10.1192/bjp.163.3.315Access the most recent version at doi: 1993 163: 315-321 The British Journal of Psychiatry

  E Guthrie, F Creed, D Dawson and B Tomenson  

refractory irritable bowel syndromeA randomised controlled trial of psychotherapy in patients with  

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British Journal of Psychiatry (1993), 163, 315—321

Irritable bowel syndrome (IBS) is a common conditionaccounting for up to 50% of all new out-patients seeneach week by gastroenterologists in the UK. Themajority of patients respond to conventional medicaltreatment, in conjunction with explanation andreassurance (Harvey et a!, 1987). However, approximately 15% are not helped by medical interventionand their symptoms persist, often resulting inextensive investigation using health service resources(Kingham & Dawson, 1985).

Treatment studies, even for pharmacologicalagents, are notoriously difficult in lBS because ofthe variable nature of the condition (Klein, 1988).Patients, however, with chronic symptoms representa stable group, although there are as yet nopharmacological studies that have specifically focusedon these ‘¿�refractory'lBS patients.

The rationale for adopting a psychotherapeuticapproach for patients with refractory irritable bowelsyndrome has developed from three main areas.Firstly, there is a substantial psychoanalytical literature on the relationship between somatic symptomsand emotional conflict (Taylor, 1987). Secondly,many studies have noted a relationship between theirritable bowel syndrome and psychological factors(Creed & Guthrie, 1987). Finally, a small number ofcontrolled treatment studies employing a variety ofpsychological methods have produced encouragingresults (Creed & Guthrie, 1989). Whorwell et a!(1984)showed considerable bowel symptom reductionin a small controlled study of hypnosis versus‘¿�psychotherapy'in refractory lBS. Their patients,however, were not consecutively selected, rather they

were self-selected for hypnosis, which introduces thepossibility of bias into the recruitment process. Theterm ‘¿�psychotherapy'in these studies was looselyemployed, and consisted of unstructured, supportivelistening by the consultant gastroenterologist, whohad had no formal psychotherapeutic training.

The only previous controlled trial of psychodynamic psychotherapy in lBS patients (Svedlund,1983) found that psychotherapy plus conventionalmedical treatment was superior to medical treatmentalone, both at three months, and one year later.However, there was no independent assessment ofthe bowel symptoms, and patients on invaliditybenefit and those with overt psychiatric illness wereexcluded. These are the patients with whom gastroenterologists most need help (Kingham & Dawson,1985; Harvey et a!, 1987).

The aim of the present study was to assess thefeasibility and efficacy of short-term dynamic psychotherapy plus conventional medical therapy versusmedical treatment plus supportive listening, in outpatients with lBS. Outcome was assessed in termsof both lBS symptoms and psychiatric symptoms.

The study was designed to address the issues raisedby the previous research outlined above. Firstly, onlypatients with a history of chronic symptoms unresponsive to medical treatment were recruited. Secondly,they were recruited in a consecutive fashion. Thirdly,patients were not excluded on the grounds of overtpsychiatric illness, but only if they had prominentsuicidal thoughts. Finally, bowel symptoms wererated independently by a gastroenterologist, andnot by the psychiatrists involved in the trial.

315

A Randomised Controlled Trial of Psychotherapy in Patients withRefractory Irritable Bowel Syndrome

ELSPETHGUTHRIE,FRANCIS CREED, DAVID DAWSON and BARBARATOMENSON

Patients with chronic, refractory irritable bowel syndrome (n = 102) were entered into arandomised controlled trial of psychotherapy versus supportive listening. Independent physicaland psychological assessments were carried out at the beginning and end of the 12-weektrial. For women, psychotherapy was found to be superior to supportive listening, interms of an improvement in both physical and psychological symptoms. There was a similartrend for men, but this did not reach significance. Followingcompletion of the trial, patients inthe controlgroup were offeredpsychotherapy; 33 accepted and followingtreatment experienceda marked improvement in their symptoms; ten declined. At follow-up one year later, thosepatients who had received psychotherapy remained well, patients who had dropped out ofthe trial were unwell with severe symptoms, and most of the controls who declinedpsychotherapy had relapsed. This study shows that psychotherapy is feasible and effectivein the majority of irritable bowel syndrome patients with chronic symptoms unresponsive tomedical treatment.

