Comprehensive self-management for irritable bowel syndrome: randomized trial of in-person vs. combined in-person and telephone sessions.

OBJECTIVES: Psychological and behavioral therapies are being increasingly used for symptom management in patients with irritable bowel syndrome (IBS). The aims of this study were to compare two delivery modes for a comprehensive self-management (CSM) intervention, primarily by telephone vs. entirely in person, and to compare each with usual care (UC). METHODS: Adults with IBS were recruited through community advertisement. Subjects (N=188) were randomly assigned to three groups: one in which all nine weekly CSM sessions were delivered in person, one in which six of the nine sessions were conducted over telephone, and one in which subjects received UC. Primary outcome measures were a gastrointestinal (GI) symptom score based on six symptoms from a daily diary and disease-specific quality of life (QOL). These and other outcomes were assessed at baseline and at 3, 6, and 12 months after randomization. Mixed model analyses tested for differences between the three groups in each outcome variable at the three follow-up occasions, controlling for the baseline level of each outcome. RESULTS: Both GI symptom score and QOL showed significantly greater improvement in the two CSM groups than in the UC group (P<0.001), with the magnitude of this difference being quite similar for the three follow-up time points. The two CSM groups experienced a very similar degree of improvement, and there were no statistically significant differences between the two. CONCLUSIONS: A CSM program is efficacious whether delivered primarily by telephone or totally in person, and there is no evidence that replacing six of the in-person sessions by telephone sessions reduces the efficacy of the intervention.

Gender differences in gastrointestinal, psychological, and somatic symptoms in irritable bowel syndrome.

In the United States, more women than men seek health-care services for symptoms of irritable bowel syndrome (IBS). A number of explanations are given for this gender difference including the higher rates of somatic non-gastrointestinal symptoms and increased psychological distress reported by women with IBS. However, these gender differences are found in studies that rely on retrospective recall with little attention to age or reproductive status. The purpose of the current analysis was to prospectively compare the frequency (days/month of moderate to severe based on a daily diary) of somatic, gastrointestinal (GI), and psychological distress symptoms, in menstruating women (N = 89) and postmenopausal women (N = 66) to men (N = 32) with IBS. In addition, the correlation between daily symptoms and daily report of overall health was evaluated. Postmenopausal women reported significantly more GI pain/discomfort symptoms, especially bloating and abdominal distension, than men, however these differences are greatly attenuated when age is controlled for. Both postmenopausal and menstruating women reported significantly more somatic symptoms (especially joint pain and muscle pain) than men with IBS. The effect was stronger in postmenopausal women, whose somatic symptoms were also higher than menstruating women (P = 0.014). Fatigue and stress were higher in women than men but anxiety and depression were not. All three types of symptoms were strongly correlated with self-rating of health, both across and within-person. Gender-related differences in GI and somatic symptoms are apparent in persons with IBS, more strongly in postmenopausal women. The presence of somatic symptoms in postmenopausal women with IBS may challenge clinicians to find suitable therapeutic options.

Daily stress and gastrointestinal symptoms in women with irritable bowel syndrome.

BACKGROUND: Stress has been implicated as contributing to the initiation and exacerbation of bowel and discomfort symptoms in patients with irritable bowel syndrome (IBS). OBJECTIVE: To examine the relationships of daily self-reported stress to gastrointestinal (GI) and psychological distress symptoms both across women and within woman in a comparison group of women without IBS and among subgroups of women with IBS. METHODS: Women with IBS (n = 181; age = 18-49 years) who were divided into subgroups based on bowel pattern (constipation, n = 52; diarrhea, n = 67; alternating, n = 62) were compared to a group of women without IBS (n = 48). Self-report stress measures; abdominal (abdominal pain, bloating, and intestinal gas), bowel pattern (constipation, diarrhea), and intestinal gas; and psychological (anxiety and depression) distress symptoms were obtained daily over 1 month. Across-women and within-woman analyses were used. RESULTS: There were significant across-women correlations among mean daily stress, psychological distress, and GI symptoms in the total IBS group and the IBS bowel pattern subgroups. The across-women relationships between daily stress and GI symptoms were diminished when anxiety and depression were controlled in the analyses. Within-woman analyses showed little evidence of relationship between day-to-day variations in stress and day-to-day variations in GI symptoms; however, stress was strongly related to anxiety and depression. DISCUSSION: Gastrointestinal symptom distress is associated with self-reported stress in women with IBS. Psychological distress moderates the effects of stress on GI symptoms. The IBS treatment protocols that incorporate strategies that decrease stress and psychological distress are likely to reduce GI symptoms.

Stress, stress response, and health.

Components of stress and the stress response differ between men and women. The tend-and-befriend response, mediated by oxytocin and endogenous opioids, may be more applicable to women than the fight-or-flight response, which was based largely on studies of men. Even within the flight-or-flight response pattern there are sex-based differences. The HPA axis interacts with reproductive function, such as menstruation. For immune function there are sex differences as well as differences within the menstrual phase. Inclusion of men and women in stress response studies is critical. Further study is needed to clarify the influence of ovarian hormones on the stress and immune responses during the reproductive stages in women's lives, including menarche. pregnancy, and perimenopause.

Natural killer cell cytotoxicity: a methods analysis of 51chromium release versus flow cytometry.

