occasionally even get worse suddenly. It just went on and on, and Mr B couldn’t understand why it had happened and why it wouldn’t stop.
After a while, it became really tiring and wore down Mr B’s patience and energy. Exasperated, he spoke to his GP, who then referred him to his consultant for an expert opinion. Mr B met with his consultant, and together they reviewed his case. Nothing appeared to have changed, and additional investigations did not produce any significant findings. His consultant then suggested that Mr B meet a colleague of his, Dr H, who was a psychoanalytic psychotherapist. Mr B had never thought of visiting a ‘quack’ but thought he had nothing to lose; anyway, he did not want to disappoint his consultant, who had helped him so much in the past and whose recent efforts he really appreciated.
So Mr B met Dr H for an initial consultation. He found Dr H rather easy to talk to, and although he was a bit nervous, he agreed to come and see Dr H for a 50-minute chat three times a week. Dr H had initially suggested to Mr B that they meet five times a week, but Mr B did not feel he either wanted this or could afford the time or money for it.
Initially, Mr B found great relief in meeting Dr H. Yes, it was strange that Dr H never mentioned anything about his own personal life and insisted on beginning and ending the sessions at the times they had initially agreed. It was also a bit strange to lie down on a couch and not actually be able to see Dr H, but Mr B found that after a while it was quite pleasant. After all, he could say exactly what came to his mind and not have to pay attention to Dr H all the time! This made him feel a bit better, and Mr B found that he could tell Dr H about his experience of irritable bowel syndrome.
Together, they realised that the current attack of irritable bowel syndrome had begun shortly after Mr B had learnt that an ambitious ex-trainee of his had been promoted over him and could now theoretically tell Mr B what to do. Additionally, and as their relationship grew, Mr B increasingly told Dr H about his past and how he had always to be careful not to upset his father, whose job often took him away from home, while at the same time he had missed his father very much.
But unfortunately, Mr B’s irritable bowel syndrome did not seem to improve greatly, and as much as he liked Dr H, this frustrated him. On top of this, Dr H always seemed to translate what Mr B said into some statement about Mr B himself. Some of these points were very interesting, but after a while it became a bit tiring. The final straw came when Mr B started arguing with his wife about the cost of his therapy. She felt that they could use the money in better ways, especially as the irritable bowel syndrome didn’t seem to be improving. Mr B suffered a really bad attack of irritable bowel syndrome, was really angry with Dr H and felt that the therapy had come to an end.
To Mr B’s surprise, though, Dr H talked to him about his dilemma in being angry and how this clashed with his valuing the time andeffort that Dr H had given to Mr B. Dr H pointed out how Mr B could not believe that Dr H understood his anger while he simultaneously did not lose sight of the fact that Mr B valued their work together. It was as if Mr B felt his anger to be purely destructive, of no use and something to be got rid of. Mr B did not quite understand but he felt very relieved, and surprisingly his irritable bowel syndrome attack resolved very quickly, staying that way for longer than Mr B expected. Over the next few weeks, he decided to stay with the therapy.
As their work subsequently proceeded, Mr B learnt that it was actually possible to be angry with Dr H without Dr H being destroyed by the anger or resentful of it. With more time and work, Mr B realised how afraid he had been of being angry and aggressive with his father as he had, in his mind, associated this with his father leaving home and Mr B feeling empty and bereft. Mr B had felt it too risky both to want his father but to be angry at him for his absence, because it seemed that in his mind such feelings had caused his father to leave rather than be there for Mr B. Anger, frustration and desire were a risky emotional mix, and it had seemed safer to expel all three from his mind.
Slowly, and by examining what had occurred in his relationship with Dr H, Mr B was able to allow himself to learn about his anxieties and resistances towards his own feelings of anger, frustration and desire, and feel them in an increasingly confident manner. He was also pleased that his irritable bowel syndrome seemed to have got significantly better, and although he occasionally had a mild spell, he was far less concerned about it than he had ever been before. Indeed, Mr B became more dedicated to his job, felt much more respected by his peers and, to his great surprise, had a more alive and fulfilling relationship with his wife than he had ever expected.
After just under 4 years of therapy, Mr B and Dr H decided to end the treatment. Although Mr B knew he could always return to Dr H if he felt he wanted to, he was struck, as he walked out of the consulting room for the last time, by the fact that he still didn’t know much about Dr H himself – but that it didn’t really matter.
So, put simply, what are the core ideas underlying a psycho – analytic approach?
Psychoanalysis as a treatment started about 100 years ago and was originally developed by Sigmund Freud. Since then, it has expanded enormously and is still doing so. Central to the psychoanalytic model are the idea of the Unconscious, the importance of feelings and the notion of conflict. It is thought that experienced difficulties sometimes represent an acceptable way of expressing conflicts within the mind that are actually too risky to deal with consciously.
In the above example, the conflict in Mr B’s mind involved love for his father versus anger towards his father. The conflict could not be resolved because Mr B’s young mind had associated anger at his father with his father leaving home. He could not risk expressing anger for fear of loss. Difficulty expressing anger became a part of his personality, and this unexpressed emotion eventually manifested as physical symptoms, in his case as exacerbations of irritable bowel syndrome. Mr B was unaware of these internal conflicts because they had developed and become embedded when he was a young child, long before he understood anything about thoughts and feelings.
Psychotherapists accept that the mind does not work just according to logic, so many people find themselves making the same sorts of mistake and/or having the same sort of difficulties over and over again. By entering a stable and consistent relationship with a properly trained psychotherapist, these underlying conflicts can gradually emerge in the relationship with the therapist and, as the therapist interprets them, can be more consciously worked on so that they might be resolved.