316 GUTHRIE ET AL

The form of exploratory psychotherapy employedwas based on the conversational model developedby Hobson (1985), the efficacy of which hasalready been established for patients with neuroticproblems (Schapiro & Firth, 1987). It was specificallychosen for patients with refractory IBS, because ofits emphasis on the development of a conversationin the context of a mutual relationship betweenclient and therapist. It was felt this kind ofapproach may be particularly suitable for patientswho often have difficulties in putting feelings intowords.

Method

The study took place in the gastrointestinal out-patient clinicof a large teaching hospital. It was planned as a randomisedcontrolled trial comparing psychotherapeutic interventionplus standard medical treatment versus standard medicaltreatment plus supportive listening.

Patients were recruited consecutively, if they fulfilled thefollowing criteria: abdominal pain, abdominal distension,and an abnormal bowel habit associated with normalhaematology, serum biochemistry, rectal biopsy, andcolonoscopy or contrast radiology. In addition, subjectswere only included if they had experienced these symptomsfor over a year and had attended the gatroenterology clinicfor over six months without any improvement fromconventional medical treatment. There was no upper agelimit and patients were not excluded if they were receivinginvalidity benefit or had psychiatric illness, unless they hadsevere depression with suicidal ideas.

The study period was three months; thereafter patientsin the control group were offered the psychotherapeutictreatment if they still had symptoms. It was thoughtunethical to leave patients in the control group, in whompsychiatric illnesshad been detected, without help for a longperiod of time.

All patients were followed up one year after finishingtherapy, and were asked to complete psychologicalassessments and gastrointestinal self-rating scales. It wasnot logistically possible for the patients to be assessed bythe gastroenterologist at this stage. Strenuous efforts weremade to contact and include all the drop-outs.

Patients were initially asked to take part in the trial bythe gastroenterologist (DD), but the psychiatrist (EG) wasalso present in the gastroenterology clinic and immediatelytook the patient to another room where the study wasexplained in detail. Thereafter the patients were randomisedand attended the psychiatry department. All patients in bothgroups continued with their medical treatment unchanged.Patients in the control group were not told they would belater offered therapy.

Detailed assessments were performed at the start of thetrial and after three months. Comprehensive measures ofgastrointestinal symptoms were employed which included:a daily diary chart of bowel symptoms, a general ratingby the patientsof gastrointestinaland generalphysical

symptoms, and an independent assessment of the patients'gastrointestinal symptoms by a gastroenterologist (DD),who remained blind to the study groups. Further detailsof these assessments have been presented elsewhere (Guthrieet a!, 1991).

Psychological symptoms were assessed in two ways.Firstly, patients were asked to complete two self-assessmentquestionnaires: the Beck Depression Inventory (BDI; Becket a!, 1961) and the Symptom Rating Test (SRI; Kellner& Sheffield, 1973). Secondly, the Psychiatric AssessmentSchedule (PAS; Dean eta!, 1983) was employed to assesspsychiatric status. This semi-structured questionnaire is amodified version of the Present State Examination (PSE;Wing et a!, 1974) that can be used with populations thathave neurotic, not psychotic illnesses. The results wereprocessed by the computer program CATEGO,to producean Index of Definition (Wing & Sturt, 1978),and a tentativeICD-9 psychiatric diagnosis (World Health Organization,1978). All PAS interviews, at the beginning and end of thetrial, were audiotaped and then rated by an independentrater (FC) blind to the study groups. As psychotherapy wasthe treatment employed in this trial, it would have beendifficultfor an independentpsychiatricrater to remainblindto the study groups if he had had direct contact with thestudy groups.

