I am writing this article as the No Panic help-lines receive a very large number of queries about irritable bowel syndrome. I hope that this article might begin to clarify some of the issues.
I suppose that one should say from the very start that irritable bowel syndrome is a umbrella term to cover a number of different conditions. These conditions have a number of common characteristics, to which I refer below, and most forms of irritable bowel syndrome comprise both physiological and psychological components. It is a condition that is extremely common and some medical textbooks state that about 50% of referrals to gastro-enterologists are for this condition.
The main symptoms are usually abdominal pain and altered bowel habits, and constipation often alternates with diarrhoea. The pain may be of a dull or aching variety, but sometimes it may be knife-like in its nature. The location of the pain also varies; sometimes it is in the lower quadrant of the abdomen, at other times it can occur in the middle of the abdomen, just under the ribs.
Sometimes the bowel motions may be very frequent and watery, particularly in the morning. This frequency of bowel activity in the morning often leads patients to avoid going out before the bowel activity slows down, or ceases, and this may also cause sufferers to develop an avoidance of situations where toilets are not readily present.
Sometimes, sufferers take regular amounts of anti-diarrhoeal medicines, which can then make the constipation aspects of the problem more severe. Yet other patients become so worried about the diarrhoea, they restrict all foods that they believe (often incorrectly) will cause their diarrhoea – so they will often have, what is in effect, a very low fibre diet. Such diets, of course, are generally unhealthy and may then cause further problems.
Thus, one can begin to see how irritable bowel syndrome may actually cause considerable anxiety and avoidance. In turn, the anxiety and avoidance produces a heightened pattern of physiological arousal, which may then cause further symptoms.
As many of you will know, anxiety sufferers, without irritable bowel syndrome, may experience diarrhoea at the height of their anxiety, and this diarrhoea is generally caused by the speeding up of activity in the gut muscles.
The causation of irritable bowel syndrome is something that remains the source of debate and controversy. However, it seems clear from the physiological point of view, that some people have particularly sensitive intestinal tracts and muscle activity is increased. There is also some evidence that some people are particularly sensitive to certain foodstuffs. Without doubt, anxiety is a factor that can increase bowel activity and, thus, it is likely in most cases that there is a mixture of both physiological and psychological components to causation. However, it should also be said that in some people the anxiety component of causation may be minor, while in other cases, anxiety is a very substantial factor. Thus, psychological factors, such as anxiety, may be important in increasing or even causing irritable bowel syndrome and the irritable bowel syndrome itself leads to secondary anxiety because of the obvious problems associated with having such symptoms.
It must be said at this point that there is some evidence that other psychological approaches have been shown to be helpful in the treatment of irritable bowel syndrome and, for some patients, it is clear that some forms of psychotherapy seems to have an effect. Having said this, the behavioural management of the bowel problem itself is important and a purely psychological approach to the problem is unlikely to be of benefit to the vast majority of patients.
Therefore, as far as treatment is concerned, psychological treatments, such as cognitive behaviour therapy, may make an important contribution to management. If the person is pre-disposed to anxiety, any form of anxiety-management training, including relaxation, breathing exercises and overall attempts to reduce arousal, such as exercise, can reduce the level of anxiety symptoms and thus reduce activity. In the case of people whose irritable bowel problem causes further anxiety and avoidance behaviour, it is very important that the patient is taught methods to reduce avoidance behaviour and to break the pattern of pre-occupation with irritable bowel syndrome-related thoughts. Over the years, I have treated many patients with irritable bowel syndrome and it is essential that one works closely with the patient’s family doctor or gastro-enterologist, to ensure that the advice given to the patient is consistent. Sometimes, patients are greatly resistant to changing their diet on the advice of their doctor, because of their fear (usually unfounded) that such dietary changes will cause the problem to increase. In my experience, most patients who present will need both help with reducing overall anxiety and dealing with an almost obsessive preoccupation with the bowel habit and associated avoidance behaviour.
It is very important for the therapist to understand the physiological nature of the problem, but unfortunately this is not always the case. As far as medication is concerned, there is no doubt that drugs that have specific action on the bowel may, in some cases, be very helpful. Equally, there is some evidence that some medication used to treat anxiety may also reduce bowel activity. However, the use of tranquillising medications, such as Valium, Ativan and similar drugs, should be avoided, although they may be very helpful in the short term, it should be borne in mind that the longer-term problems of addiction are substantial.
Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.