Jessica Seigel
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Gut Reaction -- Daily News

Gut reactions: Treating the emotional side of irritable bowel syndrome

NY Daily News
Health & Fitness

By Jessica Seigel

A

stomachache caused by emotional upset is so familiar that we've got an expression for it: getting "butterflies." But this was more like B-52s flying full bombs away in Judy's gut.

Until finding help that surprised even her, the fiftysomething interior decorator suffered bouts of stabbing abdominal pain and chronic diarrhea that made her miss work, cancel social visits, and stay home for fear she wouldn't get to a public bathroom in time.

"I was just miserable," says Judy, who didn't want her full name used because of embarrassment about her condition. For 15 years, she went from gastroenterologist to gastroenterologist seeking relief, but repeated colonoscopies, endoscopies and related tests found no lesions, inflammation or other physical sign of disease. Doctors' advice to eat more fiber caused worse cramps and gas, but it was their comments that hurt the worst.

"They looked at me like I was a mental case," she recalls, her voice tightening at the memory. "They said there was absolutely nothing wrong with me that it was all in my head."

Those words can hurt, but they can also heal, depending how they’re meant and what’s done next for people like Judy, who was finally diagnosed with irritable bowel syndrome (IBS), a particularly vexing condition thought by many specialists to have an emotional component.

Irritable bowel problems are the most frequent complaint brought to gastrointestinal (G.I.) specialists, costing $10 billion in medical care a year, according to the American Gastroenterological Association. Varying degrees of stomach troubles with no known physical cause are also second only to the common cold as a reason for missed work.

The still-controversial diagnosis for ongoing, painful stomach troubles, which may include persistent diarrhea or constipation, usually comes after tests prove fruitless. But doctors, including G.I. specialists and researchers, sharply disagree over how emotions are involved in the illness. Also in dispute is the significance of university studies in the last 20 years that show psychotherapy is successful in reducing bowel symptoms and pain.

The stomach doctors didn't help Judy. But she eventually found her way (after an Internet search) to Mary-Joan and Charles Gerson, a psychologist and gastroenterologist, respectively, who opened the Mind Body Digestive Center in Manhattan five years ago. Her gut troubles and pain largely disappeared after five "psycho-educational" group therapy sessions, plus individual meetings with the husband-and-wife team.

"Something happened when I was talking about myself. Maybe it was unconscious. They say that when you talk about it, it gets better," says Judy, who attributes her recovery six months ago to experts who helped her see the role of anxiety in her flareups, but also validated the reality of her physical symptoms. "There's definitely an emotional connection," she says.

Her story is no fluke. "This is the cutting edge of neuroscience," says Dr. Mary-Joan Gerson. "The literature clearly supports a psychological connection. We don't know exactly what that link is, but it exists."

MEDICAL CONTROVERSY

Though the exact nature of the link is poorly understood, a committee of gastroenterologists, psychiatrists and psychologists from the United States, Canada and England recently published IBS guidelines recommending that doctors include mental-health approaches in treating the disease.

The panel's report cited a "significant superiority of psychological over conventional medical treatment" in 10 of 13 small-scale studies dating to the late 1980s. ("Routine" care ranged from anti-diarrheals or laxatives to nothing at all.)

"Irritable bowel syndrome as a condition has defied good medical treatment," says gastroenterologist Douglas Drossman of the University of North Carolina at Chapel Hill. He leads the international IBS committee and is widely recognized for pioneering research on the syndrome's psychological role. "There is compelling evidence that cognitive treatment works. But it's not fully accepted yet. There may even be a stigma that this is a psychiatric problem."

The stigma originates in older theories about psychosomatic illness, which suggested that unconscious conflicts and trauma can express themselves through physical symptoms.

Today, researchers dismiss the notion of such direct cause and effect as simplistic, and instead use the term "bio-psychosocial" to describe the interplay of biology, genetics, thought, emotion and stressful events like divorce, unemployment and death of a loved one.

Destigmatizing the illness at least among medical doctors is tricky, since studies show that 40% to 60% of IBS patients surveyed in specialized clinics also suffer from psychiatric conditions like anxiety disorder and depression. Female patients outnumber male ones by two to one, and as many as half of IBS patients in specialty care also report having been sexually or physically abused in childhood.