The treatment group received one long initial session ofpsychotherapy lasting three to four hours, followed by sixpsychotherapy sessions of 45 minutes over the subsequent12 weeks. All the psychotherapy was carried out by onetherapist (EG). The main approach was exploratory,following the conversational model of Hobson (1985). Thismodel stresses the importance of the developing relationshipbetween therapist and patient, and considers the processof developing this relationship as a fundamental part of thetreatment. The model assumes the patient's presentingproblems arise from disturbance of significant personalrelationships. The development of a healthy therapeuticrelationship, and the furnishing of links between thetherapeutic relationship and other relationships in thepatient's life, produces insights and new solutions tointerpersonal problems.

It was necessary to make some modifications to thepractice of psychotherapy, because the lBS patients werenot actively seeking psychotherapy; in fact, many wereinitially resistant to the idea that psychological factors hadanything to do with their symptoms. The principalmodifications included the following.

(a) The psychotherapist was present in the gastrointestinal clinic when the patient was initially recruited.

(b) A long first session of psychotherapy lasted threeto four hours to maximise the development of a solidtherapeutic alliance and to encourage the expression oftransference material.

(c) Bowelsymptomswereexplicitlyusedas metaphorsbythe therapist to generate a feeling language between thepatient and therapist, for example “¿�youare feeling a bitbunged up?―,“¿�yourguts feel all churned up?―.

In addition, the patient was given a relaxation tape withbrief instructions. If the patient found the audiotape useful,this was used to emphasise the link between psychologicalsymptoms and bowel symptoms, and if the patient did not

317PSYCHOTHERAPY AND REFRACTORY IRRITABLE BOWEL SYNDROME

use the audiotape, this was tentatively explored at apsychodynamic level as resistance.

Patients in the control group were also seen on fiveoccasions by the same therapist (EG) during the trial period.The first session lasted approximately two hours, duringwhich detailed notes of the patient's symptoms wererecorded. Subsequent sessions lasted 30 minutes. Thetherapist appeared warm and empathic during thesemeetings and discussed and reviewed the patient's symptomsin a sympathetic manner. She did not, however, activelytry to develop a close relationship with the patient, or makelinks between psychological and somatic symptoms, orinterpret transference material.

Common factors in most psychotherapies include thepatient's experience of seeing someone who appearsinterested in their symptoms, who seems warm andsympathetic, and who treats them in a respectful way. Itis a mistake to assume these factors are not important, asthey can have a powerful therapeutic action. However, itis important to control for them to establish whether thereis a specific effect as a result of the specialised type oftherapy employed.

The results of the study were analysed in several ways:

(a) baseline comparisons to indicate any differencebetween treatment and control groups at the start ofthe trial

(b) comparisons at the end of the trial to indicatedifferencesbetweenthe treatmentand controlgroupsfollowing treatment

(c) comparison of degree of change occurring during thetrial for treatment and control groups

(d) correlations between change in bowel and psy-chiatricsymptoms during the trial.

Statistical comparisons between groups were made usingthe Mann—WhitneyU-test and the x2 test. Correlationsbetween different measures of change used the Spearmanrank correlation coefficient. Because non-parametricstatistics were used throughout, the results are shown asmedians and ranges.

Results

Consecutivepatientswithrefractoryirritablebowelsyndrome(n= 115)wereapproachedintheclinic.Elevenpatientswereexcluded from the study: five had severe depression withsuicidal ideas warranting immediate treatment, four patientsrefused, and two could not speak English. Two furtherpatients were later withdrawn, when it was discoveredthey had underlying organic pathology: one had chronicpancreatitis and the other inflammatory bowel disease.

This left 102 patients with lBS who entered the trial. Themean age was 47 years (range 20—75years) with 44 patients(43°lo)aged 50 years or over. The social class distributionin percentage terms was as follows: I, 3%; II, 21.5°lo;III, l8.6°lo;IV, 32.4%; V, 24.5%.

Fifty-three patients were allocated to the treatment groupand 49 patients to the control group. Thirteen patientsdropped out, seven from the treatment group and six fromthe control group. All but two of the drop-outs were

assessedat the end of the trial. The two patients who werenotassessed refused further contact and were actively hostile.

