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PAIN 145 (2009) 196203

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Psychodynamic interpersonal therapy and improvement in interpersonal difculties


in people with severe irritable bowel syndrome
Thomas Hyphantis a,b, Else Guthrie a, Barbara Tomenson a, Francis Creed a,*
a
b

Psychiatry Research Group, Medical School, University of Manchester, Manchester, UK


Department of Psychiatry, Medical School, University of Ioannina, Ioannina, Greece

a r t i c l e

i n f o

Article history:
Received 24 July 2008
Received in revised form 22 June 2009
Accepted 6 July 2009

Keywords:
Pain
Circumplex
Psychodynamic interpersonal psychotherapy
IBS

a b s t r a c t
The aim of the present study was to assess the relationship between change in interpersonal difculties
with change in chronic pain, health status and psychological state in 257 Irritable Bowel Syndrome (IBS)
patients in a randomized control trial comparing psychotherapy, antidepressant and usual care. We
assessed at three time points interpersonal problems (IIP-32), abdominal pain and bowel symptoms, psychological distress (SCL-90), and health status (SF-36). Analysis included repeated measures (ANOVA) to
assess change over time and multiple regressions to identify whether change in IIP was associated with
outcome after controlling for psychological status. The main ndings were: (1) difculties with social
inhibition and dependency were associated with longer disease duration; (2) change in mean IIP-32 over
15 months was signicantly correlated with changes in pain, but these relationships were mediated by
change in psychological distress; (3) change in IIP-32 was an independent predictor of improved health
status at 15 months only in the psychotherapy group. These results indicate that improvement in interpersonal problems in IBS patients appear to be primarily associated with reduced psychological distress
but, in addition, the association with improved health status following psychotherapy suggests that specic help with interpersonal problems may play a role in improving health status of patients with chronic
painful IBS.
2009 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

1. Introduction
Irritable bowel syndrome (IBS) is a common chronic pain disorder which forms a majority of patients in gastroenterology clinics
and often leads to high healthcare use and much time missed from
work [15]. In common with other chronic pain patients, those with
IBS have difculties in interpersonal relationships [26,31], which
relate to pain coping and outcome of treatment [37]. Several studies have found an association between insecure attachment and related interpersonal difculties with poor pain self efcacy, anxiety
and poor coping [4,29,30]. These have all been cross-sectional
studies, however, and all these authors suggested examining
whether improved personal relationships are associated with reduced pain and reduced disability [4,24], which is what we have
tested in this study.
Patients with IBS are said to have difculties with being assertive [26]. Such a submissive interpersonal style has been related
to pain catastrophising [25], which is associated with soliciting

* Corresponding author. Address: Psychiatry Research Group, Medical School,


Rawnsley Building, Manchester Royal Inrmary, Oxford Road, Manchester M13
9WL, United Kingdom. Fax: +44 161 273 2135.
E-mail addresses: francis.creed@man.ac.uk, hyphantis@ioa.forthnet.gr (F. Creed).

support or empathy from others [4,24] and may relate to increased


pain and disability [25]. One study suggested that difculty with
being assertive, which was associated with persistent and diarrhoea-predominant IBS, arose because the illness has a deleterious
effect on interpersonal relationships but this study was cross-sectional and could not assess causality [26]. Furthermore the study
did not control for psychological distress, which is correlated with
chronic pain and interpersonal relations [27].
In our trial of patients with severe IBS we found that both antidepressants and psychotherapy led to improved heath status in the
long term but there was no apparent difference between the treatments. The rst aim of the present study was to assess whether
changes in interpersonal difculties, symptoms of Irritable bowel
syndrome (IBS), health status and psychological state showed congruent changes over time.
Our second aim was a preliminary examination of whether the
association between change in interpersonal relationships and outcome was different in different treatment groups. Both psychological treatments and antidepressants may help IBS patients
[10,11,25,35]. Psychodynamic interpersonal therapy is designed
to help people with their interpersonal difculties, which may explain how it helps some people with IBS in addition to relieving
depression and anxiety [1619,21,33]. Antidepressants, on the

0304-3959/$36.00 2009 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2009.07.005

