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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 26-32

The effectiveness of emotional schema therapy on psychological symptoms of patients with irritable Bowel syndrome


1 Department of Psychiatry, Tehran University of Medical Science, Tehran, Iran
2 Psychosomatic Medicine Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
3 Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication3-Apr-2018

Correspondence Address:
Arefeh Erfan
Department of Psychiatry, Tehran University of Medical Science, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jepr.jepr_46_16

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  Abstract 


AIM: positive and negative emotional states are the most important factors in the process of treatment and prevention of psychosomatic diseases. This research aimed to investigate the effectiveness of emotional schemas therapy on the reduction of psychological symptoms of patients with irritable bowel syndrome (IBS).
METHODS: This research was implemented in the framework of single-subject experimental design using of stepwise multiple-baselines plan. Five patients with IBS were selected as convenience sampling on the base of the participation willingness of individuals to the research then received emotional schema therapy (EST). Research tools included ROME III scale, semi-structured interview for making DSM-IV interview, and depression, anxiety, and stress scale (DASS-21) questionnaire. The analysis of data was done using visual analysis charts, recovery percentage, and reliable change index.
RESULTS: The results showed patients that received EST detected decrease of the scores in DASS-21 rate than baseline (P ≤ 0.05).
CONCLUSIONS: EST decreases psychological symptoms of patients with IBS. Therefore, it can be proposed as an alternative therapy or together with other therapies for these patients.

Keywords: Emotional schemas therapy, irritable bowel syndrome, psychological symptoms


How to cite this article:
Erfan A, Noorbala AA, Mohammadi A, Adibi P. The effectiveness of emotional schema therapy on psychological symptoms of patients with irritable Bowel syndrome. Int J Educ Psychol Res 2018;4:26-32

How to cite this URL:
Erfan A, Noorbala AA, Mohammadi A, Adibi P. The effectiveness of emotional schema therapy on psychological symptoms of patients with irritable Bowel syndrome. Int J Educ Psychol Res [serial online] 2018 [cited 2020 Jul 4];4:26-32. Available from: http://www.ijeprjournal.org/text.asp?2018/4/1/26/229136




  Introduction Top


Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders throughout the world. The prevalence of the disease in the general population has been reported between 1.1% and 29.2%.[1] Rate infection of women to IBS is more than men.[2] Abdominal pain, bloat, and some of bowel dysfunction are symptoms of IBS. Patients with IBS often complain of nonbowel symptoms such as constant lethargy, low backache, nausea, irritable bladder, and chest pain.[3] The threshold of pain is low in patients with IBS.[4] Several factors such as intestinal permeability, visceral hypersensitivity, food intolerance, brain-gut axis dysregulation, and psychological stress help pathogenesis of IBS.[1] Chronic symptoms of IBS have a negative impact on patients' activity level and cause increase of cost of patient, family, and health-care system.[5] IBS is a large challenge for general hygiene.[6] IBS is heterogeneous disorder due to numerous genetic, hormone, infectious, immunological, and psychological factors.[7] Many studies have investigated psychological symptoms of the disease. The results of studies indicate that IBS accompany by psychological symptoms of depression,[2],[8],[9],[10] anxiety,[2],[7],[8],[9],[10],[11] and stress.[10],[12] The research show stress exacerbates symptoms of patients with IBS and influences bowel movements and visceral hypersensitivity. Visceral hypersensitivity is strong predictive of severity of gastrointestinal-specific anxiety.[13] Patients with IBS have negative schemas about self and others. Schemas generate a systematic error in thought that plays an important role in the development and systematic error of stress and depression. Irrational beliefs are a prevalent vulnerability factor for the generation of IBS. Patients with IBS distort the sense of daily events and negatively interpret themselves experiences due to irrational beliefs.[14] Research shows that negative beliefs and catastrophizing about abdominal pain are intermediate of the relationship between severity of abdominal pain and depression of patients with IBS.[15]

Recommended therapies for IBS are dietary, pharmacological, and psychological interventions. Some patients with low symptoms respond to instruction, dietary, and change of lifestyle while patients with moderate or severe symptoms are treated by pharmacological and psychological interventions.[16] Findings of a meta-analysis (41 trials) for evaluation of immediate, short-term, and long-term effectiveness of psychological treatment on decrease of severity of gastrointestinal symptoms of patients with IBS suggested that their immediate effect after treatment is moderate and remains moderate during short-term follow-up periods (1–6 months after treatment) and long-term follow-up periods (6–12 months after treatment).[17] For patients with IBS, it is recommended psychological therapies such as cognitive behavioral therapy (CBT) or hypnotherapy that symptoms are resistant to treatment.[16] Among psychological therapies, CBT is one of the scant valid therapies for IBS.[18] However, studies show the effectiveness of CBT on IBS decrease when depression and anxiety level are higher than baseline.[16] Therefore, it is required new therapies for decrease of psychological symptoms of patients with IBS.

