Controlling the Pain
by Mark Derewicz
Cognitive behavior therapy and antidepressants for IBS.
Hypnosis is one way to treat irritable bowel syndrome (IBS), but it’s not the only way. Douglas Drossman
found that cognitive behavior therapy and in some cases antidepressant medication can help just as much.
In one study, Drossman found that antidepressants helped IBS patients feel much better 75 percent of the time, as long as patients took the medication for the prescribed duration. Cognitive behavior therapy — individualized sessions with a clinical psychologist — worked 77 percent of the time.
So how can three different treatments help alleviate symptoms for a complex syndrome that affects patients in many different ways? These three treatments may actually do the same thing — help the brain regulate discomfort.
Drossman says that the brain doesn’t just interpret pain; it can actually control pain. A good example, he says, is a basketball player who sprains an ankle but doesn’t feel the severity of the sprain until after the game. “The brain, through focused attention and other factors, can send down signals to block the pain,” Drossman says.
Antidepressants were developed to treat major depression, but they also enhance pain control areas of the brain, which is why doctors use them to treat chronic migraines, diabetic neuropathy, and fibromyalgia. For IBS patients, small doses of certain antidepressants can block pain signals that travel between the gastrointestinal tract and the brain at the level of the spinal cord. In effect, Drossman says, this can help reset normal neurological brain-gut function.
But doctors have to be careful which drugs they choose. Primary serotonin drugs such as Zoloft and Prozac won’t relieve pain as much as other types of antidepressants, Drossman says. But they could help with stress and anxiety, which can aggravate IBS symptoms in some people. Drossman says that tricyclic antidepressants such as desiprimine and newer Serotonin and Norepinephrine Re-uptake Inhibitor drugs such as duloxetine alleviate pain better. In a small population of patients, tricyclic antidepressants can cause side effects such as dry mouth, blurry vision, and fatigue. Duloxetine can cause nausea.
Drossman says patients who experience mild, infrequent IBS symptoms should first try eating smaller meals and exercising more, and just waiting until the body adjusts to the medication. If symptoms do not improve or worsen and become more frequent, patients might need cognitive behavior therapy, hypnosis, or other medication. And for the most severe IBS cases, where emotional abuse or deep psychological problems likely play significant roles, he says, all three therapies might be necessary. For psychological treatment, patients should try to find a therapist who is skilled in working with people who have IBS or other GI disorders.
Douglass Drossman is co-director of the UNC Center for Functional GI and Motility Disorders. He receives funding from the National Institutes of Health.
