Handbook of Psychology

Psychological Treatment of IBS 403

this study, Sanders, Shepherd, Cleghorn, and Woolford
(1994) compared the same CBT program to standard pedi-
atric care with a sample of 44 children with RAP. The latter
treatment included reassurance that the child•s pain was real
but that no organic disease was present. Results continued to
show a signi“cant advantage for the CBT (80% symptom re-
duction vs. 40% symptom reduction) over the reassurance
condition over time„at six months, two-thirds of the CBT
group were pain free, as opposed to less than one-third in the
standard care condition.
To look at the individual components of CBT, we (Scharff,
1995) conducted a study that compared a parent-training ap-
proach with a stress management approach. In the parent-
training condition, parents received education about RAP and
psychosomatic symptoms, and learned behavior modi“cation
techniques described in Living with Children (Patterson,
1976). The treatment focused speci“cally on parents• ignor-
ing mild pain behaviors and encouraging active behaviors in
their child; the program was modi“ed to meet individual
needs. Essentially, parents were instructed to have their child
lie down in a quiet, dark room with no distractions whenever
they complained of pain. School attendance was required
unless the child was vomiting or developed a fever.
In the stress-management condition, children were taught
progressive relaxation and deep breathing exercises, and also
learned cognitive distraction techniques for acute pain.
Positive imagery and positive coping self-statements
(Michenbaum, 1977) were also used. After treatment, pa-
tients monitored their symptoms for two weeks, and if there
was no full remittance, they were crossed over to the other
condition.
Outcome was determined by pain ratings kept by the
child; ratings were made daily using a 0 to 4 scale (•no painŽ
to •very bad painŽ). Parents also rated twice a day the fre-
quency of pain behaviors. Both children and parents kept
pain records for six weeks prior to treatment, throughout
treatment, and for two weeks at posttreatment and three-
month follow-up. Signi“cant reductions were observed in
both child pain ratings (from 1.2 to 0.2, p .001) and parent
ratings of frequency of pain behavior intervals (from 40% to
8%,p .001) from the second baseline to the end of the sec-
ond treatment. Results were maintained at follow-up. There
was a trend for child pain ratings to decrease more when
stress management was the “rst treatment received. The av-
erage degree of improvement for the child ratings was 86%
and 82% for the parent ratings of pain behaviors. Overall, all
10 children were 62% improved or greater with 9 or 10 show-
ing 75% reduction in their child pain diary ratings. With
respect to parent ratings, all children were 61% improved or
greater with 6 of 10 showing reductions of 75% or greater.

Thus, there appears to be a slight advantage to the stress

management training.

What is it about RAP that predisposes a child to de-

velop IBS as an adult? Some possible explanations include:

(a) hypersensitivity to abdominal pain as a child continues

into generalized GI tract sensitivity as an adult; (b) an anx-

ious child grows up to be an anxious adult who is more likely

to develop IBS; or (c) early learning about GI symptoms, the

sick role and health care seeking predisposes him or her to be

sensitive to GI symptoms and seek health care as an adult.

General Comments

We have addressed RAP as a possible developmental precur-

sor to IBS, which has been understudied. Research in this

area has begun to address questions similar to that in the IBS

literature, including the role of stressful events and psycho-

logical distress in the onset and maintenance of symptoms.

Treatment of RAP has been limited to a few behavioral inter-

ventions, but seems to show much promise. It is possible, that

as we develop a more complete understanding of the psy-

chosocial factors in”uencing the experience of RAP, we will

be able to offer more speci“c interventions. Next, we look at

psychological interventions as they apply to IBS.

PSYCHOLOGICAL TREATMENT OF IBS

Since 1983, three broad approaches to psychological treat-

ment of IBS have been evaluated in randomized, controlled

trials (RCTs): brief psychodynamic psychotherapy, hyp-

notherapy, and various combinations of cognitive and behav-

ioral therapies. We describe each treatment approach brie”y

and summarize the outcome and follow-up results.

Brief Psychodynamic Psychotherapy

While the descriptive term, •brief psychodynamic ...,Ž may

seem a bit of a contradiction, it is accurate. The treatments

were delivered over a three-month span and consisted of

10 sessions in one instance and only 7 in the other. Thus, the

time span and number of sessions are not what we normally

associate with psychodynamic psychotherapy. The therapy is

psychodynamic to the extent that it seeks •insightŽ

(Svedlund, Sjodin, Ottosson, & Dotevall, 1983) and •explo-

ration of patients• feelings about their illnessŽ (Guthrie,

Creed, Dawson, & Tomenson, 1991).

In the “rst study (which we believe is the “rst RCT of

psychological treatment for IBS), Svedlund et al. (1983) ran-

domly assigned 101 IBS patients, all of whom were receiving