Efficacy of training in stress and contingency management in cases of irritable bowel syndrome

Copyright © 2006 John Wiley & Sons, Ltd.

E f f i c a c y o f t r a i n i n g i n s t r e s sa n d c o n t i n g e n c y m a n a g e m e n ti n c a s e s o f i r r i t a b l e b o w e ls y n d r o m e

Concepción Fernández*,† and Isaac Amigo

*Correspondence to: Dr Concepción Fernández,Department of Psychology, Faculty of Psychology, Uni-versity of Oviedo, Plaza Feijoo s/n, 33003 Oviedo, Spain.†E-mail: [email protected]

S t r e s s a n d H e a l t hStress and Health 22: 285–295 (2006)

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/smi.1106Accepted 24 April 2006

SummaryForty patients with irritable bowel syndrome were assigned at random to four treatment condi-tions (two experimental groups: training in stress management and training in contingency man-agement; and two control groups: medical treatment and placebo). In each of the groups (N =10), care was taken to ensure that half the cases were suitable for training in stress managementdue to the respondent nature of the illness in these cases and the other half suitable for trainingin contingency management due to the operant nature of their problem. The patients underwentsix individual sessions of specific treatment according to the condition. All of the subjects com-pleted symptom-monitoring diaries. In the post-treatment, a MANOVA of mixed factorial designwas carried out to analyse the interaction between the suitability of the patient and the type oftreatment for the global value of the symptomatology and for each symptom. The results showedthat statistically significant changes occurred depending on the interaction between suitability-treatment p < 0.1) and on the type of treatment (p < 0.05). The clinical changes recorded by thegastroenterologist were maintained after a year. An analysis is made of the behavioural predic-tors of the resolution of the patients according to suitability and the type of treatment. Copyright© 2006 John Wiley & Sons, Ltd.

must accompany it. IBS is a common condition,affecting approximately 3 to 15 per cent of thegeneral population based on various diagnosticcriteria. The proportion of IBS patients whoconsult a physician for their symptoms is around50 per cent (Cremonini & Talley, 2005). Distrib-ution according to age seems fairly homogeneousand, in general, it is more frequent in women. Theimportance of this disorder stems above all fromthe personal discomfort sufferers undergo, the highsocio-economic and medical costs, absenteeism,the taking up of general practitioner surgery time,diagnosis tests and medicine consumption (Cash,Sillivan, & Barghout, 2005). What is more,

Key WordsIrritable Bowel Syndrome; behavioural treatment; stress management; contingency management

Introduction

Irritable bowel syndrome (IBS) is a functional disorder characterized by a series of chronic and relapsing gastrointestinal and extradigestivesymptoms. It is diagnosed as a result of the pres-ence of abdominal pain and altered bowel habit

response to medical treatment to suppress symp-toms in the long term is unsatisfactory (Berstad,1998; Bijkerk et al., 2004; Kamm, 1999). Conse-quently, in recent decades medical literature hasconsidered the main aim of treatment to be toimprove the functional capacity of the patient andto achieve a sensation of well-being.

The characteristic behaviour of patientsseeking medical help has always underlined theimportance of psychological factors in the char-acterization of this disorder and consequently inits treatment. These people show symptoms ofanxiety and depression with greater frequencythan the population in general and than subjectswith organic digestive illnesses. It should bepointed out, however, that it is the subjects whomost frequently seek medical help for their diges-tive problems who have most emotional disor-ders, are most worried about their health, havethe most negative opinion of their state of healthand show most signs of illness behaviour (Barsky& Borus, 1999; Creed, 1999; Drossman et al.,2000; Folks, 2004; Lydiard & Falseti, 1999;Sweeting, 1984). In fact, a behavioural patternwhich is specific to these patients (when com-pared with organic digestive patients) has beenidentified and called ‘learned chronic illnessbehaviour’, which is characterized by continuousconcern about the illness, which becomes thesubject of many of their conversations and playsa major part in their daily activities, by a highnumber of visits to the doctor, even for banalproblems and apparent degrees of disability outof proportion with the findings of physical exam-inations (Whitehead, Winger, Fedoravicius,Wooley, & Blackwell, 1982). This idiosyncrasysuggests the importance of the role played, bothin the acquisition and maintenance of this illnessbehaviour, by personal learning about intestinalabnormalities and the achievement of attentionand benefits (Latimer, 1983). Furthermore, situa-tions of tension or stress often trigger off thedigestive symptoms in many patients (Dancey,Thagavi, & Fox, 1998).

