orientation and motivation

94
CHAPTER ONE ORIENTATION , MOTIVATION AND AIMS ‘What is matter, never mind What is mind, no matter’ Unknown author 1.1 Orientation and motivation Both Irritable Bowel Syndrome (IBS) and stress have been described as lifestyle disorders which are prevalent and gaining increasing awareness in this modern era, particularly within developed countries (Drossman, 1998; Salt, 1997; Sapolsky, 1994). Whilst growing attention is being devoted to both of these problems, the relationship between irritable bowel syndrome (IBS) and stress is not new but has been recorded since early civilization. It is only recently however that a more complex discussion of this relationship is beginning to elucidate the concepts and the mechanisms that may be necessary to understand this as a truly psychosomatic (mind-body) health problem. This psychologically based study seeks to adopt a more complex integrative approach by utilizing the ecosystemic paradigm which originates from a life science organismic view of man encompassing both a psychobiological and physiobehavioural perspective (Weiner, 1992). In this ecological philosophy of science all the system parts are interdependent. An ecosystemic perspective not only considers the contexts of multiple systems of influence within which human development takes place, but asks deeper epistemological questions which seek to discover the underlying patterns that connect (Bateson, 1972;

Upload: alicealexandra

Post on 22-Dec-2015

7 views

Category:

Documents


0 download

DESCRIPTION

APA, Despre motivatie

TRANSCRIPT

Page 1: Orientation and Motivation

CHAPTER ONE

ORIENTATION , MOTIVATION AND AIMS

‘What is matter, never mind

What is mind, no matter’

Unknown author 1.1 Orientation and motivation

Both Irritable Bowel Syndrome (IBS) and stress have been described as

lifestyle disorders which are prevalent and gaining increasing awareness in

this modern era, particularly within developed countries (Drossman, 1998;

Salt, 1997; Sapolsky, 1994). Whilst growing attention is being devoted to

both of these problems, the relationship between irritable bowel syndrome

(IBS) and stress is not new but has been recorded since early civilization. It is

only recently however that a more complex discussion of this relationship is

beginning to elucidate the concepts and the mechanisms that may be

necessary to understand this as a truly psychosomatic (mind-body) health

problem.

This psychologically based study seeks to adopt a more complex integrative

approach by utilizing the ecosystemic paradigm which originates from a life

science organismic view of man encompassing both a psychobiological and

physiobehavioural perspective (Weiner, 1992). In this ecological philosophy of

science all the system parts are interdependent. An ecosystemic perspective

not only considers the contexts of multiple systems of influence within which

human development takes place, but asks deeper epistemological questions

which seek to discover the underlying patterns that connect (Bateson, 1972;

Page 2: Orientation and Motivation

Capra, 1997; Keeney, 1983; Weiner, 1992). Behaviour and physiology are

seen as responses which form an integrated ‘whole’ and are interpreted in

terms of bidirectional and reciprocally causal systems of interaction. This has

been referred to as a psychosomatic communication network whereby the

nervous system, the immune system and the endocrine system are said to

‘talk to’ each other (Pert, Ruff, Weber & Herkenham, 1985; Watkins, 1995;

Weiner, 1992).

There is currently a resurgence of experimental and theoretical interest in

stressful experience which is implicated in many diseases, disorders and

lifestyle problems today. Stress either causes or exacerbates these

conditions which frequently result from a slow accumulation of symptoms due

to the modern style of living. According to Sapolsky (1994), there has been a

critical shift in medicine which now recognizes the complex intertwining in

man’s biology and mind, including emotions and cognitions, in response to

stressful experiences. It is recognized that life events, as ongoing processes,

contain both objective and subjective measures (Kimball, 1984; Lazarus &

Folkman, 1984). Modern researchers are beginning to differentiate between

chronic stress responses which occur in childhood to those which are acute

episodes occurring in ongoing life events (Kelly, Hertzman & Daniels, 1997).

Stress has been implicated in all the functional disorders of the

gastrointestinal tract (Drossman, 1994b) and irritable bowel syndrome is the

specific psychosomatic illness examined here.

IBS is defined as a functional bowel disorder in which abdominal pain is

associated with defaecation or a change in bowel habit and abdominal

distension (Drossman, 1994b). It is highly prevalent in the Western world

with epidemiological surveys indicating approximately one fifth of the

population suffe rs from one or more gastrointestinal symptoms (Drossman,

Thompson & Whitehead, 1992). Many do not seek medical attention,

however IBS constitutes 25-50% of referrals to gastroenterologists

(Drossman, 1994b). Due to the unexplained etiology and the ineffectiveness

Page 3: Orientation and Motivation

of treatment modalities, IBS sufferers are invariably subjected to costly and

invasive diagnostic procedures and medical care. Studies now show that the

costs are considerable each year in visits to doctors, diagnostic testing,

treatment and work absenteeism, with IBS ranking second only to the

common cold (Els, Gagiano, Grundling, Van Zyl & Joubert, 1995; Salt, 1997).

The etiological factors that combine IBS with stress have frequently been

studied in experimentally acute episodes that may not reflect the often chronic

nature of this disorder. Stress has been studied directly but often the

associations are made indirectly by inference and there is still much to be

discovered about its relationship with IBS.

A complex, multi-factorial perspective on ill health and the relationship

between a psychosomatic illness like IBS and stress, means that it is no

longer the exclusive domain of biomedicine, but now extends to other

disciplines. The research literature on IBS involves inputs from

gastroenterologists, psychiatrists, psychologists, dieticians, the nursing and

medical profession in general and others interested in contributing to

understanding as well as to the treatment of this intractable disorder.

Despite the acknowledgement that IBS is a biopsychosocial phenomenon,

examination of the literature reveals that treatment strategies tend to focus on

single symptom treatment modalities to those that combine multicomponent

approaches within the medical field. With the advances in molecular biology

and knowledge of the communication amongst the various systems of the

body, there is recently a call for more holistic approaches to treatment. In this

regard, Drossman, Whitehead and Camilleri (1997) have begun to consider

the individualized expression of the illness in the patient and to situate the

patient in his/her wider social systems, as well as incorporating a referral team

approach to the treatment of IBS. Salt (1997) has extended the

biopsychosocial model to include the spiritual dimension in his treatment of

IBS patients whilst Broom (1997) weaves the various internal systems of the

person into the story of the client’s illness that integrates the mind and body.

Page 4: Orientation and Motivation

Research has almost unanimously shown IBS clients to be psychologically

distressed (Schwarz, Blanchard, Berreman, Scharff, Taylor, Greene, Suls &

Malamood, 1993). As the field of behavioural medicine and psychological

healthcare moves more directly into integrative endeavours, the research

question asked in this study is whether utilizing an individualized holistic

psychotherapy and synergistic stress management programme for the

treatment of clients with IBS symptomatology and vocational stress will be

successful and will in some way contribute to the humane treatment of

persons who suffer from this debilitating disorder.

1.2 Aims of the study

This study is situated both within the broader aims of the

Psychogastroenterology project as well as within the general aims of the study

and a specific operationalized aim as elaborated next.

1.2.1 General aim

The aim of the project by the Counselling and Research Centre for

Psychogastroenterology was to approach the study of IBS from the standpoint

of psychology and to contribute to the psychosocial dimensions of the

biopsychosocial model of health and illness. Various studies addressed by

the project were psychopathology, anxiety and depression, personality

factors, abuse, stress, coping styles and strategies, defense mechanisms and

eating disorders. A second phase of this research project was to develop and

provide various forms of psychotherapeutic interventions of which this study is

one.

There were two broad aims of this particular study. Firstly, this study aims to

respond to the call from integrative medicine and behavioural health

psychology for holistic treatment approaches to IBS and stress using an

Page 5: Orientation and Motivation

integrative metatheoretical framework which examines the individual both

within his/her various subsystems such as the cognitive, behavioural,

emotional, physiological and spiritual domains of functioning as well as the

wider societal systems and relationships within which the individual is situated

making it a truly mind-body psychotherapeutic approach (O’Connor & Lubin,

1984; Salt, 1997; Schlebusch, 1990; Weiner, 1992). Secondly, researchers

such as Drossman and Thompson (1992); Guthrie, Creed, Dawson and

Tomenson (1991, 1993) have assessed various studies examining whether

psychotherapy is effective for refractory IBS sufferers. They have reached

contradictory conclusions and this study seeks to address this question as the

sample in this study falls within the range of symptom severity diagnosed as

severe or refractory IBS.

1.2.2 Specific aim

The present study seeks to ascertain the effectiveness of a holistic individual

psychotherapy combined with a synergistic stress management programme in

a sample of IBS participants who receive the intervention and to compare

them with a control group of IBS participants who received no treatment. The

control group were invited to use the facilities for therapeutic intervention

offered by the RAU Psychogastroenterology project once the post-tests had

been completed, thus addressing any ethical considerations. The

operationalized aim of the study then is to clarify this relationship by

ascertaining whether there are statistically significant differences between two

groups of participants with IBS (N = 20 in each group) with regard to the

severity of their pre- and post-test IBS scores, as measured by the Functional

Bowel Disorder Severity Index (FBDSI) (Drossman, Zhiming, Toner et al.,

1995), as well as to ascertain the differences between the two groups in terms

of their vocational stress scores as measured by the three scales of the

Occupational Stress Inventory, namely the Occupational Roles, Personal

Strain and Personal Resources Inventories respectively.

Page 6: Orientation and Motivation

1.3 Chapter delineation

Chapters two and three introduce an integrative approach to the study of IBS

and stress by presenting the paradigmatic and philosophical foundations for

the present research study. Psychosomatics and stress are currently

reviewed within an ecological and general systems approach leading to the

redefinition of mind-body illnesses. A review of the current status of stress

research wherein the history, definitions and physiology of stress are outlined,

indicates that stress is implicated in most illnesses. An outline of the broad

characteristics of IBS is provided as the specific psychosomatic illness

examined in this thesis looking at functional disorders, epidemiology and

diagnostic criteria. Reference is made to the biopsychosocial model used in

IBS and stress and the addition of the communication network model is

proposed as a possible future framework. With its complex etiology, chapter

three explores the main etiological factors which emphasize how stress is

directly or indirectly implicated in the syndrome.

Chapter four provides an overview of the treatment strategies and specific

treatments used in the management of IBS. It begins by presenting the

tenets of whole-person care, then delineates the movement from single

treatment methodologies for IBS to those that utilize combined treatment

modalities. The current interest in integrated and individualized holistic

treatments concludes with the particular intervention for this study which is an

individualized holistic psychotherapy and synergistic stress management

programme for stress and IBS.

Chapter five examines the empirical foundation of the study including a

description of the research methodology, subjects, selection and measuring

instruments used, hypotheses to be tested and methods of statistical analysis.

The statistical research findings are tabulated in chapter six, while chapter

seven presents a discussion of the results and a number of limitations,

followed by the recommendations included for future research. Finally some

Page 7: Orientation and Motivation

conclusions are drawn, whereby the study is located within the research arena

of stress and IBS and psychological research endeavours that attempt to find

holistic solutions for treating the whole person.

CHAPTER TWO

AN INTEGRATIVE APPROACH TO STRESS AND

IRRITABLE BOWEL SYNDROME

‘man should strive to have

his intestines relaxed all the

days of his life’

Moses Matmonides, AD 1135 – 1204

As the above quotation illustrates, man has been interested in the complex

association between the gut and stress since time immemorial. Modern

culture is particularly conscious of the effects of stress and it has become a

catchall phrase to explain many forms of distress created by the conditions of

living. Irritable Bowel Syndrome (IBS) is one of the many psychosomatic (or

mind-body) health related problems strongly associated with stress that is

increasingly attracting the attention of researchers.

Despite growing awareness of the role that stressful life experiences play in

promoting health or illness (Williams, Zyzanski & Wright, 1992), the overuse of

the concept has almost rendered the term ‘stress’ meaningless. This study

Page 8: Orientation and Motivation

therefore, supports and affirms the process perspective proposed by Lazarus

and Folkman (1984) which highlights stress as central to the relationship

between illness and health and which helps to explain how psychologically

relevant events translate into health-impairing physiological changes (Krantz,

Grunberg & Baum, 1985). It also affirms at a theoretical level, an ecological

perspective which serves as a ‘deep’ structure for integrating biopsychosocial

processes and for interpreting research findings in the stress/illness

relationship (Friedman, 1990).

As the title implies, this chapter seeks to understand and elucidate the role of

stress in the psychosomatic illness of irritable bowel syndrome (IBS) by

adopting an integrative approach. After discussing the paradigmatic and

philosophical context of the study, the foundation of stress research is laid out

wherein the history, definitions and physiology of stress are outlined. An

introduction to irritable bowel syndrome as the specific psychosomatic illness

examined in this thesis is then considered under headings defining functional

disorders, epidemiology and diagnostic criteria. Finally, a brief overview of the

most recently used models for dealing with IBS as well as stress are

mentioned, together with those used by both stress and IBS researchers,

where reference is made to some of the associated empirical findings.

The resurgent interest in the study of mind-body relationships and

psychosomatic illnesses like IBS means that many researchers no longer

question that there is a relationship between stress and IBS, but instead are

more interested in how they are linked and by what mechanisms. A survey of

the literature expands on the etiology in chapter three which in the light of the

ongoing research into IBS and stress, appears mainly from a biomedical

perspective based on a Cartesian-Newtonian scientific worldview. Reviewing

treatment approaches in chapter four completes the clinical picture from which

the emergence of a more recent quantum, holistic scientific worldview can be

seen.

Page 9: Orientation and Motivation

2.1 Paradigmatic orientation

The present study on stress and IBS is located in the behavioural health field

with its integrative emphasis and pragmatic concern with whole-person care.

The philosophical origins of this approach and the current status of the debate

are traced and are followed by a brief explanation of the ecosystemic

paradigm and its affiliation with a neurobiological network model which is

proposed as a potentially more appropriate meta-theoretical framework.

2.1.1 Philosophical outline

The practice of psychology, like all disciplines, is heavily influenced by the

paradigm or worldview used by the particular professional. In this regard, the

great epistemological debate of our time has centred around the objectivist

and constructivist conceptions of knowledge (Howard, 1993). Objectivism

professes a belief in a freestanding reality, the truth about which can be

discovered, whilst constructivism, as the term implies, is about an

experienced, participatory and creative reality. Constructivists acknowledge

the active role they play in creating a view of the world and in interpreting

observations made in terms of it and it is this constructivist understanding of

knowledge and reality that underpins this psychologically based study.

The development of alternative views concerning the rules for obtaining

empirical knowledge and the postmodernist emphasis on multi-perspectival

interpretations has meant an increased emphasis on the impact of values and

ethics and a greater awareness of the role of the observer. Ryder (1986)

adds that since the hypothetical constructs used to analyse human behaviour

are basically inferential and value-laden constructions about human reality,

the same data are always open to plausible but competing evaluations. The

researcher should, therefore, openly declare the values that she adheres to

(Gergen, 1985). Consequently, clear descriptions of alternative models are

Page 10: Orientation and Motivation

likely to forestall a blindness to the possibility of explanations that are equally

valid, even if mutually contradictory (Doherty, 1986). In this regard, the

paradigmatic orientation presented in this study is openly discussed prior to

the literature survey, because it is the philosophical lens through which the

study is interpreted.

In terms of the practice of psychotherapy, the debate also extends into the

tasks of the psychologist as scientist-researcher and as professional

practitioner (Kanfer, 1990). This study acknowledges the mutual influence that

exists between science and practice and as such is an endeavour which

attempts to bridge the two domains (Kanfer, 1990).

This constructivist endeavour reflects the unmistakable movement towards

meta-theoretical integrative modes of psyc hotherapy which are more

congruent with the holistic worldview (Woolfe & Dryden, 1996). Holism is

equivalent with the view that the nature of reality is interdependent and the

whole is more than the sum of the parts, implying non-linearity. The follow ing

section introduces the ecosystemic paradigm as the meta-theoretical basis for

integrating these domains in this study.

2.1.2 Ecosystemic paradigm

The paradigmatic orientation chosen for this study is one which is based on

an ecological philosophy of science (Keeney, 1983). The evolutionary-

ecological paradigm may be called holistic in the sense that all the parts

interpenetrate and interrelate with each other. But it may also be used in a

much broader and deeper sense than that, as an epistemology of questioning

which seeks deeper answers to problems, that looks for patterns that connect

which lie beneath the obvious and asks to penetrate to the more subtle layers

of our existence, whether it be in the connective tissues of our bodies or the

levels of consciousness in our psyche or the patterns of relationship in our

social systems (Bateson, 1972; Capra, 1997; Keeney, 1983).

Page 11: Orientation and Motivation

Ecosystemic epistemology which represents a relatively new way of thinking,

moves from interpreting behaviour in terms of linear cause-and-effect

sequences to conceptualizing the same behaviour as resulting from

reciprocally causal systems of interaction (Bateson, 1972). It is beginning to

be applied more widely in various interdisciplinary fields.

The term ‘ecosystem’ originated in biology and hence comes from the life

sciences. Ecosystemic thinking is founded on the principles of human

ecology and general systems theory. General systems theory starts with the

microlevels within the organism such as the single cell, organs, the various

systems of the body, through to the individual person as a system; and on to

the macrolevels such as the dyad, the family, the community and the society

(Jasnoski, 1984).

