Irritable Bowel Syndrome Message Boards | IBS � Beyond the Bowel: The Meaning of Co-existing Medical Problems

FYI I could not remmeber if I posted this before.

With permission

IBS � Beyond the Bowel: The Meaning of Co-existing Medical Problems
Olafur S. Palsson, Psy.D.
William E. Whitehead, Ph.D.
Irritable bowel syndrome (IBS) is a disorder that is defined by a specific pattern of
gastrointestinal symptoms in the absence of abnormal physical findings. The latest
diagnostic criteria for IBS, the Rome II criteria created by an international team of
experts, require that the patient has abdominal pain for at least 12 weeks in the past 12
months, and that the pain satisfies two of three criteria: It is relieved after bowel
movement, associated with change in change in stool frequency or associated with stool
form. It is becoming clear, however that these bowel symptoms do not tell the whole
story of symptoms experienced by IBS patients. People with this disorder often have
many uncomfortable non-gastrointestinal (non-GI) symptoms and health problems in
addition to their intestinal troubles.
Symptoms all over the body in IBS
Several research reports have established that IBS patients report non-bowel symptoms
more frequently than other GI patients and general medical patients. For example, four
studies that have asked IBS patients about a wide variety of body symptoms1-4 all found
headaches (reported by 23-45% of IBS patients), back pain (28-81%) and frequent
urination (20-56%) to be unusually common in individuals with IBS compared to other
people. Fatigue (36-63%) and bad breath or unpleasant taste in the mouth (16-63%) were
found by three of these four studies to be more common among IBS patients.
Additionally, a large number of other symptoms have been reported to occur with
unusually high frequency in single studies. In our recent systematic review of the medical
literature5, we found a total 26 different symptoms, listed in Table 1, that are reported to
be more common in IBS patients than comparison groups in at least one study.
Table 1. Non-gastrointestinal symptoms more common in irritable bowel syndrome
patients than in comparison groups5.
1. Headache
2. Dizziness
3. Heart Palpitations or racing heart
4. Back pain
5. Shortness of breath
6. Muscle ache
7. Frequent urinating
8. Difficulty urinating
9. Sensitivity to heat or cold
10. Constant tiredness
11. Pain during intercourse (sex)
12. Trembling hands
13. Sleeping difficulties
14. Bad breath/unpleasant taste in
mouth
15. Grinding your teeth
16. Jaw pain
17. Flushing of your face and neck
18. Dry mouth
19. Weak or wobbly legs
20. Scratchy throat
21. Tightness or pressure in chest
22. Low sex drive
23. Poor appetite
24. Eye pain
25. Stiff muscles
26. Eye twitching
Overlap with other medical conditions
Results from numerous studies (reviewed by Whitehead, Palsson & Jones, 20025) also indicate
that IBS overlaps or co-exists more often than would be expected with other medical conditions
that appear to have little logical connection with the gut. The most researched example of such
an overlap is the co-existence of IBS with fibromyalgia, a disorder characterized by widespread
muscle pain. Fibromyalgia affects an estimated 2% of the general population, but in contrast, 28-
65% of IBS patients have the disorder. Similar results are obtained when this overlap is
examined the opposite way, by studying fibromyalgia patients and looking for IBS: 32-77% of
fibromyalgia patients have IBS.
Chronic fatigue syndrome (CFS) is another medical condition that has been found to have many
times the expected co-occurrence with IBS. CFS is thought to affect only 0.4% of people in
general, but it has been reported to be present in 14% of IBS patients2, and conversely, 35-92%
of chronic fatigue syndrome patients have IBS. Other conditions documented in multiple studies
to have excess overlap with IBS are temporomandibular joint disorder (TMJ), found in 16-25%
of IBS patients2,6, and chronic pelvic pain (35% of IBS patients7). In addition to these wellestablished
relationships, many other medical conditions 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 disorders already discussed. In fact, we recently8 compared the
frequencies of a broad range of diagnoses in the medical records of 3153 IBS patients in a large
Health Maintenance Organization in the U.S. Northwest to an equal number of non-GI patients
in the same HMO, and found that the IBS patients had a higher frequency of almost half of all
non-gastrointestinal diagnoses, or 64 of the 136 sampled diagnoses.
