Whitehead W E, Crowell M D
Johns Hopkins University School of Medicine, Baltimore, Maryland.
Gastroenterol Clin North Am. 1991 Jun;20(2):249-67.
Among medical clinic patients consulting for IBS, symptoms of psychologic distress are common, and more than half of these patients are found to have a psychiatric diagnosis in addition to bowel dysfunction. Many investigators have therefore concluded that IBS is a psychophysiologic disorder and proposed that patients with IBS be treated with psychologic techniques. However, recent studies suggest that this association may be spurious; persons in the community who have symptoms of IBS but do not consult a doctor have no more psychologic symptoms than persons without bowel symptoms. This indicates that psychologic symptoms do not cause bowel symptoms, but, instead, influence which persons with bowel symptoms will consult a physician. The bowel symptoms and the psychologic symptoms that coexist in most patients with IBS may be best thought of as comorbid conditions. Neither causes the other, but both may be serious enough to warrant treatment. Moreover, in some patients whose bowel symptoms consist of vague complaints of abdominal pain not specifically related to defecation or to changes in the frequency or consistency of bowel habits, the psychologic disorder may be primary. Psychologic stress may exacerbate IBS whether or not the patient has a psychiatric disorder, and psychologic stress may trigger acute episodes of symptoms similar to those of IBS even in persons without IBS. However, the magnitude of this correlation is modest, suggesting that only about 10% of the variation in bowel symptoms is attributable to stress. Psychologically oriented treatments have a role in the management of IBS. Most patients who consult internists about bowel symptoms have significant levels of depression and anxiety, and they tend to notice and to worry about somatic complaints more when they experience these dysphoric affects. Psychologic treatments that reduce the level of their psychologic distress also frequently reduce the frequency and severity of complaints about bowel symptoms. Tricyclic antidepressants may be tried as a first line of treatment; they have been shown to be superior to placebo for the management of abdominal pain and diarrhea but not constipation. In patients who do not show an adequate response to antidepressants, brief psychotherapy focusing on better ways of coping with current problems, hypnosis, or behavior therapy emphasizing methods of controlling reactions to stress are recommended. Controlled trials show these treatment approaches to be superior to medical management alone. It may appear paradoxical that psychologic treatments aimed at the management of emotions are so frequently found to reduce bowel symptoms, because the motility disorder responsible for the bowel symptoms may be unrelated to the psychologic symptoms that influence the patient to seek treatment.+4
在因肠易激综合征（IBS）前来就诊的临床患者中，心理困扰症状很常见，并且这些患者中超过半数除肠道功能紊乱外还被诊断患有精神疾病。因此，许多研究者得出结论，认为IBS是一种心理生理障碍，并建议采用心理治疗技术来治疗IBS患者。然而，最近的研究表明这种关联可能是虚假的；社区中出现IBS症状但未就医的人，其心理症状并不比没有肠道症状的人更多。这表明心理症状不会导致肠道症状，而是影响哪些有肠道症状的人会去看医生。大多数IBS患者共存的肠道症状和心理症状，最好被视为共病情况。两者都不会导致对方，但两者可能都严重到需要治疗。此外，在一些肠道症状表现为与排便无特定关联、或与排便频率或性状改变无关的模糊腹痛主诉的患者中，心理障碍可能是主要的。无论患者是否患有精神疾病，心理压力都可能加重IBS，甚至在没有IBS的人中，心理压力也可能引发类似于IBS症状的急性发作。然而，这种相关性的程度适中，表明肠道症状的变异中只有约10%可归因于压力。以心理为导向的治疗在IBS的管理中具有作用。大多数就肠道症状咨询内科医生的患者有显著程度的抑郁和焦虑，并且当他们经历这些烦躁情绪时，往往会更注意并担心躯体不适。降低其心理困扰程度的心理治疗也常常会减少对肠道症状的主诉频率和严重程度。三环类抗抑郁药可作为一线治疗药物尝试使用；已证明它们在治疗腹痛和腹泻方面优于安慰剂，但对便秘无效。对于对抗抑郁药反应不佳的患者，建议采用聚焦于更好应对当前问题方式的简短心理治疗、催眠或强调控制压力反应方法的行为治疗。对照试验表明，这些治疗方法优于单纯的药物治疗。旨在管理情绪的心理治疗常常能减轻肠道症状，这可能看似自相矛盾，因为导致肠道症状的运动障碍可能与影响患者寻求治疗的心理症状无关。
