THE FOLLOWING LECTURE HAS BEEN APPROVED FOR ALL STUDENTS BY BIRMINGHAM CITY UNIVERSITY

1. THE FOLLOWING LECTUREHAS BEEN APPROVED FOR ALL STUDENTS BY BIRMINGHAM CITY UNIVERSITY This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging Any issues raised in the lecture may require the viewer to engage in further thought, insight, reflection or critical evaluation

2. PsychologicalAssessment of Irritable Bowel Syndrome Dr. Craig Jackson Senior Lecturer in Psychology Faculty of Education Law & Social Sciences BCU Birmingham www.hcc.bcu.ac.uk/craigjackson craig.jackson@bcu.ac.uk

3. Dualism “If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; this you have the power to revoke at any moment” Marcus Aurelius 180BC Dualism Mind & Body Divided Unification Mind & Body are One Rene Descartes BioPsychoSocial Unification popular in last 10-15 years

4. Traditional model of Disease Development Pathogen Disease(pathology) Modifiers Lifestyle Individual susceptibility

5. Dominance of the biopsychosocial model Mainstream in last 15 years Hazard Illness (well-being) Psychosocial Factors Attitudes Behaviour Quality of Life Rise of the patient as a psychological entity

6. Mental States & Physical Well-being Triggering Hypothesis Chinese # 4 Phillips et al. 2001 World cup 1998 Carroll et al. 2002 Stressful events and Breast Cancer Chen et al. 1995 Scottish Heart Attack Deaths Evans et al. 2002 Baskerville Effect Conan-Doyle

7. Is disease real or is it in the mind?

8. Linking Emotions with Physical Symptoms

9. Rome Criteria

10. Irritable Bowel Syndrome Chronic or Recurrent Lower Abdominal Pain Disturbed Defecation Bloating NOT EXPLAINED BY STRUCTURAL OR KNOWN BIOCHEMICAL ABNORMALITIES

11. Symptoms / Side Effects Abdominal pain 56.6% Limited social life 38.3% Inability to travel 24.8% Flatulence 21.5% Bloating 18.6% Diet restriction 14.8% Discomfort 9.4% Unexpected onset 7.6% Constipation 7.1% Distended abdomen 6.9% Embarrassment 6.7% Diarrhoea 6.5% Sleep disturbance 6.2% Explosive movements 5.6% Lack of energy 4.5% Depression 4.3% Nausea 4.1% Noisy Intestines 3.5% Lethargy 3.3% Interruptions at work 3.2% Mental anguish 2.5% Inability to concentrate 2.4% IBS Bulletin, 1995

12. Irritable Bowel Syndrome Common digestive disorder Functional syndrome (No organic cause) Traumatic life events Personality disorders Stress Anxiety Depression Somatization Not a psychological disorder!

13. Psychological Consequences of Irritable Bowel Syndrome • Distress • Reduced Quality of Life • Delay in seeking help • Fear • Denial • Depressed / Anxious • Increased somatic complaints • Pain • Fatigue • Breathlessness • Seeks help too readily • Adjustment Disorder – commonest psychiatric diagnosis • Increased risk of suicide in early stages (of some) conditions

14. Global Epidemiology Drossman et al. 1997

15. Help Seeking Behaviour Sandler et al. 1984

16. Psychological / Perceptual Process of Illness Internal Processes • “Do I notice internal changes?” • “Should I interpret them negatively?” • “Should I think they are important?” External processes • “Do I notice external sources?” • “What should I believe about it?” • “What should I do about it?” MENTAL SCHEMA Internal representation of the world (knowledge, attitudes, beliefs) What do we believe about health? What do we believe affects health?

17. Factors Influencing Symptom Development Selective Internal Attention Tedious & un-stimulating environment Little communication Stressful environment Learned behaviours “Negative Affectivity” OVER FOCUS ON SYMPTOMS Comparisons Attributions Responses Blame Pessimism

18. Factors Influencing Symptom Development • Selective External Attention • Heightened concern about risk involuntary uncontrolled lack of information dreaded consequences • Mistrust of government / industry • Attitudes about medicine • Political agenda • Legal agenda • Social and political climate • Media and pressure group activity OVER FOCUS ON SYMPTOMS Comparisons Attributions Responses Blame Pessimism

19. Irritable Bowel Syndrome Occupational Link - Night-workers Personality Link - Loners Not life threatening Embarrassment Pain Discomfort QoL Anguish Debilitation 1 in 5 of population suffer IBS-type symptoms Females more prone (80%) Stress considered to play important role in triggering some IBS symptoms Psychology important in how symptoms are perceived and reacted to Can poor QoL Become a predictor of who will suffer in advance?

