Impact of Cognitive-Behavioral Therapy on Symptoms and Well-Being in Irritable Bowel Syndrome Patients: a Scoping Review.

doi:10.21203/rs.3.rs-5299863/v1

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Impact of Cognitive-Behavioral Therapy on Symptoms and Well-Being in Irritable Bowel Syndrome Patients: a Scoping Review.

https://doi.org/10.21203/rs.3.rs-5299863/v1

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Introduction: Irritable Bowel Syndrome (IBS) is a common gastrointestinal disorder that significantly affects patient’s quality of life. It is characterized by a complex interplay of physical symptoms and psychological stress, with notable impact on daily function. Cognitive Behavioral Therapy (CBT) has emerged as a promising intervention, targeting the psychological aspects of IBS to manage symptoms and improve life quality. Recognizing its potential and effectiveness as a treatment modality, considering the varied presentations of IBS across different populations.

Objective: To evaluate the effectiveness of CBT in the management of IBS symptoms among adults, focusing on the reduction of symptom severity, improvement in quality of life, and decrease in associated psychological distress.

Methods: This Scoping Review adopted an exhaustive search strategy across both published and unpublished literature. It began with an initial focus on databases such as PubMed, followed by a broader search across EMBASE, Scopus, the Cochrane Central Register of Controlled Trials, LiLACS (BVS), PsycArticles (PsycNet), and ProQuest.

Results: All 21 selected studies demonstrated that CBT had a positive impact on reducing abdominal pain and frequency in patients with IBS. Additionally, four studies directly assessed quality of life, showing significant improvements in this aspect.

Conclusion: The reviewed literature highlights the significant role of CBT in IBS. CBT has been shown to improve gastrointestinal symptoms, reduce psychological distress and improve quality of life. It enhances self-efficacy and coping mechanisms by addressing cognitive distortions. Studies confirm that CBT leads to better clinical outcomes compared to educational support, with neurobiological findings showing reduced limbic activity, linked to decreased anxiety and symptoms. However, access to CBT remains limited, underscoring the need to address these barriers in standard IBS care.

Psychiatry

Irritable Bowel Syndrome

Gastrointestinal Diseases

Digestive System Diseases

Functional Colonic Diseases

Symptom Management

Symptom Relief

Cognitive-Behavioral Therapy

IBS is a functional gastrointestinal disorder characterized by recurrent abdominal pain and changes in stool frequency and/or form, affecting about 3.8% of the population according to Rome IV criteria (1, 2), with the majority of cases manifesting before the age of 45 (3), hypersensitivity, altered central nervous system (CNS) processing, and disrupted gastrointestinal motility are believed to play a role (4). It is the most prevalent functional bowel disorder and a common concern in primary care, linked to heightened healthcare utilization and expenses. (4). Treatments primarily target symptom relief, as addressing the root cause often provides limited long-term results (4).

The 2021 guidelines from the American College of Gastroenterology (ACG) emphasize accurate diagnosis and subtype classification (diarrhea-predominant, constipation-predominant, mixed-type, and IBS-U) to optimize treatment, as medications may either alleviate or worsen symptoms (5). The guidelines also recommend pharmacological, dietary interventions and gut-directed psychotherapies like CBT (5). This therapy may help manage IBS symptoms by addressing cognitive and emotional triggers such as anxiety, pain catastrophizing, and stress (5).

IBS is recognized as a disorder involving gut-brain interaction, with psychological factors like depression, anxiety, and somatization influencing gastrointestinal function (6, 7). Up to 60% of IBS patients may experience psychosocial challenges (7). Dysfunction in gut-brain communication pathways may contribute to this condition, with both psychological and physiological factors playing a role (6).

Psychotherapy, especially CBT, has shown promise in IBS management, offering long-term relief (7). CBT focuses on the relationships between thoughts, emotions, and behaviors, and is widely used for conditions like depression and anxiety (8, 9). It is the most thoroughly researched form of therapy and consistently outperforms other therapeutic approaches (10). Psychological and behavioral therapies targeting the gastrointestinal system have demonstrated effectiveness in addressing gut-brain dysregulation and alleviating IBS symptoms (7, 11). This therapy influences both central and peripheral pathways, influencing pain perception, gastrointestinal hypersensitivity, and motility (11).