The lack of agreement regarding the aetiologyand the physiopathololgical bases of this disorderprobably explains the high number of therapeu-tic measures tested. This fact and the fact that,very often, the therapeutic results are contradic-tory could explain the current medical consensusabout the use of combined pharmacological andpsychological treatments as the best strategy forthe treatment of IBS (Camilleri, 1999; Farhadi,Bruninga, Fields, & Keshavarzian, 2001; Paterson

et al., 1999; Svedlund et al., 1983; Thompson et al., 2001). However, it should be pointed outthat there are data which have shown the relativeefficacy of the different therapies and the superi-ority of a psychological approach as opposed toa medical one (Fernández, 2003; Lackner,Maemer, Morley, Dowzer, & Hamilton, 2004;Svedlund, 2002; Talley, Owen, Boyce, & Paterson, 1996; Toner et al., 1998). In particular,multicomponent cognitive therapy (Green &Blanchard, 1994) has proved to be an empiricallyvalidated treatment. It is, however, also a fact thatpsychological treatment is not as widely used asmight be expected in the light of these results. Forthat reason, it is of interest to analyse the relativeefficacy of the psychological therapies tested withregard to clinical or behavioural parameters. Inprevious studies (Fernández, Linares, Pérez, &Amigo, 1998) it was shown that conditions suchas anxiety, events precipitating the appearance of symptoms, illness behaviour, social attentionreceived and the type of treatment appliedshowed a clear predictive value.

Bearing in mind these results, the aims of thisstudy were, firstly, to establish which patients(depending on the respondent or operant natureof the syptomatology) were suitable to be trainedin stress or contingency management according tothe IBS behaviour model (Latimer, 1983). Sec-ondly, to analyse the relative usefulness of behav-ioural treatments and, finally, to compare theeffectiveness of both behaviour treatments withrespect to conventional medical treatment and agroup of non-specific (placebo) treatment toreduce the characteristic symptoms of IBS andimprove the quality of life of the patients.

Method

Participants

This study was carried out with the participationof 40 patients diagnosed with IBS who requestedmedical assistance in the Digestive SystemDepartment of the Central Hospital of Asturias(Spain). The IBS diagnosis included: medicalrecord, physical examination, routine laboratorytests and colonoscopy. Those patients who wereunable to carry out the psychological tests and fillin the symptom diaries as a result of their loweducational level (n = 3) or who did not want totake part in the research (n = 1) were excluded(see Table I).

C. Fernández and I. Amigo

Copyright © 2006 John Wiley & Sons, Ltd. Stress and Health 22: 285–295 (2006)DOI: 10.1002/smi

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In this sample, 70 per cent were women, sur-passing the figure of two women for every manfound in the majority of studies about the preva-lence of the disorder. With regard to age, thesample seemed to be representative of the popu-lation with IBS as described in epidemiological literature. In adult series the age of presentationis often given as young adulthood, althoughpatients may present at any age (Fielding, 1977;Minocha, Johnson, Abell, & Wigington, 2006).The average age was 48.1 ± 10.1, with a rangebetween 25 and 68 years. Most of the subjectswere married (72.5 per cent), had received basiceducation (67.5 per cent) and 45 per cent of thewomen were housewives. At least half admittedto having received psychiatric treatment beforeattending the gastroenterology surgery on thisoccasion. On average, the patients had been suf-fering from IBS for 8.55 ± 5.73 years (rangebetween 1 and 20 years), the average time beingsimilar in each treatment group. With regard to the number of times the patients had visitedthe gastroenterologist in the previous year, theaverage frequency was twice, whilst the averagenumber of admissions to the casualty departmentwas 0.45.

Therapists

Two gastroenterologists took part in the selectionof the sample and acted as blind examiners in thefollow-up and annual check-up. A single psy-chologist with clinical experience was in chargeof applying all the manualized treatments.

Assessment procedures

Semi-structured biographical interview. Theinterview was designed to gather informationregarding demographic and clinical data and pos-sible factors which might have triggered off orreinforced the symptomatology. Following thepattern of the behavioural interview (A-B-C),

the following was analysed: the behaviour of thepatients and people close to them when facedwith stressing situations of everyday life (work,family relationships, etc.) and the illness behav-iour maintained by reinforcement (visits to thebathroom, etc.). The aim was to evaluate whetherthe manifestations of IBS were of an operant orrespondent nature.

