No, irritable bowel syndrome is not all in your head.

Updated May 22, 2016. I have added an opening summary, as well as a few links for readers who may want to learn more about IBS as a physical health problem about which we are learning a lot, not a mental health issue.

Irritable bowel syndrome (IBS) has symptoms in common with other physical conditions. IBS ranges in severity from mild and infrequent episodes to more frequent,severe, longer, and more debilitating episodes. It is thus a  recurrent, episodic condition. For many patients in many healthcare contexts, IBS remains an undiagnosed pattern of recurrent, but different symptoms that are presented without much relief.

Often IBS is effectively managed in primary care with lifestyle management and monitoring and identifying of triggers. However, when IBS is not effectively dealt with in primary care, a patient may need a referral to a specialist. This article argues that first specialist who  is considered should be a gastroenterologist, not a mental health professional.

Evidence is accumulating that IBS is often a disturbance in the gut-brain relationship. In that sense, it has a psychological component. But it is important to recognize that it is a matter of the gut influencing the brain by way of well-documented pathways.

IBS is increasingly seen as a  disturbance in the microbiota or microbiome (I explain what that means below) of the gut. President Obama has directed the NIH to study the human microbiota or microbiome as part of a larger initiative studying these phenomena in other ecological systems, including soil. There is a lot of enthusiasm for this broad initiative, but also some caution that the enthusiasm should not get too far ahead of the data. I have added some links about this.

Anxiety and depression often accompany IBS. The symptoms may reflect the uncertainty and discomfort of trying to managing an ill-defined condition. But this distress also may be a direct effect of the gut on the brain, again through increasingly known pathways.

Patients with undiagnosed IBS challenge and ultimately frustrate physicians. When physicians cannot resolve their complaints, patients sometimes get mistreated and blamed for their condition.

Previous explanations for IBS focused on it being an expression of unconscious conflicts. Psychoanalytically oriented explanations suggest anal conflicts in which the patient struggles with hostility that she cannot express directly. IBS can been seen as a conflict between retaining in expelling fecal contents. Diarrhea or loose bowel movements can be seen as symbolically crapping on somebody in a situation where anger cannot be directly expressed. Such explanations are creative and  even literary, but they are  testable hypotheses about an individual patient. Such ideas just do not hold up in research studies, often because the hypotheses cannot be coherently expressed with key variables  assessed with validated measures.

I’m not a physician and I’m not a position to offer advice to individual sufferers from IBS. But if I or a family member developed what looked like IBS, and it could not be brought under control in primary care. I would not recommend referral not to a mental health professional as the next step.

In the UK, IBS is considered a medically unexplained symptom (MUS). IBS patients are likely to be referred to psychological interventions for which there is only weak evidence. Patients with IBS may have to get educated on their own about the condition and fend for themselves in a medical system that is unresponsive to them.

Finally, some readers have attempted to leave comments on this blog post discussing benefits they sincerely believe they have received from treatments, including dietary supplements for which there is not scientific evidence. I have not accepted those comments for posting. I’m very skeptical of alternative and complementary medicine which is basically  unproven medicine. I also see suffers from IBS vulnerable to exploitation by all sorts of deliberate or innocent quackery.

A segment of CBS This Morning Saturday News showed the view of Irritable Bowel Syndrome (IBS) as  “all in your head” is outmoded. Placing the source of IBS as “all in the head” is unlikely to lead to improvement in a chronic, intermittent condition affecting millions of people, and disproportionately women.

Jonathan LaPookThe Host Was CBS News Chief Medical Correspondent, Jonathan LaPook.

 

 

 

 

 

 

Mark Pimental

Mark Pimentel MD (@MarkPimentelMD) on Twitter

He was interviewing Mark Pimental, MD, Associate Professor of Medicine, and Director of the G.I. Motility Program of Cedars-Sinai in Los Angeles.

 

 

 

 

 

 

 

At one point, Dr. LaPook poked fun at the obsolete approach to IBS in which physicians patted women on the head and told them that their condition was result of anxiety and depression.

pat on the head.PNGDr. Pimentel offered a view of IBS coming out of his research and specialty practice:

Irritable Bowel Syndrome (IBS) is one of the most common chronic medical conditions, affecting 10%-15% of the population in the United States and worldwide. Work on two distinct fronts has suggested that the pathophysiology of IBS may have microbial origins. First, a series of studies and meta-analyses over the last decade suggests that IBS can develop after a single episode of acute bacterial gastroenteritis (referred to as post-infectious IBS (PI-IBS). While these subjects exhibit characteristic gut immunologic changes (in the mucosa and myenteric ganglia), the mechanisms underlying the transition to an IBS phenotype remain unknown. Second, subjects with IBS have been shown to have specific changes in luminal bacterial contents, the most common of which is small intestinal bacterial overgrowth (SIBO), a condition whereby coliform bacterial counts in the small bowel become excessive. The presence of SIBO in IBS subjects has recently been confirmed by both small bowel culture and by quantitative PCR (qPCR) of duodenal contents.