This review's main aim is to systematically analyze and synthesize existing research on the implementation and effectiveness of CBT in treating IBS. Specifically, this review seeks to determine whether CBT reduces abdominal pain and symptom frequency in IBS patients. Additionally, it evaluates whether CBT enhances patients' satisfaction with their bowel habits and decreases the overall impact of IBS on their quality of life. This review focuses on individuals diagnosed with IBS, assessing the effectiveness of CBT in addressing these symptoms and improving life satisfaction.

The search methodology for this scoping review followed the framework described by the Joanna Briggs Institute (JBI) Scoping Review Methodology Group and included both published and unpublished articles relevant to the research question (12). A systematic search was conducted across various databases using a combination of controlled vocabulary (MeSH and EMTREE terms) and free-text terms. Search equations incorporating these terms were applied across multiple databases, including MEDLINE (PubMed), EMBASE (EMBASE), Scopus, Cochrane Central Register of Controlled Trials (Ovid), LiLACS (BVS), and PsycArticles (PsycNet). For relevant unpublished works, the search equations were applied in ProQuest Dissertations and Theses Global (ProQuest).

Participants in the studies included in this review were required to meet specific criteria, including being adults (18+), with a confirmed diagnosis of IBS and having undergone CBT with documented outcomes. Only observational and interventional studies with full-text availability in English or Spanish were included, with no date publication restriction. Exclusion criteria ruled out studies involving participants on medications affecting intestinal function or with psychological conditions that might influence CBT outcomes. Studies involving participants with a history of drug/alcohol abuse, or not directly related to the research were also excluded. Non-peer-reviewed articles, grey literature, and documents lacking original data, such as opinions or letters to the editor, were omitted. Additionally, formats with insufficient detail were not considered for inclusion. Eligible studies included randomized controlled trials, observational, cross-sectional, and case-control studies.

Two independent reviewers initially screened studies using the Rayyan tool (13) examining titles and abstracts to identify potential inclusions. Any discrepancies were resolved through discussion or, if needed, consultation with a third reviewer. Full-text articles of potentially relevant studies were then retrieved and evaluated for final inclusion, with reasons for exclusion documented to maintain transparency. For data extraction, two reviewers independently gathered information on study characteristics, including author, publication year, design, participant demographics, intervention details, duration, frequency, outcomes assessed, and key findings. Any disagreements were addressed through consensus or, when necessary, with input from a third reviewer. The extracted data was synthesized into a narrative summary, providing a clear overview of study characteristics and findings. Results were presented using structured tables, charts, and descriptive summaries to ensure clarity and ease of interpretation regarding the effects of CBT on IBS.

All 21 studies selected showed that intervention with CBT had a positive impact in the reduction of abdominal pain and frequency in patients diagnosed with IBS.

In a randomized controlled trial by Jacobs et al. (14), it was demonstrated that CBT significantly alleviates the severity of IBS symptoms. The study aimed to explore whether initial brain and gut microbiome characteristics could predict responses to CBT and how these responses relate to alterations in the brain-gut-microbiome (BGM) axis. 84 IBS patients were selected from the IBS outcome study, undergoing brain imaging and psychological assessments at the beginning and conclusion of the study, along with fecal sample collection for microbiome analysis. The findings indicated that baseline gut microbiota and serotonin levels were linked to the effectiveness of CBT, suggesting that gut signals may play a role in influencing brain processes associated with IBS symptoms. The response to CBT was characterized by interconnected changes in brain networks and gut microbiome, indicating a potential top-down influence of the brain during treatment (14).

A different study by M. Lackner et al. (15) compared the long-term effects of CBT and IBS education in 436 patients who were randomly assigned to three groups: home-based CBT, clinic-based CBT, and IBS education. The results showed that patients receiving home-based CBT maintained symptom improvements over a 12-month follow-up, with 39% of these patients consistently reporting treatment response, compared to only 19% in the education group (p < 0.05) (15). Furthermore, symptom severity improvements were sustained, with clinically significant reductions observed post-treatment and at the 12-month mark (15). Overall, both forms of CBT provided significant and lasting relief for treatment-resistant IBS patients (15).