Symptom diary. The diary was used to evalu-ate the daily frequency and intensity of the symp-tomatology characteristic of IBS and to detect theprincipal problematic situations which might berelated to the increase, decrease or maintenanceof that symptomatology. Following the first inter-view, once the patients were familiar with the pro-cedure for keeping the diary, they were asked tonote down, on a daily basis throughout the treat-ment period, their symptoms and to describe thesituations in which they occurred (what activitythey were carrying out, who was present, whatmood they were in, what they were thinking atthat moment and what they did to alleviate thediscomfort).

The digestive symptoms registered were: abdo-minal pain, diarrhoea, constipation, dyspepsiaand excessive gases in the bowel. The severity ofthe symptoms was recorded according to the following scale: 0 = nothing, 1 = a little, 2 = quitea lot and 3 = a lot. For each patient the meanvalue for each symptom was calculated as well as the mean of the digestive symptoms as a whole during the baseline and during each of the weeks of the treatment. The mean for thesymptomatology in each treatment group at the same moments was also calculated. The same procedure as in Fernández et al. (1998) wasused.

Specific diaries. In each treatment condition,the therapist used specific behaviour diaries,which were used when applying the programmein accordance with the established objectives andprocedures and to know the degree to which thepatient was complying.

Irritable bowel syndrome


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Table I. Distribution of the subjects to the treatment groups.

Subjects SG CG PG MG(N = 10) (N = 10) (N = 10) (N = 10)

Subjects suited to contingency management 5 5 5 5Subjects suited to stress management 5 5 5 5

SG: stress management group; CG: contingency management group; PG: placebo control group; MG: medical treatment group.

Procedure

Once the gastroenterologist had establishedand/or confirmed the diagnosis of IBS and thepatient had agreed to take part in the study, thepsychologist arranged an interview with eachsubject. During the interview, the patient wasshown how to correctly fill out the symptomdiary and was given information about the func-tional nature of the illness. The baseline duringwhich the subjects were to fill out the diaries ona daily basis was 2 weeks. Based on these data,the functional analysis of the manifestations ofIBS for each patient was carried out and thesemanifestations were defined as either operant orrespondent. The behavioural approach to IBS, orany other clinical problem, begins with a descrip-tion of the symptomatic behaviour. What exactlyis the patient doing or experiencing that is prob-lematic, under what circumstances, where andwhen do the symptoms occur, and what are theirusual consequences? In cases where the gastroin-testinal symptoms are elicited by identifiablestimuli, they are classed as respondent. Suscepti-bility to respondent conditioning of intestinalmovements makes it possible to understandprocesses of conditioning in situations with noapparent emotional content, as in the case ofmoments which anticipate stressing conditions.However, when the functional analysis showsthat the symptoms and other manifestations ofthe illness could be learnt and are maintained byreinforcement (generally social), it is classed asoperant, especially if the symptoms do not getworse under conditions of stress. Having definedthe nature of the symptoms (operant or respon-dent), the patients were assigned at random toone of the treatment conditions. However, carewas taken to assure that each group contained anequal number of patients who were potentiallysuited to each of the experimental conditions.

Treatments. The treatments were carried out insix individual sessions at weekly intervals, eachsession lasting approximately 40min (except forthe ‘medical treatment’ control group which wascarried out according to conventional medicalprotocol).

Medical treatment control group. Thepatients assigned to this group were not subjectedto a programme of weekly visits but visited thedoctor when the doctor thought it appropriate.Nevertheless, these patients were also given the

symptom diaries to fill in at home over a periodof 6 weeks and were told that after that time anappointment would be arranged for them toundergo a medical check-up.

Placebo control group. The aim of this treat-ment was to provide the patients with treatmentwhich was credible but not specific to their symp-toms. At all times an effort was made to guaran-tee that the treatment would be credible and toreinforce the self-healing capacities of eachpatient. The patients were told that their intesti-nal problem was related to a disorder in theintestinal motility and that by using a biofeed-back device they would be able to learn to controlthe unsynchronized intestinal movement. Thiswould require training in the surgery and dailypractice at home without the biofeedback device.A ‘Tenso_Stop’ with elastic ring-shaped calibra-tors which fitted onto the fingertips was used. Thesubject was not able to see the needle of thedevice, and consequently did not know whetherhe was causing any changes. His only informa-tion about the effect of his efforts was the wordof the therapist, who, at random, sometimes said:‘You’re doing very well. Keep it up’, ‘You’re man-aging to control the intestinal motility’, whilst atother times implored the patient to ‘try to con-centrate harder and you’ll do it’. The patient wasgiven verbal encouragement at random, and was told insistently to concentrate on what hewas feeling. At no time were the patients taughtrelaxation techniques. At the end of each sessionthe patient was asked to practise at home whathe had done in the surgery and to note down (allthe subjects were given the same symptomdiaries) the degree of control which he felt he hadachieved. At the beginning of each session, thetherapist talked to the patient about the diaries,paying attention to the improvements and/orhealing strategies which the patient used (seekingdistraction, avoiding situations, etc.).

