Diagnosis: Irritable Bowel Syndrome
Treatment: Cognitive Behavioral Therapy for Irritable Bowel Syndrome
2015 EST Status: Treatment pending re-evaluation Very strong: High-quality evidence that treatment improves symptoms and functional outcomes at post-treatment and follow-up; little risk of harm; requires reasonable amount of resources; effective in non-research settings
Strong: Moderate- to high-quality evidence that treatment improves symptoms OR functional outcomes; not a high risk of harm; reasonable use of resources
Weak: Low or very low-quality evidence that treatment produces clinically meaningful effects on symptoms or functional outcomes; Gains from the treatment may not warrant resources involved
Insufficient Evidence: No meta-analytic study could be identified
Insufficient Evidence: Existing meta-analyses are not of sufficient quality
Treatment pending re-evaluation
1998 EST Status: Strong Research Support Strong: Support from two well-designed studies conducted by independent investigators.
Modest: Support from one well-designed study or several adequately designed studies.
Controversial: Conflicting results, or claims regarding mechanisms are unsupported.
Strength of Research Support
- Basic premise: Irritable bowel syndrome (IBS) is the most common gastrointestinal disorder, affecting up to 15% of adults worldwide. Lacking a reliable biomarker, IBS is best understood from a biopsychosocial perspective. The biopsychosocial model holds that individual peripheral (e.g. genetic predisposition, altered motility, gut microbiota alterations), behavioral, and higher-order central (brain) processes (e.g. coping, illness beliefs, abnormal central processing of gut stimuli) influences IBS through their interaction with each other and with the environment (e.g. reinforcement contingencies, interpersonal stress). At the heart of the model is recognition that IBS involve a dysregulation in interactions among the cognitive and emotional centers of the central nervous system (CNS). Although alterations at any level of the brain-gut axis may result in hallmark features of symptoms of functional gastrointestinal disorders, multiple lines of evidence underscore the importance of CNS activity in modulation symptoms, particularly in more severely affected patients seen in tertiary care settings. Cognitive behavior therapy is designed to teach patients behavioral change skills that remediate skills deficits that render patients vulnerable to pain and bowel symptoms of IBS.
- Essence of therapy: The two psychological treatments for which there is the most empirical support are two “dosages” of cognitive behavior therapy. Standard CBT (S-CBT) is a skills–based training program delivered in 10 weekly, one-hour sessions in a clinic setting. Treatment involves six overlapping phases: (1) education regarding stress and its relationship to IBS; (2) self-monitoring of stressful situations associated with IBS episodes; (3) muscle relaxation exercises to increase physiological self-regulation and to cultivate a sense of self control over GI symptoms; (4) learning to identify, reevaluate, and change negatively skewed thoughts (e.g., catastrophizing) associated with IBS; (5) changing underlying “core” beliefs (e.g., perfectionism) that fuel threatening cognitions; (6) formal training in flexible problem solving to strengthen the ability to cope with realistic stressors associated with IBS. Weekly home exercises are assigned to facilitate skills acquisition. Minimal Contact CBT (MC-CBT) is a home-based version of S-CBT. It covers the same range of procedures featured in S-CBT but relies extensively on self-study materials (see Lackner, 2007, below under Self-help Books). Whereas S-CBT involves ten, 1-hour clinic visits, MC-CBT meets for only four, 60-minute clinic visits over the same period. At the first MC-CBT session, treatment is explained, self-study materials are provided and muscle relaxation and self-monitoring are introduced. The second treatment session introduces cognitive coping techniques (e.g., decatastrophizing, prediction testing). At the third session, patients learn flexible problem solving training and advanced cognitive coping skills (e.g., modifying core beliefs such as perfectionism). The fourth session introduces relapse prevention skills to help patients maintain treatment gains. Two 10-minute phone contacts are scheduled at week 3 and 7 to troubleshoot any problems. Clinic- and home-based treatments yield comparable therapeutic benefits (global IBS symptom improvement, reduced severity of IBS symptoms) both at immediate and sustained follow up although there is some evidence that home-based CBT patient gains improve over time.
- Length: approx. 4 (home-based) or 10 (clinic-based) sessions over 10 weeks.
Editors: Jefrey Lackner, Psy.D.
Note: The resources provided below are intended to supplement not replace foundational training in mental health treatment and evidence-based practice
Treatment Manuals / Outlines
Books Available for Purchase Through External Sites
- Controlling IBS the Drug-Free Way (Lackner)
Training Materials and Workshops
- Please contact the Division of Behavioral Medicine at the Jacobs School of Medicine, University at Buffalo
Measures, Handouts and Worksheets
- Clinical materials (handouts, worksheets, etc) for CBT for IBS are available in Controlling IBS the Drug-Free Way
Important Note: The books listed above are based on empirically-supported in-person treatments. They have not necessarily been evaluated empirically either by themselves or in conjunction with in-person treatment. We list them as a resource for clinicians who assign them as an adjunct to conducting in-person treatment.
