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2. Functional abdominal pain syndrome Irritable bowel syndrome Chronic pain disorder (Somatoform disorders) Depressive & Anxiety disorders

3. The gut and the brain are highly integrated, and they communicate in a bidirectional fashion, largely through the (ANS) and (HPA) axis Limbic system: internal and external homeostasis of the organism central role in emotionality, which is a nonverbal system that facilitates survival, threat-avoidance, social interaction, and learning “mind/body interaction” may largely arise in this region “top-down” modulation of visceral pain and visceral perception cognitive/psychological factors, visceral perception, and motor abnormalities

4. UTMB Galveston Baker 2009 NTs for Depression NE – mostly located in the Locus Ceruleus 5-HT – mostly located in the Dorsal Raphe –Brainstem area with pathways to the neocortex and limbic system, as well as down the spinal cord 5-HT affects: Impulsivity Aggression Appetite Sex NE affects: Vigilance Motivation Anxiety Irritability Pain Mood Emotion Cog Function

5. Psychosocial correlates of Irritable Bowel Syndrome Psychosocial correlates Presence in Irritable Bowel Syndrome Psychiatric disorders High rates of psychiatric diagnoses (especially anxiety disorders) in people with IBS drawn from clinics and the population. Personality dysfunction High levels of neuroticism and low levels of extroversion characterise people with IBS drawn from clinics and the population. Childhood abuse A history of childhood sexual or physical abuse is more common in people with IBS versus controls, especially among consulters versus non-consulters with IBS.

6. Psychosocial correlates of Irritable Bowel Syndrome Psychosocial correlates Presence in Irritable Bowel Syndrome Life event stress Close association between life event stress and the onset and/or exacerbation of IBS symptoms. Coping ability Non-consulters exhibit greater coping capabilities under stress than consulters with IBS. Social support IBS patients have less social support in terms of tangible assistance compared with healthy controls.

8. Management of chronic functional abdominal pain Set the agenda Provide unambiguous information about findings Time planning: a longer planned session may save time in long run-Regular visit Identify psychosocial factors

9. Empathy Set limits for investigations Don't treat what patient doesn't have-Do not harm Encourage patient to take responsibility Med-psych interfere

10. Approach to patients: Disease or illness oriented Cognition: content, styles, questions. Emotion Function Expectation Concerns

11. Pain perception: Nociception Affect Depression Anxiety Fear Cognition Ruminations Catastrophizing Selective perception

12. Psychological Treatments: Cognitive therapy Behavioural therapy Interpersonal therapy Dynamic psychotherapy Hypnotherapy Psychological treatments should not be limited to people with co morbid psychiatric disorders. Psychological therapy already exists in routine clinical care and includes clear explanation and true reassurance, which helps patients cope better with their disorder.

13. Probability x (perceived cost) awfulness Anxiety = Perceived ability to cope + chance of help (rescue) Cognitive behavioural approach to understanding health anxiety

16. Antidepressant therapy: Psychiatric and non psychiatric disorders: e.g. neuropathic pain syndromes. The analgesic effect is independent and sooner than antidepressant effect. The time required to obtain analgesia : 1 day to 10 weeks. Drug intolerance is a rule: Start low go slow (Low doses).

17. Aware of potential adverse effects and be prepared to undertake either dosage adjustments or trials with other agents. No FDA approved antidepressant for IBS. Different kinds of ADs: TCA, SSRIs, SNRIs, MAOIs.

18. Tricyclic Antidepressants Frequently used In contrast, the effective dose range for TCAs in IBS appears to be about 30–50 (10-70) mg/day of amitriptyline or its equivalent. Unclear mechanism of action –Antihyperalgesia –Improved sleep –Normalized bowel transit –Coexisting depression/anxiety at higher doses

19. Tricyclic Antidepressants Inconsistent data on efficacy –Improved abdominal pain, global symptoms seen in some RCT’s, systematic reviews Evidence has significant limitations –Variable dosing –Small numbers –High discontinuation rates –Short duration –Poor/variable designs May exacerbate constipation –Appears dose related –Might be more beneficial in patients with diarrhea Decrease abdominal pain; no improvement in global symptoms Few head-to-head trials with SSRIs

20. SSRIs None are FDA approved for IBS Directly or indirectly affect gut function and motility. Analgesic properties. Effective in a variety of somatoform disorders and alleviate global distress. Extra intestinal symptoms. Affective memory bias towards positive material. Few RCTs of use in IBS: suggest improvement well being, pain, QOL scores

21. No superiority of one SSRIs. Among SSRIs, evidence is available for paroxetine, paroxetine CR, fluoxetine and citalopram. Target dose of SSRIs in IBS appears is in the range found to be efficacious in the treatment of depression. SSRI trials should be at least 8–12 weeks in duration of IBS.

22. If patients demonstrate clinical benefit; continue the medications for at least 6–12 months. A gradual reduction in dose: pay attention to withdrawal symptoms Close monitoring of patients for recurrence of symptoms-Withdrawal syndrome Co morbid anxiety or depression: long-term treatment with antidepressants. Failure to respond to one antidepressant, switching to another antidepressant.

23. SNRI Effective in decreasing pain in other chronic conditions No trials yet on effect in IBS Insufficient evidence to make recommendations about SNRIs (e.g. venlafaxine - doluxetine) in IBS. Mechanisms of action: SER- NE Reuptake inhibition