In summary, non-GI symptoms and co-existing medical problems seen in many IBS patients far
exceed what is typical for medical patients or GI patients in general. This raises important
questions about what causes this phenomenon, and what the implications of it are 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 and disorders
in IBS. Our research group is currently conducting several research studies that may help shed
some light on this mystery, but it is far too early to come to definite conclusions. We will list
here some of the possible explanations, and discuss relevant data coming from work by our team
and other investigators.
1. A common physical cause? One rather obvious explanation for the high rates of co-existing
symptoms and conditions in IBS patients would be that there is something biologically wrong in
IBS that also causes the other symptoms or conditions. There are a number of distinct
physiological characteristics or "abnormalities" that are seen in many IBS patients, although
none of them are found in all patients. These include heightened pain sensitivity in the gut,
increased intestinal contractions (motility) or hyper-reactivity to meals or stress (too much
movement of the intestines � this is the reason why IBS was called spastic colon in the past),
patterns of dysfunction in the autonomic nervous system (the part of the nervous system that
helps regulate our inner body functions) and vague signs of immune activation seen in some IBS
patients. Although one can suggest ways in which these physiological abnormalities would play
a role in some other disorders that co-exist with IBS, there is little evidence so far of a common
pattern of physical abnormality that could link IBS and its most common coexisting conditions
and symptoms. Patterns of autonomic dysfunction in IBS are not like the ones seen in
fibromyalgia and chronic fatigue syndrome, for example; and fibromyalgia patients do not show
the same gut pain sensitivity as IBS patients, and conversely, IBS patients do not show the painsensitive
tender points that are characteristic of fibromyalgia9-10. Furthermore, as can be seen
from reviewing the symptom list in Table 1, the non-GI symptoms that plague IBS patients are
so varied, and cover so many different organ systems, that it would be hard to identify any
biological connection between them. On the contrary, it seems like the only overall commonality
between these symptoms may be that they are non-specific � they are, in other words, not clear
symptoms of any identifiable disease processes or diagnosable disorders. Indeed, the symptoms
that are most common among IBS patients are generally those that are also common in the
general healthy population � they just tend to occur at an even higher rate in people with IBS.
2
. Physical expression of emotional discomfort? Another possible explanation for the high
number of non-GI symptoms and disorders in IBS is the tendency to translate strong emotions
into physical "symptoms". This is sometimes called somatization ("soma" is the Greek word for
"body" and somatization therefore literally means "to express in the body"). All people
"somatize" to some degree: It is normal to feel butterflies in your stomach, to blush or go pale,
get a lump in your throat, or feel the heart beating in your chest if you get very emotional. Shaky
hands, stiff neck or excess sweating are likewise quite ordinary when people are under a great
deal of stress. However, some people are more vulnerable than others to letting negative
emotions express themselves physically. This is often thought to be an alternative and less
healthy way of exhibiting or feeling emotional discomfort. Some people may develop a strong
tendency to do this because they have a basic personality style that shies away from interpersonal
expressiveness. For others, it could be the result of growing up in the care of strict, repressive or
abusive parents or caretakers, where normal expression of negative emotions was not allowed or
would have been dangerous: Getting a headache or a stomach ache may be an alternative way to
"give voice" to negative emotions under such circumstances. It seems that excessive habitual
suppression of ordinary verbal and emotional expression of negative emotions, regardless of the
reason for it, may lead to the tendency to somatize. There is evidence that this tendency may be
at work in IBS, at least among some women with the disorder. Dr. Brenda Toner has found in
two studies11-12 that women with IBS score higher than depressed women and healthy women on
questionnaires measuring of the tendency to avoid expression of negative emotions 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 is necessary so that we are not
overwhelmed by the vast amount of information our senses supply to our brains every moment
of our lives. For example, if you are reading this sitting down, you have probably not been at all
aware of the sensations of the seat under your body until right now � nor the feeling in your
scalp, etc. Our brains constantly sift through the mass of incoming body information and decide
what is important for us to become consciously aware of, based on such things as our past
experiences and how likely the information is to indicate threat to our health or well-being. Most
minor symptoms (those that might be uncomfortable and bothersome if they would get our
attention), are simply dismissed in our busy everyday lives, because other things win out in the
moment-to-moment competition for our limited attention resources.