The purpose of this study is to describe design considerations for the use of flow cytometry (FC) compared to 51chromium (51Cr)-release assays utilizing cryopreserved peripheral blood mononuclear cells (PBMCs) to detect natural killer (NK) cell cytotoxicity. Subjects were 10 healthy women aged 18 to 39 years. Intra-assay variability between methods differed only at the lowest effector-target ratios evaluated. Interassay variability was wide but did not differ between methods. The relationship of lytic unit-10 between methods was strongly positive. Cytotoxicity detected by 51Cr release was higher than that detected by FC for all 10 subjects. Cost was comparable. However, had more assays been performed, technician time would have been greater with flow cytometry. More whole blood was needed to perform the flow cytometry cytotoxicity assay than 51Cr-release cytotoxicity assay. The authors found no compelling reason to adopt NK cell cytotoxicity by flow cytometry over 51Cr release.

Sense of coherence and quality of life in women with and without irritable bowel syndrome.

BACKGROUND: Despite ongoing physical and psychological distress, little is known about sense of coherence (SOC) and holistic quality of life (QOL) in women with irritable bowel syndrome (IBS). OBJECTIVES: The purposes of this study were to (a) describe and compare SOC and holistic QOL of women with and without IBS, and (b) examine the relationships among SOC, holistic QOL, and gastrointestinal (GI) and psychological distress symptoms. METHOD: A two-group comparison design was used to test the study hypotheses that women with IBS would have lower SOC and holistic QOL than control women without IBS, and that SOC and holistic QOL would be inversely related to GI and psychological distress. A total of 324 women were studied (n= 235 with IBS, n= 89 controls). Measures included the 13-item SOC Questionnaire, Modified Flanagan QOL Scale, Bowel Disease Questionnaire, and Symptom-Checklist-90-R. RESULTS: Both SOC and holistic QOL were lower in women with IBS (p <.001). Correlations between SOC and global distress, depression, anxiety, and somatization without GI symptoms were moderately and inversely related (r= -.64, -.64, -.53, and -.31, respectively; p <.001) in the total sample. Relationships between holistic QOL and psychological distress indicators were universally of lower magnitude (r= -.56 to -.27, p <.001). The only GI symptom indicator significantly related to SOC and holistic QOL was alternating constipation and diarrhea (tau= -.21 and -.17, respectively; p <.001). DISCUSSION: Women with IBS have a reduced SOC and holistic QOL when compared to women without IBS. It remains to be determined whether interventions targeted at enhancing SOC and holistic QOL can impact the psychological distress associated with IBS.

Anxiety and depression are related to autonomic nervous system function in women with irritable bowel syndrome.

This study compared women with irritable bowel syndrome who had a history of an anxiety or depressive disorder to those without symptoms of either disorder on indicators of cardiac parasympathetic activity, autonomic nervous system balance, and general autonomic activity. The Diagnostic Interview Schedule was used to determine anxiety or depressive disorders, and a Holter monitor was used to record R-R intervals over 24 hr. A similar comparison was done with healthy controls. Among women with irritable bowel syndrome, those with a positive history had lower parasympathetic and general activity throughout the 24-hr period than did women without a diagnosis. Indicators of autonomic balance were slightly higher in women with a positive history compared to those without a history. Similar differences were seen in controls. Thus, a history of anxiety and depressive disorders is associated with lower parasympathetic activity, both in women with IBS and healthy controls. Further exploration is needed to understand if lower parasympathetic activity influences the pain and stool pattern changes seen in persons with irritable bowel syndrome.

Symptoms across the menstrual cycle in women with irritable bowel syndrome.

OBJECTIVE: The purpose of this study was to describe the patterns of GI, somatic, and psychological symptoms across the menstrual cycle in women with irritable bowel syndrome, and to determine whether symptoms differed by oral contraceptive use or predominant bowel pattern. METHODS: A daily diary was used to assess symptoms across one menstrual cycle. Repeated-measures analysis of covariance, controlling for age and body mass index, was used to compare patterns of symptoms across the menstrual cycle by oral contraceptive use and predominant bowel pattern (diarrhea, constipation, alternating). Data from control women are presented for comparison. RESULTS: For somatic and psychological as well as GI symptoms, women with irritable bowel syndrome had higher symptom severity than did controls. Women with irritable bowel syndrome using oral contraceptives had lower cognitive, anxiety, and depression symptoms (p < 0.05, but not significant after multiple comparison adjustment), but no differences were seen for most symptoms of irritable bowel syndrome. All symptoms except diarrhea were highest in the alternating group and lowest in the diarrhea group, with the constipation group either intermediate or close to the alternating group. This pattern was significant after multiple comparisons adjustment for GI symptoms, and trending toward significance (p < 0.05, but not significant after multiple comparison adjustment) for menstrual, sleep, and cognitive symptoms. The strongest menstrual cycle effect was seen in somatic and menstrual symptoms. The pattern of symptoms over the menstrual cycle did not differ by predominant bowel pattern or by oral contraceptive use. CONCLUSIONS: Many of the symptoms examined differed by predominant bowel pattern and menstrual cycle phase, not just the GI symptoms. The menstrual cycle variation was similar regardless of oral contraceptive use or predominant bowel pattern.