Stress management experimental group.The stress management training was carried outusing the procedure followed in Fernández et al.(1998). The patients were told about the rela-tionship between circumstances in their lives andthe worsening of their symptomatology. Theywere trained in the programme of progressivemuscular relaxation (Bernstein & Borkovec,1973) and, with each patient, a hierarchy ofstressing situations was established, which werefirst faced in their imagination and then in real



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life. The patients were also trained in self-instruction, problem-solving and were taught touse their dysfunctional behaviour as a signal toput into action successful strategies to face thereal situation. To apply the programme, the ther-apist used weekly symptom diaries, as stipulatedin the protocol of the programme.

Contingency management experimentalgroup. The training in contingency manage-ment was carried out according to the procedurefollowed in Fernández et al. (1998). The aim ofthis form of therapy was to teach the patientsand, wherever possible, other people involved intheir daily lives (relatives, friends), to put intopractice behavioural patterns which are moreappropriate to IBS symptoms and the situationswhich aggravate them and, at the same time, toavoid inappropriate behaviour (e.g. isolation,dependence, delegation, overprotection). Thebasic instrument for applying the treatment wasthe ‘contingency contract’. The programme wasapplied following an established treatment plan.In each session, a written contract was agreed toincrease the frequency of healthy behavioural pat-terns and/or replace more disruptive patterns.The patient and relatives (under the supervisionof the therapist) agreed on the contingencies towhich the objective behavioural patterns wouldbe subjected and the procedures of observationand recording. The therapist used the weeklysymptom diaries and the behavioural patternslaid down in the contingency contracts (specificfor each condition) to apply the programme inaccordance with its specific demands.

Post-treatment and follow-up. Once thepatient concluded the programme of treatment, agastroenterologist, who did not know to whichexperimental group the sample subjects had beenassigned, examined the patient and evaluatedhis/her clinical state according to the followingscale: asymptomatic (no symptoms), improve-ment (the frequency and intensity of the sympto-matology is less than 50 per cent with respect to the baseline), no change (no appreciable alterations in the frequency and intensity of thesymptomatology), worsening (the frequency andintensity of two or more symptoms is greater than50 per cent with respect to the baseline). The gas-troenterologist also asked the patient’s opinionregarding the usefulness of the treatment.

The symptoms registered in the symptom diaryduring the last week of treatment were taken as

post-treatment scores. One year after the treat-ment had finished, each patient was given anappointment to see the gastroenterologist andwas asked to undergo the same medical protocolonce again.

Data analysis

Digestive symptoms. Using the data obtainedfrom the patient’s symptom diaries a MANOVAof mixed factorial design was carried out toanalyse the interaction between suitability andtreatment in the post-treatment, taking intoaccount both the frequency of each of the diges-tive symptoms in isolation and the mean value ofsymptoms as a whole. Using Student’s t-test, themean pre- and post-treatment values were com-pared, both for the symptomatology as a wholeand for each individual symptom. Based on themedical assessment, the clinically significantchanges in each group with respect to the post-treatment and follow-up were compared usingChi-square.

Behavioural parameters. Chi-square is used tocompare the incidence of the following conditionsbefore and after the treatment: factors triggeringoff symptoms, anxiety, illness behaviour andsocial attention.

Results

Digestive symptoms

Analysis of the treatment-suitability interac-tion for the global mean of the symptoma-tology. When the interaction betweentreatment and suitability was analysed [F(3) =2.04], the level of significance obtained was p < 0.1. Consequently the simple effects analysiswas carried out and this reached statistically sig-nificant levels for stress-management treatment[F(1) = 4.8; p < 0.05].

For the digestive symptomatology mean, thetype of treatment also proved to be significant[F(3) = 2.7; p < 0.05]. When the adjusted meanvalues were observed it was seen that thosebelonging to the medical intervention group werehigher (13.1) whilst contingency managementtreatment, stress-management treatment andplacebo had lower scores (8.2, 7.6 and 8, respectively).