More frequent attention to mild physical symptoms can be learned, however, and can become a
habit. As with most things, such habitual over-attention is probably most easily learned in
childhood. It would seem reasonable, for example that a child would get into the habit of
noticing physical symptoms more if his or her parents are always talking about their own
symptoms. We have recently found13 that the more medical problems the parents in the
childhood home had, the more general physical symptoms adult IBS patients report.
A possible consequence of a childhood where the child grew up with parents or others who were
seriously ill, is a tendency to interpret common normal physical sensations as symptoms of
serious illness. Such serious view of symptoms can also be modeled after the parents' approach
to common illness. Dr. Whitehead and colleagues found in a telephone survey of 832 adults 20
years ago14 that people whose parents paid more attention to cold or flu symptoms in childhood
were more likely to view such symptoms as serious in adulthood and to visit doctors for them.
They were also more likely to have IBS diagnosis.
Evidence that IBS patients interpret physical sensations differently than others is emerging from
brain imaging studies. This type of research takes a "snapshot" of the amount of activity in
different parts of the brain in response, using techniques such as PET scans (positron emission
tomography) and functional MRI (functional Magnetic Resonance Imaging). By examining
which parts of the brain react most to painful sensations, it is possible to deduce to some degree
how the brain processes the information. In one such study, by Silverman and colleagues15 , IBS
patients but not control subjects reacted to physical sensations from a painful balloon inflation in
the rectum with increased blood flow in the left prefrontal cortex, a part of the brain known to
process personally threatening information. In contrast, that study and others16-17 found that IBS
patients do not show activity in the anterior cingulate cortex that is indicative of general
discomfort in healthy subjects. IBS patients are also more likely to respond to physical stimuli in
the GI tract by activating brain centers that handle emotional events. Collectively, this suggests
that IBS patients may process body information associated with bowel sensations (and perhaps
other physical sensations as well) differently than other people, interpreting them as personally
threatening and more emotionally relevant events rather than ordinary discomfort. Such different
interpretations of physical sensations would also explain hyper-attention to such sensations.
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 that control how much of this information passes through. Our brains continually
send signals down to these spinal gates to cause them to block signals that are of too low
intensity to provide valuable information (you do not want to constantly know about all your
minor aches and discomforts from regular body activity). This is one of the ways that the brain
uses to limit the vast amounts of information constantly streaming in from millions of nerve
sensors throughout our bodies. A current popular hypothesis in the field of IBS research is that
an inadequate amount of this "descending inhibition" of incoming pain information is at least
partly to blame for the hypersensitivity to intestinal discomfort and pain seen in IBS, and causes
signals from pain sensors that would normally be blocked to pass on through to the brain. Some
researchers have further suggested that the same kind of slack traffic control could be more
widespread in IBS and may explain the observed proneness to headaches, back pain or muscle
aches. People who have more open pain gates because of faulty inhibition would theoretically be
like the princess in H.C. Andersen's classic story "The Princess and the Pea" who could feel a
pea through 20 mattresses. The problem with this as an explanation for symptom overabundance
in IBS is, first, that it would explain only excess in pain-type symptoms, which are but one of
many types of overabundant symptoms in IBS, and secondly, that there are no direct data on IBS
patients yet to show us how valid this view is.