T. Hyphantis et al. / PAIN 145 (2009) 196203

other hand, may help IBS patients by relieving pain in addition to


anxiety and depression [10,11]. No previous study has examined
change in IIP in relation to outcome in IBS or chronic pain.
We tested the following hypotheses in patients with severe IBS:
(1) that improvement in interpersonal relationships over
15 months is associated with improvement in pain and disability, but these relationships are mediated by psychological distress.
(2) that improved health status, the outcome measure which
showed greatest long-term change in our trial, is associated
with improvement in interpersonal difculties following
both psychotherapy and antidepressant treatments.
Prior to testing these hypotheses we assessed (a) whether the
factor structure of the brief IIP was similar in this population to
previous studies and (b) the baseline relationships between the
variables we tested in the longitudinal study.
2. Methods
For this study we used data that were collected during a randomised controlled trial of patients with severe, chronic IBS to assess the cost effectiveness of psychotherapy and antidepressants in
comparison to treatment as usual [6]. We recruited from seven
gastroenterology clinics in the UK all patients who fullled both
ROME I criteria for IBS and the criteria for severe IBS. Rome I criteria require 3 months of continuous or recurring symptoms of: (1)
abdominal pain, accompanied by pain relieved by defecation and
associated with change in frequency or consistency of stool; (2)
at least two of the following: irregular pattern of defecation, altered stool consistency, incomplete rectal evacuation and/or urgency or straining; abdominal bloating or distension, and/or
mucus in stools [36]. Severe IBS refers to patients with duration
of symptoms >6 months, failure to respond to usual medical
treatment, including antispasmodics and laxatives or antidiarrheal
medication administered for a minimum of 3 months and severe
abdominal pain, dened as >59 on a visual analogue scale [13].
The trial involved random allocation of the patients to eight sessions of psychodynamic interpersonal therapy [16,18], or 3 months
of treatment with 20 mg daily of the SSRI antidepressant, paroxetine, or routine care by gastroenterologist and general practitioner
[6]. Patients allocated to psychotherapy received one long (approximately 2 h) and 7 shorter (45 min) individual sessions over
3 months. They were encouraged to discuss their symptoms in
depth; emotional factors were explored, and links between symptoms and emotional factors were identied. Therapists were
trained by a member of the study team (E.G.) using a manual
and a videotaped training package; continued conformity by the
therapist to the model was ensured by weekly supervision with
E.G. [6]. After 3 months of treatment, all patients receiving psychotherapy or paroxetine returned to their general practitioner, who
decided what further management was required over the next
year. Patients were excluded from the trial if they had a psychotic
disorder, severe personality disorder, active suicidal ideation or
consumed more than 50 units of alcohol per week, but patients
with other psychiatric disorders were included.
The assessments we quote in this study were made at baseline
(entry to the trial), after 3 months of treatment and at 12 months
after treatment was completed (i.e. 15 months after baseline). Full
details of the trial have been reported previously [6], including the
CONSORT details, and will not be repeated here.
The following self-administered questionnaires were completed
by each participant at each time point. Severity of current abdominal pain was assessed using visual analogue scales taken from the
McGill Pain Questionnaire, relating to the severity of usual

197

abdominal pain and its severity today [13]. In addition, each participant completed a daily diary recording the severity of their bowel symptoms for 14 days prior to each assessment. Psychological
distress was measured using the Global Severity Index (GSI) of
the SCL-90 [12]. Health status was measured using the Short
Form-36 (SF-36) [39], which corresponds closely to patients rating
of the disruption their daily lives [20,40]. We used the physical
component summary (SF-36-PCS) score as the main outcome variable; a low score indicates poor health status [38]. This is a composite score of the scales: physical function, role limitation
physical, bodily pain and health perception.
For the assessment of interpersonal problems, the Inventory of
Interpersonal Problems-32 (IIP-32) [2] was used. The IIP-32 is a
self-report measure developed as a shortened version of the original 127-item Inventory of Interpersonal problems [22], aiming to
assess the difculties people experience in their interpersonal relationships and comprises eight subscales which have shown high
internal consistency and conrmatory factor analysis has replicated the eight-factor structure [2]. We present results for baseline,
3 and 15 months later.
At the initial assessment only, a trained psychiatrist, who
worked independent of treating clinicians and was blind to treatment group, assessed psychiatric diagnosis using the Schedules for
Clinical Assessment in Neuropsychiatry (SCAN) [41]. The details
of the IBS symptom pattern (diarrhoea- or constipation-predominant) and IBS duration were ascertained using the questionnaire
of Drossman [36]. Diarrhoea-predominant IBS refers to patients
who had more than three bowel movements a day or watery stools
or urgency or having to rush to have a bowel movement whereas
constipation-predominant IBS refers to patients who had fewer
than three bowel movements a week or lumpy stools or straining
during a bowel movement.
A history of sexual abuse was documented using the Sexual and
Physical Abuse Questionnaire [14,28]. In this report sexual abuse
refers to either forced touching or forced penetration (rape),
against ones will either as a child or adult.
2.1. Statistical analysis
All the statistical analyses were performed using the Statistical
Package for the Social Sciences (SPSS) 15.0 (SPSS Inc., Chicago, IL,
USA) for Windows and Stata Statistical Software: Release 9 (College Station, TX: Statacorp LP. 2005). Summary statistics for all
variables were calculated. Normality was tested by the KolmogorovSmirnov test [1].
Since we used the 32-item version of the IIP for the rst time in
IBS patients, a conrmatory principal component factor analysis
was performed to conrm that the factorial structure of this version in IBS patients is comparable to that of the original version
of the IIP-32 [2].
Univariate analyses to asses the independent associations between demographic, clinical or psychopathology variables and IIP
scores used one-way analyses of variance, two-tailed t-tests, and
Pearsons or Spearmans correlations as appropriate [1].
Repeated measures (ANOVA) for IIP mean score adjusted for
baseline score was performed to test for a signicant change of
IIP over time (baseline, 3 months, and 15 months), and the relationship of this with treatment.
To test hypothesis 1, we assessed change in IIP with change in
abdominal pain severity, bowel symptoms, psychological distress
and health status between baseline and 15 months, adjusting for
baseline scores with ANCOVA.
Multiple regression analyses were performed to assess whether
SCL-90 global severity index score mediated the association of
change in pain and bowel symptoms with change in interpersonal
difculties between trial entry and follow-up. These analyses used