Living systems are all open systems which function in terms of change and

stability. They work to establish, maintain and elaborate a patterned order of

experience. Stability contributes toward equilibrium and autopoeisis,

meaning autonomy or self-regulation, within each system level. Change is the

result of perturbations or fluctuations and may occur cyclically and

rhythmically and may be mild to severe in the disruptions that occur.

Dissipative structures cause bifurcations which occur far from equilibrium and

whether mild or highly disruptive, the amount and direction of the change

remains unpredictable. In this chaotic or fragile state, the move to ordered

patterning which occurs randomly, results in new order and patterning which

cannot be predicted (Masterpasqua & Perna, 1997).

Living systems exchange matter, information and energy with their

environments. They have been described as an interlocking network of

systems which are connected to nodal points in the system. These concepts

of network and nodal come from the neurobiological theory of networks and

will be described later in this chapter to reflect a particular network model for

IBS and stress. The fact that each and every level of system is in constant

Page 12: Orientation and Motivation

interaction and communication with every other system level, highlights the

complex relationship between mind and body, such as occurs in a

psychosomatic illness like IBS.

2.2 Psychosomatic illness and stress

The terms used which attempt to address bridging the mind-body problem in

health care have continually evolved over the past few decades. The term

psyc hosomatics, whilst still in use, is presently undergoing a change to the

term ‘bodymind’ which has been credited to the neurobiologist, Pert (1997).

Descartes’ myth of separate body and mind has been transcended in favour

of the emphasis that the entire mind-body system is a network of information

(Schlebusch, 1990).

Alexander (1950), whose name is synonymous with the psychosomatic

approach, did early work on a personality-specific approach to disease. This

resulted in an oversimplification as direct correlations were made between

psychodynamic formulations of personality and various type of disorders, so

that a ‘colitis personality’ might be said to describe a person suffering from

IBS (Lipowski, 1985).

Recently however, the heavy commitment to intrapsychic concepts has given

way to a keen interest in the study of psychological adaptation to a changing

environment (Schlebusch, 1990) and towards social and psychological factors

in both illness and in health. Psychosomatic medicine and the field of

behavioral health currently reflect a body of scientific knowledge more

concerned with the interrelationship between psychological and physiological

processes. This interest extends from intra-individual to inter-individual

Page 13: Orientation and Motivation

factors as well as giving attention to those that initiate and maintain illness and

disease.

Revival of the current interest in psychosomatic/somatopsychic medicine can

be traced to the new developments within the fields of stress and illness.

Since the time that Selye (1973) made the observation that different ‘stressful

experiences’ all culminated in anatomical changes in three separate organ

systems in rats, attempts have been made to link the relationship between ill-

health and stressful experiences in humans (Weiner, 1992). Stressful

experiences and the distress they occasion seem much more closely

associated with the functional disorders and syndromes, rather than with

anatomical lesions in one or another organ. They are frequently misdiagnosed

and neglected by the traditional Western biomedicine approach to disease

(Levi, 1972). Selye’s (1973) work gives strong support to the general idea

that psychological and social factors are important in health and illness.

Advanced research on stress and hormone effect on tissues has made the

concept of ‘vulnerability’ towards diseases and/or disorders very acceptable,

enhancing the idea that diathesis or vulnerability towards stress is part of both

the internal and external routes towards disorder (Carson, Butcher &

Coleman, 1988).

The crisis and decline of interest in the medical aspects of stress came about

because it was realised that stressful experiences did not inevitably, or even

frequently, terminate in disease or injury. Even in the direst and most

catastrophic circumstances, disease is not an inevitable outcome as only a

proportion of people develop a disease not present beforehand whilst a much

larger number show a decline in health by falling ill (Weiner, 1992).

During the past decade, a major reconceptualisation of the nature of ill health,

disease and stress has occurred (Garfinkel, 1983; Glass & Mackey, 1979,

1988). The basis of the shift in thinking is that changes in the dynamic

Page 14: Orientation and Motivation

rhythmic functions of the organism, not only in its structure, underlie the

transition from health to illness and disease. It is customary in medicine to

assert that structural changes are the only cause of ill health and therefore

physicians search for structural abnormalities and etiology in order to

understand and treat illness. If illness is associated with functional or

patterned rhythmical disturbances within the physiology of the person, then no

structural abnormalities are likely to be found. In other words, a patient may

be in ill health without having a disease. In fact up to 50% of patients seen by

physicians are in ill-health (Juli & Engelbrecht-Greve, 1992).

Ill health according to these researchers, occurring in the physiology of the

person, has been divided into four syndromes each containing its own

symptomatology. The bodily symptoms of the ill person can be clustered into

hyperventilation, functional bowel, musculoskeletal and sleep disturbance

syndromes (Mechanic, 1980). The irritable bowel syndrome is a

subsyndrome found within the functional bowel disorders as distinguished by

Drossman (1994b). Each of these groups is also strongly associated with

anxiety, distress, and depressed moods which link the somatic behaviour of

the organism to the psychological behaviour of the person. A more precise

analysis of the manifestations of ill health has led these researchers to the

conclusion that they represent physiological changes in vital biological

functions, such as respiratory and cardiac rhythms, food intake, digestion,

elimination, reproduction, sleep rhythms, pain modulation and mood. They

are more likely to be perturbed by stressful experience rather than to result in

disease affecting tissue damage (Weiner, 1992). As these patients are

observed, a clear-cut relationship can be found between their ills and their

situation in life (Kellner, 1986; Lipowski, 1986). However, to add to the

complexity in the relationship between ill-health and stress, it has been

discovered that not only does stress lead to illness, but that the stress

response itself can be damaging to the health of the organism.

Page 15: Orientation and Motivation

2.3 History and definition of the concept of ‘stress’

During the past decade a resurgence of experimental and theoretical interest

in stressful experience has occurred. Interdisciplinary conferences are being

dedicated to this topic. One of the more difficult problems to resolve in

studying stress is that the concept ‘stress’ is not rigorously defined but is in

fact a ‘fuzzy’ one according to Weiner (1992). The term is applied loosely and

at times it is used so generally that its meaning is lost altogether. It cannot

conceivably describe the specific subtleties, functions and individual meanings

that people attribute to their lives and their relationships (Weiner, 1992).

There continues to be a widely held conviction that ‘stress’ is implicated

etiologically in illness and disease (DeLongis, Folkman & Lazarus, 1988).

However, despite misgivings about its usefulness as a concept, it has not

disappeared from the lexicon in the literature but continues to hold out

promise for its validity.

Various definitions of ‘stress’ have been propagated during its development

and the following discussion outlines the evolution of the concept from the

physiologically based definition to the inclusion of the psychological

dimension. Its development more recently reflects a broader and more

complex understanding that embraces an integration of the physiological and

psychosocial perspectives.

2.3.1 Stress as disturbed homeostasis

As early as 1910, Sir William Osler (Kaplan, Sallis & Patterson, 1993)

hypothesized that stress could lead to physical illness. Later in 1935,

Cannon, the physiologist (Krantz et al., 1985) who was optimistic about the

ability of the body to cope with all sorts of stresses, formulated the ‘fight or

flight’ syndrome to describe the stress -response, which he viewed as an

example of ‘the wisdom of the body’. Cannon (1935) introduced the idea of

disturbed homeostasis within the system and was the first researcher to bring

Page 16: Orientation and Motivation

together the two concepts homeostasis and stress. Both Cannon (1929,

1939) and his contemporary, Selye (1936), studied acutely stressful ‘stimuli’

and conditions and were not only interested in normal physiology and the

pathogenic effects of stress, but also emphasized the importance of including

emotional and social factors, such as occupational stress. Although many

researchers and theorists have continued to define stress as ‘any threat to or

disturbance of homeostasis’, this definition tends to limit the understanding of

stress to a largely physiological dimension.

Selye (1973), who borrowed the term ‘stress’ from mechanical engineering,

defined it as ‘the non-specific response of the body to any demand made

upon it’. Although the stress producing factors are different, they all

culminate in essentially the same general reaction, which he termed the

‘biologic stress syndrome’. For Selye (1973), these ‘stress producing factors’

or as they are called today, ‘stressors’, are overwhelming and threaten the

integrity of the organism. Selye (1973) proposed that the body has a similar

set of responses to a broad array of stressors which he called the General

Adaptation Syndrome (GAS) and that under certain conditions, stressors will

make you sick, resulting in ‘diseases of adaptation’.

The General Adaptation Syndrome (GAS) was a three-part view of how the

stress-response worked. In the initial ‘alarm’ stage, a stressor is encountered.

The second stage of ‘adaptation or resistance’ occurs when the stress -

response system is successfully mobilized and the organism attempts to

restore homeostatic balance. It is only with prolonged stress that one finally

enters the third stage, which Selye (1973) termed the stage of ‘exhaustion’,

where stress -related diseases emerge. Many researchers at that time

believed that one became sick at that point because stores of the hormones

secreted during the stress-response become depleted. It was thought that if

the organism constantly mobilizes for ‘fight or flight’ at the cost of energy

storage and replenishment, it will never store any surplus energy and will

Page 17: Orientation and Motivation

fatigue more rapidly having depleted its reserves, and that suddenly it would

not have any defenses left against the threatening stressor.

This thinking is now generally thought to be incorrect. It is not that the crucial

hormones are actually depleted during even the most sustained of stressors,

but rather that with sufficient activation, the stress -response itself can become

damaging (Sapolsky, 1994). This is a critical concept, because it underlies

the emergence of much stress -related disease and illness today.

From Selye’s (1973) views on stress it is not clear whether he defined it in

terms of the ‘stimulus’ (the stressor) or in terms of the ‘response’ (GAS). Both

Cannon’s and Selye’s models for stress are now considered to be linear and

dualistic, separating the biophysiological from the behavioural characteristics

of the organism in terms of cause and effect between stimulus and response

(Weiner, 1992).

Richards (1952, 1957) criticized Cannon’s implied view that the body was on

all occasions ‘wise’. In his view, physiological responses could be excessive,

inadequate, inappropriate, ill-timed or disordered and that these responses

could characterize behavior as well as physiology. These extremes of

responses he termed ‘a failure of homeostasis’.

Lazarus (1966); Lazarus and Folkman (1984) and Mason (1975) reached the

conclusion that empirically and conceptually it was unsatisfactory to define

stress only in terms of the stimulus or the response; but that both had to be

included in the definition of the process. Mason (1975) suggested that an

interactive stimulus -response model was more appropriate. Some

researchers today consider this to be too linear and predict that what is

required is the notion of recursive and cyclical feedback which is more in line

with an organismic perspective (Weiner, 1992).

2.3.2 Inclusion of a psychological dimension

Page 18: Orientation and Motivation

Researchers Lazarus and Folkman (1984) and Mason (1975) concluded that

human stress research is marked by both inter- and intra-individual

differences in the responses to stressful experiences. Each person appraises

potential dangers, threats and challenges and their context differently. Some

people react appropriately, some overreact, some do not react at all, whereas

some people become disorganized in their behaviours. Mason (1975)

implied but did not explicitly state, that the psychological, behavioural and

physiological responses to stressors were inextricable, that is they were

organismic (Weiner, 1992).

Lazarus and Folkman (1984) specifically focussed on psychological stress in

their transactional process model of stress. They state that whilst there are

important overlaps between psychological and physiological stress, they

require entirely different levels of analysis. In 1966, Lazarus drew a distinction

among three kinds of stress; harm refers to psychological damage that had

already been done, for example an irrevocable loss. Threat is the anticipation

of harm that has not yet taken place but may be imminent. Challenge results

from difficult demands that the individual feels confident about overcoming by

effectively mobilizing and deploying coping resources. Later Lazarus and

Folkman (1984) adopted the view that psychological stress is dependent on

cognitive mediation which is centered on the concept of appraisal, which is the

process that mediates or actively negotiates between demands, constraints

and resources of the environment on the one hand and goal hierarchy and

personal beliefs of the individual on the other hand. They included coping

strategies as part of their model, which were either instrumental or goal-

oriented; or emotion-focussed. ‘Appraisal’ and ‘coping’ they termed

evaluative thoughts and showed that these processes shaped the stress

reaction and were in turn influenced by variables in the environment and

within the individual.

Page 19: Orientation and Motivation

One of the most popular definitions of stressful experience is that given by

Lazarus and Folkman (1984) where they refer to ‘demands that tax or exceed

the resources of the system’. In this psychosocial perspective, the system is

defined as both an organism and as a social system.

In his latest work and the theory he now employs, Lazarus (1993) is

concerned that psychological stress should be considered to be part of a

larger topic which is currently producing a scientific explosion of interest – that

of the emotions. Lazarus (1993) considers that the psychological stress theory

is tantamount to a theory of emotion. This theoretical consolidation, whilst

posing some difficulties, he thinks has important positive consequences.

Firstly, though always having belonged together, the literature on

psychological stress and the literature on emotions have generally been

treated as separate. Social and biological scientists interested in the

emotions are often unaware of the relevant stress literature and vice versa.

He proposes that the field of psychological stress has already progressed

from a uni-dimensional activation theory as passive adaptation; to a multi-

dimensional, relational and contextual conceptualization of stress. Knowing,

for instance, as a consistent pattern across encounters that an individual feels

angry, anxious, guilty, sad, happy or helpful tells us much more than knowing

merely that he/she is harmed, threatened or challenged. Use of stress as a

source of information about an individual’s adaptation to environmental

pressures is extremely limited compared with the use of the full array of

emotions (Lazarus, 1993).

Activation theory as defined by Lazarus (1993) remains passive and

adaptational, and is not in keeping with the more dynamic formulation of

activation as proposed by Ursin and Murison (1980) and Maddi (1989).

According to Fiske and Maddi (1961), activation is a psychoneurobiological

term. In this theory the term ‘stress’ is replaced with the term activation

wherein all physiological changes may be summarized as activation which is

considered to be a normal response in normal individuals for preparing the

Page 20: Orientation and Motivation

body and the brain to meet the challenges of everyday life. In vulnerable

individuals, long lasting activation without proper rest periods may produce

somatic changes resulting in psychosomatic pathogenesis or illness as is

presented in this thesis.

Ursin and Murison (1980) prefer the term ‘activation’ when referring to ‘stress’

rather than ‘adaptation’ which they declare is too passive. In their view,

activation or ‘tension’ occurs in response to both internal bodily stressors as

well as to environmental and psychological stressors. Today researchers are

concerned about and impressed with the lack of any seeming linearity in the

relationship between the stimuli and the stress response. Since the brain is

built as a network rather than as a straight forward automatic reflex system,

the general consensus appears to be that there is very little hope that

research will ever be able to identify simple and general rules for ‘stressors’,

or that they will be able to measure them in simple physical or categorical

terms (Ursin & Murison, 1980; Weiner, 1992).

In general, activation is produced by novelty, threat, conflict and homeostatic

imbalance. In biological terms, whenever the actual value differs from the set

value of any variable controlled by the central nervous system, activation will

occur (Maddi, 1989; Ursin & Murison, 1980). In psychological terms,

whenever there is a discrepancy between an actual and a customary level of

activation, tension will occur. For these researchers, psychology consists

partly of in formation loads and partly of the load produced by emotional

factors. Other psychological processes that are activated by ‘tension’ are

perception, emotion, imagination, cognitions, coping, anticipation and social

support. Coping, for example, which has been studied extensively in relation

to stress, has been linked to defense mechanisms which may or may not

produce accurate perception of the situation and in turn this has been linked

to somatic risks. The endocrine response patterns are implicated and may be

important for the development of psychosomatic disease and illness (Lazarus,

Page 21: Orientation and Motivation

1993; Ursin & Murison, 1980). Life event stress includes many of these

same processes as will be discussed in chapter three.

2.3.3 Integrating physiological and psychosocial perspectives

Finally, on the long path covering the history and definition of ‘stress’,

organismic biological life science and information theory are both held to be

significant. As yet the concepts for integrating these two perspectives have

not unfolded but hold much promise for the future (Weiner, 1992). This

organismic perspective is both a psychobiological and physiobehavioural

theory. A life sciences organismic holistic view of human stressful experience

lends itself to the notion that behaviour and physiology are one and indivisible

and researchers who have adopted this perspective, trace their thinking back

to Darwin. Today with the developments of microbiology and

psychoneuroimmunology, researchers are beginning to chart the exact lines

of communication between the mind and the body so that ultimately they will

force us to erase the dividing line between what is biological and what is

psychological. Behaviour and physiology are being seen as responses which

form an integrated ‘whole’; an integrated patterned response or a

psychosomatic network (Pert et al., 1985; Watkins, 1995; Weiner, 1992).

Significant advances have within this past decade been made in our

understanding of how the organism responds in a patterned and integrated,

behavioural and physiological manner to new experiences, perturbations,

challenges, threats, injury or complex changes in the environments (Levins &

Lewontin, 1985). The patterned and coordinated changes in behaviour and

physiology in response to a stressful experience are exquisitely attuned to it

and are mediated, moderated or even neutralized as a consequence of the

evaluation on the part of the persons from which behaviour follows.

Behavioural and physiological changes also occur in anticipation of or in

preparation for challenges, threats and dangers and not merely in reaction to

Page 22: Orientation and Motivation

them (Lazarus & Folkman, 1984; Wiener, 1992). This has given rise to the

definition of stressful experience as follows:

‘Stressful experience is a potential or actual threat or challenge to the

integrity, survival and reproduction of the organism. The threat or challenge

may be anticipated, real, imaginary or an admixture of both’ (Weiner, 1992,

p.33).

