The mind as a path to comfort

When a disease is poorly understood, when it’s of a distinctly personal nature and when medication doesn’t help, there’s often little left to do but to suffer in silence.

That’s the case for the 15% of Americans -- about 25 million people -- who have irritable bowel syndrome. Although television commercials and magazine advertisements promise easy relief for a chronically misbehaving gut, many people with the condition know better. The constipation, bloating, diarrhea and gas make their lives miserable, limiting some to short excursions when they leave home at all.

Although the pharmaceutical industry is eagerly pursuing new drug treatments for irritable bowel syndrome, these potentially more effective medications are several years away. Now researchers say the best hope may be the most basic of treatments: lifestyle changes.

Experts meeting last week in Los Angeles for Digestive Disease Week, the world’s largest gathering of gastrointestinal health professionals, reported that behavior modification and dietary alterations can significantly ease symptoms of the still little-understood condition.

For example, even a brief, self-help course of cognitive behavior therapy -- in which people identify their symptoms’ triggers and learn techniques, such as relaxation and thought processes, that can alter the response -- significantly helped most patients in one study presented at the meeting. Another study found that 12 sessions of hypnotherapy reduced symptoms in many patients for at least one year.

The findings support recent theories that irritable bowel syndrome involves a communications glitch between the brain and gut. But experts disagree on whether drugs that act on the gastrointestinal tract or psychological therapies that alter thoughts and emotions will ultimately prove most beneficial.

“There is a camp totally focused on the GI tract. But there is also a lot of talk about how we’re beginning to understand the mind-body connection,” said Dr. Emeran Mayer, director of the UCLA Center for Neurovisceral Sciences and Women’s Health.

Dissatisfaction with the two medications currently approved for IBS has led to a resurgence of interest in how patients can help themselves, said Jeffrey M. Lackner, an assistant professor of medicine at University at Buffalo, State University of New York.

“At this point, there are no drugs that seem to be satisfactory for the full range of symptoms,” he said. “The real burden of IBS rests on the shoulders of patients on a day-to-day basis.”

It wasn’t long ago that many doctors doubted that IBS was a real disease. Affecting mostly women, the disorder is characterized by chronic abdominal pain and discomfort, bloating, gas, constipation and diarrhea. But there is no injury, infection or inflammation in the gut, which raised doubts about the true nature of the condition.

The word “irritable” refers to the reaction of nerve endings in the bowel wall that control muscle function and the sensations of the gut. In people with the disorder, the intestinal tract is highly sensitive, overreacting to normal events such as eating. Specific foods can set off symptoms in many patients, but strong emotions and stress are considered the most powerful triggers.

Scientists now believe this hypersensitivity is caused by abnormal levels of certain chemicals that transmit messages between the brain and gut, such as serotonin.

“Up until the last 10 years, irritable bowel syndrome was a wastebasket diagnosis. We used to think people were crazy,” said Dr. John Johanson, a gastroenterologist at the University of Illinois. “Now we’re realizing, ‘Hey, maybe there are some effective therapies out there.’ ”

The discovery of a potential biological explanation for the disorder has led to the development of two prescription drugs that focus on serotonin receptors, Lotronex and Zelnorm. Both medications, however, have been plagued with safety concerns.

Lotronex was withdrawn from the market shortly after it was approved in 2000 due to reports of life-threatening ischemic colitis, an inflammation caused by a disruption of blood flow to the large intestine.

The drug was re-approved with tighter restrictions in 2002 and is now recommended only for women with severe, diarrhea-predominant IBS who have not responded to other therapies.

Zelnorm, approved for women with constipation-predominant IBS, was approved in 2002 based on studies showing a modest improvement in symptoms. But the drug was relabeled in 2004 to warn of a rare, serious side effect involving low blood pressure. Zelnorm, too, has been linked with rare cases of ischemic colitis, but there is no evidence that the medication causes the problem.

Many patients reject the drug treatments currently available, Johanson said.

“Surveys show as many as 70% of patients have tried various medications and less than half are satisfied,” he said.

A third drug, lubiprostone (Amitiza), was approved in January for the treatment of chronic constipation in adults. A preliminary study presented last week by Johanson showed it appears to be safe and effective in IBS patients whose primary symptom is constipation.

But psychotherapies may work just as well, without side effects, to alter the communication between the brain and the gut.

Brain scans demonstrate that people with IBS react differently to emotions and stress. Specific behavioral therapies, Mayer said, can reestablish a more normal connection between the prefrontal cortex, the part of the brain that controls rational thought, and the brain’s limbic system, which responds to emotions.

“Somehow that control is strengthened during cognitive therapy,” he said.

Cognitive behavior therapy has long shown promise in helping IBS patients, but it’s hard to find therapists who offer it for IBS, said Dr. Robert Sandler, vice president of the American Gastroenterological Assn.

In addition, the therapy can be expensive and time-consuming.

In the government-sponsored behavior study presented last week, Lackner randomly assigned 59 patients to receive a 10-week, clinic-based behavioral treatment; a four-session home-based program (using a self-study workbook); or nothing.

The behavior therapy goal is to learn new ways to think about the disorder and coping behaviors. For example, patients learn muscle relaxation exercises, which can reduce stress, and how to avoid worrying about having an “attack” out in public.

Overall, 74% of the patients in the 10-week program reported moderate to substantial improvement in symptoms, but so did 73% of the patients in the quicker and less costly, four-session program. A follow-up examination of the patients after three months showed the benefits persisted. Those who got no therapy did not improve.

“People with IBS tend to think the worst,” said Lackner. “That triggers physiological and emotional reactions that aggravate symptoms. Patients need to increase their repertoire of skills so they can effectively take control of their symptoms.”

The manner in which hypnotherapy works is harder to explain, said the lead author of that study, Dr. Magnus Simren of Sahlgrenska University Hospital in Sweden.

In two studies, IBS patients were randomized to a group receiving hypnotherapy, one receiving education and visits from a nurse or no therapy at all. Just over half of the patients in the hypnotherapy group improved while the patients in the control groups did not.

“I was afraid patients would think this is hocus-pocus, but they were very open to it,” Simren said. “I think we need to address [IBS] with different kinds of therapies. We need new drugs. But we should not only focus on drugs.”