198

T. Hyphantis et al. / PAIN 145 (2009) 196203

the method of Baron and Kenny [3]. To full the requirements of


mediation according to this method, the following three associations should be signicant in multiple regression equations: (1)
change in pain and change in IIP score, (2) change in pain and
mediating variable (change in SCL-90 global severity index), and
(3) mediating variable and change in IIP score. Addition of
mediating variable to multiple regression leads to relationship 1
becoming non-signicant. The rst multiple regression analysis included change in IIP score between trial entry and follow-up as
dependent variable with the following as independent variables:
age, sex, years of education, widowed/separated or divorced, baseline scores of IIP, SF-36 Pain, diary diarrhoea and diary constipation, treatment group (as two dummy variables, psychotherapy
and antidepressants) and changes between baseline and
15 months in SF-36 Pain, diary diarrhoea and diary constipation
scores. In the second analysis, we added the SCL-90 global severity
score at baseline as well as its change between baseline and
15 month and noted whether this rendered the previous associations between change in pain and/or bowel symptoms and change
in IIP score nonsignicant. The STATA impute command was used
to replace missing values in all the independent variables. Sobel
tests were performed to gauge whether the mediator (change in
SCL-90 global severity index) signicantly carries the inuence of
each one signicant independent variable to the dependent variable (i.e. change in interpersonal relationships). These analyses included the 214 patients on whom we had IIP data at baseline and
follow-up; the drop-outs were younger than the remainder but did
not differ on baseline IIP mean score, distress scores or IBS pain
variables.
To test hypothesis 2, i.e. to assess the signicant predictors of
the improvement in the SF-36 physical component of health-related quality of life in each treatment group, separate multiple
regression analyses were performed for each treatment group.
The dependent variable was the change of SF-36 physical component score between baseline and follow-up. All variables which
were associated with change of SF-36 physical component scores
at p < 0.01 in the preceding univariate analyses in the entire sample (data not shown) were entered into the multiple regression
analysis as independent variables. Therefore, independent variables were severe sexual abuse, age, unemployment due to poor
health, baseline SF-36 physical component score, baseline IIP
mean score, change of IIP mean score between baseline and
15 months, change of SCL-90-R global severity index between
baseline and 15 months and change of VAS pain today score between baseline and 15 months. Data were complete for all these
independent variables for the patients with data on the dependent
variable, except for four patients with missing data on change in
IIP score. The Stata impute command was used to replace these
four missing values.

3. Results
3.1. Patient characteristics
The demographic and clinical characteristics of the participants
in our trial have been reported previously [6]. Briey, a total of 257
subjects (81% of eligible patients) were recruited to the study.
There were no differences in demographic and diagnostic variables
between those patients who agreed and those who declined to enter the trial (N = 60). Ages ranged from 19 to 65 years, with a median of 39 years. The majority of the patients were women (79.8%),
married (65.8%), and 54.5% had 12 or more years of education.
The IBS was chronic (median duration, 8 years; interquartile
range, 9 years) and led to restricted activities on a mean of 12.1
(SD, 11.8) days per month before baseline assessment, while sev-

enty patients (27.2%) were unemployed through illness. Mean typical pain score was 67.4 of 100. Fifty-nine patients (22.9%) reported
that they had experienced sexual abuse. Seventy four patients
(28.8%) had diarrhoea-predominant IBS, 59 (23.0%) had constipation-predominant IBS, and 124 (48.2%) had the general form of
the disorder.
Of the 85 patients randomized to psychotherapy, 59 (69.4%)
completed all eight sessions, and 43 of the 86 patients (50%) randomized to paroxetine completed the 12-week course (x2, 5.91;
df, 1; p = 0.013).
The main ndings of the study were that patients treated with
psychotherapy or antidepressants compared with those receiving
usual care showed a signicant improvement in health status
12 months post treatment [6]. In the present study we examine
whether reduction in IIP score is associated with such improvement in health status.
3.2. Preliminary (factor) analysis of IIP-32
Of the 257 IBS patients, 225 (87.5%) completed all 32 items of
IIP and these were used in analysis. Principal component analysis
showed a Kaiser-Mayer-Olkin statistic of 0.86, an average communality of 0.679 and a signicant Bartletts test for sphericity (x2,
4290; df, 496; p < 0.0005), all supporting the factorability of the
correlation matrix. An inspection of the scree plot revealed a large
rst component and a number of elbows resulting in a very small
eigenvalue after eight components. An eight component extraction
was rotated with both Varimax and Oblimax rotations. Both rotated solutions revealed the presence of a coherent multidimensional structure with eight components. Table 1 presents the
results of the Oblimax rotation, since this rotation showed the
clearer loadings. The eight components explain a cumulative
70.75% of the variance. As shown in Table 1, all items have their
strongest loadings exactly as suggested by Barckam et al. [2] with
only four of the possible 224 non-design loadings being above of
the criterion of 0.3 and all but one are below 0.4, the remaining
being 0.45. These results indicate that IIP-32 responses of the IBS
patients conform very well to the design of the instrument.
3.3. Interpersonal difculties, demographic, clinical and
psychopathology variables at baseline
Table 2 shows that socio-demographic variables and symptom
pattern (diarrhoea-predominant, constipation-predominant and
general) were not signicantly associated with IIP mean score
but depressive, generalized anxiety and panic disorders were signicantly associated. Further analysis (not shown) found that these
results held when each of the eight IIP subscales were examined
individually.
Table 3 shows that IIP mean score was associated with SCL-90
global severity index but not with bodily pain, bowel symptoms
or duration of IBS. Further analysis with the eight IIP subscales
showed that no subscale score was associated with bowel symptom pattern (data not shown). The two subscales concerning difculties with social inhibition and dependency (hard to be
sociable and too dependent) were associated with the duration
of IBS after adjustment for age, sex, marital status and psychological distress (partial correlation coefcients r = 0.166, p < 0.009 and
r = 0.125, p < 0.05, respectively).
3.4. Change in interpersonal difculties and change in pain, bowel
symptoms, psychological distress and health status
Repeated measures (ANOVA) analysis showed that IIP mean
score reduced with time (F = 11.84, p < 0.001) but there was no signicant treatment by time interaction (F = 0.79, p = 0.45). This