Glass and Mackey (1988) described most physiological and behavioural

systems as rhythmic and oscillatory. The organism’s fundamental operating

modes are oscillatory, for example; heartbeat, sleep stages; levels of

hormones, enzyme activity and neurotransmitters to name a few. One reason

for the existence of oscillations is that most, if not all, systems and

subsystems of the body are arranged in and regulated by, negative and

positive (or mixed) feedback loops. Defined in this manner abnormal

functioning (illness or disease) occurs when a system loses the stability of its

usual operating mode. Each form of abnormal functioning can be conceived

of as a bifurcation. Bifurcation is a non-linear concept entailing qualitative

changes within the various systems from one state to another (Masterpasqua

& Perna, 1997). One may therefore reconceptualize the effects of a stressful

experience. The perturbation of a system produced by ‘stress’ does not alter

the homeostatic steady state, but rather induces bifurcations which force a

system into oscillatory instability.

A further two concepts have been used in this perspective to illustrate how

integrated the behavioural and physiological systems of the body/person have

become (Weiner, 1992). The first one is the principle of parallel functioning

and the second is recruitment. Multiple parallel pathways are forged within

the body and its subsystems. The brain is able to handle simultaneously all

of the information arriving from these subsystems. Each channel also has

direct access to a memory bank. Parallel processing enables the properties

of complexity and flexibility. Recruitment refers to the process whereby

Page 23: Orientation and Motivation

different and various systems may be strengthened to join or to combine with

others that would not ordinarily be expected to do so. By activation,

sensitization and recruitment, the ‘stress’ systems as well as various illness

subsystems may be co-opted to act in a synergistically patterned and

integrated manner (Mayer & Gebhart, 1994; Weiner, 1992).

The various possible physiological and psycho/behavioural systems which

may become linked in the stress/illness relationship include the central

nervous system, immune system, endocrine system and include the brain, the

emotions, the imagination, memory, and cognitions (Pert, 1997; Ursin &

Murison, 1980).

It would appear that more recent formulations of understanding ‘stress’ have

led to the incorporation of various systems of the body and behavioural

systems which are being linked by mechanisms which are unknown at

present. As the physiological response to stress is a broad and complex one

that involves a variety of body systems, what follows is an elaboration of these

in terms of: stress physiology and the autonomic nervous system;

consideration of the argument for differentiating between ‘acute’ and ‘chronic’

stress responses and review of the research that links the stress response

itself to damage.

2.4 Stress Physiology

The central nervous system consists of the brain and the spinal cord, whereas

the autonomic nervous system is that portion of the nervous system

concerned with regulation of the activity of the cardiac muscle, smooth muscle

and the glands; and is usually restricted to the two visceral efferent peripheral

components, the sympathetic nervous system and the parasympathetic

nervous system (Sapolsky, 1994).

Page 24: Orientation and Motivation

The brain can mobilize waves of activity in response to a stressor either

through the neural pathways, or through the secretion of hormones, where

epinephrine and norepinephrine take on the role of a neurotransmitter. In this

regard Pert et al’s. (1985) work on neuropeptides is significant. All sorts of

glands secrete hormones; some of the hypothalamus-pituitary-peripheral

gland links are activated during stress, whilst the secretion of others are

inhibited. According to Watkins (1995), the neuropeptides gastrin,

cholecystokinin, motilin and substance P all increase colonic activity, causing

acute exacerbation of symptoms in patients with a history of irritable bowel

syndrome and stress. In addition, scientists have come to understand that the

peripheral hormone-secreting glands are not autonomous but are under the

control of the pituitary gland which regulates the functions of all the other

glands which in turn are regulated by the brain (Sapolsky, 1994). It is the

hypothalamus at the base of the brain which instructs the pituitary.

2.4.1 Stress and the autonomic nervous system

The physiology of the stress response according to Sapolsky (1994), is

located in the autonomic nervous system which consists of both the

sympathetic and the parasympathetic nervous systems. The sympathetic

nervous system is activated in response to stress when the individual

becomes excited or alarmed. This is known as the ‘fight or flight’ response.

It helps mediate vigilance, arousal, activation and mobilization. The nerve

endings of this system release the hormone adrenaline, also known as

epinephrine, which causes the stomach to clutch. Sympathetic nerve endings

also release a closely related substance; noradrenaline or norepinephrine.

Another important class of hormones in response to stress are called

glucocorticoids. Epinephrine acts within seconds; whilst glucocorticoids

follow this release within the course of minutes or hours. Glucocorticoids are

steroid hormones. When something stressful happens or an individual thinks

stressful thoughts, the hypothalamus secretes the critical initiating releasing

hormone, corticotropin releasing factor (CRF) into the hypothalamus-pituitary

Page 25: Orientation and Motivation

circulatory system. Within fifteen seconds or so, CRF triggers the pituitary to

release the hormone ACTH (also known as corticotropin). After ACTH is

released into the bloodstream, it reaches the adrenal gland and within a few

minutes, triggers glucocorticoid release. Together, glucocorticoids and the

secretions of the sympathetic nervous system (epinephrine and

norepinephrine) account for a large percentage of what happens in the body

during stress.

The other half of the autonomic nervous system plays an opposing role. This

parasympathetic component mediates calm, vegetative activities. The

parasympathetic system is activated mainly in sleep. It promotes growth,

energy storage and other optimistic processes. For example, the parts of the

brain that activate the sympathetic component during a stressful emergency,

or when one is anticipated, typically inhibit the parasympathetic component at

the same time. In addition, in times of stress the pancreas is stimulated to

release a hormone called glucagon. Glucocorticoids, glucagon and the

sympathetic nervous system raise the circulating le vels of the sugar glucose

which hormones are essential for mobilizing energy during stress. Other

hormones are activated as well. The pituitary secretes prolactine, which

among other effects, plays a role in suppressing reproduction during stress.

Both the pituitary and the brain also secrete a class of endogenous morphine-

like substances called endorphins and enkephalins, which help blunt pain

perception. Other hormonal systems are inhibited in response to stress. The

secretion of estrogen, progesterone and testosterone is inhibited. Growth

hormones are also inhibited as is the secretion of insulin, which normally

instructs the body to store energy for later use.

According to Munck, Guyre and Holbrook (1984), it is not only the autonomic

nervous sys tem but also the adrenal and gonadal subsystems which mediate

the physiological patterns that occur during stressful experiences and that

these subsystems interact with each other. They are multi-functional and the

various chemical products of these systems form an interconnected

Page 26: Orientation and Motivation

communication system. They all subserve autocrine, paracrine and hormonal

regulatory and signaling functions. Neither neurotransmitters nor hormones

act in isolation. They produce changes in more than one bodily system and

mediate discrete patterns of changes in function dependent on the specific

stressful experience and on individual differences. The pituitary and other

endocrine glands, as well as the autonomic nervous system, the heart,

pancreas and kidneys as well as the immune system may change with

stressful experience.

No special class of ‘stress’ hormones exists as was once thought because all

the various chemical products of these systems – catecholamines,

indoleamines, amino acids, steroid and peptide hormones, glucose,

electrolytes, fatty acids etc., all form an interconnected communication

system. It turns out however, that the pattern of response is not quite that

consistent. The orchestration, or the patterning of hormone release tends to

vary from stressor to stressor and researchers are working to discover the

hormonal ‘signature’ of particular stressors (Ursin & Olff, 1993; Weiner,

1992).

Other systems such as the endocrine and immune systems are also

considered to be part of the stress physiology (Watkins, 1995). Whilst Kelly

et al. (1997) recognize that the stress response is largely an endocrine

response, Watkins (1995) claims that there is now overwhelming evidence to

suggest that higher cognitive centres and the limbic emotional centres are

capable of regulating immune function via two efferent

neuroimmunomodulatory (NIM) pathways, namely the autonomic and

neuroendocrine pathways. Therefore, it is being suggested that rather than

being irrelevant, perception and emotions may play a crucial role in disease or

illness onset and progression. In this view, the patient’s state of mind and

psychological well-being are being placed in the foreground. Watkins (1995)

proffers the perspective that the central nervous system (CNS) including the

stress response systems such as the sympathetic and the parasympathetic

Page 27: Orientation and Motivation

and the immune system interact to maintain homeostasis and that disruption

of the communication channels between the two systems predisposes an

individual towards ill health. He states that the neural networks of the

sympathetic, parasympathetic and nor-adrenergic nor-cholinergic (NANC)

nervous systems are capable of regulating almost all the cells involved in

inflammation including airways, smooth muscle contraction, mucus

hypersecretion, vasodilation, etc. It is likely that different stressors produce a

different pattern of autonomic activation and neuroendocrine steroid

production and thus a different perturbation of the immune response.

2.4.2 Acute and chronic stress responses

Kelly et al. (1997), have introduced the very interesting idea that acute and

chronic stress responses are physiologically very different and that they have

different markers. Basically, stress research has focussed on short-term

‘acute’ stress measures. In ground breaking investigations, scientists are

searching for the biological and psychosocial markers which will differentiate

‘chronic’ stress.

The immediate ‘acute’ stress response activates the autonomic nervous

system’s ‘fight or flight’ response. This five to ten minute process releases

hormones such as norepinephrine and epinephrine, which maintain a

readiness state for one to two hours. Other endocrine systems, such as the

pituitary-adrenocorticol axis, are stimulated and perpetuate a response over

the longer term if stressors are perceived to still be present. Although

popularly associated with endocrine changes, the stress response involves

multiple physiological systems. It has been demonstrated beyond any

reasonable doubt that the acute stress response produces changes in the

body, including endocrine and immune factors. However the relation to

health requires a better understanding of how the alarm is turned off, why it

sometimes seems to be left on and what the consequences really are of

leaving the alarm on (Sapolsky, 1994; Ursin & Olff, 1993).

Page 28: Orientation and Motivation

Because of the current theory that the central nervous system ‘talks to’ the

immune, hormone and clotting systems, this gives biological plausibility to the

hypothesis that the CNS could mediate degrees of vulnerability to a wide

variety of disease and illness processes (Moyers, 1993; Pert et al., 1985;

Sapolsky, 1994; Watkins, 1995). Kelly et al. (1997) make a plea for

differentiating between laboratory experiments which measure biological as

well as psychosocial markers of the ‘acute’ stress response and those which

would be required to measure longterm ‘chronic’ stress as would be expected

from early childhood experiences, one’s place in the social environment and

the experiences of daily life. Their hypothesis is that these experiences which

have caused stress and have occurred over a long period of the individual’s

life will result in a process of ‘biological embedding’ wherein the individual’s

biological responses are conditioned in such ways that lead to systematic

differences in resilience and vulnerability to disease and illness across a

range of social class experiences. This appears to be borne out by new

findings that link early ‘acutely’ stressful situations in young children to

‘chronic’ long-term effects well into their adulthood in terms of behaviour,

physiology and health (Weiner, 1992). It is also linked to studies on early

memory and posttraumatic stress in adulthood. In this regard a large number

of physical ailments have been identified in the medical literature, such as

gastrointestinal, respiratory, gynaecological and neurological problems that

may indicate a history of abuse. In this way, medical conditions that appear to

have no organic cause may be an indication of an unresolved abuse history

(Whitfield, 1995).

In looking at the relationship between acute and chronic stressors, Kelly et al.

(1997) ask themselves several questions as to whether the acute stress

response becomes chronic under the influence of repeated acute stressors , or

do chronically stressed persons become adapted to their life stressors in such

a way that the magnitude of their biologic response is lessened? In other

words, do chronically stressed individuals begin to perceive their stressors as

Page 29: Orientation and Motivation

less stressful? For the ‘biological embedding’ hypothesis to be tenable,

chronic stress must lead to subtle, long-term changes in endocrine,

hemostatic and immune system function even if individuals have seemingly

accepted the conditions of their lives.

However, despite extensive research regarding socioeconomic and

psychosocial knowledge relating to health status, the biology of stress and the

connections between consciousness and host defense mechanisms, there is

as yet no scientific consensus that the conditions humans experience over a

lifetime do actually embed themselves in human biology over a life cycle, or if

they do, that this process is a significant determinant of health in the

populations. To look at ‘chronic’ stress requires lifelong longitudinal studies.

Kelly et al. (1997) are confident that the era of such studies has at last arrived

which would be able to examine psychosocial variables, living conditions and

biological measures to assess the current health status of individuals. They

hold out the promise that biological markers will be found in order to uncover

the chronic stress response.

2.4.3 The stress-response as itself ‘damaging’

If an individual is faced with a physical stressor and is unable to appropriately

‘turn on’ the stress-response, or secondly, if one repeatedly does elicit the

stress-response and is then unable to appropriately ‘turn off’ the stress–

response at the end of a stressful event, then researchers have found that the

stress-response itself can eventually become nearly as damaging as some

stressors themselves. According to Sapolsky (1994) a large percentage of

stress-related diseases, are disorders of excessive stress-response.

Just how particular patterns of stressors lead to disease is far from clear, but

the link is not inevitable. It is never really the case that stress makes you sick,

or even increases your risk of being sick. Rather, stress increases your risk of

getting diseases that make you ill; or if you have lifestyle diseases, stress

Page 30: Orientation and Motivation

increases the risk of your defenses being overwhelmed by the disease. This

distinction is important in a few ways. First, by putting more intervening or

mediating steps between a stressor and getting sick, there become more

rather than fewer explanations for individual differences as to why some

people actually get sick whilst others stay well (Lazarus, 1993; Sapolsky,

1994). In addition to this, the prolonged ‘turned-on’ stress response can

contribute to the variance, or make you ill itself.

In concluding, stress has been examined in its own right in order to

understand and evaluate its effects on psychosomatic illnesses. Stress has

been studied and implicated in many disorders, diseases and lifestyle

problems today such as heart disease, cancer, aids, aging and so forth

(Sapolsky, 1994) and in all the so-called functional disorders of the entire

gastrointestinal tract such as peptic ulcer and the various bowel disorders,

which includes the irritable bowel syndrome (Drossman, 1994b). The irritable

bowel syndrome which is the specific psychosomatic illness to be studied in

this thesis, is examined next.

2.5 The irritable bowel syndrome

One may be forgiven for becoming confused when reading the literature on

the irritable bowel syndrome, which hereafter will be abbreviated to IBS.

This syndrome has been variously referred to as a ‘conundrum’; as a physical

disorder which remains poorly understood, whose cause has not yet been

found; as a syndrome whose psychological aspects have definitely not been

associated with the disorder; or where psychological factors either mediate or

precipitate or exacerbate the condition once it has begun and also as ‘the only

true psychophysiological disorder’ (Farthing, 1995; Kumar, Pfeffer & Wingate,

1990). These points of view come out of the many perspectives of the

researchers, which from a postmodernist stance, show that an objective

Page 31: Orientation and Motivation

position is impossible to realize. At best, one can only hope to highlight the

confusion in the literature.

2.5.1 Functional gastrointestinal disorders

Drossman (1994b) and his working teams have gone a long way towards

attempting to clarify the complex group of disorders known as Functional

Gastrointestinal Disorders. They have developed categories, definitions,

diagnoses and criteria for inclusion, based solely on symptoms.

According to Drossman (1994b), morphologic or physiologic standards to

diagnose the functional gastrointestinal disorders do not exist and the

proposed diagnostic criteria are derived from clinical investigation and are

validated by the consensus of experts in the field. This way of reaching

consensus is based on the same method used by teams for inclusion in the

American Psychiatric Association’s Diagnostic and Statistical Manual of

Mental Disorders (DSM-IV).

These experts (Drossman, 1994b) recognize that experienced clinicians and

investigators may have different interpretations to any set of symptoms based

on training, experience and personal beliefs. This implies that medicine is

moving towards a post-modern hermeneutical understanding although this is

not necessarily recognized nor acknowledged as such. They see the

diagnosis of patients according to these criteria as a starting point for

research and treatment which will lead to new information and modification by

the process of consensus. These teams working within the domain of the

different ‘so-called’ functional disorders, come together to try and make sense

of the disorder in such a way that patients can be effectively helped.

These initiatives were first launched at the International Congress of

Gastroenterology (Rome 1988) and subsequently at a second conference in

Page 32: Orientation and Motivation

1993, and later published in Gastroenterology International. Subsequently,

researchers refer to the diagnoses there formulated as ‘the Rome criteria’.

2.5.2 Definitions of functional gastrointestinal disorders

Functional gastrointestinal disorders are defined as a ‘.....variable

combination of chronic or recurrent gastrointestinal symptoms not explained

by structural or biochemical abnormalities’. These symptoms occur

throughout the digestive tract with the disorders divided into esophaegeal,

gastroduodenal, bowel (small and large intestine), biliary tract disorders and

anorectal disorders (Drossman, 1994b; Farthing, 1995).

A functional bowel disorder is a functional gastrointestinal disorder with

symptoms attributable to the middle or lower intestinal tract. These

symptoms include abdominal pain, bloating or distension and various

symptoms of disordered defaecation (Drossman, 1994b; Farthing, 1995).

The irritable bowel syndrome is classified as one subcategory of the functional

bowel disorders.