5. Result of greater psychological distress? As was explained above, it is normal for people who
are emotionally distressed to experience more physical symptoms. At least half of IBS patients
who have consulted doctors have been diagnosed with an affective ("emotional") disorder �
typically either depression or an anxiety disorder. Additionally, many people with IBS who have
no affective disorder diagnosis have significant symptoms of anxiety and depression. One might
therefore ask whether the physical symptoms reported could simply be a side effect of
psychological distress. We have addressed this question in two studies presented at this year's
Annual Meeting of the American Gastroenterological Association18-19. In the HMO data18
mentioned above, we found that having a psychological diagnosis was associated with increased
numbers of physical diagnoses these IBS patients had received (from an average of 7.1 to 9.7).
However, we also found that even patients with no psychiatric diagnosis had more physical
diagnoses per person than the other HMO patients (7.5 vs. 5.5), so the presence of psychological
problems is not the whole answer. In the other study19, we examined the relationship between
depression and anxiety scores of 795 people with IBS and the number of physical symptoms they
had experienced over the past month. Statistical methods that estimate how much of the
variability in one measured characteristic can be explained by other measured factors tell us that
the psychological symptoms roughly accounted for 25-30% of physical symptoms of these
people. In short, psychological distress is almost certainly a part of the explanation for greater
body symptoms in IBS, but not nearly the whole story.
Future research will have to determine which of the above explanations are applicable in IBS,
but it is likely that more than one of them, and maybe some other factors unrecognized so far,
work together to account for the high frequency of symptoms and disorders that co-exist with
IBS.
The impact of extra physical symptoms and disorders on IBS patients.
What do these extra (or "non-IBS") symptoms and co-existing medical conditions mean in
practical terms for patients with IBS? The first thing to note is that not all IBS patients
experience additional health problems and symptoms, so it is not a concern for all people with
IBS. For those who do, however, symptoms and disorders beyond the bowel can add measurably
to the overall burden of illness for the individual, and also lead to greater health care needs and
health care costs for IBS patients.
It is by now well established that IBS patients visit doctors more than is typical for other people.
Only recently has it been recognized, though, that most of the extra health care visits 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 other patients in the same HMO, but they found that
78% of the additional visits were due to other problems than IBS. It seems quite likely that these
extra non-gastrointestinal doctor visits of IBS patients 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 American Gastroenterological Association last year21. Using a scale asking
patients about the 26 physical symptoms in Table 1, we found that those IBS patients who report
an unusually high number of these symptoms over the past month missed six times as many days
from school or work due to illness (see Figure 1) compared to those with low or moderate
(normal) symptoms. The "high-symptom" IBS patients also had twice as many doctor visits and
more hospital days (Figure 2), and their quality of life was furthermore measurably poorer on
the average.
A general tendency to have a large number of body symptoms is therefore very costly in terms of
the IBS patient's overall well-being and ability to function normally in life, and also increases
substantially the health care costs for these individuals. These findings clearly underline the need
to find a way to help the many IBS patients who score unusually high on body symptom
questionnaires to reduce that tendency.
Is it possible to reduce non-gastrointestinal symptoms in IBS?
It is unknown to what degree standard medical treatment for IBS, when successful, also results in
improvement in non-GI symptoms. The problem is that most IBS treatment research has not
examined how non-IBS symptoms change. Non-IBS symptoms have also not been a focus of
standard IBS treatment. An exception to this is psychological treatment trials for IBS, which
sometimes have included general physical symptom questionnaires among the measures of
treatment effects. We therefore know from our two studies of hypnosis treatment for IBS22 as
well as from research in England23 that hypnosis treatment for IBS regularly improves non-GI
symptoms substantially in addition to beneficial effects on bowel symptoms. Less is known
about improvement in non-GI symptoms from cognitive-behavioral therapy, which is the other
widely researched psychological treatment for IBS. However, there is every reason to believe
that cognitive-behavioral treatment can reduce the tendency to experience a lot of general
physical symptoms, based on a review of over 30 such treatment studies24. These benefits of
psychological treatment for IBS point to extra value of such treatments for the subgroup of IBS
patients who have many non-GI symptoms.
