Psychopharmacologic and Behavioral Treatments for Functional Gastrointestinal Disorders

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Functional gastrointestinal disorders (FGIDs) are commonly seen gastrointestinal (GI) conditions that are diagnosed using established symptom-based criteria. These disorders that typically defy traditional diagnostic methods based on structural abnormalities have intrigued researchers for several decades. This has led to the emergence of the current discipline of neurogastroenterology or the study of the “brain-gut axis,” which is based on dysregulation of neuroenteric pathways as a key pathophysiologic feature of the FGIDs. Psychopharmacologic and behavioral treatments can influence the dysregulation of these pathways, especially at the severe end of the spectrum, and improve the clinical manifestations of these conditions, visceral discomfort or pain and bowel dysfunction. Their actions are mostly at spinal and supraspinal levels with some direct benefits at the level of the gut. Improvements in coping, global distress, and overall quality of life (QOL) have been shown more consistently with these treatments compared with improvement in GI symptoms. A successful approach to patients with these treatments requires a good physician–patient relationship. Strategizing treatments with these modalities is based on recognition of their dual effects on brain and gut, understanding the nature and severity of the GI symptoms and their psychosocial concomitants, and applying them within the context of the patient's understanding of their value.

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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