Provoking symptoms to relieve symptoms: A randomized controlled dismantling study of exposure therapy in irritable bowel syndrome Brjánn Ljótsson a, * , Hugo Hesser b , Erik Andersson c , Jeffrey M. Lackner d , Samir El Alaoui c , Lisa Falk e , Kristina Aspvall a , Josefin Fransson a , Klara Hammarlund a , Anna Löfström a , Sanna Nowinski a , Perjohan Lindfors e, f , Erik Hedman a, g a Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Stockholm, Sweden b Department of Behavioural Sciences and Learning, Linköping University, Linköpings universitet, 581 83 Linköping, Sweden c Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Karolinska Universitetssjukhuset Huddinge, M46, 141 86 Stockholm, Sweden d Department of Medicine, University at Buffalo School of Medicine and Biomedical Science, ECMC, 462 Grider Street, Buffalo, NY 14215, USA e Department of Gastroenterology, Sabbatsbergs hospital, Olivecronas väg 1,113 61 Stockholm, Sweden f Department of Medicine Huddinge, Karolinska Institutet, M54, Karolinska Universitetssjukhuset Huddinge, 141 86 Stockholm, Sweden g Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Retzius väg 8 171 77 Stockholm, Sweden article info Article history: Received 26 April 2013 Received in revised form 10 January 2014 Accepted 31 January 2014 Available online 10 February 2014 Keywords: Irritable bowel syndrome Dismantling study Exposure Internet Randomized controlled trial abstract An internet-delivered cognitive behavioral treatment (ICBT) based on systematic exposure exercises has previously shown beneficial effects for patients with irritable bowel syndrome (IBS). Exposure exercises may be perceived as difficult for patients to perform because of the elicited short-term distress and clinicians may be reluctant to use these interventions. The aim of this study was to compare ICBT with the same protocol without systematic exposure (ICBT-WE) to assess if exposure had any incremental value. This randomized controlled dismantling study included 309 participants diagnosed with IBS. The treatment interventions lasted for 10 weeks and included online therapist contact. ICBT-WE comprised mindfulness, work with life values, accep- tance, and encouraged reduced avoidance behaviors, while ICBT also included systematic exposure to IBS symptoms and related situations. Severity of IBS symptoms was measured with the Gastrointestinal Symptom Rating Scale e IBS version (GSRS-IBS). The between-group Cohen’s d on GSRS-IBS was 0.47 (95% CI: 0.23e0.70) at post-treatment and 0.48 (95% CI: 0.20e0.76) at 6-month follow-up, favoring ICBT. We conclude that the systematic exposure included in the ICBT protocol has incremental effects over the other components in the protocol. This study provides evidence for the utility of exposure exercises in psychological treatments for IBS. Ó 2014 Elsevier Ltd. All rights reserved. Introduction Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder with a prevalence of about 11% (Lovell & Ford, 2012) that is associated with diminished work capacity, increased healthcare used, reduced quality of life, and low responsiveness to pharmaco- logical treatments (Camilleri & Chang, 2008; Drossman et al., 1993; Halder et al., 2004; Talley, Gabriel, Harmsen, Zinsmeister, & Evans, 1995). Several types of psychological treatments have been evalu- ated for IBS, including for example cognitive behavior therapy (CBT), Abbreviations: ACT, Acceptance and Commitment Therapy; AUDIT, Alcohol Use Disorders Identification Test; CBT, Cognitive behavior therapy; CSFBD, Cognitive scale for functional bowel disorders; GSA, Gastrointestinal symptom-specific anxiety; GSRS-IBS, Gastrointestinal Symptom Rating Scale e IBS version; HADS, Hospital Anxiety and Depression Scale; IBS, Irritable bowel syndrome; IBS-QOL, Irritable Bowel Syndrome Quality of Life Instrument; ICBT, Internet-based cognitive behavior therapy; ICBT-WE, Internet-based cognitive behavior therapy without exposure; MADRS-S, The MontgomeryeÅsberg Depression Rating Scale e Self report; VSI, Visceral Sensitivity Index; WAI, Working Alliance Inventory. * Corresponding author. Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Fogdevreten 2a, SE-17165 Stockholm, Sweden. Tel.: þ46 70 717 65 62. E-mail addresses: brjann.ljotsson@ki.se, brjann@gmail.com (B. Ljótsson), hugo.hesser@liu.se (H. Hesser), erik.m.andersson@ki.s (E. Andersson), lackner@buffalo.edu (J.M. Lackner), samir.el.alaoui@ki.se (S. El Alaoui), lisa.falk@aleris.se (L. Falk), kristina.aspvall@sll.se (K. Aspvall), josefin.fransson@sll.se (J. Fransson), klara.hammarlund@capio.se (K. Hammarlund), annalofstron@hotmail.com (A. Löfström), sanna.nowinski@gmail.com (S. Nowinski), perjohan.lindfors@ki.se (P. Lindfors), kire.hedman@ki.se (E. Hedman). Contents lists available at ScienceDirect Behaviour Research and Therapy journal homepage: www.elsevier.com/locate/brat http://dx.doi.org/10.1016/j.brat.2014.01.007 0005-7967/Ó 2014 Elsevier Ltd. All rights reserved. Behaviour Research and Therapy 55 (2014) 27e39