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Global resolution of the digestive symptoms.Table II shows the global mean for the frequencyof digestive symptoms before and after the treat-ment, showing the statistically significant differ-ences between both moments. The groups whichachieved a statistically significant decrease (p <0.05) in the digestive symptomatology were thosesuited to the type of treatment (contingency man-agement patients suited to contingency manage-ment, stress management patients suited to stressmanagement) and those subjects suited to stressmanagement treated with contingency manage-ment or with placebo. However, the groups whichwere potentially ill-suited did not prove to beeffective, with the exception of the group contin-gency management-patients suited to stress man-agement and placebo-patients suited to stressmanagement, which seems to indicate that thosesubjects who were suited to stress managementimproved even with treatments which were sup-posedly not the most suitable.

Analysis of the interaction treatment-suitability for each symptom pain. Statisticallysignificant results [F(3) = 2.76; p < 0.05] wereobtained in the interaction between treatmentand suitability, taking all the treatment sessionsas a whole. As from the third session, a differen-tial effect was shown in the contingency manage-ment treatment in favour of those suited tocontingency management (p < 0.05); and forthose patients suited to stress management whowere treated with stress management (p < 0.05).As from the fourth session an important differ-ential effect was shown in the placebo treatment

in favour of those patients suited to stress man-agement over those suited to contingency man-agement (p < 0.001). The lowest adjusted meanvalues were observed in the experimental groupscontingency management for subjects suited tocontingency management and in the group stressmanagement for subjects suited to stress man-agement, confirming the expected effect.

Diarrhoea. There were no statistically signifi-cant results for this symptom. However, therewere differences in suitability [F = (1) = 4.3; p < 0.05], indicating that those subjects who weresuited to stress management made greaterimprovement than those who were suited to con-tingency management.

Constipation. The interaction was not statisti-cally significant, but the analysis of the maineffects indicated a significantly greater improve-ment [F(3) = 2.9; p < 0.07) in favour of theplacebo, stress management and contingencymanagement with respect to the medical treatment.

Excessive gases in the bowel. The interactionbetween suitability and the type of treatment wassignificant [F(3) = 2.2; p < 0.05). As from thesecond session one could observe a differen-tial effect for the subjects in the contingency management-patients suited to contingency man-agement group and for the subjects who weresuited to stress management treated with placebo(p < 0.05). The lowest adjusted mean values wereto be found in the following groups: contingency



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Table II. Pre-treatment and post-treatment digestive symptoms scores.

Treatment Pre-treatment Post-treatment

Mean Standard deviation Mean Standard deviation t p

CC 13.09 4.00 6.20 6.10 3.64 0.05CS 11.50 6.70 6.70 8.40 3.27 0.05SC 17.00 1.50 11.30 6.00 1.45 nsSS 10.00 2.06 3.00 4.00 3.30 0.05PC 16.18 4.30 17.60 9.00 0.18 nsPS 13.80 4.40 4.70 5.60 3.06 0.05MC 15.30 7.00 13.80 9.90 0.73 nsMS 14.20 6.30 15.00 8.40 0.69 ns

CC: contingency management patients suited to contingency management; CS: contingency management patients suited to stressmanagement; SC: stress management patients suited to contingency management; SS: stress management patients suited to stress management; PC: placebo treatment patients suited to contingency management; PS: placebo treatment patients suited tostress management; MC: medical treatment patients suited to contingency management; MS: medical treatment patients suitedto stress management; ns: not significant.

management-patients suited to contingency man-agement, stress management-patients suited tostress management and placebo-patients suited tostress management, which was in line with whatwas expected.

Dyspepsia. There were no significant differ-ences in the interaction, but, following the basicassumption of this study, the lowest adjustedmean values were observed in the groups: con-tingency management-patients suited to contin-gency management, stress management-patientssuited to stress management and placebo-patientssuited to stress management. It is important tonote the worsening of the subjects assigned to themedical treatment group.

Frequency of the digestive symptoms. Thescores for the frequency of pain, constipation and excessive gases in the bowel showed signifi-cant reductions from the pre-treatment to thepost-treatment in the two ideally-suited groups:contingency management-patients suited to contingency management and stress manage-ment-patients suited to stress management. Thedyspepsia was only reduced in the contingencymanagement-patients suited to contingency man-agement group and the diarrhoea only in thestress management-patients suited to stress man-agement group (see Table III).

In subjects suited to stress management treatedwith contingency management there was a sig-nificant decrease in pain and constipation, whilstin the subjects suited to contingency managementnot treated with contingency managementtherapy there was no significant decrease in anyof the symptoms.