20. Psychosocial Balance Whitehead et al. 1988

21. Psychological Treatments Drossman et al. 1995

22. Prevalence among Twins Levy 2001

23. Modern day complaints Multiple Chemical Sensitivity Chronic Fatigue Syndrome Sick Building Syndrome Gulf War Syndrome Low-level Chemical Exposure Electrical Sensitivity Historical complaints Railway Spine Neurasthenia Combat Syndrome Symptom Prevalence % Stuffy nose 46.2 Headaches 33.0 Tiredness 29.8 Cough 25.9 Itchy eyes 24.7 Sore throat 22.4 Skin rash 12.0 Wheezing 10.1 Respiratory 10.0 Nausea 9.0 Diarrhoea 5.7 Vomiting 4.0 Heyworth & McCaul, 2001 Prevalence of Non-Specific Symptoms

24. Non-Specific Symptoms Often missed in clinical assessments

25. “Cultural” Bowel Syndrome Women in western societies in general seem more willing than men to seek medical attention for a whole variety of disorders Indian sub-continent: IBS is more common in men than women In Indian society men are known to consult doctors more often than women In this region of the world women also suffer from IBS symptoms but are not seeking help for their problem

26. Case #1 – Laura’s Weblog “Hello. This is a series of postings about my adventures, and trials, with irritable bowel syndrome (IBS). IBS is not a well defined disease. In fact most MDs don't define it as a disease at all; it is defined as a syndrome composed of varied and multiple symptoms. Traditional doctors either refuse to address it (it's all in your head) or call it what it is - a dysfunction of the digestive system, particularly the intestinal tract, that has no cure.” “I refuse to define it as a syndrome. Too much stigma for my brain. I need to work with a definition that allows for positive future energy. I haven't come up with one yet. In the meantime I consider IBS to be this large intestinal gnat.... sometimes, when the weather is just right, it doesn't bother me at all. The rest of the time I keep swatting at it. One of these days I will make it disappear altogether. Hence this blog.” Laura

27. Case #2 – Mike’s Nirvana of Peristalsis Tuesday, August 31, 2004 Dinner: leftover grilled chicken, chopped up with some baby zucchini, grilled poblano chile, and cheddar cheese. Lunch: tunafish salad, tossed salad, organic peaches. mhs@19:12 Friday, August 27, 2004 Lunch: leftover sautéed cauliflower and onion, grilled sausages, and cheese. Breakfast: homemade yogurt, fresh fruit, Lois Lang's nut bread, and some flax seed oil. mhs@14:00 Thursday, August 12, 2004 Breakfast: homemade applesauce, homemade yogurt, fresh blueberries, and some honey. A wonderful way to start the morning! mhs@06:27 Sunday, August 01, 2004 Dinner, yesterday: A feast with family and friends! Grilled salmon, grilled red snapper, grilled Cajun-rubbed catfish, and grilled shrimp with cumin, lime, and green chillies; tossed salad, roasted eggplant salad, asparagus. mhs@05:57

28. Case #3 - Kate “I have had IBS since I was a child. I remember always having stomach ache, sometimes quite severe, that no one could find the cause of. I was always at the doctor's or hospital being investigated. Finally, at age about 10, I went into hospital for a few days for tests. I think they thought I had a problem with my kidneys (I have three), but after observing me and my bowel movements for a few days they concluded that I had "irritable bowel syndrome". I don't remember having any treatment recommended at that time (this was the early 70s). I think it was just a case of "go away, your illness is not life threatening and there is nothing we can do for you". The trouble was that, apart from the bowel symptoms, I just never felt well anyway. I felt tired and mildly depressed all the time. I was okay for a few years and just suffered occasional problems. Then in my mid-twenties the IBS seemed to get worse. I had a couple of attacks in which I passed out. One time this happened in a restaurant, just after eating the first course. I had to rush to the loo as well. I saw an allergy doctor who tried to say that I was passing out to get attention! I can think of better, less painful ways, of getting attention. I went for more examinations and investigations but again I was diagnosed with IBS and sent away. I think it was about this time that I was prescribed anti-spasmodic drugs which I have been taking on and off for years. Violent attacks”

29. Case #3 - Kate “In my early-thirties it started to get worse again. I had more episodes of violent attacks in which I would have terrible pain and often pass out. I began to be scared to go out the house or anywhere that it might be difficult to find a toilet. I would wake up tired and go to bed feeling tired. It would be a struggle to get through the day, especially if I was also suffering from stomach cramps or other IBS symptoms. These symptoms were not restricted to my bowels. I also felt nauseous a lot of the time, and had general malaise. I started to get panic attacks when out in busy places. I became too frightened to even consider travelling anywhere, whether for work or a holiday. Even socialising became a nightmare and I started to want to stay in all the time. I also began to lose weight because I felt too nauseous to eat. I saw yet more doctors who gave me the all clear for various things such as stomach ulcers or cancer. But they couldn't (or weren't able to) help with the IBS. I was even referred to a psychiatrist, who suggested counselling. I found this helpful in some ways (we all enjoy talking about ourselves) but didn't get at the root of the problem, the IBS.”