The treatment and control groups did not differsignificantly in terms of age distribution, marital status,employment status, and socialclass. However, following thewithdrawal of the two patients with organic gastrointestinaldisorder, there were significantly more men in the control group (34.7%) than the treatment group (15.1%)

= 4.28, P< 0.05). On account of this, the results were

analysed for the group as a whole, and then separately formen and women, to make sure any differences between thegroups were not due to gender.

The patients had chronic symptoms: the mean durationof continuous symptoms was two years (range 1-20 years);over 40% of the subjects had seen at least three consultantgastroenterologists and had been admitted to hospital atleast twice for investigation; 47% had had abdominaloperations, mostly the removal of a normal appendix. Inthe preceding year, the 56 patients who were in work hadtaken an average of six weeks' sick leave on account of thelBS and eight (7.8%) of the other patients were receivinginvalidity benefit.

The gastrointestinal symptoms are reported in detailelsewhere (Guthrie et a!, 1991), but the major changesare summarised.

There were no significant differences between thetreatment and control group at the start of the trial on anymeasure of gastrointestinal function; this remained whenmen and women were analysed separately.

At three months, the scores for the treatment group, ona wide variety of different measures, were significantlylower than in the control group. These included the dailyreport of abdominal symptoms (P< 0.01), the gastroenterologist's rating of bowel symptoms (P< 0.05), thelimiting effect bowel symptoms had on the patients' life(P<zO.05), and the reporting of abdominal pain via a linearanalogue pain scale (P<0.Ol) (Fig. 1).

Fifty-one of the 102 patients who entered the trial haddiagnosable (cAltc,o) psychiatric illness at the start: 25.4%had depressive neurosis; 15.7% had phobic disorder; 6.9%anxiety neurosis; and 2% endogenous depressive psychosis.None of the patients were seeing a psychiatrist at the timeof the trial, although six patients in the treatment groupand nine patients in the control group had been referredto psychiatrists in the past. Out of these 15 patients onlytwo had attended for more than one appointment and themajority (66%) had defaulted from psychiatric care.Twenty-four per cent of the treatment group and 22.4%of the control group were taking a benzodiazepine, and thismedication was unaltered for the duration of the trial.Three patients had been taking subtherapeutic dosages ofantidepressant medication for several years; this again wasleft unchanged until the trial had been completed.

There were no significant differences between thetreatment and control group at the beginning of the trialon any of the psychological measures; this was true for bothmen and women. The median score on the BDI for thetreatment group was 16(range 0—38),and for controls was13 (range 0—43).The scores for the SRI were 21 for thetreatment group (range 0—48),and 18 for the control group(range 0-42). At three months, the treatment group showed

groupMeasuresTreatment

median (range)Controlmedian(range)PAll

patientsBDISRTPAS(n=50)

5 (—8to33)8(—14to45(7 (—1to40)(n=46)

2(—24to32(2(—13to26(1 )—20to24(P<0.0i

P<0.01P<0.001Men

BDISATPAS(n=7)

5 (—8to 26)1 (ito 12)3.5 (ito 20)(n=15(

2 (—8to 16)2 (—9to 26)2 (—13to 26)NS

NSNSWomen

BDISATPAS)n=43)

5 (—5to33)8)—14to45)9 (— 1 to 40)(n=3i)

3(—24to32(2(—i3to15)1 (—20to 24)P<0.05

P'zO.01P< 0.001

318

Effect of symptoms

GUTHRIE ET AL

Self-report

Abdominal symptoms Gastroenterologist

10

8

6

4

2

0 IBefore After Before After

(a) (b)

Before After Before After

(C) (d)

Fig. I The scores at the beginning and end of the trial for treatment and control groups: (a) self-report of abdominal symptoms;(b) gastroenterologist's rating; (c) the limiting effect bowel symptoms had on the patient's life; and (d) self-report of abdominal painon a linear analogue scale (@ = treatment group;@ = control group).

a significantly greater improvement on all psychologicalmeasures in comparison with controls. Table 1 shows theimprovement (baseline score —¿�three month score) in scoresat the end of the trial for the BDI, the SRT, and the totalscore of the PAS. When the results were analysed separatelyfor each sex, similar trends emerged for men and women,with greater improvement shown by the patients in thetreatment group. However, this improvement was notsignificantly different for men, and there was a slightlygreater reduction in anxiety for the men in the control groupin comparison with the treatment group.

