Conclusions and Future Directions 407treatments, alone and combined, seem to be moderately
effective in treating IBS symptoms and superior to symptom
monitoring alone. Currently, cognitive therapy appears to be
the most highly recommended approach, as it has been tested
against a credible placebo condition, in addition to symptom
monitoring (Payne & Blanchard, 1995). Clearly, more ran-
domized, controlled treatment studies that compare multiple
treatments for IBS are needed.
CONCLUSIONS AND FUTURE DIRECTIONS
IBS is a complex health problem that needs to be understood
within a biopsychosocial paradigm. This chapter offers sev-
eral interesting insights into the diagnosis, classi“cation, and
treatment of IBS. First we addressed de“nitional and epi-
demiological aspects of IBS and introduced general psy-
chosocial issues related to IBS. We then summarized the
somewhat limited research on recurrent abdominal pain, a
childhood functional GI problem that may be a developmen-
tal precursor to IBS. Finally, we reviewed the literature on
psychosocial treatments of IBS, with a special emphasis on
information gained from randomized, controlled treatment
trials. While the psychosocial literature on IBS may have
greatly bene“ted those with IBS and those who care for them,
much more research needs to be done.
Diagnosing IBS has long been problematic for gastroen-
terologists and primary care physicians alike. Currently, IBS
is diagnosed clinically when other potential causes have been
ruled out. However, recent changes in criteria, including the
Rome I and Rome II Criteria, have begun to address symp-
toms unique to IBS patients that may aid in a diagnosis with-
out unnecessary and invasive tests. Unfortunately, diagnostic
accuracy is far from perfect, and many gastroenterologists
continue to rely on invasive procedures to rule out more life-
threatening problems such as cancers and in”ammatory
bowel disease. Further research into identifying inclusive cri-
teria for IBS is crucial for the effective assessment and man-
agement of these patients. Similarly, a better understanding
of differences among IBS subtypes (diarrhea predominant,
constipation predominant, mixed type) may also be
bene“cial.
While IBS prevalence rates seem to be fairly consistent
around the world (Thompson, 1994), there do seem to be
some cultural differences in both symptom reporting and
treatment seeking. A better understanding of these differ-
ences may lead to a more contextual understanding of the
development and maintenance of IBS symptoms. It is unclear
as to why women seem to outnumber men in IBS treatment
seeking in Western countries. Research as to whether these
differences are related to variations in health care utilization,
gender differences in the experience of pain and other GI
symptoms, or other social/developmental factors would be
valuable.
Another direction for future research involves a better un-
derstanding of differences between those who seek treatment
for their symptoms (patients) and those who do not (nonpa-
tients). Literature thus far has been mixed, with some studies
suggesting that there are differences between groups on vari-
ous measures of psychological distress (Drossman et al.,
1993), and others suggesting that there are no such differ-
ences (Gick & Thompson, 1997; Whitehead et al., 1996). It is
possible that differences among groups are a result of differ-
ences in symptom severity and/or role impairment associated
with the recurrence of symptoms. This possibility has yet to
be investigated.
As discussed numerous times in this chapter, it is impor-
tant to address the somatopsychic hypothesis of IBS. In other
words, which came “rst, the IBS or the psychopathology?
Careful temporal tracking of psychological symptoms is im-
portant at this level. It may be that IBS is a causal factor in the
development of anxiety and depression„certainly , GI symp-
toms have been known to keep people housebound. On the
other hand, IBS symptoms may be an additional manifesta-
tion of psychopathological conditions. Understanding the
potential causal relation between GI symptoms and psy-
chopathology has important implications for the effective
management of IBS patients.
Another important issue that has been somewhat ne-
glected in the IBS literature is that of the role of stress in GI
symptoms. While the majority of patients will link the onset
and maintenance of their symptoms to stressful events, previ-
ous research has been unable to determine the exact relation-
ship between either major life events or daily life hassles and
GI symptoms. While some research has linked same-day
hassles with same-day GI symptoms, there is currently little
support for the notion that stressful events today lead to in-
creased IBS symptoms tomorrow. It is possible that newer
statistical methods may help us answer these questions more
directly. Further, it is important to explore the role that GI
symptoms, and even more speci“cally, GI ”are-ups, play in
the total experience of stress and the cycle of symptoms.
In addition, little is known about the role Axis II personal-
ity disorders may play in the onset and maintenance of GI
symptoms. There are very few data that estimate the preva-
lence of such personality disorders in IBS treatment-seeking
population. However, given the high rate of sexual and phys-
ical abuse, it is possible that a high level of such disorders
exist. Assessing for personality disorders may have important
treatment implications as well. For example, is treatment less