Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional disorder of the lower gastrointestinal tract defined by the presence of chronic or recurring symptoms that include abdominal pain, flatulence, bloating, and altered bowel habits (Dross- man 1994). Prior to 2010 there were no reports in the literature on the application of MBIs for people with IBS, but since that time several research groups have reported large, well-designed RCTs. The first treatment results were published by Ljotsson and colleagues (2011a) in Sweden, who evaluated a ten- session group focusing on three themes: Cognitive awareness and education around stress and coping; mindfulness training; and exposure to noxious IBS symptoms. They conducted an RCT of an online adapted version of their acceptance and mindfulness-based intervention with 61 patients, compared to wait-list control. The intervention was conducted online largely by patients on their own at home, following a structured program of education and practice, and included weekly internet contact with therapists via e-mail. There was also a closed discussion forum for patients to share questions or progress with one another (Ljotsson et al. 2011a). Compared to those on the wait-list, participants improved more over time on IBS symptom severity, quality of life, and IBS- related fear and avoidance behaviors, and these improvements were maintained over 12 months.

This group continued investigating the online MBI against active controls, randomly assigning 86 patients to either the online acceptance and mindfulness intervention or an online discussion forum wait-list (Ljotsson et al. 2010). In this case, participants in the treatment condition reported a 42% decrease (compared to a 12% increase in the control group) in primary IBS symptoms, and they improved on GI-specific anxiety, depression, and general functioning with large effect sizes. These participants were followed-up 16 months later after they had all completed the intervention (Ljotsson et al. 2011c). Treatment gains were maintained on all outcome measures, including IBS symptoms, quality of life, and anxiety related to gastrointestinal symptoms, again with large effect sizes (most d > 1.0).

Finally, in a large and well-designed RCT, this group investigated their online mindfulness intervention compared to online stress management matched in time and format with 195 patients, and also measured credibility of the treatments, expectancy for improvement, and therapeutic alliance (Ljotsson et al. 2011b). At post-treatment and six-month follow-up, the MBI group improved more than stress management controls on IBS symptom severity, IBS quality of life, visceral sensitivity, and the cognitive scale for functional bowel disorders. Both groups improved similarly on the perceived stress scale and hospital anxiety and depression scale subscales. There were also no group differences on the treatment credibility scale or the working alliance inventory. This impressive series of studies provides strong support for the efficacy of the online MBI for improving both physical symptoms and QL in IBS patients, but showed that other active interventions can also successfully treat stress, anxiety, and depression.

Two North American groups have also evaluated in-person traditional MBSR. In an RCT of MBSR versus wait-list for 90 IBS patients, Zernicke et al. (2012) showed that while both groups exhibited a decrease in IBS symptom severity scores over time, the improvement in the MBSR group was greater than the controls and was clinically meaningful, with symptom severity decreasing from constantly to occasionally present, which was maintained in the MBSR group six months later.

In an active comparison trial, 75 women with IBS were randomized to MBSR or a support group matched for time and other non-specific factors (Gaylord et al. 2011). Women in MBSR, compared to the support group, showed greater reductions in IBS symptom severity post-training (26.4% vs. 6.2% reduction) and at three-month follow-up (38.2% vs. 11.8%). Changes in quality of life, psychological distress, and visceral anxiety favoring MBSR emerged only at the three-month follow-up. Path analysis suggested that MBSR worked by promoting non-reactivity to gut-focused anxiety and less catastrophic appraisals of the significance of abdominal sensations, as well as refocusing attention onto interoceptive data without the high levels of emotional reactivity often characteristic of the disorder (E. L. Garland et al. 2011).

Considered together, this body of well-designed and executed studies provides consistent evidence for the efficacy of both in-person and online versions of MBIs for IBS sufferers, showing greater improvements specifically in IBS symptoms over other credible treatments, including stress management and social support.

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