Emotional schema therapy (EST) is a form of CBT treatment [19] that Leahy codifies it derived from some aspects of traditional cognitive therapy and metacognitive and acceptance-based models. The treatment is focused on the content of thoughts about emotions and resulted inefficient oppositional approaches.[20] EST helps patient identify troubling beliefs and strategies that are used for interpretation, judgement, control, and action for emotion.[19] It seems that EST is an appropriate therapeutic option to decrease psychological symptoms of patients with IBS. Because research indicates that beginning of IBS symptoms and its accompanying emotional disorders are due to inappropriate cognitive interpretations.[21]

According to the conducted studies by researchers, it was not observed any research about the effectiveness of EST on decrease of psychological symptoms of patients with IBS. However, the findings support the effectiveness of some EST techniques including mindfulness on the improvement of psychological symptoms of patients with IBS. One of the major results of mindfulness exercise is reduction of depression, anxiety, and stress scale (DASS-21) and ability of regulation of negative emotions.[22] Results of conducted research on women with IBS showed that there is meaningful reduction in scores average of psychological symptoms of patients after implementation of mindfulness technique.[23],[24] On the base of mentioned contents, in this research, the effectiveness of EST on decrease of psychological symptoms of patients with IBS was considered to generate research knowledge through it.


  Methods Top


The method of research is of single-subject design type. It was used A-B schema with stepwise method. In general, the first position (a) is the basic line, in second position (b) it is performed a therapeutic intervention, and then, dependent variable is evaluated. In the study, independent variable is EST, and dependent variables are therapeutic variations due use of the treatment method on the reduction of DASS-21. Statistical people included all women with IBS that came to the office of a specialist in Isfahan in summer of 2016. Five people were selected as convenience sampling based on the participation willingness of individuals to the research and taking criteria for inclusion of study (having ROME III diagnostic criteria confirmed by digestion specialist for differentiation IBS from other functional gastrointestinal disorders, no consumption of psychiatry drugs during 3 months ago, no participation in psychology interventions session during 6 months ago, having at least high school education, dominance on Persian language, having satisfaction for participation, and lack of sever psychiatry diseases) and exclusion from study (no participation in three consecutive session of psychotherapy sessions). After the statement of consent and endorsement of written testimonial, treatment was begun. To control the demographic effects, subjects were matched on the base of age, education, disease history, lack of other physical diseases, and lack of mental disorders through semi-structured interview for making DSM-IV (SCID) screening tools. Treatment was started with stepwise method with 1-week interval, so that first patient initially enters to the therapy schema. In second treatment session of the first patient, second patient enters to the treatment schema and in third therapy session of first patient and sec session of second patient, third patient and as the same way to fifth patient enter to treatment schema. EST was implemented according to the Leahy therapeutic protocol through 12 sessions. Patients performed baseline stage tests in baseline as well as third, sixth, ninth, and twelfth sessions. In addition, at last session, each patient was asked to refer once a month for 3 months. In addition, to follow-up patients' problems, 1 month, 2 months, and 3 months follow-up test were done. After completion of questionnaires, researcher investigated them whether all questions were answered. If a questionnaire was incomplete, with the presentation of more explanation, participations were asked to answer reminder questions. It has been presented a summary of the content of sessions of EST in [Table 1].
Table 1: A summary of content of sessions of emotional schema therapy

