Psychopharmacologic and Behavioral Treatments for Functional Gastrointestinal Disorders
Section snippets
Rationale for the use of psychopharmacologic and behavioral treatments
The most commonly used psychotropic agents for FGIDs are antidepressants, especially tricyclic antidepressants (TCAs). The rationale for their use in FGIDs is highlighted in Box 1. Several reviews and meta-analyses have shown that antidepressants achieve both pain reduction and global symptom improvement in IBS and other FGIDs.6 Notably, the analgesic effect appears independent of the actions on mood disturbance, and it occurs before improvement in psychological symptoms.7, 8
Second, in higher
Role of psychological factors
Psychosocial factors play a vital role in the natural history of FGIDs, being responsible for predisposition, precipitation, and perpetuation of symptoms and illness behavior. Up to three-fourths of FGID patients seeking care at tertiary care referral centers meet diagnostic criteria for a psychiatric disorder, the most common being anxiety and depression,15 though in general the prevalence is much lower for patients seen in primary care or even general gastroenterology practice.16 A history of
General Approach
The IBS and other FGIDs exist across a wide spectrum of severity. On one end are patients with mild to moderate symptoms who can be successfully treated with education, dietary and lifestyle modifications, and gut acting agents (eg, anticholinergics, peripheral 5-HT agents). On the opposite end are the 20% of patients who suffer from severe FGIDs characterized by increased levels of pain, poorer HRQOL, higher levels of health care use, more psychosocial difficulties, and a higher frequency of
General Approach
Behavioral treatments have advantages because of their safety and ability to target factors contributing to symptom perpetuation. These include modifying maladaptive illness beliefs (such as “I can never get better,” “My symptoms will lead to cancer,” etc), behaviors (such as fear-based avoidance and withdrawal from activities) called “catastrophizing,” symptom-specific anxiety (specific fears about symptoms and activities associated with symptoms), and feelings of helplessness and lack of
Combined psychopharmacologic and behavioral treatments
Fig 1 offers an algorithmic approach to the treatment of FGIDs from mild to severe, once the diagnosis is established. For the majority of patients with mild symptoms, symptomatic medical treatment (mostly gut acting agents) is warranted. Psychotropic drugs and/or psychotherapy are usually initiated with more moderate and persistent symptoms. Generally, a low-dose TCA or another antidepressant can be tried, and if the patient is motivated, psychological intervention can be considered. As the
Summary
With the evolving understanding of the etiopathogenesis and clinical manifestations of FGIDs, the use of centrally acting psychopharmacologic and behavioral treatments is expected to grow. There is evidence for the role of psychosocial factors on FGID disease processes and treatment outcomes. Although better-designed treatment trials are needed, the existing evidence favors the use of both psychopharmacologic and behavioral therapies. To enhance the therapeutic effect and improve adherence to
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Functional gallbladder disorder: Gallbladder Dyskinesia
2010, Gastroenterology Clinics of North AmericaCitation Excerpt :Evaluation of psychological conditions and treatment for visceral hyperalgesia have been proposed but not well studied20 as has the case for prokinetic agents, bile acid composition modifiers, and anti-inflammatory agents. Even though evidence-based recommendations cannot be made, the use of neuromodulators, similar to their use in other functional GI disorders, seems reasonable to consider in those with suspected functional gallbladder disorder.44 Many retrospective, generally low-quality, studies have been published that support the performance of cholecystectomy in patients with suspected functional gallbladder disorder, particularly in patients with a GBEF less than 35%.20
Comparison of fluoxetine and duloxetine hydrochloride therapeutic effects on patients with constipation-predominant irritable bowel syndrome
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All authors report no conflict of interest with regard to financial interests or affiliations with institutions, organizations, or companies as related to this manuscript, and no products or services are discussed.