The irritable bowel syndrome is widely regarded as the prototypical functional

bowel disorder and the most common one according to Thompson, Creed,

Drossman, Heaton and Mazzacca (1992) and Thompson (1993). The

disorder is defined as a functional bowel disorder in which abdominal pain is

associated with defaecation or a change in bowel habit, with the additional

features of disordered defaecation and abdominal distension (Drossman,

1994b). According to Farthing (1995), the insistence that both abdominal

pain and disordered bowel habit must be present may be too restrictive, with

many gastroenterologists in practice making a positive clinical diagnosis of the

condition even if abdominal pain is only a minor, infrequent symptom or is

even absent, provided that the other characteristic features are present.

This comment reflects the tension that sometimes occurs between the

Page 33: Orientation and Motivation

necessity for discrete categorization in research and the practice of medicine

where practitioners feel that they need to do something to relieve their client’s

discomfort, irrespective of whether their symptoms actually ‘fit’ the diagnostic

criteria or not.

These classifications of the various functional gastrointestinal disorders and

their subcategories were developed by a second Rome congress in 1993

when working teams consisting of specialists in different areas of the

gastrointestinal tract decided on definitions for the functional bowel disorders,

proposed criteria for diagnosis, discussed the physiological data and

proposed a management plan for each one (Thompson et al., 1992).

According to Drossman (1994b), these working groups represented by the

world’s most active and preeminent scholars in the field, have presented to

physicians and patients a consensus document categorizing, giving clear

definitions and clarification for this complex group of disorders. Drossman

(1994b) does not consider that their work is the definitive answer to all the

problems which beset these functional disorders but rather that with

consensus, some of the confusion will dissipate and that they will act more as

a point of departure for researchers and physicians.

2.5.3 Epidemiology

A summary of several epidemiological surveys conducted in a number of

Western countries indicate that between 15-20%, that is roughly one fifth of

the population, suffer from the irritable bowel syndrome (Drossman et al.,

1992; Simjee, 1995). Most people with symptoms of the condition (60-75%)

reportedly do not consult a doctor (Farthing, 1995).

There appears to be a slight predominance among women (Heaton,

O’Donnell, Braddon, Mountford, Hughes & Cripps, 1992; Jones & Lydeard,

1992; Talley, 1991). Women seem to present more commonly than men to

doctors with symptoms of the condition although the prevalence of symptoms

Page 34: Orientation and Motivation

in the community appears to be similar in men and women (Drossman,

1994b). The high prevalence of these symptoms in women, particularly those

in their 30s and 40s, reflects the fact that as seen in clinical practice, doctors

and gastroenterologists find more women seeking assistance for IBS.

However, the finding of a similar community prevalence of symptoms of IBS in

both men and women, particularly in the 20-40 and over 60 age groups, is

clearly at odds with the traditional thought that IBS is a condition

predominantly experienced by women (Talley, 1994; Thompson, 1986).

Those who do seek medical attention constitute 25-50% of referrals to

gastroenterologists (Drossman, 1994b). Furthermore, the irritable bowel

syndrome is probably the most common disorder encountered by

gastroenterologists in the industrialised world and the most common

functional bowel disorder seen by physicians in primary care.

It is thought that sociocultural factors may influence the prevalence and the

gender of IBS. For instance, in Western countries, 75-80% of patients seen

in practice with IBS are female, whereas in India and Sri Lanka male patients

predominate, with only 20-30% being female. It appears to be more common

in urban societies rather than in areas where a large rural population reside

such as in South Africa (Segal & Walker, 1984), although this finding could

reflect research bias rather than prevalence.

2.5.4 Diagnostic criteria of irritable bowel syndrome (IBS)

The working team for IBS looked to several historical antecedents before

establishing their so-called ‘Rome’ criteria. Manning, Thompson, Heaton

and Morris (1978) described several abdominal symptoms that were more

likely to be present in the irritable bowel syndrome than in organic abdominal

disease which became known as ‘the Manning criteria’.

The six symptoms are: - pain eased after bowel movement

Page 35: Orientation and Motivation

- looser stools at onset of pain

- more frequent bowel movements at onset of pain

- abdominal distension

- mucus in rectum

- feeling of incomplete emptying

Manning et al. (1978); Thompson (1984) found that the more of these

symptoms that are present, the more likely the patient is to have the irritable

bowel syndrome. These symptoms were tested prospectively in subsequent

studies and their validity confirmed. Kruis, Thieme, Weinzierl, Schussler, Hall

and Paulus (1984) subsequently added other criteria requiring the symptoms

to have been present for more than two years and the use of symptom

complexes making it more positive in confirming a clinical diagnosis.

The Drossman working teams considered all the previous efforts at producing

diagnostic criteria and they in turn worked to produce clear cut diagnostic

criteria for the irritable bowel syndrome which are particularly valuable as

entry criteria for research studies and were used in this present study for that

purpose (Drossman, 1994b; Thompson et al., 1992; Thompson, 1993).

These diagnostic criteria for the irritable bowel syndrome are:

- At least three months of continuous or recurrent symptoms of:

- Abdominal pain or discomfort which is:

- Relieved with defaecation and/or

- Associated with change in frequency of stool and/or

- Associated with a change in consistency of stool

- Two or more of the following, on at least a quarter of occasions or days:

- Altered bowel frequency (more than 3 bowel movements a day or

less than 3 bowel movements a week)

- Altered form of stool (lumpy/hard or loose/watery)

Page 36: Orientation and Motivation

- Altered passage of stool (straining, urgency, or

feeling of incomplete evacuation)

- Passage of mucus

- Bloating or feeling of abdominal distension

2.5.4.1 Other diagnostic procedures in IBS

Drossman and his working teams, whilst internationally recognized, are not

the only voices expressing concern about diagnosis. On June 26 1993, the

European working team of the IBiS Club (Stockbrugger, Coremans, Dapoigny,

Muller-Lissner, Pace, Smout & Whorwell, 1993) met in Brussels for the

second time to discuss diagnostic procedures in IBS. The consensus

reached by the club which represented different countries of the European

Union, was that a ‘mixed’ diagnostic approach to the patient based on a

symptom score and the limited exclusion of structural and biochemical

abnormalities would be more acceptable. As a consequence, the diagnosis of

IBS is dependent on the competence of the family physician and/or the

gastroenterologist. This ‘differential diagnosis’ is therefore a more

conservative approach than that of Drossman (1994b) who base confidence

in their diagnosis on positive identification of symptoms alone.

The argument in Europe is that an accurate positive diagnosis of the

syndrome is impossible because IBS lacks an acceptable pathophysiological

marker. Therefore the final diagnosis is based on probability and on the

elimination of organic disease mimicking IBS by conducting some tests.

Weber and McCallum (1992) suggest that a pure clinical approach based on a

carefully taken history is sufficient.

Agreus, Svardsudd, Nyren and Tibblin (1995) found in a sample of unselected

persons with symptoms, that nosological classifications of functional

gastrointestinal disorders based on symptom etiologies may be futile. They

Page 37: Orientation and Motivation

found that individual symptoms intercorrelated in such a way that the

existence of natural clusters is refuted. Also the findings concerning the

overlap between traditional symptom classes and the flux between them over

time, strongly suggest that the prevailing classification may be inappropriate,

at least from nosological, etiologic and pathophysiological points of view. The

seemingly distinct symptom profiles seen in clinical practice may well reflect

patient selection or selective reporting rather than true clustering of

symptoms.

Noting the high prevalence of emotional distress in patients with IBS,

Whitehead, Bosmajian, Zonderman, Costa and Schuster (1988) suggested

that psychological criteria also be incorporated into the definition.

Additionally, they proposed the need for two distinct sets of criteria, one for

research and another for clinical use. Research diagnostic criteria would

select a specific narrowly defined, homogeneous population for

epidemiological and treatment outcome studies; but a more sensitive, broad

set of clinical criteria could be used for treatment in outpatient clinics by

physicians and gastroenterologists.

The existence of diagnostic criteria for IBS does not imply the validity of the

diagnosis because if it is a valid diagnosis it should be distinguishable from

other medical and psychiatric illnesses. This is not always possible as

gastrointestinal complaints are not always restricted to those of a colonic

origin.

2.5.5 Upper and non-gastrointestinal features

Although IBS was first recognized as a disorder of the colon, some

gastroenterologists feel that because the motility and functioning of various

parts of the gastrointestinal tract are more alike than dissimilar, IBS may

represent a continuum of similar gastrointestinal diagnoses with symptoms

Page 38: Orientation and Motivation

that are site -specific depending on the level of involvement (Whitehead et al.,

1988).

Andrews (1994) reports that symptoms such as nausea and early satiety are

common. Burns (1990) also notes the prevalence of heartburn and

dyspepsia in patients with IBS. In addition to ubiquitous lower abdominal

pain, gas, weight loss, indigestion and diarrhea and/or constipation, 88% of

patients complain of globus and 87% of nausea, dyspepsia and heartburn

(Dotevall, Svedlund & Sjodin, 1982). This was confirmed in a second study by

Svedland, Sjodin, Dotevall and Gillberg (1984) wherein dyspepsia appears to

overlap with IBS in 87% of a sample of patients. They also have headaches,

backaches and aching muscles. They complain of fatigue and weakness,

flushing, worry, anxiety and depression. Fifty percent fear cancer (Drossman,

Powell & Sessions, 1977). Whorwell, McCullum, Creed and Roberts (1986)

found non-colonic gastrointestinal symptoms of nausea, vomiting, dysphagia

and early satiety more often than in matched healthy controls. It has been

suggested that IBS is characterized not only by bowel symptoms, but also by

an excess of headaches, backaches, lethargy and urinary symptoms

(Whorwell et al., 1986).

According to Almy and Rothstein (1987) the increased reporting of non-

colonic symptoms in patients with IBS is related to global physiological

responses and heightened emotional arousal rather than to disparate

mechanisms. This statement has very important implications for

psychological therapeutic interventions.

Although there may be a slight loss of weight due to IBS, if this becomes

significant it is essential that other causative factors such as anorexia nervosa

or organic disease be investigated (Bloch, 1997). According to Bloch (1997),

disrupted eating and behavioural patterns characteristic of anorexia nervosa

and bulimia nervosa are also noted in a sample of IBS subjects, but that this

behaviour appears to mimic bulimic behaviour and is not actually diagnostic,

Page 39: Orientation and Motivation

but rather signifies a lack of control over their environment. In this study

subjects appeared to experience levels of confusion and apprehension in the

recognition of and accurate response to emotional states. They furthermore

appear to have problems of ‘perception’ in that they failed to recognize and

correctly identify hunger or satiation sensations.

Some of these manifestations of ill health are also called the somatoform

disorders, which according to Swartz, Blazer, Woodbury, George and

Landerman (1986) and Swartz, Hughes, Blazer and George (1987), have

several different subforms. One of these subforms is the full gamut of

gastrointestinal symptoms including headache, pain, anxiety, depression,

unpleasant bodily sensations and disability.

Patients with IBS manifest some symptoms that clearly suggest

gastrointestinal distress (pain, distention, flatus and urgency), but they also

show features of autonomic arousal that are common in mood and anxiety

disorders, such as weakness, fatigue, palpitations, nervousness, dizziness,

headache, hand tremour, back pain, sleep disturbance and symptoms of

sexual dysfunction (Weiner, 1992). It is the combination of these

gastrointestinal and psychiatric symptoms that appear to separate patients

with IBS from other patients with pure gastrointestinal or psychiatric illness.

In summary, IBS appears to be a chronic condition marked by waxing and

waning symptoms with occasional exacerbations as well as overlap with

upper and non-gastrointestinal features (Talley, 1994). According to Weiner

(1992) the entire person is afflicted, yet the relationship amongst all the

various variables has not been resolved - for example, the link between

diarrhea and backache to depression.

Schlebusch (1990) states that by definition, science operates with models

which alert us to the influence of paradigm and theory and the complex

multifaceted parameters that are implicated in diagnostic, etiological and

Page 40: Orientation and Motivation

treatment considerations. It is some of those models that have guided these

considerations in both stress and illnesses such as IBS, which are addressed

below.

2.6 Models for irritable bowel syndrome and stress

Models represent paradigms and paradigms represent different scientific

worldviews. During the past few years, newer and different paradigms have

emerged. A brief overview of the most recently used models for dealing with

IBS as well as stress are mentioned and also the biopsychosocial model

which is used differently by both IBS and by stress researchers. An additional

model, the network model, as yet merely implicit in some of the newest

research emerging in dealing with IBS and with stress separately, but which

could be used integratively for both, is proposed. It uses molecular biology as

the underlying science and is therefore very much based on the new quantum

science worldview. This places both stress and IBS, as a psychosomatic

illness, into the body-mind research arena and the postmodernistic era.

2.6.1 Biomedical model

The biomedical model has until quite recently been the most successfully

used for studying and treating IBS. It is based on the assumption that medical

illness occurs as a result of histopathologic disease. This approach has

governed the thinking of most Western health practitioners for the past 300

years (Salt, 1997). It presumes that identifiable abnormalities in the structure

and function of organs and tissues or its biochemical associations, have a

linear and causal relationship to disease. This model has been extremely

successful over the past few years and is supported by the rapid growth of

information relating to the endoscopic and radiologic correlates and most

recently, to the molecular determinants, of disease (Drossman, 1994b).

However, gastroenterologists and physicians are aware of the poor correlation

Page 41: Orientation and Motivation

between morphologic findings on endoscopy and their patients reporting of

their symptoms. There does not appear to be a clear-cut association

between patients reporting of pain and the occurrence of symptoms, nor is the

counter assumption, that they must therefore be psychiatric due to the high

frequency of psychiatric conditions in patients who have IBS, because recent

epidemiological studies have shown that persons who do not seek health

care, are psychologically similar to healthy subjects (Drossman, 1994b).

This has led to the necessity of developing a different framework to

understand, categorize and treat the symptoms which are believed to be

biologically multi-determined and to vary with cultural, social, interpersonal

and psychological influences (Drossman, 1993; Drossman, 1994a).

2.6.2 Diathesis-stress model

Scientists have assumed a specific method of interaction between genes and

the environment. Individuals inherit tendencies to express certain traits or

behaviours, which may then be activated under stressful conditions. Each

inherited tendency is a diathesis, which means a condition that makes one

susceptible or vulnerable to developing a disorder or illness as a result of

stress.

In an attempt to explain individual differences in response to stress, the

vulnerability hypothesis proposes that pre-existing personal dispositions and

social conditions interact with life events to produce negative health

consequences (Kaplan et al., 1993). This model emphasizes the interaction

or buffering effect of various factors. Thus, the absence of personal and/or

social resources when experiencing stressful life events increases the

likelihood of health problems (Bayne, 1997).

2.6.3 Biopsychosocial model

Page 42: Orientation and Motivation

Both stress and IBS researchers have used the framework of the

biopsychosocial model, albeit differently, to help show the interacting effects

of physiological and psychosocial factors that influence these conditions.

‘In challenging the exclusive emphasis on one domain of functioning such as

the biological, to the neglect of other domains such as the psychological and

social, the biopsychosocial model assumes the development of IBS to be a

multicausal, complex process, whereby both physiological and psychological

processes are operative’ (Pretorius & Stanley, 1999, p.6).

As early as 1977, Lipowski (1985) the so-called ‘father’ of psychosomatic

medicine, stated that psychosomatic medicine needs to change its paradigm

from the medical model to the one of general living systems, as most suitable

because it was holistic and connected the body and mind as one. In this

regard, one such biopsychosocial model was developed by Drossman and

Thompson (1992) who proposed a relationship between psychosocial factors

and illness behaviours for IBS. They suggested that early in life, genetic and

environmental factors affect one’s susceptibility to IBS symptoms, or at least

one’s ability to cope with them. The seriousness with which these symptoms

are perceived, communicated and acted on (illness behaviour) is influenced

by psychosocial factors such as stressful life events, personality, social

support and coping skills. These factors in turn, may modify an underl ying

gut, motor or sensory disturbance to determine symptom severity, medication

and health care use. Thus, while one person who has good coping strategies

and social supports may not seek medical care, another having similar

symptoms, together with some psychosocial factor, such as high life stress or

poor social support may pay visits to physicians more frequently (Bayne,

1997).

PREDISPOSING FACTORS PSYCHOSOCIAL

MODIFIERS

Genetic Life Events

Page 43: Orientation and Motivation

Demographic Personality

Early Environment Social Support

Coping

Well being

Daily functioning

Health care use

Figure 2.1: The role of psychosocial factors in IBS (Drossman 1994b, p.14)

Schlebusch (1990) points out what could be considered to be a limitation of

the biopsychosocial model in its use for psychosomatic illnesses like IBS, is

that it has been used more as a treatment or management tool, rather than as

a research methodology. He postulates that in effect, physicians still treat

primarily the medical aspects and psychologists deal with the client using their

main focus which is psychological interventions. In this way ‘lipservice’ is

paid to the conceptualization of the biopsychosocial model but in practice the

client is still primarily treated from one level of the model.

Stress researchers are aware of the complexity of the potential relationships

between health and stress (Kaplan et al., 1993). The biopsychosocial model

reflected below attempts to show how several subsystems of the body interact

among themselves as well as the psychological mediating factors that need to

be accounted for in order to assess the person suffering from stress.