The number of patients in the treatment group whowarranteda psychiatricdiagnosisfelldramaticallyfollowingtreatment, from 30 to only five at three months; whereas 16of the control group still had psychiatric illness at this point.

The improvementin gastrointestinalfunctionwassignificantly correlated with changes in psychological symptomscores (Table 2). In view of the high correlations, an analysisof covariance was performed to determine whether thechange in bowel scores remained significant after adjustingfor group differences in the psychological variables. Forboth depression and anxiety the covariate effect of thepsychological variable was significant and, once this was

Table 1Comparison of improvement of psychological scoresat the end of the trial: treatment group v. control

Higher scores indicate greater improvement.

AssesMeasures Baselinesment

points12 weeksthroughout

trial24 weeks 18 months

319PSYCHOTHERAPY AND REFRACTORY IRRITABLE BOWEL SYNDROME

Table 2Spearman correlation coefficients showing the relationshipbetween the change in psychiatric symptoms and the

change in bowel symptoms

Changein bowelsymptoms Changein psychologicalsymptomsBDI SAT PAS

Gastroenterologist'srating 0.49 * 0.51k' 0.64's(totalscore)

Abdominal pain1 (self-rating) 0.38** 039** 0.59

**P<o.ool.1.Abdominalpain=totalscoreon linearanaloguescale.

accounted for, no significantdifferenceremained betweenthetreatment and control groups with respect to the bowel symptom scores. When the situation was reversed and thepsychologicalvariableswereanalysedusingthebowelsymptom scoresas thecovariate,thetreatmenteffectsallremainedsignificant, suggesting that improvement in psychologicalstatus led to an improvement in bowel symptoms.

At the end of the three-month trial, patients in the controlgroup were offered the 12-weekcourse of psychotherapy.Of the original 49 controls, six had dropped out, so 43 wereoffered treatment. Ten patients declined at this stage, asthey reported that their symptoms had improved, leaving33 patients who went on to receive psychotherapy. Medianand range scores on the BDI, the SRI, the linear analogueabdominal pain scale, and the gastroenterologist's ratingare shownin Table3, for both thosecontrolswhoacceptedand declined psychotherapy. The controls who acceptedfurther treatment showed a marginal improvement duringthe control period followed by a much greater improvementafter psychotherapy. Individual patients were deemed tohave improved if their independent ratings had fallen bymore than one standard deviation of the initial gastroenterologist's scores. None of the controls who acceptedfurther treatment improved during the control period

Table 3Median (range) scores at 0, 12 weeks, 24 weeks andfollow-up, for controls who received psychotherapy and

controls who declined psychotherapy

25

drop-outs

contr@s@Iuspsychotherapy

treatmentgroup

contr@s-nO PsychotherapY I

0 3 6 9 12 15 18lime: months

Fig. 2 Total PAS scores throughout the trial period and atfollow-up.

(0—12weeks), although after receiving psychotherapy(12—24weeks), six patients' scores improved by onestandard deviation, and a further 19 patients' scoresimproved by two or more standard deviations. Only twopatients were rated by the gastroenterologist as having gotworse.Thepatientswhodeclinedpsychotherapyshowednofurther improvement over weeks 12—24,and two patients'scores deteriorated by more than one standard deviation.

Eight (7.8%) patients could not be followed up. Theseincluded the two drop-outs who refused assessment at threemonths, one further drop-out who refused assessment, onepatient who could not be traced, two elderly patients whohad died, and two patients who had moved to live abroad(both these patients reported they were well, when contactedby post, but as a full assessment could not be made, theirresults were not included in the analysis).

Figure 2 presents the global ratings of psychiatricmorbidity (medians of total PAS scores) at the beginningand end of the trial and at the one-year follow-upassessment. The patients are divided into four groups: thosewho completed treatment in the treatment group; drop-outsfrom treatment and control groups; patients in the controlgroup who went on to receive psychotherapy; and patientsin the control group who improved during the trial and didnot receive any psychotherapy.

