XX male syndrome

BRENDA B. TONER, ZINDEL V. SEGAL, SHELAGH D. EMMOTT, and DAVID MYRAN

Cognitive-Behavioral Treatment of Irritable Bowel Syndrome: The Brain-Gut Connection

New York: The Guilford Press, 2000, xx + 188 pp. (ISBN 1-57230-135-X, us$30.00, Hardcover)

Reviewed by DONALD BAKAL

As a health psychologist, I am dismayed by the number of individuals who find little or no relief through medical interventions for the chronic pain associated with irritable bowel symptoms. These patients have often undergone repeated surgeries and also have become dependent on a variety of gastrointestinal, mood, and analgesic medications. These are the same patients who come to be viewed as "difficult," because they seem to suffer in spite of having received repeated medical investigations and interventions. This treatment manual represents a significant step forward in improving the biopsychosocial understanding and level of care available to patients with irritable bowel syndrome (IBS). Couched in cognitive-behavioural terms, the book identifies the pathogenic schema or "toxic" thoughts that characterize individuals prone to CBS symptoms. The goal of treatment is to shift the patient from a medical view that the mBS condition is largely outside the person's control to a view that the symptoms are under significant patient control.

The authors of this remarkable book possess diverse clinical expertise in dealing with gastrointestinal symptoms, affective disorders, and cognitive therapy. Dr. Toner is an international scholar in the management of IBS, as well as an advocate of women's health. With this book, she and her colleagues are able to integrate women's health and cognitive content specific to the IBS and dysregulation of the central nervous system-- neuroenteric pathway. Douglas Drossman, a medical leader in the field of functional gastrointestinal disorders and advocate of the "brain-gut" connection, wrote the foreword.

The book, part of the publisher's series of treatment manuals for practitioners, follows an accepted format with respect to cognitive techniques and interventions (collaborative empiricism, use of questions, present focus, self-help assignments, automatic thoughts). Practitioners who are not familiar with the rationale and techniques of cognitive behaviour therapy will appreciate the detail, which is provided for implementing their program. For example, they use the CALM method of cognitive restructuring. The "M" of the mnemonic stands for "meaning" and recognizes the importance of core beliefs for understanding the origins of automatic thoughts surrounding IBS symptoms. From my experience, the power of meaning is illustrated by a female patient who developed an episode of severe abdominal pain in the presence of a male patient who was speaking in a controlling manner similar to that of a former abusive spouse.

The emnhasis on women's health makes this a unique treatment manual. Toner and colleagues have identified the negative experiences of women living and coping with IBS that need to be addressed in order to restore wellness: "...women in modern culture appear to be in a `double-bind' situation whereby in order to be seen as psychologically adjusted, they are encouraged to fulfill a gender role that is counterproductive to psychological well-being." Many of their observations apply to a number of chronic illness conditions that afflict women more frequently than men. Fibromyalgia and rheumatoid arthritis are often called women's illnesses and both these illnesses co-occur with IBS. They link the feminine gender role to both passivity and disease conviction. This of course makes it difficult to provide these patients with a belief in the power of bodily self-control and wellness. According to the authors, the greater tendency for adult males to believe in bodily control has its origins, at least in part, in the belching and farting contests practiced during adolescence. We learn, from the material presented in the book, that there are more adaptive ways to achieve self-control of sensitive physiologic systems.

The authors also point to the greater tendency of women than men to take care of others before taking care of themselves. Other related traits and life experiences given attention are nonassertiveness, pleasing others, self-silencing schema and history of emotional, physical and sexual abuse. The relationship between a history of abuse and gastrointestinal symptoms is incredibly high. Again, these attributes contribute to the high incidence of several chronic illness conditions in women.

The "guts" of the book deal with clinical application from a cognitive behavioural perspective. The format is designed for group but can easily be adapted to the individual patient. The reader is taken through a very detailed discussion of "how to" deliver cognitive therapy to IBS patients. Toner's extensive clinical and research experience with IBS patients allows the book to identify the relevant psychological and emotional issues that need attention in order to helping these individuals manage their symptoms. The clinical discussion is organized around themes of bowel performance anxiety, control, social approval, perfectionism, anger, pain, self-- efficacy, shame and self-nurturance. The detail is excellent, to the point of providing a script for the treatment rationale, as well as for challenging the common myths of treating such patients. Great pains are taken to provide health professionals with the ability to address this complicated condition in cognitive behavioural terms by understanding how to link thoughts, feelings, behavior and bowels. Instruction for monitoring automatic thoughts, hints for providing new thinking patterns, and cognitive strategies for managing pain and bowel urgency management are outlined in detail.

The book would have been strengthened by a discussion of medication, especially analgesic and bowel medications that might be having positive and negative effects on the IBS condition. By remaining loyal to the cognitive behavioural framework, they may have missed an important dimension of biopsychosocial patient care. Also, more attention to the sensory aspects of IBS symptoms (e.g., uncontrollable urges) would have strengthened the intervention. Still, this remains an excellent book and is highly recommended to all health professionals who work with patients with gastrointestinal symptoms and chronic illness conditions. The majority of potential readers might not have the need to deliver an illness-specific program of this nature but the approach is applicable to a variety of chronic illness conditions.

Brenda B. Toner is Head of the Women's Mental Health Program and Associate Professor in the department of psychiatry at the University of Toronto. She is also Head of the Women's Mental Health Research Section at the Centre for Addiction and Mental Health in Toronto.

Zindel V. Segal is Head of the Cognitive Behavior Therapy Unit at the Centre for Addiction and Mental Health in Toronto. He is also Professor in the departments of psychiatry and psychology and Head of the Psychotherapy Research for Psychotherapy Program in the Department of Psychiatry at the University of Toronto.

Shelagh D. Emmott is a clinical psychologist specializing in the cognitive behavioural treatment of irritable bowel syndrome. She is in private practice and affiliated with the Centre for Addiction and Mental Health, Clarke Division, in Toronto.

David Myran is Assistant Professor of Psychiatry at the University of Toronto and Director of the Clarke Crisis Clinic at the Centre for Addiction and Mental Health, Toronto. He is also coordinator of the Geriatric Psychiatric Community Service at Baycrest Centre for Geriatric Care.

Donald A. Bakal is Professor of Psychology at the University of Calgary and Consulting Clinical Psychologist,

Seniors' Health, at Rockyview Hospital, Calgary Regional Health Authority. He is author of The Psychobiology of Chronic Headache (Springer Publishing Co., 1982), Psychology and Health (Springer Publishing Co., 1992), and Minding the Body: Clinical Uses of Somatic Awareness (Guilford Press, 1999).

Copyright Canadian Psychological Association Aug 2000
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