The placebo applied to the subjects suited tostress management training reduced the pain andexcessive gases in the bowel to a statistically sig-nificant degree. No significant decreases wereobserved in the symptoms when it was applied tothe subjects suited to contingency management.

Firstly, it was observed that in the subjectssuited to training in stress management therewere decreases in a greater number of symptomsthan in the subjects suited to training in contin-gency management when they were treated withthe therapy which was supposedly not ideal orwith the placebo. Secondly, pain was the sym-ptom which showed the greatest reduction inmost of the treatments, although it is also truethat it was the symptom which affected thesample most frequently.

Follow-up medical resolution. One year afterfinishing the treatment, the gastroenterologistassessed the subjects and observed that all thesubjects who had received the type of treatmentfor which they were considered to be suited main-tained the benefits observed in the post-treatmentor even improved. No patient got worse.

Amongst the patients suited to stress manage-ment treated with contingency management orwith placebo, those who at the end of the treat-ment had undergone a reduction in symptomsmaintained the improvement; however, the restsuffered a worsening in their condition. None ofthe subjects treated according to conventionalmedical procedures informed of changes withregard to the post-treatment.

Behavioural parameters

Precipitating factors. The subjects who weresuited to stress management training were char-acterized, obviously, by the existence of condi-tions precipitating the symptomatology, since thiswas one of the selection criteria. The mostcommon were the following: family conflicts (25per cent), time administration conflicts (25 percent) and foods or situations associated witheating (without clinical justification) (20 percent).

In those subjects suited to stress managementtraining, no statistically significant differenceswere found in the percentage of precipitatingfactors in the pre-treatment. However, in thepost-treatment, amongst the subjects whoshowed improvement there was a decrease in theappearance of precipitating conditions. This wasnot the case amongst those who did not showimprovement. As a whole, there was a significantreduction in: family conflicts, eating problems,cancerphobia (p < 0.01) and time administrationproblems and work problems (p < 0.1).

With regard to each treatment group, it wasobserved that in the post-treatment there was astatistically significant (p < 0.05) reduction in thepresence of some precipitating conditions in thethree groups which were suited to stress manage-ment and were treated with stress management(in problems of time administration, cancerpho-bia and ingestion), with contingency management(in cancerphobia) or with placebo ( in timeadministration problems and cancerphobia).

Anxiety. Anxiety was observed as a symtoma-tology precipitant in 32.5 per cent of the sample.



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Table III. Frequency of the digestive symptoms.

Treatment Pain Diarrhoea

Pre-treatment Post-treatment Pre-treatment Post-treatment

Mean Standard Mean Standard t p Mean Standard Mean Standard t pdeviation deviation deviation deviation

CC 3.2 1.6 1.6 2.3 2.06 0.1 0.8 1.3 0.8 1.7 1.63 nsCS 3.7 1.7 2.5 2.6 2.10 0.1 1.7 3.5 0.2 1.0 0.69 nsSC 6.3 0.5 4.0 2.0 0.79 ns 0.8 1.7 1.2 2.6 0.27 nsSS 2.6 2.0 1.0 1.2 2.11 0.1 2.4 2.3 0.8 0.8 2.21 0.1PC 6.3 1.1 5.6 1.5 0.60 ns 1.0 2.0 0.7 1.5 0.21 nsPS 5.2 2.0 1.5 1.7 2.92 0.05 0.5 1.0 0.0 0.0 1.71 nsMC 5.4 1.3 4.8 1.9 0.68 ns 1.0 2.2 1.2 2.6 0.12 nsMS 5.5 1.2 5.7 1.8 0.30 ns 1.0 1.1 1.2 1.5 0.12 ns

CC: contingency management patients suited to contingency management; CS: contingency management patients suited to stress management; SC: stressmanagement patients suited to contingency management; SS: stress management patients suited to stress management; PC: placebo treatment patients suitedto contingency management; PS: placebo treatment patients suited to stress management; MC: medical treatment patients suited to contingency manage-ment; MS: medical treatment patients suited to stress management; ns: not significant.

Also 42.5 per cent of subjects were shown to haveanxiety that was not directly related to the clini-cal symptoms. In the sample as a whole, no dif-ferences were found between the patients whoshowed improvement and those who did not inrelation to the presence in the pre-treatment ofanxiety when it did not act as a precipitant of thesymptoms. However, the absence of anxiety in thepost-treatment was associated with a better reso-lution of the symptomatology (p < 0.002).

