# IBS ï¿½ Beyond the Bowel:



## eric (Jul 8, 1999)

FYIwith permissionIBS ï¿½ Beyond the Bowel:The Meaning of Co-existing Medical ProblemsOlafur S. Palsson, Psy.D. and William E. Whitehead, Ph.D.UNC Center for Functional GI & Motility DisordersIrritable bowel syndrome (IBS) is a disorder that is defined by a specific pattern ofgastrointestinal (GI) symptoms in the absence of abnormal physical findings. The latestdiagnostic criteria for IBS -- the Rome II criteria created by an international team ofexperts -- require that the patient have abdominal pain for at least 12 weeks within thepast 12 months and that the pain meets two of the following three criteria: it is relievedafter bowel movement, associated with change in stool frequency, or associated withstool form. It is becoming clear, however, that these bowel symptoms do not tell thewhole story of symptoms experienced by IBS patients. People with this disorder oftenhave many uncomfortable non-gastrointestinal (non-GI) symptoms and other healthproblems in addition to their intestinal troubles.SYMPTOMS ALL OVER THE BODY IN IBSSeveral research reports have established that IBS patients report non-bowel symptomsmore frequently than other GI patients and general medical patients. For example, fourstudies that have asked IBS patients about a wide variety of body symptoms(1-4) all foundheadaches (reported by 23-45% of IBS patients), back pain (28-81%), and frequenturination (20-56%) to be unusually common in individuals with IBS compared to otherpeople. Fatigue (36-63%) and bad breath or unpleasant taste in the mouth (16-63%) werefound in three of these four studies to be more common among IBS patients, as well.Furthermore, a large number of other symptoms have been reported to occur withunusually high frequency in single studies. In our recent systematic review of the medicalliterature(5), we found a total 26 different symptoms, listed in Table 1, that are reported tobe more common in IBS patients than comparison groups in at least one study.Table 1. Non-gastrointestinal symptoms more common in irritable bowel syndromepatients than in comparison groups(5).1. Headache2. Dizziness3. Heart palpitations or racing heart4. Back pain5. Shortness of breath6. Muscle ache7. Frequent urinating8. Difficulty urinating9. Sensitivity to heat or cold10. Constant tiredness11. Pain during intercourse (sex)12. Trembling hands13. Sleeping difficulties14. Bad breath/unpleasant taste inmouth15. Grinding your teeth16. Jaw pain17. Flushing of your face and neck18. Dry mouth19. Weak or wobbly legs20. Scratchy throat21. Tightness or pressure in chest22. Low sex drive23. Poor appetite24. Eye pain25. Stiff muscles26. Eye twitchingOVERLAP WITH OTHER MEDICAL CONDITIONSResults from numerous studies (reviewed by Whitehead, Palsson & Jones, 2002(5)) alsoindicate that IBS overlaps or co-exists more often than would be expected with othermedical conditions that appear to have little logical connection with the gut. The mostresearched example of such an overlap is the co-existence of IBS with fibromyalgia, adisorder characterized by widespread muscle pain. Fibromyalgia affects an estimated 2%of the general population, but 28-65% of IBS patients have the disorder. Similar resultsare obtained when this overlap is examined the opposite way, by studying fibromyalgiapatients and looking for IBS -- 32-77% of fibromyalgia patients have IBS.Chronic fatigue syndrome (CFS) is another medical condition that has been found to havemany times the expected co-occurrence with IBS. CFS is thought to affect only 0.4% ofthe general population, but it has been reported in 14% of IBS patients. Conversely, 35-92% of chronic fatigue syndrome patients have IBS. Other conditions documented inmultiple studies to have excess overlap with IBS are temporomandibular joint disorder(TMJ), found in 16-25% of IBS patients(2,6), and chronic pelvic pain (35% of IBSpatients(7). In addition to these well established relationships, many other medicalconditions appear (judging from single study reports) to have an excess overlap with IBS,although the frequencies of most of them in IBS are much lower than for the disordersalready discussed. In fact, we recently(8) compared the frequencies of a broad range ofdiagnoses in the medical records of 3153 IBS patients in a large health maintenanceorganization in the U.S. Northwest to an equal number of non-GI patients in the sameHMO, and found that the IBS patients had a higher frequency of almost half of all non-GIdiagnoses, or 64 of the 136 sampled diagnoses.In summary, non-GI symptoms and co-existing medical problems seen in many IBSpatients far exceed what is typical for medical patients or GI patients in general. Thisraises important questions about what causes this phenomenon and what the implicationsare for IBS patients.WHAT EXPLAINS NON-GI SYMPTOMS AND CO-EXISTENCE OF OTHER DISORDERS IN IBS?There are several possible explanations for the preponderance of general