Early Life

No IBS

IBS

Chronic Patient

Patient

Non – Patient

Hypothalmic / Pituitary Stress hormones

Page 44: Orientation and Motivation

Figure 2.2: The biopsychosocial stress model (Kaplan et al., 1993, p.115)

2.6.4 Through the ‘lens’ of the biopsychosocial-spiritual camera

Salt (1997) has introduced into his work with IBS in mainstream medical

education, research and treatment, the beginning interest and concern for the

spirituality of patients. Recent researchers and authors have been

emphasizing the healing power and potential of spirituality and belief in a

higher power. In addition to the biopsychosocial factors, spirituality is

included. This four-pronged model which incorporates the mind-body-spirit

dimensions of the person’s functioning has been researched and given

attention by Benson (1996); Dossey (1993); Levin, Larson and Puchalski

(1997) amongst others. Benson (1996) has researched in the scientific field,

today recognized as mind-body medicine, the ‘relaxation response’, based on

beliefs and expectancy of wellness and its links to the stress response. He

stated that the ‘relaxation response’ is as hardwired into the neurological

circuitry of the body as the ‘fight or flight’ response. The difference between

the two is that the ‘stress response’ is automatic whereas the ‘relaxation

response’ takes some practice in order to counteract stress.

Background Characteristics of Individual

Perceived Stress

Mediators: Supports Self- concept Coping

Autonomic Nervous System Activity

Health Behaviours

Immune System

Health

Page 45: Orientation and Motivation

2.6.5 Network model

Schlebusch (1990) accredits Pert et al. (1985) with coining the term

‘bodymind’; which emphasizes that the entire mind-body system is a network

of information. Pert et al. (1985), a neuromolecular biologist, is known for her

peptide research. In the mid-eighties she and her colleagues identified a

group of molecules, called peptides, as the molecular messengers that

facilitate the conversation between the nervous system and the immune

system and that these messengers interconnect three distinct systems - the

nervous system, the immune system and the endocrine system. This peptide

research has shown that the conceptual separations in the disciplines of

neuroscience, endocrinology and immunology are merely ‘historical artifacts’

that can no longer be maintained. Rather, according to Pert (1997); Pert et

al. (1985), the three systems ought to be seen as forming a single

psychosomatic network of communication.

These peptides consist of at present 60-70 macromolecules which were

studied in other contexts and given other names such as hormones,

neurotransmitters, endorphines, ‘gut’ peptides, growth factors etc. It has now

been recognized that these macromolecules belong to a single family of

molecular messengers. These messengers are short chains of amino acids

that attach themselves to specific receptors which exist in abundance on the

surfaces of all cells of the body. By interlinking immune cells, glands and

brain cells, peptides form a psychosomatic network extending throughout the

entire organism. Of particular interest to the link between IBS and

psychology is the theory developed by Pert (1997) that peptides are the

biochemical mediators of emotions: they play a crucial role in the coordinating

activities of the immune system; they interlink and integrate mental, emotional

and biological activities. The ‘gut’ or intestines are richly lined with ‘gut’

peptides. Peptides have an ‘emotional tone’ and link to the limbic system.

Therefore, via peptides that occur throughout the body, it is possible to

hypothesize a link between emotions, stress and the irritable bowel syndrome.

Page 46: Orientation and Motivation

The mechanisms involved in these processes have not been understood as

yet but the psychosomatic network model offers the promise of the beginnings

of a conceptual and integrative language with which to approach this mind-

body problem.

2.7 Summary and conclusion

After providing the basic philosophical and theoretical orientation of the study,

this chapter assessed the current status of the research on stress and

psychosomatic illness. This was followed by a brief history and the outline of

the evolution of the definition of stress from a physiologically based

understanding, to one that incorporates the psychological dimension and the

interaction between them. An introduction to irritable bowel syndrome as the

specific psychosomatic illness examined in this thesis was then developed

and the various biomedical and biopsychosocial models that have been used

as a framework to explain the stress-IBS link, examined. The new ‘network’

model is included as a more appropriate language for describing the part that

stress plays in psychosomatic illnesses. Not only does it emphasize the

communication that occurs between the neurological, endocrinological and

immunological systems of the body, but it also highlights the mediating role

that emotions play in gut-stress reactions.

Lastly, this points the way to an examination of the empirical literature which

explores the links between stress and IBS. The role stress plays in the

pathogenesis and psychosocial etiological development of the irritable bowel

syndrome is the subject of the next chapter.

Page 47: Orientation and Motivation

CHAPTER THREE

ETIOLOGICAL LINKS BETWEEN STRESS AND IRRITABLE

BOWEL SYNDROME

‘It is a hard matter, my fellow citizens,

to argue with the belly, since it has no ears’

- From Plutarch, Lives (Marcus Porcium Cato or Cato the Elder)

Drossman (1994b) suggests that the perspective for looking at a

psychosomatic illness such as irritable bowel syndrome is best characterized

by the use of the biopsychosocial model which is based on the assumption

Page 48: Orientation and Motivation

that both physiological as well as psychological processes interact to produce

the complex phenomenon known as IBS. These researchers have also stated

that persons with IBS have a biological vulnerability that is modulated or

mediated by psychosocial factors. The etiology of IBS defies a simple

understanding and therefore remains largely unknown and poorly understood

(Farthing, 1995; Lynn & Friedman, 1993). Despite the fact that the evidence

appears to make a very good case for accepting the irritable bowel syndrome

as a heterogeneous disorder, with apparently multiple pathways towards the

final clinical picture, research frequently considers single causes.

It is interesting to note that the heterogeneity present in this psychosomatic

disorder which strongly indicates individual differences, does not create

excitement in its own right. Some researchers are beginning to examine the

clinical picture in a more complex way, nevertheless a composite picture is

still not clear. Hope is still held out that with the refinement of technological

advances, more and more will reveal itself biologically (Lynn & Friedman

1993).

It may be that this contributes to the uncertainty which surrounds this disorder

as at present there are no clear-cut physiological and psychological

mechanisms nor pathways which have been found to clearly delineate the

etiology of IBS. It is likely that these connections are nonlinear, multi-factorial

and change over time (Pretorius & Stanley, 1999).

The role of stress in the etiology of IBS has been studied as both a direct and

an indirect cause of both physiological as well as psychological phenomena,

in the form of moderating as well as mediating factors. Some conceptual and

methodological clarity is needed in order to begin to understand the various

and complex relationships that are entertained in the literature which has

studied the links between ‘stress and IBS’.

3.1 Conceptual and methodological factors in ‘stress’ research

Page 49: Orientation and Motivation

Conceptual systems like those proposed in the models which were described

briefly in chapter two, are usually embedded in a set of general

methodological assumptions about how to approach the phenomena of

concern and in this case the relationship between stress and IBS. The three

distinct levels of analysis are the physiological, psychological and the social.

Researchers usually attempt to link one or more of these three levels.

Lazarus and Folkman (1984) hold the view that each level is always partially

independent (self-regulatory and autopoeitic as understood in general

systems theory) and als o always partially interdependent. They claim that

each level has its own principles which guide thinking about the relationships

that exist among these levels. They state that physiological stress and

somatic illness like IBS are often assumed, without justification, to indicate the

presence of psychological stress, or even stress in the social system. Or in

other instances, the physical and psychological levels are confounded as

when heat, cold, bodily symptoms and/or infections are assumed to result in

psychological stress. Often it is difficult to know whether the physiological

stress responses that emanate from the experience of physical symptoms are

the consequence of physical or psychological processes, or both. For Lazarus

and Folkman (1984), the links are established through cognitive appraisal,

whilst for Weiner (1992) they are established through signals which offer

information at many system levels, bi-directionally, simultaneously and in

parallel processing.

A stressor can be internal or external, acute or chronic (Kaplan, Sadock &

Grebb, 1994). Internal stressors could include genetic, perceptional, somatic

including the central nervous system (CNS), adrenal glands, hormonal ‘fight or

flight’ syndrome, constitutional, personality factors and limbic structures

involving negative emotions and cognitions (appraisals, beliefs). External

stressors may be direct or indirect, in the environment or ecology, infectious,

in the cultural or social life, or in the life events of the person and may include

factors such as poor social support, inadequate coping strategies, history of

Page 50: Orientation and Motivation

abuse, poor self-care and health habits, lack of faith and spirituality (Kaplan et

al., 1994; Salt, 1997; Weiner, 1992).

Ongoing debate surrounds the distinctions made between mediators and

moderators which involve both theoretical and methodological difficulties.

Some researchers such as Cronkite and Moos (1984), make the distinction on

the basis of ‘predisposing factors’ as mediating and ‘moderating factors’ as

moderators to describe the very complex process of the stress-illness

relationship. The position adopted by Lazarus (1990) is that a mediator refers

to a process, generated in the encounter, that actively changes the mental

state that would have occurred in its absence and a moderator is a variable

that is present from the outset. More recent research (Weiner, 1992)

indicates that all variables in the stress-illness relationship are bidirectional

with reciprocal effects occurring at all times so that at any point in time, a

moderator could become a mediator and vice versa. It is this latter position

which is in keeping with a general systems paradigm and biological

organismic/behavioural perspective on stress and illness which was

advocated in chapter two.

Given the complexity in the factors associated between illness and stress and

the small variance attributed to objective measures of life events, Maddi

(1990) suggests that in order to measure the link between stress and illness,

an objective doctor’s diagnosis, an objective social consensus measure as

well as subjective measures of stress be used. Cohen, Tyrrell and Smith

(1993) showed that life events related differently to biological mediators than

did ‘perceived’ stress or affect. Cox and Gonder-Frederick (1992) found that

the evidence is stronger for studies using subjective evaluations of stress than

for those using other measures. These findings suggest that aspects of stress

may play a different role at different stages of disease/illness onset and

indicate the need for better specification of the stress process and its effect on

the body. These studies are supportive of the contextual, subjective approach

Page 51: Orientation and Motivation

to the study of stress and illness as proposed by Lazarus and Folkman

(1984).

3.2 Etiology

Nowhere is the confusion surrounding the study of IBS and all the interacting

variables more apparent than when one attempts to unravel the etiological

considerations of this disorder. Enck and Wienbeck (1993) subdivided the

psychological aspects of IBS into six categories. This chapter has adapted

their model linking stress and IBS within a biopsychosocial framework and

includes experimental stress effects on intestinal motility, visceral sensitivity

and pain perception; as well as a number of facets of life event stress, illness

beliefs, personality traits, psychopathology and social resources. Whilst many

of these effects are interactive, they have been separated and examined from

the biological level first.

3.2.1 Pathophysiology

From the biological preposition, numerous authors have variously proposed

that IBS is the result of: disordered gut motility; central nervous system

dysfunction; lowered sensory threshold or supersensitive intestines as well as

possible chemical imbalances in the autonomic innervation of the gut. It has

been suggested that there is a basic predisposition to IBS and that it is

triggered by various factors, including antibiotics, abdominal operations,

gastroenteritis and stress (Dancey & Backhouse, 1993). Muller-Lissner,

Coremans, Dapoigny et al. (1997) conclude that an examination of the

literature divides IBS sufferers into three subgroups: constipation-

predominant, diarrhea-predominant and pain-predominant.

Page 52: Orientation and Motivation

However many patients have normal bowel function until an episode of

travellers’ diarrhea or food poisoning disrupts bowel function. Little if any

controlled evidence exists that such events truly precipitate the symptoms of

IBS, but anecdotal accounts and frequent reference to this in the literature

suggests that the model should include in the somatic component, extra -

colonic factors such as infections, dietary indiscretion, food intolerance,

female hormonal changes in either pregnancy, menses or hysterectomy, or

bacteria such as helicobacterpylori (Farthing, 1995).

3.2.1.1 Motility

Despite the general agreement that IBS is a disorder which includes intestinal

motility, studies have varied in their control of critical methodological variables.

McKee and Quigley (1993) in their review, warn that the research is fraught

with technical and interpretive difficulties which need to be considered when

making an assessment of colonic dysmotility in IBS. In all of these studies,

few clear-cut differences have emerged between healthy control subjects and

patients with IBS (Gorard & Farthing, 1994), indicating that no

pathophysiological marker of the syndrome exists.

Because of the difficulties of placing manometric catheters throughout the

colon, most studies have focussed on the sigmoid colon, the rectum and the

small bowel (McKee & Quigley, 1993; Muller-Lissner et al., 1997). There is

reason however to suspect the involvement of other areas of the

gastrointestinal tract outside the colon. Lind (1992); McKee and Quigley

(1993) suggest that studies ought to be combined from these different areas

and studied longitudinally in order to effectively study the pathophysiologic

aspects of IBS and the correlation between symptoms and motor

disturbances. None of the findings are present in all patients and it is possible

that the reported findings are based on different symptomatic subsets of IBS

patients whether diarrhea-predominant or constipation-predominant, which

may result in different abnormalities in intestinal transit or motility. These

heterogeneous findings make it difficult to construct a single unifying

Page 53: Orientation and Motivation

hypothesis for the cause and development of the IBS syndrome (Gorard &

Farthing, 1994).

One such cause is the known ability of psychological stress to profoundly alter

gastrointestinal function and dysmotility (McKee & Quigley, 1993).

Essentially, evidence for this comes from studies of motor responses to

various experimentally induced stresses. Lind (1992) states that in recent

years improved techniques have been able to measure normal motor

responses to food, external stress, hormonal stimulation and intraluminal

contents like bile acids. In this way, specific sensor and motor abnormalities

of the gastrointestinal tract in patients with IBS have been identified. For

instance, IBS patients as a group show an exaggerated or altered sensation

and motor activity response in both the small and large intestines in relation to

various stimuli, which include diet, fatty acids, bile salts, hormonal stimulation,

physical pain and psychological stress (Drossman, 1994b; Lind, 1992); as

well as sensation and motor activity in response to balloon distention of the

rectosigmoid region (Drossman, 1994b). In the small bowel, an exaggerated

motor response was noted after ingestion of fatty meals, after ileal balloon

distention, or hormonal stimulation, during altered ileocecal transit times,

discrete clustered contractions during fasting and increased sensitivity to pain

(Kellow, Gill & Wingate, 1990). Thus, patients with IBS may have a sensitive

gastrointestinal tract that responds in an exaggerated way to both intrinsic as

well as extrinsic stimuli (stressors) which normally regulate motor activity.

Lind (1992) observes that these abnormalities of motility are frequently more

pronounced under the influence of external stressors such as pain,

psychologic stress and anger (Kellow et al., 1990; Welgan, Meshkinpour &

Beeler, 1988). Several studies have shown that immediately before

presenting with IBS, patients had a significantly increased stress score

compared with healthy individuals (Whitehead et al., 1988). Furthermore,

motility disturbances have been identified in patients with psychoneuroses

who do not have symptoms of IBS and similarly, normal control subjects with

Page 54: Orientation and Motivation

the same external stressors such as pain, stress or anger, may also have the

intestinal motor changes that have been detected in IBS patients (Latimer,

Sarna & Campbell, 1981).

Camilleri and Neri (1989) have stated that whilst stress in everyday life would

be more relevant in the study of IBS subjects, most studies have examined

‘acute’ stress. As such, they consider the best examples of experimental

measurement of acute psychologic or painful stress which induced motor

changes in the gut were those done by Almy and his coworkers. As early as

1947, Almy and Tulin observed an increase in rectal motor activity during

submersion of a volunteer’s hand in ice-water. Later on these same

researchers noted that the motility changes appeared to depend on the

intensity of the accompanying emotional reaction. For example, subjects who

cried in response to psychological stress showed decreased rectal tone

whereas those who did not cry, developed increased rectosigmoid activity.

However, other studies have failed to demonstrate significant differences in

the rectosigmoid motor response to psychological stress between IBS and

control patients. These contradictory findings may be due to the fact that a

standardized measure of the stressors was not utilized (Schuster, 1983). To

counteract this problem, Welgan et al. (1988) found, using a standardized

interview designed to evoke the single emotion of anger, that IBS patients

developed a significantly greater increase in both spike activity and motility

indices in response to stress than did the control subjects.

Any acute stress, such as an examination or an interview, can produce bowel

frequency, nausea, vomiting or early satiety. These symptoms suggest that

acute, stressful events can affect the entire gastrointestinal tract, possibly with

the patterns of symptoms being determined by individual susceptibility. It is

also well recognized that urinary frequency commonly accompanies anxiety or

acute, stressful events. Specifically, acute anger has been shown to increase

the motility index in the colon and acute stresses such as loud music and

being woken from sleep can promote abnormalities of motility in the small

Page 55: Orientation and Motivation

intestine in patients with IBS that are different from responses in controls

(Gorard & Farthing, 1994).

However, IBS is known to be a chronic illness (Talley, 1994) and these acute

measures may not do justice to the underlying chronic stress experienced by

some sufferers of IBS. As mentioned in chapter two, more recent stress

research is beginning to search for the biological markers of chronic stress

and this is promising for future research into chronic stress and IBS (Kelly et

al., 1997).

Lind (1992) raises another interesting observation, that it is only in conscious

patients, when control of intestinal motility by the enteric nervous system is

under the control of input from the central nervous system that these motor

abnormalities are detected in the small bowel and the colon in IBS patients. At

night there is no difference in small bowel motility and patterns of migrating

motor complexes, however, what is noticed at night is that there is an

increased length of time of Rapid Eye Movement (REM) sleep (Kumar,

Thompson, Wingate, Vesselinova-Jenkins & Libby, 1992). Devroede (1994)

links this to unconscious processes that may reveal the ‘hidden agenda’ of

patients with IBS. Orr, Crowell, Lin, Harnish and Chen (1997) support this

finding of REM sleep but also found altered intrinsic gastric functioning. Their

results suggest both unconscious psychological parameters as well as

possible central nervous system dysfunction in IBS patients.

