A Mixed Methods Study of Cognitive Flexibility in Irritable Bowel Syndrome


Introduction: Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction associated with reduced quality of life, increased rates of depression and anxiety, and high economic burden to society and the individual. Current behavioral interventions, which target well-known symptom exacerbating factors such as catastrophizing and gastrointestinal- specific anxiety, have demonstrated efficacy. However, not all patients experience symptom improvement. Cognitive flexibility may be an important factor in IBS not targeted by current treatments. This study seeks to develop a preliminary measure of cognitive flexibility in IBS in order to understand its relationship to previously- studied constructs and clinical outcomes. Methods: This study used an inductive, mixed methods approach to understand cognitive flexibility. First, experts in IBS were interviewed about cognitive flexibility in IBS. This expert opinion was used to categorize IBS into cognitively flexible (CF) or cognitively inflexible (CI) groups. Patients from each group were interviewed about their experiences with IBS, and interview data was analyzed and compared between groups. These differences formed the basis of a preliminary measure of cognitive flexibility in IBS (CI-IBS). In Study 3, we distributed the CI-IBS online sample of individuals with IBS in order to evaluate the range of cognitive flexibility in a larger sample and its relationships with other flexibility and outcome variables. Results: Six characteristics of CI patients emerged from clinician interviews, which guided recruitment for patient interviews. Patient interview data highlighted differences between CF and CI patients, and these formed the basis of a 20-item measure. This measure was distributed to an online sample of 38 individuals with IBS. The CI-IBS was highly correlated with the AAQ-II (adapted for IBS) (r=.797, p<.01), a measure of psychological flexibility. The CI-IBS was also significantly correlated with mental health quality of life, depression, anxiety, readiness for psychotherapy and intolerance of uncertainty. Together, severity and mental health quality of life predicted 53.5% of the variance in CI-IBS score. Discussion: Given the relationship between the CI-IBS and the AAQ-II (adapted for IBS), it may be a measure of psychological, rather than cognitive, flexibility. These findings suggest that less flexible patients may also be more likely to have higher symptom severity and poor mental health quality of life compared to more flexible patients. Limitations of this study include small sample size, which underpowered statistical analyses, and a homogenous, online patient sample, which limits generalizability of results. A larger and more diverse sample should be recruited to further understand this construct.

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