T. Hyphantis et al. / PAIN 145 (2009) 196203

199

Table 1
Factor loadings of the IIP-32 in the IBS sample.
Factors
Items

Hard to be sociable

7
3
1
9
14
15
13
16
28
30
20
21
24
29
10
17
25
26
18
32
4
11
6
2
19
5
12
8
23
31
22
27

.901
.867
.737
.719

Hard to be supportive

Too aggressive

Too open

Too caring

Hard to be assertive

Hard to be involved

Too dependent

.879
.875
.786
.555
.923
.892
.827
.791
.839
.798
.463
.455

.327
.391
.865
.799
.656
.547
.842
.832
.774
.733
.758
.633
.457
.352

.458
.364

0.89

0.86

0.87

0.63

0.78

0.85

.717
.603
.600
.444
0.75

0.80

Note. Jblimin rotation with Kaiser normalization; loadings censored at 0.3; item loadings that correspond to the loadings of the original version are highlighted with bold characters.

Table 2
IIP-32 total mean score and demographic, clinical and psychiatric categorical
variables.
N

Mean

SD

Sex
Male
Female

50
197

1.16
1.06

0.04
0.09

t=

1.01

0.311

Education
Less than GCSE
GCSE or more

112
135

1.04
1.11

0.63
0.65

t=

0.86

0.391

Unemployment due to ill health


No
179
Yes
68

1.07
1.11

0.63
0.68

t=

0.40

0.688

Marital status
Married
Singles
Div/Sep

1.15
1.11
0.86

0.74
0.62
0.57

Sexual abuse
No
Yes

159
50
38
188
59

1.05
1.18

0.64
0.63

Rome diagnosis (symptom pattern)


General
124
Diarrhoea predominant
74
Constipation predominant
59

1.07
1.17
0.99

0.63
0.66
0.63

Depressive disorder
No
Yes

174
73

0.93
1.43

Generalized anxiety disorder


No
Yes

212
35

Panic disorder
No
Yes

218
29

F2,244 = 2.78

t=

1.36

reduction of IIP mean score between baseline and 15 months follow-up was associated with the reduction of all measurements of
pain and with improvement of disability (Table 4).
Fig. 1a and b show the temporal sequence of changes. In the
psychotherapy and antidepressant groups improvement in pain
and psychological distress occur during the 3 months of treatment
before the reduction in IIP; the latter occurs predominantly during
the follow-up year. This means that change in IIP should not be regarded as the primary change with treatment as the other parameters (pain, psychological distress and health status) show change
before change in IIP.
A much greater change in IIP score is apparent at follow-up and
multiple regression analysis was used to identify the variables
most closely associated with this change; they are shown in

0.064

0.173

F2,244 = 1.29

0.277

0.58
0.64

t=

5.96

<0.0005

1.04
1.33

0.64
0.61

t=

2.48

0.014

1.01
1.61

0.61
0.61

t=

4.97

<0.0005

Table 3
Correlations of baseline IIP-32 total mean score with demographic, baseline clinical
and baseline psychiatric continuous variables.

Age
Age of onset
Duration of IBS
VAS typical pain
VAS pain today
Number of days with pain
SF-36 physical component
SF-36 pain
Diarrhoea
Constipation
SCL-90 Global severity index
a
b

ra

0.031
0.099
0.077
0.099
0.057
0.016b
0.022
0.037
0.002
0.034
0.676

0.623
0.122
0.229
0.122
0.375
0.826
0.731
0.558
0.998
0.780
<0.0005

Pearsons correlation coefcients except:


Spearmans correlation coefcient VAS = visual analogue scale.

T. Hyphantis et al. / PAIN 145 (2009) 196203

200

Table 4
Associations of change in IIP mean score with change in psychological distress, pain,
diary measure diarrhoea and diary measure constipation scores between baseline and
follow-up, adjusted for baseline scores.