symptoms anddisorders in IBS. Our research group is engaged in several research studies that may helpshed some light on this mystery, but it is still too early to come to definitive conclusions.We will list here some of the possible explanations, and discuss relevant data comingfrom work by our team and other investigators.1. A common physical cause? One explanation for the high rates of co-existingsymptoms and conditions in IBS patients would be that there is something biologicallywrong in IBS patients that also causes other symptoms or conditions. There are a numberof distinct physiological characteristics or ï¿½abnormalitiesï¿½ seen in many IBS patients,although none of them are found in all IBS patients. These include: heightened painsensitivity in the gut, increased intestinal contractions (motility) or hyper-reactivity inresponse to meals or stress (too much movement of the intestines ï¿½ this is the reason whyIBS was called spastic colon in the past), patterns of dysfunction in the autonomicnervous system (that part of the nervous system that helps regulate our inner bodyfunctions), and vague signs of immune activation seen in some IBS patients. Althoughone could suggest ways in which these physiological abnormalities would play a role insome other disorders that co-exist with IBS, there is little evidence so far of a commonpattern of physical abnormality that could link IBS and its most common coexistingconditions and symptoms. Patterns of autonomic dysfunction in IBS are not like the onesseen in fibromyalgia and chronic fatigue syndrome, for example. And, fibromyalgiapatients do not show the same gut pain sensitivity as IBS patients, while conversely, IBSpatients do not show the pain-sensitive tender points that are characteristic offibromyalgia(9-10). Furthermore, as can be seen from reviewing the symptom list in Table1, the non-GI symptoms that plague IBS patients are so varied and cover so manydifferent organ systems, that it would be hard to identify a specific biological connectionbetween them. On the contrary, it seems like the only overall commonality between thesesymptoms may be that they are non-specific ï¿½ they are, in other words, not clearsymptoms of any identifiable disease processes or diagnosable disorders. Indeed, thesymptoms that are most common among IBS patients are generally those that are alsocommon in the general healthy population ï¿½ they just tend to occur at a higher level inpeople with IBS.2. Physical expression of emotional discomfort?Another possible explanation for the high number of non-GI symptoms and disorders inIBS patients is the tendency to translate strong emotions into physical symptoms. This issometimes called somatization (ï¿½somaï¿½ is the Greek word for ï¿½bodyï¿½ and somatizationtherefore literally means ï¿½to express in the bodyï¿½). All people ï¿½somatizeï¿½ to some degree;it is normal to feel butterflies in your stomach, to blush or go pale, get a lump in yourthroat, or feel the heart beating in your chest when you get very emotional. Shaky hands,stiff neck or excess sweating are likewise quite ordinary when people are under a greatdeal of stress. However, some people are more vulnerable than others to letting negativeemotions express themselves physically. This is often thought to be an alternative andless healthy way of exhibiting or feeling emotional discomfort. Some people maydevelop a strong tendency to do this because they have a basic personality trait that shiesaway from interpersonal expressiveness. For others, it could be the result of growing upin the care of strict, repressive or abusive parents or caretakers, where normal expressionof negative emotions was not allowed or would have been dangerous. Getting a headacheor a stomach ache may be an alternative way to ï¿½give voiceï¿½ to negative emotions undersuch circumstances. It seems that excessive habitual suppression of ordinary verbal andemotional expressions of negative emotions, regardless of the reason for it, may lead tothe tendency to somatize. There is evidence that this tendency may be at work in IBS, atleast among some women with the disorder. Dr. Brenda Toner has found in twostudies(11-12) that women with IBS score higher than depressed women and healthywomen on questionnaires measuring of the tendency to avoid the expression of negativeemotions or views.3. Learned over-attention to body symptoms and excess disease attribution?All people ignore most of the sensations from their bodies most of the time. This isnecessary so that we are not overwhelmed by the vast amount of information our sensessupply to our brains every moment of our lives. For example, if you are reading thissitting down, you have probably not been at all aware of the sensations of the seat underyour body until right now. Our brains constantly sift through the mass of incoming bodyinformation and decide what is important for us to become consciously aware of, basedon such things as our past