These observations give rise to the suggestion that the central nervous

system’s modulation of the enteric nervous system’s control of intestinal

motility may be of consequence in the pathogenesis of IBS (Lind, 1992;

McKee & Quigley, 1993). The variety of stressful stimuli used in such studies

may be mediated by different afferent pathways and may reach different

levels of the higher centres and that the potential importance of the pathways

and centres mediating the effects of stress have received little consideration.

Page 56: Orientation and Motivation

3.2.1.2 Autonomic nervous system or ‘brain-gut’ connection

Lydiard (1992) proposes a model for understanding the brain-gut interactions

which may link IBS and psychiatric disorders. As his model includes

pathways used in the stress physiology, it may be hypothesized as a further

explanation for the mediating effects of stress and IBS. Lydiard (1992)

explains that fear and arousal responses are mediated in part via the

septohippocampal area, the amygdala component of the limbic system and

midbrain central gray areas. The hypothalamus receives input from these

areas, integrates the input and then orchestrates the appropriate set of

autonomic and somatic responses, including output to the gut via the

sympathetic and parasympathetic pathways (Kuperman, 1985).

Some researchers refer to the ‘gut’ in the GI tract as the second or little ‘brain’.

The enteric nervous system (ENS) is an elaborate neuronal network in the gut

which has also been called the third division of the autonomic nervous

system. The GI tract/ENS is located in the lining of the esophagus, stomach,

small intestine and colon. The GI tract and the brain come from the same part

of the developing embryonic baby and as a result the digestive tract and brain

have many similar nerve endings and chemicals that relay signals and

messages (neurotransmitters). In this way the brain and the gut are

connected. The system is a complex circuit with nerve cells (neurons) and

chemicals that enable the two ‘brains’ to act independently and

interdependently to remember, learn, and produce ‘gut feelings’ (Salt, 1997).

The vast majority of the vagal fibres connecting the gut and the central

nervous system (CNS) are afferent fibres which bring information to the CNS.

Much of the ENS is similar to the CNS, both containing neurotransmitters and

neuropeptides (Gershon, 1981). One such ‘gut’ peptide found in both

research within the stress arena as well as in anxiety disorders is

cholecystokinin.

Page 57: Orientation and Motivation

What is of particular interest as to the possible mechanisms which link stress,

IBS and some psychiatric disorders is the model for brain-gut interaction

proposed by Lydiard (1992). He suggests the link between the CNS and the

GI system may be found at the level of a pontine noradrenergic nucleus, the

locus coeruleus, situated at the floor of the brain, which is postulated to

mediate some aspects of fear and arousal states, including panic disorder.

This nucleus receives afferent input from the gut such that perturbation of the

bladder, bowel, or stomach may cause increased neuronal firing of this

noradrenergic nucleus. Patients may experience GI distress as part of the

sympathetic discharge, which results in afferent input back to the locus

coeruleus and other important parts of the brain, potentially creating a vicious

positive -feedback cycle. Patients with IBS or certain psychiatric conditions

such as anxiety or depression, or experiencing distress or negative emotions,

also often complain of numerous autonomic symptoms suggesting that there

may be some common pathophysiology. Further study of the interplay

between the gut/ENS and the CNS (in particular the locus coeruleus) may be

important in understanding the brain-gut interactions.

[see figure 3.1 over page]

CNS

LC

GI Arousal

ENS

Distress Fear

Page 58: Orientation and Motivation

GUT

Figure 3.1: The brain-gut interaction: CNS = central nervous system, ENS = enteric

nervous system, LC = locus coeruleus (Lydiard, 1992, p.615).

If the autonomic nervous system (ANS) is involved in the control of

gastrointestinal motility and sensitivity, then it would suggest that a

disturbance of this system may be involved in the pathophysiology of IBS

according to Maxton and Whorwell (1991). The results of their study suggest

that control of bowel habit is more dependent on the total integrity of the

autonomic nervous system (ANS) but a fully intact ANS is not critical for the

perception of abdominal pain or distention. In particular the parasympathetic

system appears to be affected before the sympathetic system. Their results

suggest that bowel function as opposed to abdominal pain or distension is

relatively sensitive to damage of the ANS (Maxton & Whorwell, 1991).

In Camilleri and Ford (1994), there is increasing evidence that autonomic

neuropathies not associated with specific neurological disorders but affecting

the extrinsic nerves to the gut may also play a role in gastrointestinal

disorders. Camilleri and Ford (1994) point out that looking for disturbances in

the ANS may be the way to get ahead in learning more about this intractable

disorder. They refer to a report by Aggarwal, Cutts, Abell, Cardoso, Familoni,

Bremer and Karas (1994), which lends support to the hypothesis that

autonomic system dysfunction may be an important cause of IBS in a minority

of patients. Their data suggest that vagal cholinergic dysfunction is

specifically associated with a constipation-predominant subgroup of patients

with IBS, whereas patients with diarrhea-predominant symptoms show

evidence of sympathetic adrenergic dysfunction. The autonomic regulation of

gastrointestinal motor function includes both extrinsic control by the

Page 59: Orientation and Motivation

parasympathetic and sympathetic nervous systems as well as intrinsic control

imposed by the enteric plexuses. The enteric nervous system contains a

semiautonomous system that possesses specific motor response ‘programs’

such as peristaltic reflexes and the pacemaker systems that control the rate of

contraction in the foregut and midgut.

In summary, the links to stress are not explicitly spelled out but may be

indirectly inferred from the common link to stress physiology. Furthermore,

the inability to demonstrate a precise motility disturbance to explain the

symptoms and the apparent hypersensitivity in IBS to many stimuli, suggest

that the manner in which information about symptoms is processed in the

CNS may help determine how they are perceived and acted on (Drossman,

1994a). Essentially it remains unclear to what extent IBS symptoms

represent normal perception of abnormal function or abnormal perception of

normal function.

3.2.1.3 Visceral hyperalgesia or disturbed visceral nociception

The pain network is a very complex system that includes both peripheral or

skin pain as well as visceral or central pain in the physical systems of the

body (Brand & Yancey, 1993). Brand and Yancey (1993) write that this

visceral pain is a slower, less localized kind of pain that warns of problems

deep inside the body. Internal organs, such as the stomach and intestines,

have a sparse supply of pain sensors yet at the same time have an exquisite

sensitivity to one particular type of pain, the pain of distention where people

experience one of the most acute pains the human body knows, that of colic.

Pain originating in deep tissues such as the viscera are recognized as being

clinically ‘different’ from pain originating in cutaneous tissues since deep

tissue pain generally produces greater autonomic and emotional responses

(Ness, Metcalf & Gebhart, 1990).

Page 60: Orientation and Motivation

Drossman and Thompson (1992) state that in recent years, researchers have

come to acknowledge that pain is by consensus a necessary part of the

diagnosis of IBS because of the evolving research on visceral hypersensitivity.

Chronic abdominal discomfort and pain are the most common symptoms

resulting in patient visits with gastroenterologists. However, pain is not only

physical but is also a sensory, emotional and cognitive experience; therefore

the abdominal pain and other symptoms of IBS cannot be attributed solely to

gut dysfunction but need to include other factors such as the contributions of

stress, strong emotions and other psychological phenomena. Stressful stimuli

can produce disturbances in intestinal motility, enteric nervous system and

pain perception; whilst conversely bowel disturbances can affect mood and

behaviour. Drossman and Thompson (1992) propose that further research is

needed to delineate these interactions along the brain-gut axis.

Many people with IBS have enhanced sensation and perception of bowel

function. They can feel things in their GI tract, chest, abdomen and rectum

that people without IBS cannot. This has been referred to as disturbed

visceral nociception. Another way of considering this is that patients with IBS

and other functional GI disorders have lowered internal pain threshold for

reasons which at present are poorly understood (Salt, 1997). Patients with

IBS report pain at a lower threshold than healthy individuals when a balloon is

gradually inflated in the distal bowel to simulate the accumulation of gas or

stool. They also report the sensations of gas and urgency at a lower volume

of distention (Ness et al., 1990).

Mayer and Reybould (1990) and Mayer and Gebhart (1994) have written two

very comprehensive reviews of the extremely complicated research literature

which attempts to analyze the clinical and physiological evidence supporting

the role that pain or altered visceral afferent mechanisms play in IBS amongst

other ‘so-called’ functional bowel disorders. Their proposal is that multiple

mechanisms either alone or in combination work to produce the visceral

hyperalgesia reported so frequently by patients suffering from IBS. Their

Page 61: Orientation and Motivation

reviews point to the heterogeneity in the clinical presentation which indicates

either a lifelong history (chronic) or recent onset (acute); and the possibility of

a multi-factorial etiology of the various functional bowel syndromes. It is

also possible to hypothesize that the physiological processes they elucidate,

may point to a possible way in which the mechanisms involved in stress

physiology could be linked to IBS.

The long-term changes in visceral sensitivity, which are possibly mediated by

central neuroplastic changes result from changes in central excitability in

addition to intermediate and short-term changes. This is the waxing and

waning hypothesis where periods of exacerbation occur, frequently in

response to acute stress (Talley, 1994). Mechanisms involving descending

pain modulatory systems contribute to or complement long-term plastic

changes. Alterations in responsiveness of tonic descending pain modulatory

systems is expected to result in chronic visceral hyperalgesia even in the

absence of peripheral sensitizing events. Although the end result is similar,

widely different central and peripheral mechanisms may be responsible for

sensitization in different parts of the gut or even in the same location. Central

mechanisms include stress via the sympathetic and parasympathetic

pathways, anxiety and depression. The peripheral mechanisms include acid

formation, bile salt, inflammation, mechanical irritation and nerve damage

(Mayer & Gebhart, 1994).

Simjee (1995) suggests a theory for ‘visceral hyperalgesia’ when he

introduces the idea of the down-up and the up-down hypothesis to explain this

further. He suggests that multiple factors such as genetic, inflammation, local

nerve mechanical irritation and psychological factors, alter neuroreceptor and

afferent (sensory) spinal neuron function and the CNS modulation of afferent

input in such a way that it produces long-term sensitization of pathways

involved in the transmission of visceral sensation (Mayer & Gebhart, 1994).

According to the down-up hypothesis (Simjee, 1995) this alteration is possibly

as a result of the recruitment of high threshold ‘silent’ spinal nociceptors (C

Page 62: Orientation and Motivation

fibres) in response to inflammation or injury, which down-regulate the central

processing of afferent (sensory) signals (Cervero & Jaenig, 1992). During

sensitization, the strength of the stimulus is greater and therefore previously

non-responsive C fibres (‘silent nociceptors’) become responsive and result in

an increase in synaptic activity in the excitability of dorsal horn projection

neurons. After resolution of the peripheral irritation, the peripheral sensory

mechanisms may not return to the normal presensitized state and a ‘normal’

stimulus can result in an increased response even when the peripheral

irritation is reduced. This means that the spinal afferents hold a ‘pain memory’

that amplifies the subthreshold stimuli so that it is perceived as painful, even

when it is recorded as normal.

According to the up-down hypothesis, because there is a ‘brain-gut’ axis,

higher neural centres modulate peripheral intestinal motor or sensory activity.

Normally the CNS has an inhibitory effect on the dorsal horn so that

subthreshold stimuli do not cause pain. Stress interferes with this inhibitory

effect. Loss of descending inhibitory modulation which could occur in

response to stress, means that subthreshold stimuli are amplified, resulting in

pain. Extrinsic factors such as vision and smell, as well as intrinsic factors

such as emotions and cognitions are other forms of information which are also

neurally connected from higher centres of the brain and have the capability to

affect GI sensation, motility and secretion. The messengers that regulate

these activities and have varied effects on pain control and GI motility are the

numerous neurotransmitters and neuropeptides found in the brain and gut.

Many of these are commonly found in stress research, like cholecystokinin

(Simjee, 1995).

The changes found in the functions and mechanisms in both the peripheral

and central neuronal activity that produce abnormal visceral hypersensitivity

may have long-term effects that last for years (Mayer & Gebhart, 1994).

Fitzgerald (1991) sugges ts that transient noxious stimuli in new-borns can

permanently alter afferent pathways. Through the principles of recruitment

Page 63: Orientation and Motivation

and sensitization, the increased sensory input to other neurons of the spinal

cord could explain not only the increased severity of pain, but also the wider

area of effect, for example, to the skin over the abdomen, to other areas of the

GI tract, to the genitourinary area, or to the abnormal qualitative descriptions

of pain (Ness et al., 1990).

When the physiology of stress was discussed in chapter two, it was seen that

there is currently speculation about the long-term effects of stress from early

childhood (Weiner, 1992). The visceral pathways utilize the sympathetic and

parasympathetic pathways as does stress. Given the concepts of recruitment

and sensitization, it is possible to hypothesize that chronic early childhood

trauma or stresses, as well as visceral hyperalgesia may in some way

become linked so that in adulthood, the current stressors and episodes of IBS

are linked and programmed into the body to occur simultaneously. It is further

hypothesized that even in the event of acute stress or acute episodes of IBS,

the origins may be quite unrelated to the current presence or absence of

particular stressors.

In summary of the biological component, it can be seen that many factors

interact and that it is extremely difficult to separate these effects, whether they

be biological or psychological. What is clear, however, is that bowel

symptoms do not always correlate with the presence, or absence, of

pathophysiological abnormalities and that there are also a variety of

psychosocial symptoms which are brought to doctors (Drossman et al., 1992).

Psychological stress is widely believed to play a major role in IBS and even in

healthy individuals, psychological stress and emotional responses to stress

can affect gastrointestinal function producing symptoms (Drossman et al.,

1992). The role of various psychosocial factors and their relationship to stress

and IBS will be examined.

3.2.2 The role of psychosocial factors in IBS

Page 64: Orientation and Motivation

Some of the psychosocial factors which have been linked to IBS include

behaviours relating to illness which are learnt in childhood from parents’

behaviour and bowel complaints, or behavioural conditioning occurring in

childhood, current life stressors, personality style, sexual abuse, coping

strategies and the quality of social support. These all influence how an

individual responds to illness, how symptoms are perceived, communicated

and acted upon (Drossman et al., 1992).

IBS causes symptoms and discomfort ranging from mild and inconvenient, to

moderate and severe, resulting in incapacitation and disability. Current

evidence shows that any chronic illness such as IBS, can have significant

psychosocial consequences which could lead to restricted living in multiple

areas: diet, social activities and daily living, altered energy levels and

problems with interpersonal relationships with family, friends and co-workers.

Finally, it leads to disability with many missed days of work. IBS is the

second leading cause of industrial absenteeism in the United States

(Drossman, 1994a; Salt, 1997).

Numerous studies now show that patients with IBS who see doctors for their

symptoms are more likely to have psychological problems than are those

people with symptoms who do not consult with a doctor about them. This

means that psychological disorders such as anxiety, panic, depression,

somatoform disorders, a history of sexual abuse, alcohol or substance abuse

or an eating disorder, acute or chronic stress, can lead to increased

symptoms and illness and will reduce the person’s ability to cope. According

to gastroenterologists, psychological problems are not the cause of the

functional disorders such as IBS but rather are likely to increase the need to

consult with doctors (Drossman, 1994a). This leads to the new research which

implicates the psychological more directly in the simultaneous and parallel

processing which is both within the body and the mind.

Page 65: Orientation and Motivation

Studies conducted to evaluate the psychological concomitant of IBS have

unfortunately not been able to reach consensus concerning the exact nature

of the psychological involvement nor how this should be evaluated

(Blanchard, Schwarz & Radnitz, 1987). Researchers conclude that

psychological factors are diagnosed in 50-60% of clinic patients (Whitehead et

al., 1988). Frequently the role of psychological factors in IBS and their

relationship to ‘stress’ remains unclear (Drossman, McKee, Sandler, Mitchell,

Cramer, Lowman & Burger, 1988; Thornton, McIntyre, Murray-Lyon &

Gruzelier, 1990). There seem to be two aspects to consider when examining

the psychological aspects of stress in the etiology of IBS. Firstly, that it comes

as a consequence of the disorder and, secondly that psychological aspects

trigger the disorder in persons who are vulnerable to it.

3.2.2.1 Stressful life events

Approximately 50% of patients with IBS are aware that their symptoms are

worsened at time of stress; whilst some patients may even relate their

symptom onset to a significant episode of acute stress. Patients with IBS also

report significantly more anxiety-provoking life events than patients who have

organic gastrointestinal disorders in the preceding one year (Ford, Miller,

Eastwood & Eas twood, 1987).

The nature of the relationship between stressful events and health/illness is a

complex one which is not as yet fully understood. Clearly in some situations,

the relationship is causal as stressful events exert direct effects resulting in

illness. In other circumstances stress may be a cofactor, predisposing the

individual to illness. Another way in which the relationship could be

conceptualized is that illness itself causes greater stress throughout a

person’s relationships and life experiences. It is also quite probable in fact

(Williams et al., 1992) that both stress and illness are not in fact related at all

but are rather both expressions of a general vulnerability existing in a person.

Page 66: Orientation and Motivation

Nevertheless, whatever the relationship turns out to be, over the last two

decades there has been increasing interest in the role that stressful life events

play in promoting health or illness (Williams et al., 1992). Beginning with the

work of Holmes and Rahe (1967), life events have been examined variously

as precipitants, mediators and as an expression of ill health. In the last ten

years, there has also been recognition of the importance of daily irritants and

pleasant experiences in explaining some of the variability in the expression of

disease and illness (Kanner, Coyne, Schaefer & Lazarus, 1981).

