Psychodynamic interpersonal therapy and improvement in interpersonal difficulties in people with severe irritable bowel syndrome Thomas Hyphantis a,b , Else Guthrie a , Barbara Tomenson a , Francis Creed a, * a Psychiatry Research Group, Medical School, University of Manchester, Manchester, UK b Department of Psychiatry, Medical School, University of Ioannina, Ioannina, Greece article info Article history: Received 24 July 2008 Received in revised form 22 June 2009 Accepted 6 July 2009 Keywords: Pain Circumplex Psychodynamic interpersonal psychotherapy IBS abstract The aim of the present study was to assess the relationship between change in interpersonal difficulties 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, psy- chological 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 findings were: (1) difficulties with social inhibition and dependency were associated with longer disease duration; (2) change in mean IIP-32 over 15 months was significantly 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 inter- personal 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 spe- cific help with interpersonal problems may play a role in improving health status of patients with chronic painful IBS. Ó 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 disor- der 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 difficulties in interpersonal relationships [26,31], which relate to pain coping and outcome of treatment [37]. Several stud- ies have found an association between insecure attachment and re- lated interpersonal difficulties with poor pain self efficacy, 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 re- duced pain and reduced disability [4,24], which is what we have tested in this study. Patients with IBS are said to have difficulties with being asser- tive [26]. Such a submissive interpersonal style has been related to pain catastrophising [25], which is associated with soliciting support or empathy from others [4,24] and may relate to increased pain and disability [25]. One study suggested that difficulty with being assertive, which was associated with persistent and diar- rhoea-predominant IBS, arose because the illness has a deleterious effect on interpersonal relationships but this study was cross-sec- tional 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 anti- depressants and psychotherapy led to improved heath status in the long term but there was no apparent difference between the treat- ments. The first aim of the present study was to assess whether changes in interpersonal difficulties, symptoms of Irritable bowel syndrome (IBS), health status and psychological state showed con- gruent changes over time. Our second aim was a preliminary examination of whether the association between change in interpersonal relationships and out- come was different in different treatment groups. Both psycholog- ical treatments and antidepressants may help IBS patients [10,11,25,35]. Psychodynamic interpersonal therapy is designed to help people with their interpersonal difficulties, which may ex- plain how it helps some people with IBS in addition to relieving depression and anxiety [16–19,21,33]. Antidepressants, on the 0304-3959/$36.00 Ó 2009 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.pain.2009.07.005 * Corresponding author. Address: Psychiatry Research Group, Medical School, Rawnsley Building, Manchester Royal Infirmary, 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). www.elsevier.com/locate/pain PAIN Ò 145 (2009) 196–203