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Editor,—The Guidelines for the management of the irritable bowel syndrome supplement was a commendable enterprise,1 but with physicians tending to depend more and more on sources other than reading for their continuing education, actual guidance is also necessary, especially from what physicians such as Almy2 and Kirsner3 have found does and does not work. Sadly they were not not quoted. In addition, indecision and “fence sitting” has been found to be the most common stressful life situation present at the time of onset or relapse of IBS.4 Therefore, any indecisiveness on the part of doctors about choice of treatment of IBS is likely to be picked up by their patients.
The guidelines rightly pointed out the limitations of “ end organ” treatments compared with centrally directed therapies, such as hypnosis and relaxation methods. However, these are also rarely effective when a patient has a nagging personal problem at the back of his or her mind. Uncovering such doubts requires open ended questions as recommended by Almy.2 Patients may be encouraged to make such decisions by the likelihood of remission of symptoms if they do.
The importance of stressful life events is of course well recognised and new evidence is constantly accumulating. In addition to the earlier papers quoted by Dr Paulley, more recent publications inGut 1-1 indicate that resolution of chronic life stresses are important predictors of clinical outcome in irritable bowel syndrome supporting the earlier publications quoted by Dr Paulley.