Change
Change
Change
Change
Change
Change
Change
Change

in
in
in
in
in
in
in
in

VAS pain today


VAS pain typical
diarrhoea
constipation
SF-36 physical component
SF-36 health perceptions
SF-36 pain
psychological distress (SCL-90 GSI)

Correlation coefcient

p-value

0.201
0.208
0.301
0.200
0.236
0.355
0.281
0.567

0.003
0.003
<0.005
0.008
0.001
<0.0005
<0.0005
<0.0005

Table 5. Model 1 shows that the improvement of pain was a significant predictor of improvement in interpersonal difculties, but
this is not so in model 2, when the improvement in SCL-90 global
severity index was added to the linear regression equation.
Sobel tests showed that the indirect effect of each one signicant independent variable (i.e. change in pain, change in diary diarrhoea and change in diary constipation) on the dependent variable
(i.e. change in interpersonal relationships) through the mediator
(i.e. change in SCL-90 global severity index) was signicant (Sobel
test statistics (Z): 4.59, p < 0.0005; 3.62, p < 0.0004 and 3.09,
p < 0.002, respectively). Sobel tests for the indirect effects of baseline values of the independent variables on the dependent variable
through change in SCL-90 global severity index values were not

Psychotherapy group

0.5
0.4
0.3

z-score

0.2
IIP
SF-36 pcs
SCL-90 global severity index
VAS pain today

0.1
0
-0.1
-0.2
-0.3
-0.4
baseline

3 months

15 months

Paroxetine group

0.5
0.4
0.3

z-score

0.2
0.1

IIP
SF-36 pcs
SCL-90 global severity index
Vas pain today

0
-0.1
-0.2
-0.3
-0.4
baseline

3 months

15 months

Fig. 1. Effect size for changes from baseline for IIP-32, SCL-90 global severity index
SF-36 physical component summary and VAS-pain today in psychotherapy (a) and
antidepressant group (b).

signicant. This indicates that change in psychological distress


mediates the relationships between improvement of pain and
improvement in interpersonal difculties.
3.5. Health status improvement and treatment modality (hypothesis 2)
Table 6 shows the results of the separate multiple regression
analyses performed for each treatment group with SF-36 physical
component score as the dependent variable. It can be seen that
for both, psychotherapy and antidepressant groups, the baseline
value of this variable was a signicant predictor. However, in the
psychotherapy group, the other independent predictors of change
in SF-36 physical component score were change in IIP mean scores
between baseline and 15 months, reported severe sexual abuse
and unemployment, but not change in SCL-90 global severity index. By contrast, in the antidepressant group, age and change in
SCL-90 global severity index were the only additional independent
predictors of change in SF-36 physical component score.
4. Discussion
There are several new ndings in this study. First, in patients
with severe IBS interpersonal problems concerning difculties
with social inhibition and dependency, were associated with longer disease duration, after controlling for psychological distress. We
did not nd that the overall mean score of the IIP was associated
with duration or with diarrhoea-predominant IBS after adjustment
for psychological distress. Thus we only partially conrmed the
previous ndings of Lackner and Gurtman [26] regarding duration
of IBS and interpersonal difculties.
Second, we found that change in IIP score over time was clearly
associated with change in pain, bowel symptom pattern and health
status and this association was mediated by psychological distress.
Reduction of psychological distress, and improvement of pain, occurred mostly during the 3 months of treatment whereas change in
IIP score occurred mostly during the subsequent 1 year, indicating
that the improvement of psychological distress precedes the
improvement of interpersonal difculties. This suggests that the
improvement in IIP score may be secondary to reduction of distress
rather than a direct result of the therapy.
Third, IIP mean score (baseline and change values) showed borderline signicance as predictors of our main trial outcome,
improvement in health status (SF-36 physical component score)
only in the psychotherapy group. This contrasts with the antidepressant group where the reduction of psychological distress was
associated with improved health status. This raises the possibility
that for those receiving psychotherapy, reduction of distress may
not be the only driver for improved health status. It is possible that
the improvement in health status over the follow-up year is linked
in some more direct way to improved interpersonal relationships.
A small accompanying qualitative study suggested that people
receiving psychotherapy were twice as likely as those receiving
antidepressants to appreciate that stress affected their bowel
symptoms and had made changes in their lives to reduce stress
during the follow-up year (C. Rigby, personal communication). This
may have included improved interpersonal relationships and may
have been related to improvement in health status. This concept
needs to be tested in future research.
It has been suggested that incorporating strategies to address
interpersonal concerns may increase the efcacy of treatment of
chronic pain as chronic pain patients are said to be overly nurturant, exploitable, non-assertive and socially avoidant according to
the circumplex version of IIP [29,31,37]. Our results suggest that
there may be benet in doing so. On the one hand we have shown
that interpersonal relationships are related to the level of psychological distress and that distress mediates the relationship between

T. Hyphantis et al. / PAIN 145 (2009) 196203

201

Table 5
Multiple regression analyses to predict change in IIP mean score between baseline and follow-up (N = 214).
Predictor variables

Model 1; change in IIP as dependent variable


Beta

Beta

Age
Sex
Education
Widowed, divorced, separated
Baseline IIP-32 mean score
Baseline SF-36 pain
Baseline diary diarrhoea
Baseline diary constipation
SF-36 pain improvement between baseline and 15 months
Diary diarrhoea improvement between baseline and
15 months
Diary constipation improvement between baseline and
15 months
Psychotherapy
Antidepressant
Baseline SCL-90-R GSI
SCL-90-R GSI improvement between baseline and 15 months
Regression statistics
R square adjusted
F-values

