406 Irritable Bowel Syndrome
Included are synoptic descriptions of treatment conditions,
sample sizes, and a summary of signi“cant between group ef-
fects at the end of treatment and at follow-up.
There are a total of 15 RCTs involving cognitive and be-
havioral treatments presented in Table 17.1. Most are small
trials, involving 12 or fewer patients per condition. Only two
trials had 30 patients per condition (Blanchard et al., 1992,
Study 2; Toner et al., 1998) while two others had between 20
and 30 per condition. The two larger trials found some ad-
vantage for CBT combinations over symptom monitoring
controls but neither found the CBT combination superior to a
psychological treatment control.
Of the 10 trials with combinations of cognitive and behav-
ioral treatments, most include an education component (9
of 10) and a relaxation training (8 of 10) component (usually
in the form of progressive muscle relaxation, PMR). Almost
all included some attempt at directly modifying cognitive as-
pects of functioning, such as self-talk, cognitions, and
schemas, or coping strategies.
Work from our center has begun the task of dismantling
these CBT combinations. We have described two small trials
comparing a pure relaxation condition (PMR in Blanchard &
Andrasik, 1985; use of Benson•s ([1975] relaxation response
meditation in Keefer & Blanchard, 2001); both found relax-
ation superior to symptom monitoring.
We also summarize in Table 17.1, three small RCTs eval-
uating purely cognitive therapy alone. In all three, cognitive
therapy was superior to symptom monitoring. More impor-
tantly, in the only RCT to show an advantage for cognitive or
behavioral treatment in comparison to a credible placebo,
Payne and Blanchard (1995) showed that cognitive therapy
was superior to psychoeducational support groups.
Our center has reported on one-, two-, and four-year
follow-ups of IBS patients treated with CBT. In the longest
follow-up (Schwarz, Taylor, Scharff, & Blanchard, 1990),
we found 50% of treated patients still much improved (as
veri“ed by daily GI symptom diary). Other long-term follow-
ups such as van Dulmen et al. (1996) and Shaw et al. (1991)
have likewise reported good maintenance of GI symptom
reduction.
It is clear that combinations of cognitive and behavioral
treatment techniques, adapted to an IBS population, are supe-
rior to symptom monitoring and to some extent routine med-
ical care. Moreover, the improvements have been shown to
endure over follow-ups ranging from one to four years
(Blanchard, Schwarz, & Neff, 1988).
Three studies from Albany, all using the same cognitive
therapy protocol (B. Greene & Blanchard, 1994) have
yielded consistently strong results across three different
therapists and with three separate cohorts of IBS sufferers.
Payne and Blanchard (1995) have shown the cognitive
therapy superior to a highly credible psychological control
condition. We recommend this approach at present.General CommentsWe have addressed the current psychological treatment
literature as it applies to IBS. Many different forms of
psychological treatment, including brief psychodynamic psy-
chotherapy, hypnotherapy, and cognitive and behavioralTABLE 17.1 (Continued)
Sample
Authors Conditions Size Differential Results
Cognitive Therapy Alone
Greene and Blanchard, 1994 Cognitive Therapy. 10 Cognitive Therapy improved
Symptom monitoring. 10 more on symptom
composite than SM, also on
BDI and Trait anxiety.
Payne and Blanchard, 1995 Cognitive Therapy. 12 Cognitive Therapy improved
Group: Psycho-education support. 12 more on symptom
Symptom monitoring. 10 composite than psycho-
education and SM, also on
BDI and Trait anxiety.
Vollmer and Blanchard, 1998 Group Cognitive Therapy. 11 Both cognitive therapy
Individual Cognitive Therapy. 11 improved more than SM on
Symptom monitoring. 10 symptom composite; no
difference between
cognitive therapy conditions.
Note:PMR = Progressive Muscle Relaxation; SM Symptom Monitoring.