Figure 2 shows that improvement, with regard to psychologicalstatus,wasmaintainedfollowingpsychotherapy.Thedrop-outs did not improve, and the patients in the controlgroupwhodeclinedpsychotherapyshoweda relapsein theirsymptoms after their initial improvement.

As a rough estimate of the use of services, the numberof out-patient visits to the gastrointestinal clinic werecompared for the year before the trial, with the yearfollowing treatment. The median number of appointmentsbefore the trial was 4 (range 2—7),which fell to 1 (range0—6)following treatment (x2= 75.2, P<0.00l).

Discussion

20

15

@ 10@2

5

Controls who receivedpsychotherapy (n = 33)Gl rating1 4 (2-8) 5 (2-8) 1 (0-6) -Abdominal pain2 66 (31-98) 64 (36-92) 13 (0-91) 17 (0-91)BDI 17 (0-43) 15 (0-38) 4 (0-46) 3 (0-24)SAT 21 (0-39) 17 (1-41) 7 (0-37) 5 (0-36)PAS 18 (2-40)16 (2-39)5 (0-37)4 (0-34)

Controls who declinedpsychotherapy (n = 10)Gl rating1 5 (2—7)1 (0—2)1 (0—3) —¿�Abdominal pain2 61(43-77)16 (6-31) 30 (2-54) 57 (0-79)BDI 7 (0-28) 5 (0-12) 4 (0-8) 8 (0-20)SAT 7 (0-38) 2 (0-12) 6 (0-15) 6 (0-36)PAS 8 (0-28) 2 (0-7) 4 (0-12) 6 (0-40)

Psychotherapy trials have been criticised for notemploying independent measures of change and

1. GI rating = Gastroenterologist's rating total score.2. AbdomInal pain = Linear analogue scale score.

320 GUTHRIE ET AL

assessment (Eysenck, 1952). This study of lBSpatients used independent ratings of bowel symptomsmade by a gastroenterologist as the primary indicatorof outcome (Guthrie et a!, 1991). Since bothtreatment and control groups were regularly attendingthe psychiatric department to discuss their symptomswith the same psychiatrist, it was possible for thegastroenterologist to remain blind to the trial groups.He made no attempt to enquire about the length oftime patients were seen or the nature of the sessions.The other independent ratings were made by theaudiotaped semistructured interview, which preventedthe psychiatric rater from identifying the trial groupof each patient. This is, therefore, one of the fewcontrolled trials of psychotherapy involving a largenumber of patients that has employed independentmeasures of both psychological and physical status.

The study shows that a short-term psychotherapeutic approach in women with refractory irritablebowel syndrome is an effective treatment. It issuperior to supportive listening, and the one-yearfollow-up data suggest that the majority of patientsmaintain their improvement following the end oftreatment. Although there was a similar trendfor men on some measures, this could not beconclusively established.

The two original trial groups could not becompared at one year because a proportion of thecontrol group went on to receive treatment. Bydefinition, all the patients in the trial had hadcontinuous bowel symptoms for over one year,had received considerable medical investigation andtreatment, but had been unresponsive to medicaltreatments. Many had missed time from work. Thesestable and chronic symptoms meant that spontaneousimprovement was unlikely. Ten patients, however,in the control group did improve during the trialperiod. It is possible these patients experienced aspontaneous recovery, but this improvement couldhave resulted from keeping a diary of bowel symptoms and receiving supportive help in their sessionswith the psychiatrist. The later relapse of thesepatients, compared with the continued health ofthose who received psychotherapy, was considerable.

Ideally, the one-year follow-up would have beenperformed on the control subjects without theintroduction of psychotherapy after 12 weeks. Wefelt, however, this was justified in view of thesuffering caused by the condition and the highprevalence of psychiatric distress. In the event, thecommencement of psychotherapy for the patientsin the control group, at the end of the trial, andtheir subsequent improvement was a further demonstration of the effectiveness of the psychotherapeuticapproach. It is important to emphasise that the

controls were not told that they were going to beoffered psychotherapy so their subsequent improvement cannot be attributed to therapeutic expectation.