0.006
0.001
0.034
0.022
0.521
0.158
0.188
0.026
0.149
0.201

0.925
0.992
0.549
0.705
<0.0005
0.014
0.004
0.684
0.033
0.003

0.002
0.024
0.001
0.003
0.775
0.037
0.089
0.037
0.028
0.100

0.968
0.579
0.974
0.951
<0.0005
0.469
0.073
0.447
0.607
0.059

0.133

0.041

0.038

0.014
0.004

0.829
0.953

0.008
0.005
0.626
0.603

0.343
F(13,200) = 9.53, p < 0.0005

pain and IIP, so reducing distress should be an important aspect of


managing chronic pain. On the other hand our results are compatible with the suggestion that improved health status one year after
treatment with psychotherapy may be associated with improved
interpersonal relationships.
Our results are not identical to those of Lackner as we found social inhibition and difculties with dependency were associated
only with the duration of IBS. The difference probably reects the
fact that we adjusted for psychological distress and all our patients
had severe pain as a selection criterion of our trial. This means that
pain scores, and others, showed little variation at baseline whereas
the greater spread of scores after 15 months could explain why our

Model 2 (nal); change in IIP as dependent variable

0.453
0.868
0.915
<0.0005
<0.0005

0.632
F(15,198) = 25.4, p < 0.0005

change scores showed clear association between pain measures


and IIP when baseline scores had not.
The association between certain interpersonal difculties and
duration of IBS, even after adjustment for psychological distress,
is compatible with the suggestion that interpersonal difculties
are a consequence of a chronic painful condition [34]. Pain patients
with a very long history have been said to perceive their spouses as
less supportive and more punitive than patients with shorter duration pain [5]. On the other hand, people with difculties with
assertiveness or social inhibition may develop IBS early in life
and/or cope poorly with the symptoms of this relapsing and remitting illness [23].

Table 6
Multiple regression analyses to predict change in SF-36 physical component summary score between baseline and follow-up for psychotherapy and antidepressant groups.
Variables
Psychotherapy group
Severe sexual abuse
Age
Baseline SF-36 physical component score
Unemployed due to poor health
Baseline IIP-32 mean score
IIP-32 mean improvement between
baseline and 15 months
SCL-90-R GSI improvement between
baseline and 15 months
VAS pain today improvement between
baseline and 15 months
Adjusted R square
Antidepressant group
Severe sexual abuse
Age
Baseline SF-36 physical component score
Unemployed due to poor health
Baseline IIP-32 mean score
IIP-32 mean improvement between
baseline and 15 months
SCL-90-R GSI improvement between
baseline and 15 months
VAS pain today improvement between
baseline and 15 months
Adjusted R square

Unstandardized regression
coefcient (B)

Std. Error

Standardized regression
coefcient (beta)

10.317
0.152
0.512
5.427
3.299
4.59

3.502
0.092
0.114
2.262
1.761
2.34

0.324
0.192
0.495
0.267
0.244
0.276

0.005
0.104
<0.0005
0.02
0.067
0.05

3.992

2.376

0.198

0.099

0.003

0.034

0.010

0.933

4.510
0.172
0.375
2.845
1.913
0.554

2.451
0.082
0.094
2.411
1.656
2.209

0.185
0.221
0.488
0.146
0.136
0.041

0.070
0.041
<0.0005
0.242
0.252
0.803

4.689

2.238

0.328

0.040

0.040

0.032

0.136

0.214

0.428 (F = 6.43,
p < 0.0005)

0.301 (F = 4.82, p < 0.0005)