When anxiety acted as a symptomatology pre-cipitant it was associated with a clinical improve-ment in the subjects suited to stress managementtraining and treated with stress management. Inthe pre-treatment this condition was present in all those patients whose symptoms resolvedfavourably in the post-treatment (p < 0.1). Ingeneral, it was shown that in all the patientstreated with stress management, regardless oftheir degree of improvement in the post-treatment, anxiety disappeared as a precipitant,which was the aim for which this treatment wasdesigned. This was not the case in the other studygroups.

Illness behaviour. The presence of learnedillness behaviour is a differential characteristic ofpatients with IBS, and, at least in the case of thestudy sample, seemed to be of some value for predicting clinical resolution. Whilst in the pre-treatment there were no significant differences inthe presence of this parameter in the sample as awhole, the presence in the post-treatment of fouror more types of illness behaviour seemed to berelated to an unfavourable prognosis (p < 0.05).However, the absence in the post-treatment of

manifestations of pain, and the loss of reinforce-ment of illness behavior, was associated with animprovement with a significance level of p <0.001; the significance was of p < 0.05 when areduction in activity and avoidance of situationswere not present at the conclusion of the treat-ment, and of p < 0.1 with regard to delegatingwork.

Amongst the subjects who received contin-gency management training, regardless of theirsuitability, those whose symptoms resolvedfavourably still showed signs of illness behaviourin the post-treatment (despite the fact that the aimof the treatment was to change that behaviour),whilst none of the subjects who improved showedsigns of illness behaviour in the post-treatment. Itwas those patients who were suited to contin-gency management training who showed leastsigns of illness behaviour in the post-treatmentwhen they received the treatment.

Social attention. The social attention receivedprevious to the treatment was not a parameterwhich could be related to clinical resolution.However, receiving social attention in the post-treatment was directly related to unfavourableclinical resolution (p < 0.005). In particular, in thegroup of subjects suited to contingency manage-ment training, all of the subjects who did notimprove were receiving attention for their illnessbehaviour at the end of the treatment. This wasnot the case amongst those whose symptomsresolved favourably. The subjects who receivedcontingency management training were the oneswho were best able to eliminate social attentionin the post-treatment although it was not possi-

ble (despite this being the aim of the treatment)in all cases.

Discussion

The subject samples that took part in this studywere assigned to four therapeutic groups: stressmanagement training, contingency managementtraining, conventional medical treatment andplacebo treatment. In turn, each group was sub-divided into two groups depending on whetherthe patients were better-suited to training in stressmanagement or in contingency management,according to whether their symptomatology wasof a respondent or operant nature. The effective-ness of these treatments has already been proved(Bennett & Wilkinson, 1985; Blanchard &Scharff, 2002; Blanchard, Greene, & Scharff,1993; Blanchard, Schwarz, & Neff, 1988; Blanchard, Schwarz, & Suls, 1992; Drossman et al., 2003; Fernández et al., 1998; Heymann-Monnikes et al., 2000; Lynch & Zamble, 1989;Neff & Blanchard, 1987; Payne & Blanchard,1995; Rumsey, 1991; Shaw, Srisvistava, & Sadlier,1991; Toner et al., 1998; van Dulmen et al.,1996). It is for that reason that the aim of thisstudy was to show the specificity of behaviouraltreatment for the different types of IBS patients,as has been shown in some previous studies(Boyce, 2001; Dancey et al., 1998; Drossman etal., 2000; Fernández et al., 1998) and also thebehavioural model of IBS itself (Latimer, 1983).The results obtained confirmed the efficacy andspecificity of the behavioural methods used in thisstudy in the treatment of IBS.

The post-treatment and follow-up effectivenessof both behavioural treatments suggests (withoutforgetting that the reduced number of subjects inthis study limits the generalization of the results)the presence of individual and behavioural char-acteristics which, indeed, affect whether stressmanagement or contingency management treat-ment is more suitable. The presence of illnessbehaviour and social attention makes contin-gency management treatment particularly recom-mendable, as no other therapy was successful ineliminating these conditions. Furthermore, thepresence of illness behaviour seems to have a clearpredictive value regarding clinical resolution. Notonly was it the case that the reduction or elimi-nation of illness behaviour and social attentionalways led to clinical improvement, but also, inthe cases where it was not possible to modify this behaviour, there was no decrease in the diges-tive symptoms. Similarly, the presence of illnessbehaviour amongst patients whose symptomatol-ogy was directly provoked by specific events wasalways related to a worse clinical resolution. Con-tingency management treatment was also shownto be useful in reducing precipitants amongstpatients suited to stress management, whichcould be explained by the fact that contingencymanagement implies replacing situations ofanxiety with alternative behavioural patterns.