UNITING MIND AND BODY

But about half of IBS patients have no psychiatric disorders except, perhaps, anxiety about often humiliating symptoms of an illness that can cause incontinence and flatulence. So what comes first stress or the symptoms causing stress? This "vicious cycle," according to the latest view, involves a continuous feedback loop connecting the central nervous system and stomach. "It's not a nebulous notion of mind over body," says Susan Lucak, a gastroenterologist and medical professor who treats IBS patients in tandem with a psychologist at Columbia Presbyterian Hospital. "There are direct nerve connections from the gut to the brain."

The gut contains 95% of the body's serotonin, the chemical that sends messages between nerves and also affects mood. Dubbed the body's "second brain," the gut somehow uses these neurotransmitters to digest and push food to the colon without requiring direct orders from the brain. That may be one reason low-dose anti-depressants decrease some irritable bowel troubles, particularly pain — and why emotions make the stomach act up.

THERAPY IN ACTION

Researchers don't know how it all works, but experiments using probes have shown that IBS patients are more sensitive to pain in the bowel. Brain images also reveal that stomach pain for IBS patients overactivates a part of the brain associated with anxiety.

Imaging also shows that psychotherapy reduces activity in areas of the brain associated with worry, sadness and anxiety. "Many people don't understand that psychotherapy is active in the brain," explains psychiatry professor Sanjaya Saxena, co-author of imaging studies at the University of California at Los Angeles.

But not all psychological strategies equally reduce pain and bowel symptoms, according to an analysis of 20 small-scale studies published in the June 2002 Journal of Consulting and Clinical Psychology. Treatments rated as effective were combinations of cognitive and behavioral therapy aimed at modifying negative thoughts and actions; psychodynamic therapy focused on personal "insight" and linking present and past experience, and hypnosis that creates a state of deep relaxation and suggestibility. On the other hand, biofeedback and peer-run support groups without a therapist had the same effect as no treatment.

"The goal of most treatment programs is to cut episodes in half in terms of frequency and pain intensity," says Lisa Scharff, assistant professor of psychiatry at Harvard Medical School, who co-authored the review. "You can't change someone's anatomy, but you can help them change the way they respond to stress, which is the big trigger for an individual IBS episode."

GETTING RESULTS

In cognitive therapy a treatment popular in the U.S. patients learn to become aware of emotions before and during outbreaks through diaries and counseling. They then work on changing negative thinking that causes stress. In three widely cited but small-scale studies at the University at Albany, 55% to 80% of patients reported fewer symptoms after 10 sessions, compared with about 10% improvement in the untreated control group.

"People surprise themselves when they actually slow down enough to see what they're thinking," says psychologist Edward Blanchard, director of the University at Albany's Center for Stress and Anxiety Disorders.

Blanchard led the Albany studies and is completing a larger, two-university research project with 200 patients. Typical "negative" thoughts, like "I must always be perfect. If I'm not, no one will ever love me," he says, can change once patients realize how such irrational, "catastrophic" thinking causes the stress that leads to irritable bowel episodes.

Blanchard, on the psychology end, and Drossman, in the medical camp, say their larger studies, to be published next year, may answer basic questions about which treatments work best for certain patients, and why they work. In the meantime, doctors such as Lucak at Columbia are designing combinations of therapy and drugs depending on the case.

Patients with negative views about themselves may respond best to cognitive-behavioral therapy, she says. Those who feel stressed or mildly anxious may benefit from hypnotherapy, and those with difficult personal relationships may do well in psychodynamic therapy.

Though many questions have yet to be answered, IBS experts say, adding psychological therapy to standard medical care cuts down or eliminates the need for drugs, which require continual use and often cause unhealthy side effects.

Therapy also can protect against relapse in the long run. That's been the case for Kathleen Mottus, an environmental scientist whose debilitating symptoms have not returned in four years since she finished three months of cognitive therapy in a university research study.

"I don't know exactly how the therapy worked," says Mottus, 39, who still has occasional but manageable outbreaks. I just know it did. It won't cure everybody nothing does. But it can make a big difference."

SIDEBAR
Useful Internet Sites
Irritable Bowel Syndrome Self-Help and Support Group: www.ibsgroup.org
International Foundation for Gastrointestinal Disorders: www.iffgd.org

Recommended Reading
"Breaking the Bonds of Irritable Bowel Syndrome: A Psychological Approach to Regaining Control of Your Life" by Barbara Bradley Bolen Ph.D.

December 9, 2002

END