202

T. Hyphantis et al. / PAIN 145 (2009) 196203

There are some limitations of this study, which need to be recognized. First, this is a secondary analysis of a dataset that was collected for another purpose. Another limitation lies in the absence
of a healthy control group, which could allow us clearer conclusions with regard to IBS patients specic interpersonal difculties.
In addition, our results pertain to patients with severe IBS and may
not hold for people with less severe IBS. We used only a self-report
questionnaire to assess interpersonal difculties and it is not clear
whether such an instrument measures the discomfort in relationships that is associated with eliciting sympathetic response from
others [37]. Similarly we did not measure catastrophising which
means we cannot compare our results with those which found
an association between interpersonal problems and pain catastrophizing [4,2426].
This paper does overcome some of the limitations of the previous studies, however, notably the prospective design. Strengths of
our study include also the representative nature of our sample
(81% of the eligible patients were recruited), the detailed measures,
our ability to demonstrate the factorial structure of the main
instrument used (IIP-32) and the reasonably large sample size, at
least as compared to other studies using IIP.
The prospective design and response to treatment are the major
assets of this study. We found that interpersonal problems improved over time and this is, we believe, the rst study that shows
this in IBS patients. We found a clear association between improvement in IIP score and improvement in all our measures of pain and
disability and we also found that this was mediated by change in
psychological distress. This occurred irrespective of treatment
group and it is most plausible that improved mood leads to feeling
better about interpersonal relationships. The additional nding is
also new-improvement in IIP was associated directly with improved health status in the psychotherapy group but not in the
antidepressant group. This nding suggests, perhaps, that the
mode of action of antidepressants and psychotherapy may not be
identical. We interpret this nding as suggesting that a component
of the change following psychotherapy was some aspect of
improvement of interpersonal difculties (sexual abuse was also
a predictor of improved health status [7]) whereas following antidepressant treatment a reduction in the level of distress was the
primary change [6].
It has not been possible to identify a single major predictor of
outcome in this group of patients with severe IBS, unlike the study
of temporomandibular disorder patients reported by Rudy [32].
This probably results from our selection of a relatively homogenous group of patients with severe IBS. We have shown previously
that depressive and panic disorders, neurasthenia and marked
somatisation predict a poor outcome [8,9] and that a history of sexual abuse predicts a good response [7]. In this paper we aimed to
identify whether interpersonal difculties also predict outcome
and it seems that this is the case in the psychotherapy group,
though the effect was of borderline signicance, possibly reecting
small sample size. Since this analysis showed that a history of sexual abuse and interpersonal difculties are independent predictors
of outcome in the psychotherapy, even after controlling for the
reduction of distress, we conclude that specic interpersonal
change following our brief psychotherapy is an important aspect
of the long-term outcome following this type of treatment. This effect was not found in the antidepressant group suggesting that the
two treatments act differently in this respect. Both aspects of treatment could be utilised in the treatment of chronic pain patients, in
addition to cognitive behavioural treatment, which acts principally
on different aspects of the persons response to pain.
The main clinical implication of this study is that IBS patients
interpersonal difculties improved over time and that this
improvement was associated with improved health status in both
treatment groups. Therefore, the choice of treatment might be

determined by patient preference or availability of psychotherapy.


Future research should aim to clarify the specic mechanism of action of psychotherapy in IBS patients and further study of the relationship between patients interpersonal difculties and IBS.
Acknowledgments
This work supported by the Medical Research Council of the
United Kingdom and the North Western Region Health Authority
(U.K.) R&D Directorate. There was not any nancial interest which
could create a potential conict of interest or the appearance of a
conict of interest with regard to the present submitted work.
SmithKlineBeecham provided the paroxetine but was not involved
in the design, conduct, or analysis of the trial.
References
[1] Altman DG. Practical statistics for medical research. London: Chapman and
Hall; 1991. p. 285.
[2] Barkham M, Hardy GE, Startup M. The IIP-32: a short version of the inventory
of interpersonal problems. Br J Clin Psychol 1996;35:2135.
[3] Baron RM, Kenny DA. The moderatormediator variable distinction in social
psychological research: conceptual, strategic, and statistical considerations. J
Pers Soc Psychol 1986;51:117382.
[4] Buenaver LF, Edwards RR, Haythornthwaite JA. Pain-related catastrophizing
and perceived social responses: inter-relationships in the context of chronic
pain. Pain 2007;127:23442.
[5] Cano A. Pain catastrophizing and social support in married individuals with
chronic pain: the moderating role of pain duration. Pain 2004;110:65664.
[6] Creed F, Fernandes L, Guthrie E, Palmer S, Ratcliffe J, Read N, Rigby C,
Thompson D, Tomenson B. North of England IBS Research Group. The costeffectiveness of psychotherapy and paroxetine for severe irritable bowel
syndrome. Gastroenterology 2003;124:30317.
[7] Creed F, Guthrie E, Ratcliffe J, Fernandes L, Rigby C, Tomenson B, Read N,
Thompson DG. Reported sexual abuse predicts impaired functioning but a
good response to psychological treatments in patients with severe irritable
bowel syndrome. Psychosom Med 2005;67:4909.
[8] Creed F, Ratcliffe J, Fernandes L, Palmer S, Rigby C, Tomenson B, Guthrie E, Read
N, Thompson DG. North of England IBS Research Group. Outcome in severe
irritable bowel syndrome with and without accompanying depressive, panic
and neurasthenic disorders. Br J Psychiatry 2005;186:50715.
[9] Creed F, Tomenson B, Guthrie E, Ratcliffe J, Fernandes L, Read N, Palmer S,
Thompson DG. The relationship between somatisation and outcome in
patients with severe irritable bowel syndrome. J Psychosom Res
2008;64:61320.
[10] Creed F. Antidepressants and psychological interventions for functional
gastrointestinal disorders. Gastroenterol Hepatol 2006;1:626.
[11] Creed F. How do SSRIs help patients with irritable bowel syndrome? Gut
2006;55:10657.
[12] Derogatis LR. The SCL-90-R Manual-II: scoring* administration and procedures
for the SCL-90-R. 2nd ed. Towson, MD: Clinical Psychometric Research; 1992.
[13] Drossman DA, Li Z, Toner BB, Diamant NE, Creed FH, Thompson D, Read NW,
Babbs C, Barreiro M, Bank L, Whitehead WE, Schuster MM, Guthrie EA.
Functional bowel disorders: a multicenter comparison of health status, and
development of illness severity index. Digest Dis Sci 1995;40:98695.
[14] Drossman DA, Talley N, Leserman J, Olden KW, Barreiro MA. Sexual and
physical abuse and gastrointestinal illness: a review and recommendations.
Ann Intern Med 1995;123:78294.
[15] Drossman DA. The functional gastrointestinal disorders and the Rome III
process. Gastroenterology 2006;130:137790.
[16] Guthrie E, Creed F, Dawson D, Tomenson B. A controlled trial of psychological
treatment
for
the
irritable
bowel
syndrome.
Gastroenterology
1991;100:4507.
[17] Guthrie E, Kapur N, Mackway-Jones K, Chew-Graham C, Moorey J, Mendel E,
Francis FM, Sanderson S, Turpin C, Boddy G. Predictors of outcome following
brief psychodynamic-interpersonal therapy for deliberate self-poisoning. Aust
NZ J Psychiatry 2003;37:5326.
[18] Guthrie E. Brief psychotherapy with patients with refractory irritable bowel
syndrome. Br J Psychother 1991;8:17588.
[19] Guthrie E. Psychodynamic interpersonal therapy. Adv Psychiat Treat
1999;5:13545.
[20] Hahn BA, Kirchdoerfer LJ, Fullerton S, Mayer E. Patient-perceived severity of
irritable bowel syndrome in relation to symptoms, health resource utilization
and quality of life. Aliment Pharmacol Therap 1997;11:5539.
[21] Hamilton J, Guthrie E, Creed F, Thompson D, Tomenson B, Bennett R, Moriarty
K, Stephens W, Liston R. A randomized controlled trial of psychotherapy in
patients
with
chronic
functional
dyspepsia.
Gastroenterology
2000;119:6619.
[22] Horowitz LM, Rosenberg SE, Baer BA, Ureo G, Villaseor VS. Inventory of
interpersonal problems: psychometric properties and clinical applications. J
Consult Clin Psychol 1988;56:88592.