Dr. LaPook advised sufferers of IBS to work with their primary care physicians to determine whether lifestyle changes could avoid episodes of IBS or at least make them less frequent and severe. If these efforts were not successful, Dr. LaPook recommended that they consult a specialist – a gastroenterologist, not a mental health professional!

More resources about contemporary views of IBS

Here’s a link to a US National Institute of Health webpage about Symptoms and Causes of Irritable Bowel Syndrome:

What causes IBS?

Doctors aren’t sure what causes IBS. Experts think that a combination of problems can lead to IBS.

Physical Problems

Brain-Gut Signal Problems

Signals between your brain and the nerves of your gut, or small and large intestines, control how your gut works. Problems with brain-gut signals may cause IBS symptoms.

GI Motility Problems

If you have IBS, you may not have normal motility in your colon. Slow motility can lead to constipation and fast motility can lead to diarrhea. Spasms can cause abdominal pain. If you have IBS, you may also experience hyperreactivity—a dramatic increase in bowel contractions when you feel stress or after you eat.

Pain Sensitivity

If you have IBS, the nerves in your gut may be extra sensitive, causing you to feel more pain or discomfort than normal when gas or stool is in your gut. Your brain may process pain signals from your bowel differently if you have IBS.

Infections

A bacterial infection in the GI tract may cause some people to develop IBS. Researchers don’t know why infections in the GI tract lead to IBS in some people and not others, although abnormalities of the GI tract lining and mental health problems may play a role.

Small Intestinal Bacterial Overgrowth

Normally, few bacteria live in your small intestine. Small intestinal bacterial overgrowth is an increase in the number or a change in the type of bacteria in your small intestine. These bacteria can produce extra gas and may also cause diarrhea and weight loss. Some experts think small intestinal bacterial overgrowth may lead to IBS. Research continues to explore a possible link between the two conditions.

Neurotransmitters (Body Chemicals)

People with IBS have altered levels of neurotransmitters—chemicals in the body that transmit nerve signals—and GI hormones. The role these chemicals play in IBS is unclear.

Younger women with IBS often have more symptoms during their menstrual periods. Post-menopausal women have fewer symptoms compared with women who are still menstruating. These findings suggest that reproductive hormones can worsen IBS problems.

Only at the bottom of the page is any reference to the traditional view that IBS somehow expresses psychological conflicts.

The dominant theme of the fact sheet is that IBS is often a disorder of the brain-gut signaling. However, the signaling problem originates in the gut which influences the brain.

Here is a link to a freely available  article in JAMA, the Journal of the American Medical Association, Small Intestinal Bacterial Overgrowth: A Framework for Understanding Irritable Bowel Syndrome.

IBS as a disorder of the microbiota or microbiome.

A microbiota is “the ecological community of commensal, symbiotic and pathogenic microorganisms that literally share our body space”.[1][2] Joshua Lederberg coined the term, emphasising the importance of microorganisms inhabiting the human body in health and disease. Many scientific articles distinguish microbiome and microbiota to describe either the collective genomes of the microorganisms that reside in an environmental niche or the microorganisms themselves, respectively.[3][4][5] However, by the original definitions these terms are largely synonymous There are trillions of microbes in the human microbiome, although the entire microbiome only accounts for about for 1-3% total body mass,[6] with some weight-estimates ranging as high as 3 pounds (approximately 48 ounces or 1,400 grams).[n 1] Research into the role that microbiota in the gut might play in the human immune system started in the late 1990s.[9] The microbiome of the gut has been characterised as a “forgotten organ”,[10] and the possibility has been raised that “the mammalian immune system, which seems to be designed to control microorganisms, is in fact controlled by microorganisms”.[11] The human microbiome may have a role in auto-immune diseases like diabetes, rheumatoid arthritis, muscular dystrophy, multiple sclerosis, fibromyalgia, and perhaps some cancers.[12] A poor mix of microbes in the gut may also aggravate common obesity.[13][14][15] Since some of the microbes in the human body can modify the regulation of some neurotransmitters, it may be possible to use certain microorganisms to supplement treatments for depression, bipolar disorder and other stress-related psychiatric disorders.[16]

BMC Medicine is assembling a new article collection “The Microbiome and Man,” guest edited by Dr Omry Koren.

But I warn you it is heavy going and highly technical.

Here’s a more accessible link describing President Barack Obama’s National Microbiome Initiative:

Microbiomes are the communities of microorganisms that live on or in people, plants, soil, oceans, and the atmosphere. Microbiomes maintain healthy function of these diverse ecosystems, influencing human health, climate change, food security, and other factors. Dysfunctional microbiomes are associated with issues including human chronic diseases such as obesity, diabetes, and asthma; local ecological disruptions such as the hypoxic zone in the Gulf of Mexico; and reductions in agricultural productivity.

