به نام خدا

Functional abdominal pain syndrome

Irritable bowel syndromeChronic pain disorder

(Somatoform disorders)

Depressive & Anxiety disorders

The gut and the brain are highly integrated, and they communicate in a bidirectional fashion, largely through the (ANS)

and (HPA) axis

• Limbic system:• internal and external homeostasis of the organism• central role in emotionality, which is a nonverbal system that

facilitates survival, threat-avoidance, social interaction, and learning• “mind/body interaction” may largely arise in this region• “top-down” modulation of visceral pain and visceral perception• cognitive/psychological factors, visceral perception, and motor

abnormalities

UTMB GalvestonBaker 2009

NTs for Depression

• NE – mostly located in the Locus Ceruleus• 5-HT – mostly located in the Dorsal

Raphe– Brainstem area with pathways to the neocortex and

limbic system, as well as down the spinal cord

5-HT affects:ImpulsivityAggression

AppetiteSex

NE affects:Vigilance

Motivation

AnxietyIrritability

PainMood

EmotionCog Function

Psychosocial correlates ofPsychosocial correlates ofIrritable Bowel SyndromeIrritable Bowel Syndrome

Psychosocial correlates

Presence in Irritable Bowel Syndrome

Psychiatric

disorders

High rates of psychiatric diagnoses (especially anxiety disorders) in people with IBS drawn from clinics and the population.

Personality dysfunction

High levels of neuroticism and low levels of extroversion characterise people with IBS drawn from clinics and the population.

Childhood

abuse

A history of childhood sexual or physical abuse is more common in people with IBS versus controls, especially among consulters versus non-consulters with IBS.

Psychosocial correlates ofPsychosocial correlates ofIrritable Bowel SyndromeIrritable Bowel Syndrome

Psychosocial correlates

Presence in Irritable Bowel Syndrome

Life event stress Close association between life event stress and the onset and/or exacerbation of IBS symptoms.

Coping ability Non-consulters exhibit greater coping capabilities under stress than consulters with IBS.

Social support IBS patients have less social support in terms of tangible assistance compared with healthy controls.

Management of chronic functional abdominal pain

• Set the agenda• Provide unambiguous

information about findings• Time planning: a longer planned

session may save time in long run-Regular visit

• Identify psychosocial factors

• Empathy• Set limits for investigations Don't

treat what patient doesn't have-Do not harm

• Encourage patient to take responsibility

• Med-psych interfere•

Approach to patients: Disease or illness oriented

• Cognition: content, styles, questions.• Emotion• Function• Expectation• Concerns

Pain perception:

Nociception

Affect

Depression Anxiety

Fear

Cognition

RuminationsCatastrophizing

Selective perception

Psychological Treatments:

• Cognitive therapy• Behavioural therapy • Interpersonal

therapy• Dynamic

psychotherapy• Hypnotherapy

• Psychological treatments should not be limited to people with co morbid psychiatric disorders.

• Psychological therapy already exists in routine clinical care and includes clear explanation and true reassurance, which helps patients cope better with their disorder.

Probability x (perceived cost) awfulness

Anxiety =Perceived ability to cope + chance of help (rescue)

Cognitive behavioural approachto understanding health anxiety

Antidepressant therapy:• Psychiatric and non psychiatric disorders: e.g.

neuropathic pain syndromes.• The analgesic effect is independent and sooner than

antidepressant effect.

The time required to obtain analgesia : 1 day to 10 weeks.

• Drug intolerance is a rule: Start low go slow (Low doses).

•

• Aware of potential adverse effects and be prepared to undertake either dosage adjustments or trials with other agents.

• No FDA approved antidepressant for IBS.

• Different kinds of ADs: TCA, SSRIs, SNRIs, MAOIs.

Tricyclic Antidepressants• Frequently used• In contrast, the effective dose range for

TCAs in IBS appears to be about 30–50 (10-70) mg/day of amitriptyline or its equivalent.

• Unclear mechanism of action– Antihyperalgesia – Improved sleep– Normalized bowel transit– Coexisting depression/anxiety at higher doses

Tricyclic Antidepressants• Inconsistent data on efficacy

– Improved abdominal pain, global symptoms seen in some RCT’s, systematic reviews

• Evidence has significant limitations– Variable dosing – Small numbers – High discontinuation rates– Short duration– Poor/variable designs

• May exacerbate constipation– Appears dose related– Might be more beneficial in patients with diarrhea

• Decrease abdominal pain; no improvement in global symptoms • Few head-to-head trials with SSRIs

SSRIs• None are FDA approved for IBS• Directly or indirectly affect gut function and

motility.• Analgesic properties. • Effective in a variety of somatoform disorders

and alleviate global distress.• Extra intestinal symptoms.• Affective memory bias towards positive

material. • Few RCTs of use in IBS: suggest improvement well being, pain, QOL scores

• No superiority of one SSRIs.• Among SSRIs, evidence is available for paroxetine,

paroxetine CR, fluoxetine and citalopram.

• Target dose of SSRIs in IBS appears is in the range found to be efficacious in the treatment of depression.

• SSRI trials should be at least 8–12 weeks in duration of IBS.

• If patients demonstrate clinical benefit; continue the medications for at least 6–12 months.

• A gradual reduction in dose: pay attention to withdrawal symptoms

• Close monitoring of patients for recurrence of symptoms-Withdrawal syndrome

• Co morbid anxiety or depression: long-term treatment with antidepressants.

• Failure to respond to one antidepressant, switching to another antidepressant.

SNRI• Effective in decreasing pain in other

chronic conditions• No trials yet on effect in IBS

Insufficient evidence to make recommendations about SNRIs (e.g. venlafaxine - doluxetine) in IBS.

• Mechanisms of action: SER- NE Reuptake inhibition