The patients in the treatment group received moretime with the therapist than those in the supportivelistening group. In particular, the first session wasmuch longer for the treatment group than forthe control group. This first session was specificallydesigned to generate a strong transference reaction,and it would have been difficult to give the controlgroup a similar length of time, without strongfeelings being generated. It could be argued, however,that the significant difference between the two groupswas purely a result of the treatment group spendingmore time with the therapist, although clinically thisseems unlikely.

As both kinds of intervention were carried out bythe same therapist, the possibility of bias needs tobe addressed. The therapist could have unwittinglytried harder with the patients in the treatment groupand been less helpful with those in the control group.This is unlikely, however, as patients in the controlgroup did show evidence of some improvement,which suggests that the therapist was behaving in asupportive and therapeutic way towards them.Ideally, all the sessions should have been taperecorded to exclude the possibility of bias and alsoto establish that there were clear differences intherapist behaviour between the two groups.

The subjects in this trial were not representative ofthe usual kind of patients who receive psychotherapy.Many were over the age of 50 years, and the majoritywere of low social status. They were not psychologically minded, and were not actively seeking psychotherapy. Most psychiatrists and psychotherapistsrarely see patients of this kind because they areseldom referred, and even if they are referred theydo not attend. A few had previously been offeredpsychiatric treatment, but 66°loof these patientsdiscontinued it. The high recruitment rate of thestudy (only four patients refused to take part), andlow drop-out rate (12.7%) was probably due to threefactors. Firstly, the careful explanation of the trialby the gastroenterologist. Secondly, the presence ofthe psychiatrist actually in the clinic. Thirdly, thespecial skills used by the psychiatrist to engage thepatients in treatment (these techniques will bediscussed in detail elsewhere).

The psychological theories of the development ofpsychosomatic symptoms are complex and confusing(Taylor, 1987). The data collected in the presentstudy are not sophisticated enough to determine the waypsychotherapy was able to relieve patients' distress,although the improvement in bowel symptomsappeared to follow improvement in psychological

321PSYCHOTHERAPY AND REFRACTORY IRRITABLE BOWEL SYNDROME

status. This adds weight to the view that psychologicalfactors are of primary importance in patients withsevere lBS. and even those trial subjects who did nothave diagnosable psychiatric illness had emotionalfactors that were relevant to their bowel symptoms.Research on gut motility suggests that lBS subjectsmay have a constitutional liability to develop painfulbowel spasms (Thompson, 1979). Thus, one mustpostulate a subtle interplay between physiologicaland psychosocial factors when presented with an lBSpatient.

This study raises several interesting points. Firstly,various psychological approaches, including psychotherapy, hypnotherapy, and behavioural therapy,may help patients with lBS (Creed & Guthrie, 1989),but it is not known whether these treatments helpsimilar or different groups of patients. Therefore,more detailed measurement and examination ofpredictive factors are required. Secondly, the therapyemployed in this study was specifically intended to bebrief, so if found to be effective, the cost benefit of itsuse in refractory patients could be assessed. Thenumber of out-patient appointments fell dramaticallyfollowing treatment, and a more systematic andrigorous cost-benefit study, taking account of hiddencosts, is now required. Thirdly, Barkham & Hobson(1989) have recently reported the effect of an evenshorter psychotherapeutic intervention, involvingonly three sessions with a patient with neuroticsymptoms. It is possible that such a brief intervention may be effective in some patients withrefractory lBS.

Finally, it is important to put this trial in perspective. The gastroenterological department wherethe work was carried out is well recognised as aspecialised centre of excellence, and it receives manysecondary and tertiary referrals. Therefore, thepatients in this trial represent a small group ofindividuals with chronic symptoms and are notrepresentative of lBS subjects in general.

Acknowledgements

This research was performed with a grant from the North WestRegional Health Authority. Reckitt and Coleman also providedsupport. We wish to thank Dr R. Holmes, Dr T. Warnes, and

Dr J. Braganza for allowing us to study patients under theircare.