A crucial factor is how the client experiences the relationship with the therapist, which is why the psychotherapist will not divulge personal information. It is also why the times of sessions are fixed and not changed from week to week, even though the latter may seem more convenient. Finally, given the depth of the psychological work done, psychoanalytic psychotherapies tend to take much longer than other forms of treatment, although this in turn means that the benefits of psychotherapy are usually more widespread than only being focused on the original problem.
Do psychological treatments work, and what might be expected of me?
Modern research into all forms of psychological treatment is only about 55 years old at present. Evaluating psychological treatment programmes is notoriously difficult, and all the results need to be taken with a pinch of salt; unlike testing medicines, for example, psychological treatments cannot be tested in a what is called a double- blind manner, when neither the therapist nor the client knows who is receiving a real treatment and who is receiving a placebo (dummy treatment). With psychoanalysis, both the client and the therapist know what treatment is being given, and this knowledge may affect the result.
Studies looking at CBT in irritable bowel syndrome have mostly been rather small, with fewer than 50 subjects. Despite this, there is agreement that CBT is as effective as, and possibly superior to, other psychological treatments as well as conventional medical therapy in irritable bowel syndrome. In the largest study of CBT, over 400 patients were randomly allocated to receive CBT, an antidepressant, a placebo or education on their condition. The placebo (an inert, ineffective tablet) helped in 49% of individuals, which is a common finding in irritable bowel syndrome studies. CBT was effective in 70% of subjects, and the antidepressant was effective in 60%. The usual criticism of studies like this is that they do not follow up their subjects for very long after the end of the treatment, so it is difficult to know whether these positive effects actually persisted.
There have only been a few studies on psychodynamic psychotherapy for irritable bowel syndrome. All of them show it to be more successful than medical treatment alone or than ‘sympathetic listening’ from, for example, a nurse. The most recent and largest study, published in 2003, looked at 257 individuals with irritable bowel syndrome and severe abdominal pain who had not responded to usual medical treatments over 3 months. These people were randomly allocated to receive psychotherapy or the antidepressant paroxetine (an SSRI type of antidepressant), or to continue the medical therapy they were already having. They were reassessed after 3 months and again after 5 months. Disappointingly, there was only a small improvement in the symptom scores from all three groups. No one treatment proved to be any better than any other.
Findings such as those above emphasise a general factor reported in research – that the more motivated the person, the better chance any therapy has of working. Psychological treatments involve a lot more effort than just taking a tablet or avoiding certain foods. People have to think about themselves and their problems in ways that they have not tried before. The approach may appear alien and incomprehensible at first and can be psychologically painful. Any psychological treatment requires an investment of time and effort, but most of all, people must be prepared to talk about their personal thoughts and feelings. Moreover, they must be prepared to have their assumptions about themselves challenged. The prize to be aimed for is better control of your life through self-knowledge and awareness.
OK, I want to try a psychological route to tackling my irritable bowel syndrome. What now? Where do I go?
Unfortunately, psychology services are relatively poorly available in the UK, and CBT for irritable bowel syndrome is not readily available in most hospitals. Furthermore, psychological services in the UK are not currently regulated by law, so although there are many well-trained therapists, there are also many very poor or untrained ones. Your family doctor is always a good place to start. Or, for properly qualified clinical psychologists who practise CBT, you could try the British Psychological Society. For psychoanalytic therapy, you should contact the London Clinic of Psychoanalysis. Both organisations are highly reputable (see the contact details).
CONCLUSION
Most people with irritable bowel syndrome will acknowledge that their symptoms are worse at times of stress or psychological difficulty. Which came first – the irritable bowel syndrome or the psychological problem – is difficult to determine and probably does not matter anyway as it is clear that each will exacerbate the other. Just as it is worth trying the various physical therapies available, so it is worth exploring the psychological aspects of irritable bowel syndrome. Admitting that you have some psychological areas to deal with does not mean denying your physical symptoms. It does not mean that ‘it is all in the mind’, that you are, for example, expected to stop your medication. It is just another way of getting control of your symptoms and of gaining the self-knowledge that may help in other aspects of your life.
SUMMARY
Psychological disorders are very common in the general population.
Gastrointestinal symptoms are very common in anxiety.
Transient physical, emotional or psychological stress is perfectly normal and healthy. But stress that goes on for a prolonged period of time is thought to result in problems.
irritable bowel syndrome can cause psychological distress, and it may itself be caused or aggravated by psychological distress. Regardless of which came first, alleviating psychological distress is likely to help.
Informal psychological treatment happens all the time, when talking to friends, relatives and healthcare professionals.
The process of putting your problems into words and expressing them to other people may give you a better sense of perspective on the situation and make you feel less burdened.
CBT is a treatment provided by clinical psychologists using cognitive (thinking) and behavioural (action) techniques. Thoughts come before feelings. In other words, having negative thoughts makes us feel worse, whereas positive thoughts can make us better.
In psychodynamic psychotherapy, a trained psychotherapist listens to individual people talking about their innermost feelings. An intense relationship develops in the service of understanding how the person’s emotional life interacts with his or her physical and psychological symptoms, and in thereby alleviating the distress caused.
Psychological treatments involve a major investment of time, money and emotion.
Take care that you are consulting a properly qualified psychologist.
The ultimate aim is a better life through self-knowledge and awareness.
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