The role of avoidance behavior in the treatment of adolescents with irritable bowel syndrome: A mediation analysis

• Published in: Behaviour research and therapy 2018-06, Vol.105, p.27-35
• Main Authors: Bonnert, Marianne, Olén, Ola, Bjureberg, Johan, Lalouni, Maria, Hedman-Lagerlöf, Erik, Serlachius, Eva, Ljótsson, Brjánn
• Format: Article
• Language: English
• Subjects: Adolescent; Adolescents; Avoidance behavior; Avoidance Learning - physiology; Behavior change; Behavior therapy; Behavioral psychology; Clinical trials; Cognitive ability; Cognitive behavior therapy; Cognitive Behavioral Therapy; Exposure-based treatment; Female; Humans; Implosive Therapy; Internet; Intestine; Irritable bowel syndrome; Irritable Bowel Syndrome - psychology; Irritable Bowel Syndrome - therapy; Male; Mediation; Mediation analysis; NCT02306369; Quality of Life; Stress; Stress, Psychological - psychology; Stress, Psychological - therapy; Treatment Outcome
• ISSN: 0005-7967; 1873-622X
• DOI: 10.1016/j.brat.2018.03.006

Irritable bowel syndrome (IBS) is common in adolescents with a pronounced negative impact on quality of life. A pattern of avoidance behavior is commonly seen in the IBS population, which is associated with more gastrointestinal (GI) symptoms. Exposure-based cognitive behavior therapy (CBT) targets the avoidance behavior to reduce symptoms, but it is unknown whether reduced avoidance is a mediator of symptom improvement in adolescent IBS. Stress has been suggested to play a key role in worsening GI symptoms and is also a potential mediator of the treatment effect in IBS. This study was based on data from a randomized controlled trial (N = 101) that evaluated exposure-based internet-delivered CBT (Internet-CBT) compared with a wait-list for adolescents with IBS. We investigated whether avoidance behavior and perceived stress mediated the improvement in global GI symptoms due to treatment. We found that a change in avoidance behavior, but not perceived stress, mediated the effect of exposure-based Internet-CBT on GI symptoms. The decrease in avoidance behavior explained a large portion (67%) of the total treatment effect. Moreover, a unidirectional relationship over time was observed between avoidance behavior and GI symptoms. Our conclusion is that exposure-based CBT in adolescent IBS reduces avoidance and, consequently, reduces GI symptoms. •Adolescents with irritable bowel syndrome (IBS) improved during CBT due to reduced avoidance.•Decreases in GI symptoms were not mediated by a reduction in perceived stress.•It seems to be important to help patients with IBS to minimize avoidance of abdominal symptoms.