Holmes and Rahe (1967) have identified a 43-item list of stressful life events

organized on the basis of the amount of readjustment a life event would

occasion. This list represents an objective quantified amount of stress,

expected to have occurred as a result of the life event experienced. The

majority of items identified were presumed to be experienced by the majority

of individuals as ‘loss’. The basis of the resultant life stress would depend on

the individual’s innate capacity, previous or present learned coping style and

other personality attributes or resources. In terms of this life event measure of

stress, stress is perceived as a social or environmental event, or as an event

that is externally induced. However, what is identified by an individual as

stress, either consciously or unconsciously, may lead to feelings of distress

which is largely then an internal psychological and subjective experience.

This experience of a life event according to Kimball (1984) involves a number

of factors which are dependent on the individual’s internal processes which

include: an intactness of cognitive functions such as orientation, capacity for

arousal, memory, concentration and affective stability. Implicit in Kimball’s

(1984) usage of internal processes are both physiological arousal and

emotional content.

During many life events, whether experienced as painful but retained in

consciousness, or traumatic and either retained or ‘forgotten’, researchers are

becoming aware of the important part played by ‘memory’ and the crucial role

it plays in how individuals express or do not express their pain, whether

somatically, behaviourally or in the psyche (Whitfield, 1995). Recent and

Page 67: Orientation and Motivation

ongoing research is being done in studying the body’s role in memory.

Scientists no longer believe that the brain is the only repository for feelings

and memory. Bolen (1994) states that the body is an organ of memory as

well as perception. Pert (1997) declares that she can no longer make a

strong distinction between the brain and the body. Van der Kolk (1994)

makes the statement that ‘trauma is stored in somatic (body) memory and

expressed as changes in the biological stress response as a means in which

the body keeps the score’. It is clearly evident that to view life events as

merely external to and impinging on the person without taking into account the

mind-body effects within the person, is to deny or distort the reality as it is

experienced by many people currently suffering from IBS.

Two types of observations support the statement that IBS patients show a

greater reactivity to life event stress than non-patients. When asked directly,

more than half of the IBS patients and non-patients who nevertheless

exhibited IBS-like symptoms, reported that psychologically stressful events

either preceded the onset of their IBS or that they exacerbated their bowel

symptoms (Whitehead, Crowell, Robinson, Heller & Schuster, 1992).

Secondly, Drossman et al. (1992) who support this finding, also found that IBS

patients differ from healthy controls by having greater symptomatic and

physiological responses to various stressors. As early as 1962, Chaudhary

and Truelove found that stressful life events such as marital difficulties,

problems with children or parents and worries related to business or career

were more common in the period preceding symptoms of IBS. Exacerbation

of pain following a ‘loss’ or threat situation was reported by Hislop (1971), in

which a degree of self blame was also often present. Singh and Kaur (1984);

Dinan, O’Keane, O’Boyle, Chua and Keeling (1991) reported undesirable life

events, perceived as negative, were more stressful than desirable life events.

Whitehead et al. (1992) found many similar findings in their study with the IBS

group showing significantly higher levels of stress and reactivity to stress.

Arun, Kanwal, Vyas and Sushil (1993) concluded that whilst specific and

Page 68: Orientation and Motivation

definite sets of stressors cannot be identified, life events do play a role in

onset or exacerbation of IBS.

3.2.2.2 Daily hassles

Research has vied between two measures of stress, those objectively named

‘major’ life events and those focussing on relatively minor events, namely, the

hassles and daily irritants of everyday life (Kanner et al., 1981). Kanner et al.

(1981) concluded in their research comparing the two modes of stress, that

hassles are more strongly associated with adaptational outcome than are life

events and that hassles contribute to symptoms independently of major life

events. They do concede however that generally, even if not independently,

life events and daily hassles overlap considerably.

Daily hassles are the irritating, frustrating and distressing demands that

characterize everyday transactions with the environment. Some occur in

particular life contexts such as in the occupational work environment resulting

in work overload, underload and role ambiguity. Others occur in the

environment itself such as commuting to work in rush-hour traffic (Kanner et

al., 1981).

Studies on the relationship between daily hassles and IBS have not proved

this association conclusively. Suls, Wan, and Blanchard (1994) concluded

that the link between stress and GI symptomatology may not be as

straightforward as originally thought. Their results suggest that daily stress

does not apply to the majority of IBS patients. They also found that

sympathetic and parasympathetic systems may be uncoupled or coupled in a

non-reciprocal mode and that autonomic influences may occur at different

sites along the lower GI tract with different time courses, therefore the

relationship is not simply one-to-one. Dancey, Whitehouse, Painter and

Backhouse (1995) conducted a similar enquiry and also found no significant

associations between hassles and any symptom on its own. However their

Page 69: Orientation and Motivation

results do suggest that an increase in overall symptom severity is likely to

precede an increase in severity of common place stresses. They

hypothesized that hassles perhaps do cause an increase in severity of

symptoms but that they make their effect known only a few days later, or that

a severity of symptoms may cause the sufferer to perceive hassles as

becoming more severe.

Bayne (1997) appears to confirm this conclusion in a recent study where an

IBS group did not report significantly more or less stressful events in the

previous 24 hours than a group of non-IBS controls, but their Impact scores

for the sub-scales of Interpersonal Problems, Environmental Hassles and

Varied Stressors as measured by the Daily Stress Inventory (DSI) were

elevated, which indicated that these stressors tended to be experienced as

more stressful by the IBS sufferers.

Sapolsky (1994); Weiner (1992) both indicate that life events will vary in

effects depending on the intricate and complex physiobehavioural

coordinating factors that occur within the organism during the whole process

of illness or symptom occurrence and stressful experience. Many researchers

refer to the mediating processes that interact to produce the effects of the

stress/illness relationship and coping, referred to below, is one of the most

researched mediating factors.

3.2.2.3 Coping Research in the past few decades has shown increasing evidence that stress

and coping strategies are related to various psychosomatic illnesses and

disease (Bennett, 1989). Whilst there are not many studies linking IBS

specifically to coping styles, research by Grossarth -Maticek and Eysenck

(1990) found a clear connection between certain types of personalities and

coping styles on the one hand and health behaviour on the other. These

were found to be associated with different kinds of psychosomatic complaints

and diseases, as well as coronary heart disease and gastritis.

Page 70: Orientation and Motivation

Traditional approaches to coping emphasize traits or styles which are stable

properties of personality, such as hardiness or resilience, which are said to

moderate the experience of stress itself. In contrast, Lazarus and Folkman

(1984) emphasize coping as a process and refer to a person’s ongoing

efforts in thought and action to manage specific demands appraised as taxing

or overwhelming. Although stable coping styles do exist and are important,

coping is highly contextual, since to be effective it must change over time and

across different stressful conditions (Folkman & Lazarus, 1985). According to

these researchers, coping affects subsequent stress reactions in two main

ways: firstly, if a person’s relationship with the environment is changed by

coping actions, the conditions of psychological stress may also be changed

for the better. This they called problem-focussed coping. The second way

coping affects stress reactions is called emotion-focussed coping and

changes only how an individual attends to or interprets what is happening. A

threat which is successfully avoided in thought, even if only temporarily,

doesn’t affect one. Likewise, reappraisal of a threat in non-threatening terms

removes the cognitive basis of the stress reaction. For example, if a person

can reinterpret a demeaning comment by his/her spouse as the unintended

result of personal illness or job stress, the appraisal basis for reactive anger

will dissipate. Coping influences psychological stress via appraisal which is

always the mediator (Lazarus, 1993).

Folkman and Lazarus (1988b) created a procedure called The Ways of

Coping Questionnaire which yields eight factor scales, each representing a

different coping strategy. They discovered that coping occurs in patterns

which vary according to the type of stressful encounter, the type of personality

stressed and the outcome modality studied; such as subjective well-being,

social functioning or somatic health.

According to a study done by Mayer (1997), hers was the first study to attempt

to find a direct link between coping styles and IBS and as such the

Page 71: Orientation and Motivation

hypotheses of her study were based on extrapolation and inference. The

coping style used significantly more by the IBS patient group than any of the

other coping styles, was an emotion focussed coping style named ‘escape-

avoidance’ coping. This includes wishful thinking and behavioural efforts to

escape or avoid the problem. One uses this type of coping style to maintain

hope and optimism, to refuse to acknowledge the worst and to act as if what

has happened does not matter. This lends itself to self-deception or reality

distortion (Lazarus & Folkman, 1984). Escape-avoidance is also a denial-like

type of coping and denial can also be helpful up to a point (Lazarus, 1993).

Persons who use this type of coping style avoid threatening information and

tend to keep unpleasant experiences out of their consciousness. But

according to Lazarus (1993), it could be seen as a beneficial means of coping

when there is nothing one can do about one’s stress. IBS clients in this study

had not been in therapy and tended to view their illness as beyond their

control and that they were unable to change their condition. They had not

learnt that emotional and psychological factors are implicated as components

of their illness. Often this style of coping is one they have learnt to adopt in

the face of misunderstanding from health-care professionals and physicians

from whom they have sought support (Lazarus, 1993). In this way support

can be linked to coping, but people offering this support may be pejorative in

how they assist the person suffering from a somatic illness.

The literature supports the view that escape-avoidance behaviour plays a

significant role in the development of other disorders such as heart disease

(Bekker, Hentschel & Reinsch, 1993) and is associated with risk factors such

as Type A behaviour patterns and hostility. Deterioration of health is more

likely to be found among individuals who use escape-avoidance behaviour

(Denollet, 1991; Dimsdale & Hackett, 1982). Mayer (1997) suggests that

IBS could now be linked to the list of psychosomatic illnesses affected by this

pattern of coping.

Page 72: Orientation and Motivation

Pokroy (1997) studied psychological defense mechanisms and found that

Turning-against-self was significantly used by IBS sufferers as a means of

coping with their stress. They did not confront or deal effectively with their

aggression but rather turned it inward on themselves. Thus aggression and

anxiety is internalized and is expressed via the gastrointestinal system. She

hypothesized that this could possibly lead to the development of IBS.

An alternative view of defense propagated by Ursin and Olff (1993) involves a

psychobiological view of coping. Instead of the traditional view of

psychological defense mechanisms in humans as a psychodynamic concept,

it is also possible to treat defense as distorted stimulus expectancies within

the information processing theory. Stimulus expectancy refers to the storing

of information that one stimulus precedes another as occurring in classical

conditioning. When an aversive event is expected, a stress response occurs.

When this relationship is misperceived by the individual through mechanisms

distorting the relationship, the individual is said to use defense. This filtering

mechanism depends on complex cognitive functions. Three types of

expectancies are important in determining the internal, physiological state of

the individual. The first one is coping which is defined as a positive response

as the result of a learning process. Inability to cope incorporates the

remaining two effects, the first which results in high levels of activation or

‘stress’ called helplessness; and the second defined as hopelessness, which

is the term now most commonly used for cognitive models for depression.

This has not been studied directly in IBS, but what Ursin and Olff (1993)

conclude is that while the alarm system in the stress response is prolonged

and sustained due to lack of coping, the homeostatic elements in the

response may be surpassed. If this takes place, disease or psychosomatic

illness might occur in the somatic locus of least resistance in that particular

individual. What is required in relation to health is a better understanding of

how the alarm is turned off, why it sometimes seems to be left on and what

the consequences really are of leaving the alarm on.

Page 73: Orientation and Motivation

3.2.2.4 Emotional factors in stress and IBS

One of the internal, subjective processes associated with life events as

mentioned by Kimball (1984) is the emotions. Emotional pain, stressful

conditions and chronic intestinal pain have frequently been linked and the

mechanisms that effect these associations have been partially studied since

Almy and Tulin (1947).

As early as 1942, Freiss and Nelson declared that the abdomen is indeed the

sounding board of the emotions after discovering that 42.5% of neurotic

patients mentioned gastrointestinal symptoms as their main complaint. Even

earlier, Stevenson (1930) found an emotional problem in two thirds of the

cases presenting to a gastrointestinal clinic. Various emotions have been

studied experimentally in relation to their physiological effects on the motility

of the colon (Almy & Tulin, 1947). Evidence strongly suggests that

psychological stress or emotional responses to increased life stress,

frequently including a theme of ‘loss’, exacerbates symptoms to a greater

degree in IBS patients (Mayer & Gebhart, 1994; Whitehead et al., 1988).

Lazarus (1993) linked strong negative emotions and intense arousal to stress

and thought that in many ways that a theory of stress is actually a theory of

emotions. Segal (1997) described emotions as physical events, such as

feeling extremely frightened or feeling a pang in our stomachs. She states

that the emotional pain which we ‘stave off’ in the short term, usually returns

as chronic physical pain in the long term. It is crucial to circumvent the fear of

‘feeling’ because all emotion brings us important information which we can

utilize more successfully by developing body awareness and physical fitness.

Our perceptions are the language of our body, which gives us information

Page 74: Orientation and Motivation

through our senses. Linked to this is our memory for those perceptions and

emotions we have long since forgotten or buried.

Zawacki (1993) refers to emotions as ‘who we are as people’. It is not

recognized, he explains, that by taking notice of our emotions, we can slow

things down and look at our lives and what is going on in our body and in our

relationships. Life-style, stress and the emotional component of conditions

like IBS are extremely complex. It is the emotional component of IBS

expressed in the present time by stories of life event stress which bring the

patients to the physician for their pain, but often masks emotional aspects that

have been buried and forgotten and which give rise to deep hurt, emptiness

and psychological pain. Frequently pain is related to intestinal complaints

which in turn is related to anxiety and often to a history of physical and/or

sexual abuse (Devroede, 1994; Drossman, 1992).

A communication network theory emanating from neurobiology lends support

to the fact that neuropeptide receptors have rich and numerous nodal points in

the limbic system, which is considered to mediate emotional behaviour.

These receptors are found throughout the gastrointestinal tract as well as in

the immune and endocrine systems (Pert et al., 1985). Pert (1997) refers to

neuropeptide receptors as the biochemical mediators of emotion which form a

‘bridge’ between the psyche and the soma. This offers a theory that does

indeed link stress, emotions and somatic complaints like those experienced by

IBS sufferers. It also suggests that emotional states can significantly alter the

course and outcome of biologic illness previously considered to be strictly in

the somatic realm.

It was thought some years ago that due to their inability to link somatic

complaints to their emotions, IBS patients were expressing the

psychodynamic trait of alexithymia. In one study, IBS patients were found to

be the lowest on alexithymia and more closely associated with neuroticism

(Fava & Pavan, 1976). Alexithymia is defined as the inability of individuals to

Page 75: Orientation and Motivation

find words to describe their emotions, or to ‘feel’ their emotions. However,

more recent research suggests that structural or functional abnormalities in

the communication pathways between cortical and limbic centres, can result

in profound immunological and behavioural impairment such as is seen in

alexithymic individuals. This disconnection between cognitive and emotional

centres can be produced by persistently high levels of adrenal corticotrophic

hormones resulting in damage to hippocampal cells (Watkins, 1995). This

same effect is seen in persistently high levels of stress (Sapolsky, 1994). This

suggests that the trait of alexithymia as seen in individuals with IBS may be

not that they lack words or feelings but rather that they appear to have an

inability to express their emotions. Later in this chapter, it will be seen that

many emotionally painful events are defended against through the defences

of repression, dissociation and denial. Painful emotional events have to be

recovered in memory (Whitfield, 1995).

Ogden and Von Sturmer (1984) examined the emotional strategies that

people use and their psychological consequences, between a group

categorized as emotives and those called suppressed-emotives. These

strategies were measured against psychological maladjustment and

psychosomatic complaints. Ogden and Von Sturmer (1984) hypothesized that

the ways in which people cope with intense emotions may have a significant

effect on their psychological and physical health. Being exposed to stressful

events together with the suppression of emotions has been associated with

relevance in the etiology and the exacerbation of psychosomatic illness.

Ogden and Von Sturmer (1984) confirmed their hypothesis and discovered

furthermore, that one way in which suppressed-emotives differed from

emotives is that they see themselves as having more psychological problems,

more ‘aches and pains’ and greater difficulties in relating to other people.

Medical science and psychology are now forging a more comprehensive view

of how our emotional lives directly affect our physical well-being by

investigating the actual links between psychological events, emotions, brain

Page 76: Orientation and Motivation

function, hormone secretion in stress and the potency of the immune

response. With the proposed pathways via peptides to the gastrointestinal

tract, the way is clear for the future study of more direct associations between

emotions, stress and IBS (Pert et al., 1985). Another way in which these

processes are being studied which link yet another system of the human body

and mind to stress and psychosomatic illness is through the higher cognitive

centres of the brain as discussed next.

3.2.2.5 Illness beliefs, symptomatology and the stress response

A basic premise underlying much IBS research is that psychosocial factors

are not a part of the illness per se, but influence illness behaviour as

manifested by increased physician visits, medication use, seeking alternative

medical treatments, requests for unneeded surgery and secondary gain

(Drossman, 1994b; Prior, 1995). Consulters appear to differ from non-

consulters in having more psychological distress and abnormal illness

behaviour as expressed in patients health beliefs and concerns (Drossman,

1991). The following research suggests ways in which illness beliefs, which

may link to illness behaviour, may also play a role in linking stress and IBS.