T. Hyphantis et al. / PAIN 145 (2009) 196203


[23] Jones MP, Wessinger S, Crowell MD. Coping strategies and interpersonal
support in patients with irritable bowel syndrome and inammatory bowel
disease. Clin Gastroenterol Hepatol 2006;4:47481.
[24] Keefe FJ, Lipkus I, Lefebvre JC, Hurwitz H, Clipp E, Smith J, Porter L. The social
context of gastrointestinal cancer pain: a preliminary study examining the
relation of patient pain catastrophizing to patient perceptions of social support
and caregiver stress and negative responses. Pain 2003;103:1516.
[25] Lackner JM, Gurtman MB. Pain catastrophizing and interpersonal problems: a
circumplex analysis of the communal coping model. Pain 2004;110:597604.
[26] Lackner JM, Gurtman MB. Patterns of interpersonal problems in irritable bowel
syndrome patients: a circumplex analysis. J Psychosom Res 2005;58:52332.
[27] Leonard MT, Cano A, Johansen AB. Chronic pain in a couples context: a review
and integration of theoretical models and empirical evidence. J Pain
2006;7:37790.
[28] Leserman J, Drossman DA, Li Z, Toomey TC, Nachman G. The reliability and
validity of a sexual and physical abuse history questionnaire in female patients
with gastrointestinal disorders. Behav Med 1995;21:14150.
[29] McWilliams LA, Asmundson GJ. The relationship of adult attachment
dimensions to pain-related fear, hypervigilance, and catastrophizing. Pain
2007;127:2734.
[30] Meredith P, Strong J, Feeney JA. Adult attachment, anxiety, and pain selfefcacy as predictors of pain intensity and disability. Pain 2006;123:14654.
[31] Monsen K, Havik OE. Psychological functioning and bodily conditions in
patients with pain disorder associated with psychological factors. Br J Med
Psychol 2001;74 Part 2:18395.

203

[32] Rudy TE, Turk DC, Kubinski JA, Zaki HS. Differential treatment responses of
TMD patients as a function of psychological characteristics. Pain 1995;61:
10312.
[33] Shapiro DA, Firth JA. Exploratory therapy manual for the Shefeld
Psychotherapy Project (Memo No.733) [Available from University of Leeds,
Leeds, England].
[34] Silk DB. Impact of irritable bowel syndrome on personal relationships and
working practices. Eur J Gastroenterol Hepatol 2001;13:132732.
[35] Spanier JA, Howden CW, Jones MP. A systematic review of alternative
therapies in the irritable bowel syndrome. Arch Intern Med 2003;163:
26574.
[36] Thompson WG, Creed F, Drossman DA, Heaton KW, Mazzacca G. Functional
bowel disease and functional abdominal pain. Gastroenterol Int 1992;5:7591.
[37] Thorn BE, Keefe FJ, Anderson T. The communal coping model and interpersonal
context: problems or process? Pain 2004;110:5057.
[38] Ware JE, Kosinski M, Keller SD. SF-36 physical and mental health summary
scales: a users manual. Boston: The Health Institute, New Engl. Med. Centre;
1994.
[39] Ware JE, Sherbourne CD. The MOS 36-item short-form health survey
(SF-36): 1. Conceptual framework and item selection. Med Care 1992;30:
47383.
[40] Whitehead WE, Burnett CK, Cook III E, Taub E. Impact of irritable bowel
syndrome on quality of life. Digest Dis Sci 1996;41:224853.
[41] World Health Organization. Schedules for clinical assessment in
neuropsychiatry. Geneva, Switzerland: Division of Mental Health; 1994.

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