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Data were collected by researchers using ROME III and SCID diagnostic interviews and DASS-21 questionnaire. ROME III is about functional gastrointestinal disorders that have been normalized by Safaee et al. (2013) in Iran. Reliability of questionnaire by Cronbach's alpha was >0.7 in all principal symptoms.[25] In the research, this tool was performed by gastrointestinal specialist to differentiate between IBS and functional gastrointestinal disorders. SCID interview is a semi-structured interview that provides diagnostics based on the DSM-IV. The tool has been devised by Spitzer et al. (1992) In addition, it has been normalized by Sharifi et al. in Iran.[26] In the current study, the interview was used for investigation of lack of sever psychiatry diseases (inclusion criteria) such as psychosis and chronic bipolar, etc., DASS-21 scale is a self-report scale that evaluates each symptoms of DASS-21. Subjects should reply to multiple choice terms (never to very much) with scoring zero for never and three for very much choice. Asgharimoghadam et al. (2008) reported the internal consistency coefficients of 0.93, 0.90, and 0.93 and retest coefficients of 084, 0.89, and 0.90 for DASS-21, respectively. In addition, retest reliability has been reported 0.78, 0.87, and 0.80 for DASS-21, respectively.[27] In this research, the test was used to investigate psychological components.

Like more single-subject schemas, the first strategy of obtained results analysis was visual method. In addition to visual and chart analysis, recovery percent [28] as well as reliable change index (RCI) that have initially been presented by Jacobson and Truax to analyze resultant data of single-subject experimental schemas, were used.[29] In the RCI formula, if variations rate or difference between before and after treatment is >1.96, by regarding 0.5 error probability, it can be resulted that obtained change and improvement are due to therapy intervention and resultant change is not accident.


  Results Top


Of five participant patients, an individual ended treatment from third session because of his parent death. Of four patients, three were undergraduate, and one of them was graduate. An individual was single, and three of them were married. Mean age of patients was 34. For investigation of research questions, results of psychological symptoms test (depression, anxiety, and stress) of patients during pretest, posttest, and 3 months follow-up, recovery percent, and RCI were reported in [Table 2] and [Figure 1], [Figure 2], [Figure 3].
Table 2: Subjects' depression, anxiety, and stress

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Figure 1: Changes in patients' scores in depression

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Figure 2: Changes in patients' scores in anxiety

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Figure 3: Changes in patients' scores in stress

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According to the [Table 2], total recovery percent of depression variable is −34.33 in posttest. The amount of RCI of the depression score is meaningful just for first patients. However, decrease of scores of other patients is observed in [Figure 1]. In follow-up test, recovery percent is −41.80 and RCI of first, second, and fourth patient is higher than 1.96 and statistically meaningful (P ≤ 0.05). It is concluded with 95% confidence that obtained change or recovery is due to intervention effect (P ≤ 0.05).

Total recovery percent of depression variable is −27.65 in posttest, and the amount of RCI of depression variable is meaningful only in first and second patient in posttest. However, decrease of score of anxiety is observed in two other patients, too. In follow-up test, recovery percent is −27.65 and RCI of all patients is >1.96 and statistically meaningful (P ≤ 0.05). Then, with 95% confidence, it is concluded that obtained change or recovery is due to intervention effect (P ≤ 0.05).

Total recovery percentage of depression variable is −24.34 in posttest, and the amount of RCI is meaningful in posttest and follow-up of the first and fourth patient (P ≤ 0.05). However, it is not meaningful in second and third patient (P > 0.05). However, there is decrease of score compared to baseline. Then, with 95% confidence, it is concluded that obtained change or recovery is due to intervention effect (P ≤ 0.05).


  Discussion Top


The results of current study show high level of score of psychological symptoms (DASS-21)) of patients with IBS in baseline. These results are in agreement with findings of the past investigations mention that DASS-21 accompany by IBS.[6]

The results indicate that first, second, and fourth patient have had meaningful change or decrease in depression symptoms of 3-month follow-up due EST intervention. Because depression score of third patient has also decreased, it can be said EST influences reduction of depression symptoms of third patient. All patients with IBS have also had meaningful change or decrease in anxiety symptoms of 3-month follow-up because of EST intervention. In this research, the process of change of stress symptoms in posttest and 3-month follow-up is statistically meaningful for first and fourth patient. However, it is not for second and third patient. Because decrease of score of this component is observed than baseline, it can be said that EST successes for reduction of stress symptoms of patients with IBS.