30. The Brain-Gut Axis A variety of features that effect function of the central nervous system or brain have now been shown to effect, by virtue of the connections of the brain gut axis, the symptoms described above at the 'end organ' level This could be caused by psychological factors for example:Stress Anxiety Depression Or by psychological trauma such as:Verbal abuse Physical abuse Emotional abuse Sexual abuse

31. The Role of the Brain Modern strategies / treatments that have been developed for IBS reflect researchers’ understanding of the important role that the brain gut axis plays in causing symptoms In treatment of IBS variants, a concept of centrally and end organ treatment has been developed Centrally targeted treatments include therapies to counter the influence of: Stress, Anxiety and Depression Including: 1) physiological explanation of symptom generation2) various forms of counselling3) simple relaxation therapy4) gut-focused hypnotherapy5) cognitive behavioural therapy6) use of tricyclics / MAOIs

32. Stress Factor Many sufferers consider stress an important factor responsible for flare ups IBS may be a primary disorder of the brain/gut axis Psychological factors that influence the mental state of IBS sufferers are thought to cause chemical changes or imbalances in the brain that may in turn influence motility e.g. 5HT Stress-related chemical changes may influence perception of pain signals sent to the brain from sensory nerve endings that respond to events occurring in the intestines 70% of the non-patient population suffer changes in bowel function as a reaction to stressful situations Drossman 2001

33. Stress Factor Such 'gut reactions' tend to occur more frequently and more severely in those with IBS Half of IBS patients reporting stress believe their psychological situation helped contribute to their initial IBS (Summer 1999) IBS sufferers have a lower threshold for coping with stressful situations and are more likely to react to negative events that in turn, can have catastrophic effects on the workings of the gut The relationship between life events and gastrointestinal symptoms has long been accepted Environmental stresses can be common causes - childhood stress, early parental loss, parental alcoholism, unsatisfactory parent- relationships, sexual and physical abuse

34. Case Summary of an “IBS Patient” Date Symptoms Referral Investigation Outcome 1980 (18) Abdominal pain GP --> surgical OP Appendicectomy Normal 1983 (21) Pregnancy GP --> obs and gynae Termination (boyfriend in prison) OP 1985-7 Bloating, abdominal GP --> Gastro and All tests normal IBS diagnosis (23-25) blackouts (divorce) neurology OP unexplained syncope 1989 (27) Pelvic pain GP --> obs and gynae Sterilised Pain persists for 2 years (wants sterilisation) OP 1991 (29) Fatigue GP --> infectious Nothing abnormal Diagnosis of ME by patient diseases unit and self help group 1993 (31) Aching muscles GP --> rheumatology Mild cervical Pain clinic - Tryptizol clinic spondylosis 1995 (34) Chest pain, breathless A&E --> chest clinic Nothing abnormal Refer to psychiatric services (child truanting) poss hyperventilation

35. Screening Questionnaires Self-report screening instruments Beck Depression Inventory (BDI) General Health Questionnaire (GHQ) Hospital Anxiety Depression Scale (HAD) “How have you been feeling recently?” “Have you been low in spirits?” “Have you been able to enjoy the things you usually enjoy?” “Have you had your usual level of energy, or have you been feeling tired?” “How has your sleep been?” “Have you been able to concentrate on your favourite tv shows?” Persistent low mood and lackof interest and pleasure in life cannot be accounted for by severephysical illness alone

36. A Profile of IBS Sufferers? No such thing as a “typical” IBS patient How valid is this profile? Personality: introvert Occupation: night-time sedentary Sex: female Increased risk of IBS History of anxiety History of depression Food allergy / intolerance

37. Epidemiology of Chronic Patients • 4% of general population • 9% of admitted patients • 10-15 per GP • Mostly female • Recurrent depressive disorder • Longstanding difficulty in personal relationships • Possible substance misuse • Associated with emotionally deprived childhood, physical & sexual abuse • Some personality disturbance • Iatrogenic harm issues • Increased investigations + Increased treatments = Increased risk of harm

38. Common Chronic Ill-Health Complaints • Low Back Pain • Carpal Tunnel Syndrome • Cumulative Trauma Disorders FORMS OF • Tendonytis CHRONIC PAIN • Repetitive Strain Injury & FATIGUE • Fibromyalgia • Irritable Bowel Syndrome • Chronic Fatigue • Those with heightened symptoms choose attributions to match concepts of what is currently acceptable in medicine • External cause for illness preferred - patient becomes a helpless victim • “O R G A N I F I C A T I O N”

