Outcome studies and meta-analyses reveal that psychological treatments such as hypnotherapy and cognitive-behavioral therapy (CBT) are effective in treating somatic symptoms in adults with functional gastrointestinal (GI) disorders (1,2). Preliminary research suggests that improvements achieved with psychological treatments are similar to (or possibly greater than) those obtained with gut-directed pharmacological treatments. Especially interesting, preliminary research suggests that CBT may have direct effects on GI symptoms, independent of psychological distress (3).
Among children and adolescents with functional abdominal pain or irritable bowel syndrome, initial case studies and retrospective reviews suggested effectiveness of cognitive and behavioral interventions, (4–8) and recent randomized trials (using standard pediatric care as the control group intervention) provide more robust evidence for the effectiveness of psychological treatments (9–14). Cognitive behavioral techniques not only have direct effects on symptoms but also promote self-efficacy by increasing the child's ability to self-manage symptoms. Although parents may need an initial explanation to understand how the techniques can alter physiological function to provide symptom relief, some parents are pleased to avoid medications and their possible side effects. Psychological management strategies include parent training, family interventions, psychotherapy/CBT, relaxation, distraction, hypnotherapy/guided imagery, and biofeedback.
Parent training and family therapy approaches are used to facilitate acceptance of a rehabilitation approach to treatment, alter family patterns that maintain disability or exacerbate symptoms, help parents learn to better tolerate distress, and develop behavioral plans that support the child's self-management of symptoms and independent functioning.
Psychotherapy is used to reduce somatic and psychological symptoms, improve coping and functioning, improve communication and problem solving, and reduce stress load. CBT refers to psychotherapy focused on achieving these goals by modifying unhelpful cognitions, assumptions, beliefs, and behaviors. Techniques may include developing a biopsychosocial view of symptoms; keeping a diary of symptoms and associated events, feelings, thoughts and/or behaviors (to identify triggers and outcomes that could be targeted for intervention); learning relaxation and distraction techniques; questioning cognitions, assumptions, and beliefs that may be unhelpful or unrealistic and trying new ones; and gradually facing activities that may have been avoided.
Relaxation techniques, such as progressive muscle relaxation and controlled breathing, can directly alter pain perception by facilitating a relaxation response (including muscle relaxation, reduced heart rate and blood pressure, and improved mood). Distraction techniques shift attention away from pain and have been shown to increase pain tolerance and decrease pain perception. Distraction techniques vary widely but include formal interventions such as hypnotherapy/guided imagery or everyday distracters like games, television, or school. Some distracters, such as school, can also improve functioning and decrease distress by helping the child gain mastery over difficult situations.
Hypnotherapy and guided imagery can focus attention away from symptoms, alter sensory experiences, reduce distress, induce relaxation, reframe symptom experiences, facilitate dissociation from pain, and enhance feelings of mastery/self-control. These techniques can also be used to solve problems (eg, to imagine being calm during a test) and to feel a sense of accomplishment. “Gut-directed” hypnotherapy, which includes gut-specific treatments and suggestions, was developed for individuals with irritable bowel syndrome and digestive disorders. It includes gut-specific treatments and suggestions.
Biofeedback uses a computer paired with controlled breathing, relaxation, or hypnotic techniques. The computer generates a visual or auditory indicator of the child's muscle tension, peripheral skin temperature, or anal control, allowing the child to have external validation of the physiological changes he or she has produced using the techniques.
Future research on cognitive behavioral treatment of childhood functional GI disorders would benefit from direct comparison of efficacy of psychological compared to medication treatments. If both are found to be equally effective, then research designs may then shift to optimizing combinations of cognitive, behavioral, and medication treatments to maximize effectiveness and patient satisfaction. Research on mechanisms of change will require inclusion of specific and repeated measures of dysfunction, such as anxiety sensitivity, vigilance, pain catastrophizing, self-efficacy, physiological measures, and imaging to test theoretical models. Additional recommendations for future research include the inclusion of comorbid psychopathology, standardized inclusion and exclusion criteria, and standardized outcome measures of childhood pain and functioning.
1. Whitehead WE. Hypnosis for irritable bowel syndrome: the empirical evidence of therapeutic effects. Int J Clin Exp Hypn 2006; 54:7–20.
2. Lackner JM, Mesmer C, Morley S, et al
. Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis. J Consult Clin Psychol 2004; 72:1100–1103.
3. Lackner JM, Jaccard J, Krasner SS, et al
. How does cognitive behavior therapy for irritable bowel syndrome work? A mediational analysis of a randomized clinical trial. Gastroenterology 2007; 133:433–444.
4. Anbar R. Self-hypnosis for the treatment of functional abdominal pain in childhood. Clin Pediatr 2001; 40:447–451.
5. Miller AJ, Kratochwill TR. Reduction of frequent stomach complaints by time out. Behav Ther 1979; 10:211–218.
6. Sank LI, Biglan A. Operant treatment of a case of recurrent abdominal pain in a 10 year old boy. Behav Ther 1974; 5:677–681.
7. Youssef NN, Rosh JR, Loughran M, et al
. Treatment of functional abdominal pain in childhood with cognitive behavioral strategies. J Pediatr Gastroenterol Nutr 2004; 39:192–196.
8. Duarte MA, Penna FJ, Andrade EM, et al
. Treatment of nonorganic recurrent abdominal pain: cognitive-behavioral family intervention. J Pediatr Gastroenterol Nutr 2006; 43:59–64.
9. Hicks CL, von Baeyer CL, McGrath PJ. Online psychological treatment for pediatric recurrent pain: a randomized evaluation. J Pediatr Psychol 2006; 31:724–736.
10. Humphreys PA, Gevirtz RN. Treatment of recurrent abdominal pain: components analysis of four treatment protocols. J Pediatr Gastroenterol Nutr 2000; 31:47.
11. Robins PM, Smith SM, Glutting JJ, et al
. A randomized controlled trial of a cognitive-behavioral family intervention for pediatric recurrent abdominal pain. J Pediatr Psychol 2005; 30:397–408.
12. Sanders MR, Shepherd RW, Cleghorn G, et al
. The treatment of recurrent abdominal pain in children: a controlled comparison of cognitive-behavioral family intervention and standard pediatric care. J Consult Clin Psychol 1994; 62:306–314.
13. Weydert JA, Shapiro DE, Acra SA, et al
. Evaluation of guided imagery as treatment for recurrent abdominal pain in children: a randomized controlled trial. BMC Pediatr 2006; 6:29.
14. Vlieger AM, Menko-Frankenhuis C, Wolfkamp SC, et al
. Hypnotherapy for children with function abdominal pain or irritable bowel syndrome: a randomized controlled trial. Gastroenterology 2007; 133:1430–1436.