experiences and how likely the information is to indicate athreat to our health or well-being. Most minor symptoms (those that might beuncomfortable and bothersome if they would get our attention), are simply dismissed inour busy everyday lives, because other things win out in the moment-to-momentcompetition for our limited attention resources.More frequent attention to mild physical symptoms can be learned, however, and canbecome a habit. As with most things, such habitual over-attention is probably most easilylearned in childhood. It would seem reasonable, for example, that a child could get intothe habit of noticing physical symptoms more if his or her parents are always talkingabout their own symptoms. We have recently found(13) that the more medical problemsthe parents in the childhood home had, the more general physical symptoms adult IBSpatients report. The possible consequence of a childhood where the child grew up withparents or others who were seriously ill, is a tendency to interpret common normalphysical sensations as symptoms of serious illness. Such a serious view of symptoms canalso be modeled after the parentï¿½s approach to common illness. Dr. Whitehead andcolleagues found in a telephone survey of 832 adults 20 years ago(14) that people whoseparents paid more attention to cold or flu symptoms in childhood were more likely toview such symptoms as serious in adulthood and to visit doctors for them. They were alsomore likely to have IBS diagnosis.Evidence that IBS patients interpret physical sensations differently than others isemerging from brain imaging studies. This type of research takes a ï¿½snapshotï¿½ of theamount of activity in different parts of the brain in response to sensations, usingtechniques such as PET scans (positron emission tomography) and fMRI (functionalMagnetic Resonance Imaging). By examining which parts of the brain react the most topainful sensations, it is possible to deduce to some degree how the brain processes theinformation. In one such study, by Silverman and colleagues(15), IBS patients but notcontrol subjects reacted to physical sensations from a painful balloon inflation in therectum with increased blood flow in the left prefrontal cortex, a part of the brain knownto process personally threatening information. In contrast, this study and others(16-17)found that IBS patients do not show activity in the anterior cingulate cortex that isindicative of general discomfort in healthy subjects. IBS patients are also more likely torespond to physical stimuli in the GI tract by activating brain centers that handleemotional events. Collectively, this suggests that IBS patients may process bodyinformation associated with bowel sensations (and perhaps other physical sensations, aswell) differently than other people, interpreting them as personally threatening and moreemotionally relevant events rather than just ordinary discomfort. Such differentinterpretations of physical sensations would also explain hyper-attention to suchsensations.4. Faulty neurological filtering?After entering the spine (the information highway from the body to the brain),information destined for the brain about body pain is sent along nerves through gates thatcontrol how much of this information passes through. Our brains continually send signalsdown these spinal gates to cause them to block signals that are of too low intensity toprovide valuable information (you do not want to constantly know about all of yourminor aches and discomforts from regular body activity). This is one of the ways thebrain uses to limit the vast amounts of information constantly streaming in from millionsof nerve sensors throughout our bodies. A current popular hypothesis in the field of IBSresearch is that an inadequate amount of this ï¿½descending inhibitionï¿½ of incoming paininformation is, at least partly, to blame for the hypersensitivity to intestinal discomfortand pain seen in IBS patients. Some researchers have further suggested that the samekind of slack traffic control could be more widespread in IBS patients and may explainthe observed proneness to headaches, back pain or muscle aches. People who have moreopen pain gates because of faulty inhibition would theoretically be like the princess inï¿½The Princess and the Pea.