39. Chronic Patients’ Attributions of Ill-Health • Work • Stress • Environment • Chemicals • Toxins • Virus • Allergies • Traumatic injury • Anatomy / Ergonomic

40. Cognitive Model of Physical Symptoms

41. Measuring the Impact of IBS The IBS-QOL scale (Patrick & Drossman, 2004) Self-Completion questionnaire 10 minutes to complete 34 Items 5-Point likert scale 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely 1-100 score: Greater score = Better QoL 8 sub-scales: Dysphoria, Activity, Body image, Health worries, Food avoidance, Social reactions, Sexual activity, Relationships

42. Compensation Neurosis Improvement in health..... ...may result in loss of status Patient compelled to guard against getting better Financial reward for illness is a powerful nocebo Exacerbates illness In a litigious society, will compensation neurosis become more widespread?

43. Abnormal Illness Behaviour after Compensable Injury Accident neurosis Accident victim syndrome Aftermath neurosis American disease Attitudinal pathosis Barristogenic illness Compensatory hysteria Compensationitis Compensation neurosis Fright neurosis Functional overlay Greek disease Greenback neurosis Invalid syndrome Justice neurosis Perceptual augmenter Post accident anxiety syndrome Pensionitis Postaccident fibromyalgia Post-traumatic syndrome Profit neurosis Psychogenic invalidism Railway spine Secondary gain neurosis Traumatic hysteria Symptom magnification syndrome Traumatic neurasthenia Traumatic neurosis Triggered neurosis Unconscious malingering Vertebral neurosis Wharfie’s back Whiplash neurosis Mendelson, 1984

44. Secondary Gain Pre-disposition • Motivation • Desire for attention • Punish spouse / others • Solve life’s problems • Cry for help • Diversion from work • Socially approved task avoidance • sex with spouse • work • military duty

45. Behavioural Yellow Flags of Irritable Bowel Syndrome • Indicative of long term chronicity and disability • Negative attitude – some food is harmful and disabling • Fear avoidance • Reduced activity • Expects passive treatment to be better than active treatment • Tendency to low morale, depression and social withdrawal • Social / Financial problems

46. 10 20 30 40 50 60 70 80 90 100 % returning to work <1 2 4 6 8 10 12 14 16 18 20 22 24 months not working • Returning to Work • Longer off work = Less likely to return to work Waddell, 1994

47. Conclusions • IBS influenced by numerous factors – no single cause established • Some acknowledgement that brain / mood / personality effects IBS • Treatments focus equally on physiological and psychological • “Fashionable” diagnoses have considerable overlap • Environmental syndromes – sufferers often seek “organification” • Overlap with prior depression, anxiety, and history of unexplained complaints • Psychology plays a role in the cause, the toleration and the cure • Society is more “Accommodating” to chronic ill-health than ever before • Psychological assessment for the affects of IBS on the patient are important • Longer-term IBS patients may slip into the “chronic patient role”

48. Some References Corazziari E. Definition and epidemiology of functional gastrointestinal disorders. Best Pract Res Clin Gastroenterol. 2004 Aug; 18(4):613-31. Drossman DA. The "organification" of functional GI disorders: implications for research. Gastroenterology. 2003 Jan; 124(1): 6-7. Gralnek IM, Hays RD, Kilbourne AM, Chang L, Mayer EA.Racial Differences in the Impact of Irritable Bowel Syndrome on Health-Related Quality of Life. J Clin Gastroenterol. 2004 Oct; 38(9):782-789. Isolauri E, Rautava S, Kalliomaki M. Food allergy in irritable bowel syndrome: new facts and old fallacies. Gut. 2004 Oct; 53(10):1391-3. Patrick DL, Drossman DA. Re: Groll et al.--Comparison of IBS-36 and IBS-QOL instruments. Am J Gastroenterol. 2002 Dec; 97(12):3204

49. Malingering: Definition Intentional production of false or grossly exaggerated physical or psychological symptoms or signs for external gain (avoiding responsibility, or obtaining financial reward or drugs) not a medical diagnosis but a form of deviant behaviour ICD-10 Z76.5 Includes: + Munchhausen’s syndrome Excludes: - Somatoform disorder (hysterical conversion) - Hypochondriasis - Factitious Disorder – intentional production of false or grossly exaggerated physical or psychological symptoms or signs for internal gain (the sick role) ICD-10 F68.1

50. Historical Context Bible Several references e.g. King David; feigns madness when frightened by Saul’s military success (Samuel I, 21) Ancient Greece Punished malingerers in the military, by death War Combatants feign illness to avoid battle/ hard labour Workmen’s Compensation Act 1908 State sickness benefits, pension schemes, injury litigation