- Cognitive Behavioral Therapy for IBS (Lackner)
- Self-administered cognitive behavior therapy for moderate to severe irritable bowel syndrome: Clinical efficacy, tolerability, feasibility (Lackner et al., 2008)
- Improvement in gastrointestinal symptoms after cognitive behavior therapy for refractory irritable bowel syndrome (Lackner et al., 2018)
- Durability and decay of treatment benefit of cognitive behavioral therapy for irritable bowel syndrome: 12-month follow-up (Lackner et al., 2018)
- Clinical and cost effectiveness of minimal-contact versus standard cognitive behavior therapy for irritable bowel syndrome: Results of the IBS Outcome Study (IBSOS; Dunlap et al., 2018)
Meta-analyses and Systematic Reviews
- Efficacy of psychological therapies for irritable bowel syndrome: systematic review and network meta-analysis (Black et al., 2020)
- Best management of irritable bowel syndrome (Black & Ford, 2020)
- New treatments and therapeutic targets for IBS and other functional bowel disorders (Simrén & Tack, 2018)
- Management options for irritable bowel syndrome (Camilleri, 2018)
- Canadian Association of Gastroenterology clinical practice guideline for the management of irritable bowel syndrome (IBS) (Moayyedi et al., 2019)
- Clinical practice: Irritable bowel syndrome (Mayer, 2008)
- Irritable bowel syndrome in adults: diagnosis and management (National Institute for Health and Clinical Excellence (NICE) guidelines, UK, 2017)
- Irritable bowel syndrome (Enck et al., 2016)
- Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: A systematic review and meta-analysis (Laird et al., 2017)
- Short-term and long-term efficacy of psychological therapies for irritable bowel syndrome: A systematic review and meta-analysis (Laird et al., 2016)
- Irritable bowel syndrome (Ford & Vandvik, 2012)
- Psychological approach to managing irritable bowel syndrome (Hayee & Forgacs, 2007)
- Biopsychosocial aspects of functional gastrointestinal disorders: How central and environmental processes contribute to the development and expression of functional gastrointestinal disorders (Van Oudenhove et al., 2016)
- Cognitive-behavioral therapy for irritable bowel syndrome: a meta-analysis (Li et al., 2014)
- Irritable bowel syndrome (Ford, Lacy, & Talley, 2017)
- Psychological approach to managing irritable bowel syndrome (Hayee & Forgacs, 2007)
- Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable bowel syndrome: Systematic review and meta-analysis (Ford et al., 2014)
- Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis (Lackner et al., 2004)
- Are self-administered or minimal therapist contact psychotherapies an effective treatment for irritable bowel syndrome (IBS): a systematic review (Ahl et al., 2013)
- A systematic review of minimal-contact psychological treatments for symptom management in irritable bowel syndrome (Pajak, Lackner, & Kamboj, 2013)
- Clinical practice guidelines for irritable bowel syndrome in Korea (Song et al., 2018)
- Best practice update: Incorporating psychogastroenterology into management of digestive disorders (Keefer, Palsson, & Pandolfino, 2018)
- Psychological treatments in functional gastrointestinal disorders: a primer for the gastroenterologist (Palsson & Whitehead, 2013)
Other Treatment Resources
- Factors associated with efficacy of cognitive behavior therapy vs education for patients with irritable bowel syndrome (Lackner & Jaccard, 2019)
- Cognitive behavioral therapy for IBS: How useful, how often, and how does it work? (Radziwon & Lackner, 2017)
- What Is behavioral therapy and will it help my patients with IBS? (Radziwon & Lackner, 2011)
- Coping flexibility, GI symptoms, and functional GI disorders: How translational behavioral medicine research can inform GI practice (Radziwon & Lackner, 2015)
- Psychosocial factors in the care of patients with functional gastrointestinal disorders (Naliboff, Lackner, & Mayer, 2008)
- Cognitive-behavioral therapy for patients with irritable bowel syndrome: current insights (Kinsinger, 2017)
- Rapid response to cognitive behavior therapy predicts treatment outcome in patients with irritable bowel syndrome (Lackner et al., 2010)
- Cognitive therapy for irritable bowel syndrome is associated with reduced limbic activity, GI symptoms, and anxiety (Lackner et al., 2006)
- The Irritable Bowel Syndrome Outcome Study (IBSOS): rationale and design of a randomized, placebo-controlled trial with 12 month follow up of self- versus clinician-administered CBT for moderate to severe irritable bowel syndrome (Lackner et al., 2012)