ï¿½ who could feel a pea through 20 mattresses. The problemwith this as an explanation for symptom overabundance among IBS patients is that itwould explain only excess in pain-type symptoms, which are just one of many types ofoverabundant symptoms in IBS. There are also no direct data on IBS patients to provehow valid this view is.5. Result of greater psychological distress?As was explained earlier, it is normal for people who are emotionally distressed toexperience more physical symptoms. At least half of IBS patients who have consulteddoctors have been diagnosed with an affective (ï¿½emotionalï¿½) disorder ï¿½ generally eitherdepression or an anxiety disorder. Additionally, many people with IBS who have noaffective disorder diagnosis have significant symptoms of anxiety and depression. Onemight, therefore, ask whether the physical symptoms reported could simply be a sideeffect of psychological distress.We have addressed this question in two studies presented at the 2003 Annual Meeting ofthe American Gastroenterological Association(18-19). In the HMO data mentioned earlier(18), we found that having a psychological diagnosis was associated with increasednumbers of physical diagnoses that these IBS patients had received (from an average of7.1 to 9.7). However, we also found that even patients with no psychiatric diagnosis hadmore physical diagnoses per person than the other HMO patients (7.5 vs. 5.5), so thepresence of psychological problems is not the whole answer. In the other study(19), weexamined the relationship between depression and anxiety scores of 795 people with IBSand the number of physical symptoms they had experienced over the past month.Statistical methods that estimate how much of the variability in one measuredcharacteristic can be explained by other measured factors tell us that the psychologicalsymptoms roughly accounted for 25-30% of physical symptoms of these people. In short,psychological distress is almost certainly part of the explanation for greater bodysymptoms in IBS, but not nearly the whole story.Further research will have to determine which of the above explanations are applicable inIBS, but it is likely that more than one of them, and maybe some other factorsunrecognized so far, work together to account for the high frequency of symptoms anddisorders that co-exist with IBS.THE IMPACT OF EXTRA PHYSICAL SYMPTOMS AND DISORDERS ON IBS PATIENTS.What do these extra (ï¿½non-IBSï¿½) symptoms and co-existing medical conditions mean inpractical terms for patients with IBS? The first thing to note is that not all IBS patientsexperience additional health problems and symptoms, so it is not a concern for all peoplewith IBS. For those who do, however, symptoms and disorders beyond the bowel can addmeasurably to the overall burden of illness for the individual and also lead to greaterhealth care needs and health care costs for IBS patients.It is by now well established that IBS patients visit doctors more than the generalpopulation. Only recently has it been recognized, howver, that most of the extra healthcare visits that people with IBS make are not for their bowel problems. Levy et al.(20)reported that IBS patients had about twice as many doctor visits compared to otherpatients in the same HMO, but they found that 78% of the additional visits were due toproblems other than IBS. It seems quite likely that these extra non-GI doctor visits of IBSpatients are due to the tendency to experience more general body symptoms over time,based on study results we presented at the Annual Meeting of the AmericanGastroenterologicalAssociation last year(21). Usinga scale asking patients aboutthe 26 physical symptoms inTable 1, we found that thoseIBS patients who report anunusually high number of thesesymptoms over the past monthmissed six times as many daysfrom school or work due toillness (see Figure 1)compared to those with low ormoderate (normal) symptoms.The ï¿½high-symptomï¿½ IBSpatients also had twice as manydoctor visits and more hospitaldays (Figure 2), and their qualityof life was furthermoremeasurably poorer on theaverage.A general tendency to have alarge number of body symptomsis, therefore, very costly in termsof the IBS patientï¿½s overall wellbeingand ability to functionnormally in life, and increasessubstantially the health care costsfor these individuals. Thesefindings clearly underline theneed to find a way to help themany IBS patients who score unusually high on body symptom questionnaires to reducethat tendency.IS IT POSSIBLE TO REDUCE NON-GI SYMPTOMS IN IBS?It is unknown to what degree standard medical treatment for IBS, when successful, alsoresults in improvement in non-GI symptoms. The problem is that most IBS treatmentresearch has not examined how non-IBS symptoms change. Non-IBS symptoms havealso not been a focus of standard IBS treatment. An exception to this is psychologicaltreatment trials for IBS, which sometimes have included general physical symptomquestionnaires among the measures of treatment effects. We, therefore, know from ourtwo studies of hypnosis treatment for IBS(22) as well as from research in England(23) thathypnosis treatment for IBS regularly improves non-GI symptoms substantially in additionto its beneficial effects on bowel symptoms. Less is known about improvement in non-GIsymptoms from cognitive-behavioral therapy (CBT), which is the other widelyresearched psychological treatment for IBS. However, there is every reason to believethat CBT can reduce the tendency to experience a lot of general physical symptoms,based on a review of over 30 such treatment studies(24). These benefits of psychologicaltreatment for