In explanation of effectiveness of EST on reduction of psychological symptoms of patients with IBS, it can be hinted about the presence of some techniques and skills in EST therapy protocol. The therapy helps patients in processing of emotions through mindfulness, cognitive reconstruction, and decrease of stress.[30] The results of studies suggest the effectiveness of mindfulness on reduction of psychological symptoms of DASS-21 of patients with IBS.[16],[23],[24],[31],[32] The results of the current study are agreement with these findings and support them. Catastrophizing (exaggeration in expression of own problem) is one of thought styles of patients with IBS, and its outcome is the experience of DASS-21. Mindfulness training targets infrastructure mechanisms of IBS that is catastrophic evaluation of sensation and emotion processing of pain by increasing of individual nonreactive awareness about experience of emotion and sensation [33] and it appears that it can be reduced psychological symptoms of patients with IBS using this method. When patient with IBS feels turmoil, it is possible to pass a difficult time to know his emotion. At first, it is likely to have only physical sensations such as abdominal pain, diarrhea, irregularity, bloat, and inflation while he reacts to sensations and what has occurred, knows that he is experiencing sadness. The sadness amazes patient with IBS. He does not recognize what has depressed him. He entangles in negative evaluations of his sadness. Then, he feels inability about sadness because he does not find any reason for it. He is despaired and disturbed about his sadness. It seems mindfulness training destroys the erroneous cycle. Mindfulness training can improve the performance of emotion processing by intensifying direct translation of physical sense to different emotions and without inordinate relating of these emotions with narrative memories.[19] In addition to main feature of mindfulness that is emotion awareness, other its features including observation and internal attention, expression and labeling of experience, ability to implementation of activities with conversance and without distraction and no reaction to internal experiences are important.[34]

Cognitive reconstruction is the other EST technique that such as mindfulness technique decreases psychological symptoms of patients with IBS by targeting IBS infrastructure mechanism, that is, catastrophizing about abdominal pain. The results of current research support the researchers' opinion that believes cognitive reconstruction is of essential components for behavior change.

It appears that patients with IBS are not aware of their body tension when they experience symptoms. EST can help the patient with IBS decrease his stress using of muscle progressive relaxation technique when experience symptoms by generating kind of awareness about this tension and then learning of relaxation of body muscles approach.

In sum, the results of study indicate that it can be used EST as independent therapeutic approach or with other available therapies to decrease psychological symptoms of patients with IBS. EST does not focus on the beginning of IBS symptoms but more on wrong beliefs and schemas that patient has for interpretation, judgement, and control of related emotions to IBS. Patients with IBS and even some physicians are not aware that intruder factors such as wrong beliefs about disease can divert a process of an integrated therapy. Therefore, the emphasis on individual medical and the most important involved variables of it including evaluations of sick about disease is now one of the most important domains that it is necessary to proceed it in sciences such as health psychology, clinical psychology, and medic.

Regarding some limitations of case studies including small sample and being single-sex limit generalizability of findings. Thus, to remove the limitations and to confirm efficiency and capability of EST intervention for decrease of psychological symptoms of patients with IBS, more studies with larger sample are necessary.

The results of research show the effectiveness of mindfulness on reduction of psychological symptoms of depression,[23],[24] anxiety,[16],[23],[24],[31] and stress [32] of patients with IBS. The results of present study are agreement with the findings. Mindfulness training targets infrastructure mechanisms of IBS, that is, catastrophic evaluation of sensation and emotion processing of pain by increasing of individual nonreactive awareness about experience of emotion and sensation.[33] Mindfulness training can improve the performance of emotion processing by intensifying direct translation of physical sense to different emotions and without inordinate relating of these emotions with narrative memories.[19] In addition to evaluation of main feature of mindfulness that is emotion awareness, other its features including observation and internal attention, expression, and labeling of experience, ability to the implementation of activities with conversance and without distraction and no reaction to internal experiences are important, too.[34]

Cognitive reconstruction is the other EST technique that targets IBS infrastructure mechanism, that is, catastrophizing about abdominal pain. Cognitive reconstruction is of essential components of behavior change. Of course, regarding some limitations of case studies including small sample and being single-sex limit generalizability of findings. Thus, to remove the limitations and to confirm efficiency and capability of EST intervention for decrease of psychological symptoms of patients with IBS, more studies with larger sample are necessary.


  Conclusions Top


In sum, the results suggest EST decreases psychological symptoms of patients with IBS. It can be used as an independent therapeutic approach or with other available therapies to decrease psychological symptoms of patients with IBS.

Acknowledgment

This article is a part of Master's thesis approved at Tehran University of Medical Sciences. From support of Research Assistant of Tehran University of Medical Sciences as well as helpful cooperation of patients and other experts are acknowledged.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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