Research in coming years will hopefully identify other ways to improve the well-being and life
functioning of IBS patients by reducing non-GI symptoms, and this is likely to become an
integral part of managing IBS effectively in the subset of patients who suffer many symptoms
and conditions beyond the bowel.
References:
1. Whorwell PJ, McCallum M, Creed FH, Roberts CT. Non-colonic features of irritable bowel syndrome. Gut 1986; 27:37�40.
2. Jones KR, Palsson OS, Levy RL, Feld AJ, Longstreth GF, Bradshaw BH, Drossman DA, & Whitehead WE. Comorbid disorders and
symptoms in irritable bowel syndrome (IBS) Compared to other gastroenterology patients. Gastroenterology 2001:120:A66.
3. Zaman MS, Chavez NF, Krueger R, Talley NJ, Lembo T. Extraintestinal symptoms in patients with 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 the use of "non-colonic" symptomatology. Gut
1991; 32:784�786.
5. Whitehead WE, Palsson O, Jones KR. Systematic review of the comorbidity of irritable bowel syndrome 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 fatigue syndrome, fibromyalgia, and
temporomandibular disorder. Arch Intern Med 2000; 160: 221�227.
7. Walker EA, Gelfand AN, Gelfand MD, Green C, Katon WJ. Chronic pelvic pain and gynecological symptoms in women with irritable bowel
syndrome. J Psychosom Obstet Gynaecol 1996; 17:39�46.
8. Whitehead WE, Palsson OS, Levy RL, Von Korff M, Feld AD, Turner MJ. Excess comorbidity for 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 Surg Suppl 1998 ;( 583):32-6.
10. Chang L, Mayer EA, Johnson T, FitzGerald LZ, Naliboff B. Differences in somatic perception in female 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 J Psychiatry. 1990 Mar; 35(2):158-61
12. Toner BB, Koyama E, Garfinkel PE, Jeejeebhoy KN, Di Gasbarro I. Social desirability and irritable 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 in somatization 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 in patients 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 cerebral activity 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. Central processing of rectal pain in patients with
irritable bowel syndrome: an fMRI study.Am J Gastroenterol 2002 Mar;97(3):654-61.
17. Bernstein CN, Frankenstein UN, Rawsthorne P, Pitz M, Summers R, McIntyre MC. Cortical mapping of visceral pain in patients with GI
disorders using functional magnetic resonance imaging. Am J Gastroenterol 2002 Feb;97(2):319-27.
18. Whitehead WE, Palsson OS, Levy RL, Von Korff M, Feld AD, Turner MJ. Comorbid psychiatric disorders 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 and psychological distress in irritable bowel syndrome
(IBS). Gastroenterology 2003 (abstract in press).
20. Levy RL, Whitehead WE, Von Korff MR, Feld AD. Intergenerational transmission of gastrointestinal illness behavior. Am J Gastroenterol
2000; 95:451�456.
21. Palsson, O.S., Jones K.R., Turner M.J., Drossman D.A., & Whitehead, W.E. (2002). Impact of somatization and comorbid medical
conditions on health care utilization, disability, and quality of life 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 severe irritable bowel syndrome: investigation of
mechanism and effects on symptoms. Dig Dis Sci 2002 Nov; 47(11):2605-14.
23. Gonsalkorale WM, Houghton LA, Whorwell PJ. Hypnotherapy in irritable bowel syndrome: a large-scale audit of a clinical service with
examination of factors influencing responsiveness. Am J Gastroenterol 2002 Apr; 97(4):954-61.
24. Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials.
Psychother Psychosom 2000 Jul-Aug; 69(4):205-15.

http://www.med.unc.edu/wrkunits/2depts/medicine/fgidc/sitemap.htm

--------------------
My website on IBS is www.ibshealth.com

Print Remind Me Notify Moderator