Another study by M. Lackner et al. found that improvements in IBS symptoms were mediated by factors such as increased self-efficacy, positive treatment expectancy, and alignment between patient and therapist on treatment goals (16). Both CBT groups exhibited rapid response rates significantly higher than the education group, indicating that both specific and non-specific processes contribute to the effectiveness of CBT in achieving and maintaining gastrointestinal symptom relief (16).

Although the 21 articles included demonstrate efficacy in reducing the symptoms of IBS through CBT, not all of them directly assessed satisfaction with symptom improvement or its impact on quality of life, instead focusing solely on symptom reduction. Only four studies directly addressed these variables.

A study involving 436 participants, conducted by Roger A. et al. in 2023 and published in Science Direct, evaluated the IBS-QOL before and after CBT treatment, showing that CBT improves the quality of life in patients with IBS. This improvement was associated with the reduction of negative thoughts and a greater sense of control over their condition (17).

Additionally, a case report was identified involving a 31-year-old Indian male who underwent eight sessions of CBT. This patient showed subjective improvement in his quality of life and a reduction in the frequency of daily bowel movements. He also experienced symptomatic relief that allowed him to expand his diet and participate in social events he previously avoided due to fear of IBS symptoms (18).

A study by Lackner J et al. (2007) explored the mediating role of psychological distress in IBS symptom reduction after CBT. Involving 147 participants diagnosed under the Rome II criteria, the study aimed to assess whether the improvement in IBS symptoms was directly due to reduced distress or through other mechanisms. Results showed small but statistically significant differences in psychological distress between the CBT and control groups (95% CI, 4.77 to 0.36). These differences were likely mediated by improvements in quality of life resulting from gastrointestinal symptom relief (95% CI, 2.57–11.53; P = .05), which in turn led to lower distress levels in the CBT group (95% CI, 0.21 to 0.05; P = .05). However, caution is needed in drawing causal inferences, as quality of life, distress, and gastrointestinal symptoms were measured simultaneously (19).

A predictive analysis by Ljótsson B. et al, involving 79 participants, investigated symptomatic changes from pre-treatment to post-treatment and from pre-treatment to follow-up, based on pre-treatment characteristics, including quality of life measured by IBS-QOL. The results showed that patients with worse baseline quality of life experienced fewer symptomatic changes, but no post-treatment IBS-QOL assessment was included (20).

Finally, five studies, while not directly measuring quality of life or satisfaction with symptom improvement, used the IBSSS scale, which includes the assessment of satisfaction with bowel habits and interference with daily activities, demonstrating improvement in these scores across all five articles.

The impact of CBT on IBS has garnered significant attention in recent research, highlighting its efficacy in alleviating gastrointestinal (GI) symptoms and associated psychological distress. CBT is recognized as a valuable intervention for IBS, particularly due to its focus on the cognitive and emotional factors that contribute to symptom severity. The evidence suggests that CBT not only improves GI symptoms but also reduces anxiety and enhances overall quality of life for patients suffering from IBS. Research indicates that CBT can lead to substantial improvements in IBS symptoms. For instance, Lackner et al. demonstrated that patients undergoing CBT exhibited significant reductions in GI symptom severity and anxiety, which are crucial in the brain-gut axis interactions associated with IBS (21). Furthermore, the improvement rates following CBT are among the highest reported in the IBS literature, often surpassing those of pharmacological treatments (21). This suggests that CBT may be a more effective long-term solution for managing IBS symptoms compared to traditional medical therapies, which typically yield lower response rates (21). The psychological underpinnings of IBS are critical to understanding the effectiveness of CBT.

