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Chapter 3 62 health related quality of life. 44 This raises the question whether current treatment goals for IBS in daily clinical practice should be revised. Gaining insight into which symptoms specifically affect a patient’s quality of life can aid in reprioritizing personal treatment goals and increase the chance of a successful individualized treatment trajectory. 45 Currently, treatment is merely targeted towards the patient’s predominant GI symptoms and in many cases, this entails primary treatment of pain, constipation, or diarrhea. Targeting GI symptom improvement without characterizing the full extent of the disorder and possible psychosocial modifiers may therefore contribute to treatment failure concerning quality of life over time. A helpful and pragmatic framework in this regard has been suggested by the Rome expert panel. 45 By following their five-step approach, clinicians can identify if and which psychological factors contribute to the disease burden in the individual patient and consider psychological treatments. In some patients, this might include the use of pharmacological neuromodulators 46 , but other therapy options include cognitive behavioral therapy (CBT), gut-directed hypnotherapy 47 , and dynamic psychotherapy. 48 Due to the relative lack in therapist availability, clinical implementation of these therapies is still limited. Recent attempts to reduce resource use without compromising effectiveness may assist in making psychological treatment more widely available; e.g. group hypnotherapy 49 , internet- delivered exposure-based CBT 50 , and home-based CBT. 51 In that light, it will be interesting to explore whether these developments can affect long-term quality of life and well-being in patients with IBS. Several limitations of the current study should be noted. Only two time-points within the five-year period were assessed; no further data were available about the period in between the baseline and follow-up measurement, including data on treatment received in this period. Therefore, we can neither comment about the frequency and duration of IBS flares within these five years, nor about the effect of treatment on symptoms, nor on the causal order of the impaired quality of life and psychological comorbidities. Moreover, selection bias cannot be excluded . Follow-up cohort studies depend on long- term dedication of their participants and the proportion of non-responders (loss to follow) in this study was 46.4%. To assess for potential selection bias, we tested for differences in baseline characteristics between responders and non-responders at follow-up. The groups did not differ in baseline demographic and lifestyle characteristics, nor in baseline symptom scores and subtypes (data not shown). Hence, there is no clear reason to assume that the non-responders would have had different outcomes at follow-up. Finally, a larger sample size would have been desirable. Due to a relatively small Rome III-negative group, small effects concerning quality of life or other parameters could have been missed, especially since we have corrected for multiple