With regard to stress management treatment,the success of the treatment seems to lie in itsspecificity for resolving the emotional nature ofthe symptomatic manifestations of IBS. When itwas applied to subjects suited to contingencymanagement it did not relieve any of the symp-toms. However, the stress management treatment



293

Constipation Dyspepsia Gases

Pre-treatment Post-treatment Pre-treatment Post-treatment Pre-treatment Post-treatment

Mean Standard Mean Standard t p Mean Standard Mean Standard t p Mean Standard Mean Standard t pdeviation deviation deviation deviation deviation deviation

2.4 3.2 0.6 0.8 0.08 0.1 2.4 3.0 1.0 1.7 1.89 0.1 3.8 3.4 2.2 2.2 1.46 0.12.2 2.6 1.2 1.8 0.77 0.1 1.0 1.7 0.8 1.7 0.27 ns 1.7 2.2 1.5 2.3 0.80 ns2.6 2.5 1.6 1.5 0.64 ns 2.4 3.3 1.2 2.1 0.83 ns 2.3 4.0 1.6 2.8 0.23 ns1.2 0.8 0.4 0.8 2.14 0.1 1.6 2.0 0.6 1.3 1.06 ns 1.6 1.5 0.2 0.4 2.07 0.14.6 4.0 3.3 3.5 0.43 ns 1.0 1.7 2.3 4.0 0.53 ns 3.5 3.0 4.0 2.9 0.36 ns1.5 3.0 0.5 1.0 1.15 ns 2.4 2.5 1.2 2.1 0.95 ns 3.2 2.7 1.2 1.8 2.18 0.12.6 1.8 2.6 2.4 0.05 ns 2.2 3.0 2.2 3.0 0.09 ns 3.4 2.7 3.0 3.6 0.32 ns2.4 2.6 2.4 2.8 0.12 ns 1.5 1.9 2.0 2.8 0.21 ns 2.2 3.0 2.4 3.2 0.05 ns

was the only one which managed to reduceanxiety in all the cases where it was applied, inde-pendently of the potential ideal suitability of thepatients. It should be stressed that when anxietyacted as a precipitant of the symptomatology andthe patient did not have a consolidated illnessbehaviour, the condition was always related toshort- and long-term clinical improvement. In anycase, patients of this type were the ones whosesymptoms resolved best with any therapy, exceptwith conventional medicine.

The effectiveness of the placebo treatment inreducing digestive symptoms can also be relatedto the characteristics of the subjects. In fact, the placebo proved to be effective in the post-treatment for three of the five subjects who weresuited to stress-management and for only onesubject amongst those suited to contingency man-agement. With regard to the follow-up, it was noteffective for subjects suited to contingency man-agement but was effective for two of the subjectssuited to stress management. Neither of the subjects whose symptoms resolved favourablyshowed signs of illness behaviour or receivedsocial attention as a result of the symptoms. Thefact that the placebo was effective exclusively inthose patients suited to stress-management whodid not show the consolidated illness behaviouralpatterns might be explained by the fact that thetreatment encouraged the subjects to use theirown resources to reduce the physiologicalresponse and to face up to the precipitating con-ditions. It is also true that although this treatmentwas defined as placebo because of its unspecificnature, from a behavioural point of view it is notunspecific at all as it helps in the patient’s under-standing of the nature of the problem.

Finally, an important aspect of these results isthat they show the usefulness of the idea ofassigning IBS patients to a specific type of psy-chological treatment depending on determinedpersonal and behavioural parameters. The devel-opment and putting into practice of a reliableevaluation protocol which could involve the gas-troenterologist in the elaboration of a diagnosisand be used as a basis for therapeutic guidelines,even if it involved many patients being referredfor psychological treatment, would lead, withoutdoubt, to a reduction in the extremely high costsboth in terms of health care (diagnostic tests,surgery time, medicines) and social costs (workabsenteeism) produced by digestive functional ill-nesses as a result of how widespread they are. Itshould not be forgotten that unsolved digestive

problems result in a high percentage of patientsbeing passed from one medical department toanother and that this itself is, to a large extent,contributing to the chronification of the problemin as much as it reinforces learned chronic illnessbehaviour, which is clearly associated with aworse clinical resolution.

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Efficacy of training in stress and contingency management in cases of irritable bowel syndrome