IBS point to extra value of such treatments for the subgroup of IBS patientswho have many non-GI symptoms.Research in coming years will hopefully identify other ways to improve the well-beingand life functioning of IBS patients by reducing non-GI symptoms. This is likely tobecome an integral part of managing IBS effectively in the subset of patients who suffermany symptoms and conditions beyond the bowel.References:1. Whorwell PJ, McCallum M, Creed FH, Roberts CT. Non-colonic features of irritable bowelsyndrome. Gut 1986; 27:37ï¿½40.2. Jones KR, Palsson OS, Levy RL, Feld AJ, Longstreth GF, Bradshaw BH, Drossman DA, &Whitehead WE. Comorbid disorders andsymptoms in irritable bowel syndrome (IBS) Comparedto other gastroenterology patients. Gastroenterology 2001:120:A66.3. Zaman MS, Chavez NF, Krueger R, Talley NJ, Lembo T. Extraintestinal symptoms in patientswith irritable bowel syndrome (IBS). Gastroenterology 2001; 120(Suppl 1):A636.4. Maxton DG, Morris J, Whorwell PJ. More accurate diagnosis of irritable bowel syndrome by theuse of ï¿½non-colonicï¿½ symptomatology. Gut 1991; 32:784ï¿½786.5. Whitehead WE, Palsson O, Jones KR. Systematic review of the comorbidity of irritable bowelsyndrome with other disorders: what are the causes and implications? Gastroenterology 2002 Apr;122(4):1140-56.6. Aaron LA, Burke MM, Buchwald D. Overlapping conditions among patients with chronic fatiguesyndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med 2000; 160: 221ï¿½227.7. Walker EA, Gelfand AN, Gelfand MD, Green C, Katon WJ. Chronic pelvic pain andgynecological symptoms in women with irritable bowel syndrome. J Psychosom Obstet Gynaecol1996; 17:39ï¿½46.8. Whitehead WE, Palsson OS, Levy RL, Von Korff M, Feld AD, Turner MJ. Excess comorbidityfor somatic disorders in irritable bowel syndrome (IBS) is related to hypervigilance.Gastroenterology 2003 (abstract in press).9. Chang L. The association of functional gastrointestinal disorders and fibromyalgia. Eur J SurgSuppl 1998 ;( 583):32-6.10. Chang L, Mayer EA, Johnson T, FitzGerald LZ, Naliboff B. Differences in somatic perception infemale patients with irritable bowel syndrome with and without fibromyalgia. Pain 2000 Feb;84(2-3):297-307.11. Toner BB, Garfinkel PE, Jeejeebhoy KN. Psychological factors in irritable bowel syndrome. Can JPsychiatry. 1990 Mar; 35(2):158-6112. Toner BB, Koyama E, Garfinkel PE, Jeejeebhoy KN, Di Gasbarro I. Social desirability andirritable bowel syndrome. Int J Psychiatry Med 1992; 22(1):99-103.13. Whitehead WE, Palsson OS, Jones KR, Turner MJ, Drossman DA. Role of parental modeling insomatization of adults with irritable bowel syndrome. Gastroenterology 2000; 122 (Suppl 1):A502.14. Whitehead WE, Winget C, Fedoravicius AS, Wooley S, Blackwell B. Learned illness behavior inpatients with irritable bowel syndrome and peptic ulcer. Dig Dis Sci 1982 Mar;27(3):202-8.15. Silverman DH, Munakata JA, Ennes H, Mandelkern MA, Hoh CK, Mayer EA. Regional cerebralactivity in normal and pathological perception of visceral pain. Gastroenterology 1997 Jan;112(1):64-72.16. Bonaz B, Baciu M, Papillon E, Bost R, Gueddah N, Le Bas JF, Fournet J, Segebarth C. Centralprocessing of rectal pain in patients with irritable bowel syndrome: an fMRI study.Am JGastroenterol 2002 Mar;97(3):654-61.17. Bernstein CN, Frankenstein UN, Rawsthorne P, Pitz M, Summers R, McIntyre MC. Corticalmapping of visceral pain in patients with GI disorders using functional magnetic resonanceimaging. Am J Gastroenterol 2002 Feb;97(2):319-27.18. Whitehead WE, Palsson OS, Levy RL, Von Korff M, Feld AD, Turner MJ. Comorbid psychiatricdisorders in irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).Gastroenterology 2003 (abstract in press).19. Palsson OS, Levy R,Von Korff M, Feld A, Turner MJ, Whitehead WE. Comorbidity andpsychological distress in irritable bowel syndrome (IBS). Gastroenterology 2003 (abstract inpress).20. Levy RL, Whitehead WE, Von Korff MR, Feld AD. Intergenerational transmission ofgastrointestinal illness behavior. Am J Gastroenterol 2000; 95:451ï¿½456.21. Palsson, O.S., Jones K.R., Turner M.J., Drossman D.A., & Whitehead, W.E. (2002). Impact ofsomatization and comorbid medical conditions on health care utilization, disability, and quality oflife in irritable bowel syndrome (IBS). Gastroenterology, 122 (Suppl 1): A501-502.22. Palsson OS, Turner MJ, Johnson DA, Burnelt CK, Whitehead WE. Hypnosis treatment for severeirritable bowel syndrome: investigation of mechanism and effects on symptoms. Dig Dis Sci 2002Nov; 47(11):2605-14.23. Gonsalkorale WM, Houghton LA, Whorwell PJ. Hypnotherapy in irritable bowel syndrome: alarge-scale audit of a clinical service with examination of factors influencing responsiveness. Am JGastroenterol 2002 Apr; 97(4):954-61.24. Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: acritical review of controlled clinical trials. Psychother Psychosom 2000 Jul-Aug; 69(4):205-15.


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