Many patients with IBS present with comorbid psychiatric disorders, such as anxiety and depression, which exacerbate their GI symptoms (22). The interplay between emotional states and GI function is well-documented, with psychological disturbances influencing visceral sensitivity and motility (22). CBT addresses these cognitive factors by helping patients reframe their thoughts about their symptoms and develop coping strategies, thereby reducing the perception of pain and discomfort associated with IBS (22). This cognitive restructuring is essential, as it not only alleviates symptoms but also empowers patients to manage their condition more effectively.

Moreover, the therapeutic alliance formed during CBT sessions plays a significant role in treatment outcomes. Studies suggest that a strong therapeutic relationship can enhance treatment adherence and engagement, leading to better symptom relief (16). The expectation of positive outcomes, fostered through the therapeutic alliance, has also been shown to correlate with treatment success in various psychological interventions (16). This underscores the importance of the technical aspects of CBT and the relational dynamics between therapist and patient.

The studies consistently demonstrate the efficacy of CBT in reducing irritable bowel syndrome IBS symptoms. However, only four of the 21 studies directly evaluated the impact of CBT on quality of life and satisfaction with symptom improvement. This highlights a gap in the literature, as these aspects are crucial in assessing treatment outcomes for IBS patients. Studies that used IBS-QOL showed significant improvements in quality of life, suggesting that CBT positively affects overall well-being, beyond just symptom reduction. Larger studies, such as Roger A. et al.'s with 436 participants, as well as case reports, consistently demonstrated these benefits.

Additionally, five studies utilized the IBSSS scale, showing improvements in bowel habits and daily activity interference, but the limited focus on quality of life across studies indicates a need for further research. While symptom reduction is well-documented, the assessment of patient satisfaction and quality of life remains underreported. The existing evidence supports the positive impact of CBT on these variables, warranting further research to better capture the full therapeutic effect.

While conducting this scoping review, several limitations became apparent that may impact the overall findings. First, there was significant heterogeneity across the studies included, with considerable variation in methodologies, populations, diagnostic criteria, and interventions. This diversity made it challenging to compare results and prevented the drawing of firm, generalized conclusions. Also, as scoping reviews do not assess the quality of evidence or risk of bias, including studies with methodological weaknesses may affect the reliability of the conclusions. Another limitation was the potential for language bias, as only studies in English and Spanish were considered, possibly excluding relevant research published in other languages. Furthermore, time lag bias might have influenced the results, as newer studies or developments in the field may not have been published at the time of this review. Lastly, the scoping review’s nature emphasizes mapping the literature rather than deep analysis, limiting the ability to provide in-depth insights or specific recommendations for clinical practice.

In conclusion, the findings from the reviewed literature underscore the significant role of CBT in IBS. CBT has been shown to lead to substantial improvements in gastrointestinal symptoms and associated psychological distress, as evidenced by studies demonstrating reductions in symptom severity and anxiety levels among patients undergoing this treatment (21). The effectiveness of CBT is particularly notable in patients with comorbid psychiatric symptoms, where the therapy not only addresses the cognitive distortions related to their condition but also enhances self-efficacy and coping mechanisms (22, 16). Furthermore, the data triangulation employed in these studies strengthens the validity of the outcomes, confirming that patients who engage in CBT experience a more favorable clinical response compared to those receiving standard educational support (21). Moreover, the neurobiological underpinnings of CBT's efficacy in IBS have been explored, revealing that this therapeutic approach is associated with reduced limbic activity, which correlates with decreased anxiety and gastrointestinal symptoms (23). This suggests that CBT may not only provide symptomatic relief but also facilitate changes in brain function related to emotional processing and pain perception (23).

Despite its proven benefits, the accessibility of CBT remains a challenge, as it is not routinely available in standard care settings for IBS (22). Addressing these barriers is essential to ensure that more patients can benefit from this effective treatment modality. Overall, the evidence supports the integration of CBT into the management plans for IBS, highlighting its importance in improving both psychological and gastrointestinal health outcomes for affected individuals (21)

The authors declare no conflicts of interest. No specific funding was received for this work. No ethical approval was required for this scoping review as it did not involve human participants.

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The authors declare no competing interests.

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Impact of Cognitive-Behavioral Therapy on Symptoms and Well-Being in Irritable Bowel Syndrome Patients: a Scoping Review.

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