References

BAP.KHAM, M. & HoBsoN, R. (1989) Exploratory therapy in twoplus-one sessions. II: A single case study. British Journal ofPsychotherapy,6, 89—100.

BECK, A. T., WARD, C. H., MENDELSON, M., ci a! (1961) Aninventory for measuring depression. Archives of GeneralPsychiatry, 4, 561—571.

CREED, F. H. & GUTHRIE, E. A. (1987) Psychological factors andthe irritable bowel syndrome. Gut, 28, 1307—1318.

—¿� & —¿� (1989) Psychological treatments of the irritable

bowelsyndrome:a review.Gut, 30, 1601—1609.D@, C., SURTEES,P.O. & S@sHli)It@s@t,S. P. (1983)Comparison

of research diagnostic systems in an Edinburgh community:associations with demographic factors. British Journal ofPsychiatry, 142, 238—247.

EYSENCK, E. (1952) The effects of psychotherapy: an evaluation.Journal of Consultation Psychology, 16, 319-324.

GUTHRIE, E. A., CREED, F. H., DAWSON,D., ci a! (1991) Acontrolledtrialof psychologicaltreatmentfor theirritablebowelsyndrome. Gastroenterology,100, 450—457.

HARVEY,R. F., MAUAD, E. C. & BROWN,A. M. (1987) Prognosisin the irritable bowel syndrome: a 5-year prospective study.Lancet, i, 963-965.

HOBsON, R. F. (1985) Forms of Feeling. London: Tavistock.KELLNER, R. & SHEFFIELD, B. F. (1973) A self-rating scale of

distress.PsychologicalMedicine, 3, 88—100.KINGHAM,J. 0. C. & DAWSON,A. M. (1985) Origin of chronic

right upper quadrant pain. Gut, 26, 783—788.KLEIN, K. B. (1988) Controlled treatment trials in the irritable

bowel syndrome: a critique. Gastroenterology, 95, 232—241.SHAPIRO, D. A. & FIRTH, J. (1987) Prescriptive v. exploratory

psychotherapy: outcomes of the Sheffield psychotherapy project.British Journal of Psychiatry, 151, 790—799.

SVEDLUND, J. (1983) Psychotherapy in irritable bowel syndrome:A controlledoutcomestudy.ActaPsychiatricaScandinavica,67(suppl.306).

TAYLOR, 0. 3. (1987) Psychosomatic Medicine and ContemporaryPsychoanalysis. Stress and Health Series (monograph no. 3).Madison, Connecticut: International Universities Press.

THOMPSON, W. 0. (1979) The Irritable Gut. Baltimore: UniversityPark Press.

WHORWELL, P. 3., PRIOR, A. & FARAGHER, E. B. (1984) Controlledtrial of hypnotherapy in the treatment of severe refractoryirritable bowel syndrome. Lancet, ii, 1232—1234.

WING, 3. K., COOPER, 3. E. & SARTORIUS, N. (1974) The Measure

ment and Class(flcation of Psychiatric Symptoms. London:Cambridge University Press.

—¿� & STURT, E. (1978) The PSE-ID-CATEGO System.

Supplementary Manual. London: MRC Social Psychiatry Unit.WORLD HEALTH ORGANIZATION (1978) Mental Disorders: Glossary

and Guide to their Classification in Accordancewith the NinthRevision of the International Classification of Diseases (ICD-9).Geneva: WHO.

Elspeth Guthrie, MRCPsych,MSc, MD, Diplomain DynamicPsychotherapy,North West Regional Health Authority,Lecturer in Psychiatry, Manchester Royal Infirmary; *Francis Creed, MRCP,MRCPsych,MD, Professor ofPsychiatry, Rawnsley Building, Manchester Royal Infirmary, Manchester M13 9WL; David Dawson,MRCP, MD, Formerly Senior Registrar in Gastroenterology, Manchester Royal Infirmary, now ConsultantGastroenterologist, Royal Northern Hospital, Sheffield; Barbara Tomenson, BSc,Statistician, ManchesterRoyal Infirmary

*Correspondence