Here is an interesting link to an account of a participant in a citizen scientist effort to map the human microbiota, Some of My Best Friends Are Germs:

 Microbiomes are the communities of microorganisms that live on or in people, plants, soil, oceans, and the atmosphere. Microbiomes maintain healthy function of these diverse ecosystems, influencing human health, climate change, food security, and other factors. Dysfunctional microbiomes are associated with issues including human chronic diseases such as obesity, diabetes, and asthma; local ecological disruptions such as the hypoxic zone in the Gulf of Mexico; and reductions in agricultural productivity.

This article from USA Today is reasonably well-informed:There’s 10 trillion microbes on you; the White House wants to figure them out.

This freely available article from Nature expresses enthusiasm about the US initiative, but indicates that there are some challenges ahead that require an international effort. It’s balanced: Microbiology: Create a global microbiome effort.

The outmoded view of IBS is dominant in the UK

Suzanne O’Sullivan’s  “It’s All in Your Head “is a collection of obsolete and simply wrong ideas about “psychosomatic conditions” in itself an outmoded term, but still in circulation in the UK. She specifically mentions IBS in an editorial based on the book in The Lancet:

 Some 20% of people in the UK have irritable bowel syndrome. This is one of the most common reasons for people to present to a gastroenterology clinic. It is also a condition that is affected by psychological distress and where no organic bowel disease is evident. And yet, to convince patients that psychosomatic disorders are an everyday problem that could affect any sort of person is very difficult. To tell somebody that their medical complaint might have an emotional cause is often met with anger. It is hard to believe that we can lose control of our bodies so completely and without our knowledge. And if our subconscious has chosen to mask our psychological distress and express it in a way more palatable to us then it follows that to remove the mask will be painful.

Suzanne O’Sullivan suggests the role of the physician in the UK is to convince the patient that IBS is all in her head. The notion that “our subconscious is choosing to mask psychological distress” is at the root of the problem would be considered rubbish by informed American professionals. It’s one of many neo-crypto-psychoanalytic ideas that of have crept into CBT in the UK, despite lacking empirical evidence and being untestable with the individual patient.

O’Sullivan doesn’t tell us, but she’s referring to the old psychoanalytic literature that considers IBS as expressing unresolved anal issues acquired in potty training. Then she expresses confusion why some patients are offended by this.

Stay tuned for a blog post in Mind the Brain that traces this idea to the fraudulent data of Hans Eysenck.

Simon Wessely has praised Suzanne O’Sullivan’s book.  It was picked for Wellcome book award as a ‘thoughtful, humane and heartfelt’ study” by Baroness Joan Bakewall. The  Baroness  closed her Twitter account and fled social media after making uninformed comments blaming sufferers of anorexia for their condition:

Bakewell, 82, said: “I am alarmed by anorexia among young people, which arises presumably because they are preoccupied with being beautiful and healthy and thin.

“No one has anorexia in societies where there is not enough food. They do not have anorexia in the camps in Syria. I think it’s possible anorexia could be about narcissism.”

She added: “To be unhappy because you are the wrong weight is a sign of the overindulgence of our society, over-introspection, narcissism, really.”

It’s all in your head”is also the view of IBS promoted by Trudie Chalder and her co-investigator Simon Wessely in a King’s College, London slide presentation aimed at getting primary-care physicians to refer patients to their PRINCE Project. PRINCE is an clumsy acronym for Persistent physical symptoms Reduction INtervention:  a system Change & Evaluation in Primary and Secondary Care.

first slide MUS presentation 2015-2-page-0

second slide MUS presentation 2015-2-page-0

third slide MUS presentation 2015-2-page-0

As can be seen, the brain-gut connection is portrayed as running from the controlling brain  down to the gut.

An article about CBT for medically unexplained symptoms is recommended for the GP’s self-study.

fourth slide MUS presentation 2015-2-page-0.jpg

The preferred treatment for IBS is CBT.

fifth slide-page-0.jpg

As an American, I can’t make a positive identification of this, but I strongly suspect a British attempt at humor. However, I find it quite revealing of how psychoanalysis intrudes into what passes for CBT in the UK. This is associated with lots of patient-blaming notions about somatic conditions expressing hidden conflicts about sex and aggression and dependency.

Participation in clinical trials should be based on patients being fully informed about alternatives. I don’t know if modern treatment of IBS is available in the UK. But if I had a friend who was approached by their GP in the UK about participating in PRINCE, I would recommend that the friend become acquainted with the contemporary view of IBS in the rest of the world, and if necessary, educate their GP.