408 Irritable Bowel Syndrome
effective when chronic and persistent psychopathology af-
fects an individual•s general role functioning?
While it has been fairly well established that there are high
rates of prior abuse in the IBS population, it is unclear as to
how such abuse relates to the experience of symptoms and
distress levels seen in IBS populations. For example, does the
abuse form a direct pathway to the onset and maintenance of
GI symptoms? Or does abuse lead to psychopathology, which
in turn leads to IBS? This is an important differentiation to
make, as it is likely to in”uence the direction of psychosocial
treatments for IBS.
While the IBS literature has many gaps and limitations,
the literature on recurrent abdominal pain in children is even
more scarce. Clearly, continued research on the appropriate
diagnosis, prevalence, and relationship to IBS is necessary to
effectively treat, and perhaps prevent problems in adulthood.
Further, better differentiation between children with RAP and
children with other GI symptom complaints is necessary for
accurate assessment and treatment of such children. Finally,
an understanding of possible maintaining factors in child-
hood may provide a more comprehensive model of func-
tional GI problems in both childhood and later in life.
In addition to gaps in our understanding of IBS patients, it
is important to address limitations of the treatment literature.
Essentially, there are three (or probably four) psychological
approaches to the treatment of IBS that have demonstrated
ef“cacy in RCTs and for which follow-ups of at least a
year demonstrate durability of improvement: brief psychody-
namic psychotherapy, hypnotherapy, and cognitive behav-
ioral therapy combinations. Purely cognitive therapy should
also be on this list. Despite the variety of psychosocial treat-
ments that have been shown to be effective in the treatment of
IBS patients, very little is known about whysuch treatments
work. One hypothesis is that a reduction in psychological dis-
tress can in”uence the manifestation of such symptoms. On
the contrary, however, it is possible that a reduction in symp-
toms leads to reductions in psychological distress. This could
be addressed within the drug treatment literature as well„
what happens to Axis I disorders when drug (or psychologi-
cal) treatment is effective in reducing GI symptoms?
Another limitation of the current psychosocial treatment
literature is the lack of large, randomized treatment trials that
compare two or more of the effective treatments for IBS, both
with respect to effective drug treatments and established psy-
chosocial treatments. It is possible that all of the established
treatments for IBS are comparable to each other, and that our
focus should turn to appropriate ways to match patients to ap-
propriate treatments, or to determine the necessary combina-
tion of treatments to best manage GI symptoms. Research of
two kinds could address these limitations: (a) controlled
comparisons of the ef“cacious treatments. (The latter will
need to be a very large, multi|minus|center trial; even then, it
may be dif“cult to “nd a •winnerŽ since all approaches yield
very good outcome); and (b) research that attempts to match
IBS patient characteristics to treatment. Finally, efforts to
expand the work of Heymann-Monnikes et al. (2000), who is
seeking to “nd the optimal blend of psychological treatment
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