Correspondence
Irritable Bowel Syndrome
N Engl J Med 1994; 330:1390-1391May 12, 1994
- Article
To the Editor:
In the review of irritable bowel syndrome by Lynn and Friedman (Dec. 23 issue),1 much is made of the pathophysiology of the symptoms and somatization, but little is made of environmental causes such as food intolerance. The literature now supports the concept that an elimination diet relieves the symptoms of the disease in approximately 50 percent of patients2,3. Interestingly, when such patients start elimination diets, many of the “soft” symptoms that suggest neuroticism also clear4.
The concept of somatization is not disprovable, whereas the concept of food intolerance is. It seems a shame to blame the patients for their disease,5 without asking whether external factors such as food intolerance could be playing a part. The role of food intolerance is being seriously underestimated.
5 ReferencesJonathan Brostoff, D.M., D.Sc.
University College London Hospitals, London W1N 8AA, United Kingdom1
Lynn RB ,Friedman LS . Irritable bowel syndrome. N Engl J Med 1993;329:1940-1945
Full Text | Web of Science | Medline2
Jones VA ,McLaughlan P ,Shorthouse M ,Workman E ,Hunter JO . Food intolerance: a major factor in the pathogenesis of irritable bowel syndrome. Lancet 1982;2:1115-1117
CrossRef | Web of Science | Medline3
Nanda R ,James R ,Smith H ,Dudley CR ,Jewell DP . Food intolerance and the irritable bowel syndrome. Gut 1989;30:1099-1104
CrossRef | Web of Science | Medline4
Hunter JO. Food intolerance in irritable bowel syndrome. In: Read NW, ed. Irritable bowel syndrome. Oxford, England: Blackwell Scientific, 1991:203-21.
5
Goudsmit E ,Gadd R . The psychologisation of illness. Psychologist 1991;4:449-453
To the Editor:
In their excellent review of the irritable bowel syndrome, Lynn and Friedman state that stress is known to exacerbate bowel symptoms and that a recent study by Guthrie et al.1 demonstrates that psychotherapy is efficacious. They hesitate to recommend psychiatric treatment, stating that further studies are needed.
A follow-up study by Guthrie et al.2 describes the psychotherapeutic treatment that the patients received in the 1991 study. These authors suggest that brief, targeted psychotherapy may be beneficial for patients with treatment-resistant irritable bowel syndrome.
Psychiatric investigators have found that 94 percent of patients with irritable bowel syndrome have a history of a major psychiatric illness3. In addition, 30 percent of these patients have a panic disorder3,4. Interestingly, 41 percent of patients with panic disorder meet the diagnostic criteria for irritable bowel syndrome5. Patients with a diagnosis of both irritable bowel syndrome and panic disorder, generalized anxiety disorder, or major depression have good control of their bowel symptoms after their psychiatric disorders are treated3.
I suggest that gastroenterologists seriously consider brief, targeted psychotherapy or psychiatric consultation for patients with treatment-resistant irritable bowel syndrome.
5 ReferencesMichael J. Tueth, M.D.
University of Florida, Gainesville, FL 326101
Guthrie E ,Creed F ,Dawson D ,Tomenson B . A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology 1991;100:450-457
Web of Science | Medline2
Guthrie E ,Creed F ,Dawson D ,Tomenson B . A randomised controlled trial of psychotherapy in patients with refractory irritable bowel syndrome. Br J Psychiatry 1993;163:315-321
CrossRef | Web of Science | Medline3
Lydiard RB . Anxiety and the irritable bowel syndrome. Psychiatr Ann 1992;22:612-618
Web of Science4
Walker EA ,Roy-Byrne PP ,Katon WJ ,Li L ,Amos D ,Jiranek G . Psychiatric illness and irritable bowel syndrome: a comparison with inflammatory bowel disease. Am J Psychiatry 1990;147:1656-1661
Web of Science | Medline5
Lydiard RB ,Fossey MD ,Ballenger JC . Irritable bowel syndrome in patients with panic disorder. Am J Psychiatry 1991;148:1614-1614
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We agree that certain foods or food-related problems can cause gastrointestinal symptoms that mimic irritable bowel syndrome. The best example is lactase deficiency, a specific disorder that should be excluded before the diagnosis of irritable bowel syndrome is considered. Furthermore, our initial recommendations to patients with irritable bowel syndrome focused on dietary modifications, including the elimination of dairy products or legumes. The food-exclusion diets used in the studies cited by Dr. Brostoff allow only “fresh meat and fish, vegetables, rice and products derived from goats, sheep or soya milk for three weeks,”1 or “a single meat, a single fruit, and distilled or spring water for one week”2. Thereafter, one food is reintroduced each day or two to identify the food that causes symptoms. This approach seems laborious and impractical. Furthermore, such dramatic dietary restrictions most likely decrease overall food consumption, which may account for the improvement in the symptoms of irritable bowel syndrome. The return of symptoms with the reintroduction of specific foods may be the result of increased food intake rather than a specific food intolerance.
Dr. Tueth agrees with us that major psychiatric illnesses such as panic disorder and depression can present with gastrointestinal symptoms suggestive of irritable bowel syndrome and that the bowel symptoms may respond to therapy directed at the psychiatric disorder. For patients with irritable bowel syndrome who do not have a major psychiatric illness, the role of psychiatric intervention in the treatment of symptoms refractory to standard therapy is not well defined, although brief, targeted psychotherapy appears to be a promising approach. However, the number of patients for whom such therapy might be indicated may be sizable, and the practicality of this approach remains to be proved.
2 ReferencesRichard B. Lynn, M.D.
Jefferson Medical College, Philadelphia, PA 19107Lawrence S. Friedman, M.D.
Massachusetts General Hospital, Boston, MA 021141
Nanda R ,James R ,Smith H ,Dudley CR ,Jewell DP . Food intolerance and the irritable bowel syndrome. Gut 1989;30:1099-1104
CrossRef | Web of Science | Medline2
Jones VA ,McLaughlan P ,Shorthouse M ,Workman E ,Hunter JO . Food intolerance: a major factor in the pathogenesis of irritable bowel syndrome. Lancet 1982;2:1115-1117
CrossRef | Web of Science | Medline