Integrative mind-body research which is examining the relationship between

cognitive function and hypothalamic activation is receiving attention through

four main avenues of research, namely, depression, stress, personality and

conditioning. This provides evidence that higher cognitive centres as well as

limbic emotional centres, can modulate neuroendocrine and autonomic

efferent NIM pathways as seen in stressful experiences (Watkins, 1995).

Through inference and association, the following research suggests links

between stress and IBS.

Using self-discrepancy theory, which states that there is a discrepancy

between customary and actual activation levels and between an ideal and

actual view of one’s own capabilities, Higgins, Vookles and Tykocinski (1992)

Page 77: Orientation and Motivation

found support for their proposal that it is the significance of self-belief patterns

as a whole that predicts physical and emotional problems rather than just the

positivity or negativity of the self-beliefs as independent elements. From this

perspective, self-beliefs can become interconnected to function like unitary

cognitive structures that tend to holistically represent both psychological

situations and symptom responses. They also stated that self-discrepancy

theory shares the assumption with ‘gestalt psychology’ that psychological

phenomena occur as part of a system of coexisting and mutually

interdependent elements which have particular significance for the type of

emotional suffering and physiological symptoms which would result. Both

self-discrepancy theory and gestalt psychology share in turn the assumption

with cognitive neuroscience theory (Hebb, 1949) that internal representations

of stimuli can be conceptualized as massive interconnections of neural

networks where the activation of one set of stimuli can initiate phase

sequences of synapses in nerve cells and produce distress.

Higgins et al. (1992) found two specific patterns of self-belief. The first

pattern produced a discrepancy between the actual and the ideal view of the

self in relation to its capabilities and this resulted in feelings of dejection-

related suffering (e.g. feeling sad, disappointed, discouraged); which in turn

was linked to symptoms such as vomiting and depression which in turn has

been linked to the IBS symptom of constipation (American Psychiatric

Association, 1994; Drossman, 1992). The second pattern produced a

discrepancy between the actual and what one ‘ought to be’ views of self and

this resulted in feelings of despondency-related suffering which in turn was

linked to symptoms such as autonomic hyperactivity, muscle aches and

diarrhea where diarrhea is a symptom of IBS.

In turn, Higgins et al. (1992) linked two stress-related biological response

systems that are differentially associated with the sort of distinct symptoms

which were found in the IBS symptom clusters. The first is the sympatho-

adrenomedullary system (SAM) essentially found in the defensive ‘fight or

Page 78: Orientation and Motivation

flight’ reaction and is associated more with diarrhea and muscles cramps.

The second system is the hypothalamico-pituitary-adrenocortical system

(HPAC) and is associated with cardiovascular disorders, peptic ulcerations

and depression and indirectly therefore, more associated with the IBS

symptom of constipation.

Toner, Garfinkel, Jeejeebhoy, Scher, Shulhan and Gasbarro (1990)

investigated whether IBS patients differed in their self-schema from depressed

patients. Self-schema refers to a cognitive framework of the individual’s

beliefs, attitudes and self-perceptions which are stored in memory and which

influence incoming information. They found that while some IBS and

depressed psychiatric outpatients may share depressive symptoms, these

groups differed in the extent of negative adjectives they used to describe

themselves. IBS patients recalled more non-depressed words and did not

appear to hold as negative a view of themselves as is more characteristic of

psychiatric patients experiencing major depression. However they also had

elevated Lie scores which Toner et al. (1990) interpreted in three ways:

deliberate ‘faking’; or a response in terms of an ‘honest’ but inaccurate and

uninsightful self-assessment; or a response in terms of an ideal self-concept

rather than realistic self-appraisal. They concluded that some IBS patients

may adopt a self-schema characterized by social desirability and Toner,

Koyama, Garfinkel, Jeejeebhoy and Gasbarro (1992), tested and confirmed

this hypothesis. One implication they drew from this is that having a need to

present oneself in a socially favourable light may preclude researchers from

gaining an accurate psychological profile of an individual with IBS.

Gomborone, Dewsnap, Libby and Farthing (1993) investigated IBS patients

from the perspective of their cognitive psychopathology and not their

psychiatric symptoms and came to the opposite conclusion to Toner et al.

(1990). They used a different procedure to study affective biasing in memory

among depressed and IBS patients. They found both groups shared a

similarly negative schema but that a subgroup of IBS patients who were not

Page 79: Orientation and Motivation

depressed as measured on the Beck’s Depression Inventory, also used a

negative self-schema. They believed that their investigation was at an

unconscious level as compared with that of Toner et al. (1990) and therefore

the issue of social desirability was substantially reduced. They hold the

opinion that an inability or unwillingness to present oneself as ‘emotionally

distressed’ is one of the aspects of the process of somatization, as the

mechanism whereby distress is manifested in the soma as physical

symptoms. They then link this to how the individual attends to and evaluates

his or her internal sensory stimuli in terms of illness as a necessary

antecedent as to whether to seek medical consultation. In this way negative

self schema may incorporate themes of physical illness rather than those of

worthlessness, guilt and the like which are characteristic of depression. This

they proffer, then helps to explain the dimension of healthcare seeking

behaviour which has widely become recognized as part of the clinical

syndrome (Drossman, 1994b; Whitehead et al., 1988).

Subsequently, Gomborone, Dewsnap, Libby and Farthing (1994), using the

psychosocial dimension of illness behaviour as measured by the Illness

Attitude Scales (IAS), found that IBS patients had elevated scores on bodily

preoccupation, disease phobia and hypochondriacal beliefs. These abnormal

illness-related fears, beliefs and attitudes distinguished the IBS group from

those patients with organic gastrointestinal disease or depression. Illness

attitudes appeared to influence subjective symptom severity not only in terms

of consultation behaviour but also by focussing anxiously on physical

sensations which are in turn amplified (Barsky, 1979).

In conclusion, it appears that the dimension of health-care seeking behaviour

is influenced not only by the severity of functional abdominal complaints but is

also influenced by non-organic dimensions such as cognitive, behavioural and

environmental factors. Van Dulmen, Fennis, Mokkink, Van Der Velden and

Bleijenberg (1994) found that doctors frequently correctly estimate the somatic

component of the illness but underestimate the severity of the pain and the

Page 80: Orientation and Motivation

psychosocial components, therefore they risk overlooking and correctly

perceiving psychological factors, such as anxiety, catastrophizing cognitions

and avoidance behaviour. It appears that a strong case can be made for

evaluating this distress in terms of the negative cognitions involved in illness

perceptions and beliefs which are frequently learned in childhood, or as a

result of parental distress.

3.2.2.6 Physical and sexual abuse and IBS

A psychosocial trauma, such as an abuse history, whether sexual and/or

physical abuse, is an example of a particular type of stressor. Since a trauma

induces and activates many components of our inner life, including

biochemistry and physiology as well as the psychological, which may have

begun in early childhood or have occurred for the first time in adulthood, what

results is usually a painfu l experience (Whitfield, 1995). In the late 1800’s and

early 1900s, Janet, the French neurologist who was a pioneer in the field of

trauma and recovery, viewed memory as the central organizing apparatus of

the mind which sorts and integrates the many parts of inner and outer

experience. He was also the first to differentiate ordinary memory from

traumatic memory (Van der Kolk, 1994). Ordinary memory tends to be

conscious, voluntary, oriented in time and flexible; whereas traumatic

memory, also called somatosensory memory, is unconscious, more

involuntary, frozen outside of time and is often rigid. Van der Kolk (1994)

studied the psychobiological manifestations of posttraumatic stress syndrome

wherein he views memory as the way in which the body keeps a tally of the

experiences of the person in the form of somatic memory and changes in the

biological stress response.

When an individual experiences a traumatic event, it involves the metabolism

and immune system on the physical level; emotional and cognitive

psychological effects; and frequently leads to difficulties with relationships.

Page 81: Orientation and Motivation

Another effect is in the form of illness such as IBS. Traumatic memories may

be held in consciousness but can also be either fully or partially ‘forgotten’.

Memories are ‘forgotten’ through three defenses against emotional pain –

repression, dissociation and denial, which may involve physical, sexual,

cognitive, emotional and spiritual aspects of experience.

Conscious Difficulty with Physical and Relationships Mental Illness Survival A W Repetition Compulsion A R Weakened Projection and E Immune System other defenses N E S postponed processing & grieving S Stored Loss of Memory Painful Energy and Awareness of True Self Unconscious Dissociation Repression Denial Traumatic Event(s)

Figure 3.2: Some results and consequences of traumatic forgetting

(Dissociation, Repression and Denial – Whitfield, 1995, p.125)

Repression is an automatic psychological defense against unbearable

emotional pain wherein a painful experience is forgotten and stored in the

Page 82: Orientation and Motivation

unconscious mind. Dissociation is a separation from and loss of awareness

of the present moment experience, including beliefs, feelings, decisions,

needs, sensations, intuitions and external events. Denial is a complex

defense which involves not recognizing and thus avoiding the awareness of

the reality of a traumatic experience. In contrast to repression; dissociation

and denial are at times a part of healthy psychological functioning, because

they may allow a gradual acceptance of a hurt, loss or trauma. They may be

useful survival mechanisms for defending against the pain of mistreatment

either as a child or when suffering abuse or trauma at any age. The results of

a study of early childhood abuse suggest that children remember traumatic

experiences in at least four dimensions, including the somatic, behavioural,

verbal and visual (Whitfield, 1995).

Wall and Melzack (1984) developed a theory called the ‘spinal gate -control

theory’ which offered an explanation for part of the complexity of pain. Very

simply, thousands of nerve fibres, some descending from the higher brain and

some ascending from the extremities of the body, come together in a

switching station, the gate, located where the spinal cord joins the brain. So

many nerve cells converging in one place creates a bottle neck of information

which alters the perception of pain. Some messages have to wait to get

through, whilst others may not get through at all. Janov (1989) utilized the

gating theory to explain how memory for traumatic events can cause a

disconnection between emotions and cognitions (Watkins, 1995). Salt (1997)

in his treatment of IBS clients makes reference to this theory when he

explains that symptoms and pain coming from the body and GI tract to the

brain through the spinal cord can be either enhanced and worsened or

blocked and reduced through the ‘descending inhibitory pathway’. Reducing

stress can close the gate to the sensation of pain, by contrast stress and

emotional, physical or sexual abuse can open the gate to the reception of

pain. This also increases the brain’s perception and sensation of

uncomfortable symptoms like those experienced in IBS.

Page 83: Orientation and Motivation

Whitfield (1995) in his analysis of abuse history, states that the blocked event

or trauma needs to be brought back into memory and relived, so that it can be

processed and the suffering connected in consciousness to the present where

it can be used to inform the person’s life. This he says is the domain of

psychologists specially trained to do trauma work (Scarinci, McDonald-Haile,

Bradley & Richter, 1994).

Since the first study to document the high prevalence of sexual and physical

abuse among female patients in a referral gastroenterology clinic, where 44%

had an abuse history (Drossman, Leserman & Nachman, 1990), numerous

other studies have reproduced these findings (Leserman, Drossman, Li,

Toomey, Nachman & Glogau, 1996). However there is little clarity or

evidence concerning which aspects of abuse may impact on health status.

Only two of these studies examined the separate effects of sexual versus

physical abuse on GI disorders. In their study Leserman et al. (1996) not only

separated physical from sexual abuse, but also examined the difference

between whether the abuse first occurred in childhood or adulthood or both,

and they also differentiated more severe abuse from less severe, including

experiences involving life threat.

Leserman et al. (1996) confirmed the previous findings on health status of IBS

patients who have been abused, that they report an increased frequency of GI

and non-GI symptoms, more physician visits and more lifetime surgical

procedures, hysterectomy amongst them. Thus, psychosocial trauma, such

as an abuse history, leads to a poorer adjustment to illness and is associated

with altered and increased pain reporting, selective referral to medical centres

and, in general, a poor clinical outcome (Drossman, 1992; Devroede, 1990;

Scarinci et al., 1994; Walker, Gelfand & Gelfand, 1995).

Leserman et al. (1996) situate these negative health effects within a broader

theoretical model which they say lies at the heart of psychosomatic and

behavioural medicine; which is the relationship of stress and health. These

Page 84: Orientation and Motivation

effects may be mediated through the central nervous system and will include

behavioural as well as emotional factors. They list some of the explanations

proposed to explain this relationship. From a physiologic standpoint, for

example, abdominal pelvic pain is the most frequent symptom reported by

women with an early abuse history, which may result from vaginal or rectal

trauma that sensitizes afferent neurons (Drossman, 1994a). Traumatic

stimulation of the genitals might downregulate the sensation threshold of

visceral nociceptors, thereby increasing sensitivity to abdominal/pelvic pain or

other bowel symptoms (Cervero & Jaenig, 1992). From a psychological

standpoint, sexual abuse may produce feelings of guilt and shame or negative

cognitions and ineffective coping styles. From a behavioural perspective,

increased attention to illness complaints early in life may lead to reinforcement

of illness behaviours setting up a vicious cycle of continued symptoms,

disability and health care utilization.

According to Drossman (1992) and Devroede (1994) physical and sexual

abuse is so common as to require that physicians or other persons

encountering the sufferer of IBS, routinely ask patients whether they have

been abused in the past or in the present. Leserman et al. (1996) state that

despite the epidemic of sexual and physical abuse, these experiences still

remain hidden from practitioners and women are consequently not referred for

psychological counselling. Besides the effects of sexual and physical abuse,

many IBS patients also report a preponderance of psychiatric complaints such

as depression and anxiety and these co-morbid Axis I disorders may indicate

the necessity for further inquiry into areas such as abuse history.

3.2.2.7 Psychiatric disorders, stress and IBS

This raises the important question as to the part played by stress, either

internal or external, chronic or acute, in the development of psychiatric

disorders such as anxiety and depression and by which mechanisms they are

in turn linked to IBS. According to the Diagnostic and Statistical Manual of

Page 85: Orientation and Motivation

Mental Disorders (DSM-IV), classification of mental illnesses is based on

identification of disorders as discrete and essentially non-overlapping

distinctions (Kaplan et al., 1994). These distinctions are based on consensus

in much the same way as the criteria for the functional bowel disorders are

agreed upon. However, this has not meant that debate and differences in

approaches have not been expressed. One such approach is that of the

dimensional or continuum approach to psychopathology. In this approach it

is assumed that the typical behaviour of persons is the product of differing

strengths or intensities of behaviour along several definable dimensions

(Carson et al., 1988). What this implies is that when stress is sufficiently

prolonged and severe, nearly everyone will show psychiatric symptoms

(Dohrenwend, 1975). Clouse and Alpers (1986) found that nearly all

psychiatric illnesses are associated with heightened emotional distress and

that possibly some common phenomenon overlaps the psychiatric syndromes

and is related to the somatic syndrome of IBS. Enck and Wienbeck (1993) in

their review of IBS and psychological factors, found that stressors do not by

themselves provoke symptom onset unless they provoke an anxiety state or

other psychiatric episodes in these patients.

Whilst the specific interactions and mechanisms for linking stress, IBS and

psychiatric syndromes have not been carefully elucidated, if Lazarus’ (1993)

model of associating negative emotions and stress is accepted, then there are

certainly grounds for including an evaluation of psychiatric co-morbidity in the

etiological analysis of stress and IBS. Many patients with IBS have

identifiable psychiatric illnesses and also describe antecedent stressful

experiences at its onset.

The three main psychiatric diagnoses found in the IBS literature are for

depression, panic disorder and generalized anxiety disorder, followed by

research on somatization. A frequent association exists between IBS and

the incidence of anxiety and depression. Depression occurred in 72% of

patients with IBS when they were compared to patients with other forms of

Page 86: Orientation and Motivation

chronic bowel disease, in whom it occurred only 18% (Alpers, 1983; Young,

Alpers, Norland & Woodruff, 1976).

Els et al. (1995) analyzed the findings of several studies conducted over the

past twenty-five years which investigated lifetime prevalence of psychiatric

disorders and apparent co-morbidity with IBS. Among these studies were six

compared by Walker, Katon and Katon (1990); two by Lydiard, Laraia, Howell

and Ballenger (1986); Lydiard, Fossey and Ballenger (1991) and their own

study, Els et al. (1995). In all of these studies, people with IBS had sought

treatment for their IBS and all had a co-morbid Axis I - DSM diagnosis which

was found in a range from 70% to 100% of the cases with the exception of

Ford et al. (1987) where the percentage was only 54%. This finding was

confirmed by Wilson (1997) where 98% of the IBS (all female) group,

assessed on the Personality Assessment Inventory (PAI), which measures

psychopathological personality tendencies, were found to have

psychopathological personality trends and symptoms of depression and

anxiety.

Lydiard et al. (1986); Lydiard et al. (1991) confirmed the overlap between

panic disorder and IBS. Whilst not all had received a diagnosis of IBS, the

majority of the sixty eight subjects in their 1991 study had been treated for

gastrointestinal symptoms. Noyes and Cook (1990) maintained that the link

between IBS and panic disorder was not an unexpected one given the

number of symptoms shared by the two conditions. It was also stated that

neither IBS nor panic disorder were able to be objectively diagnosed at the

time of the study but that nevertheless, once again it was found that by

treating with benzodiazepine and tricyclic anti-depressants, this helped with

the symptoms of the panic disorder and many of the IBS-like symptoms

consequently cleared up too (Wilson, 1997).

Talley (1991) reviewed the literature which claims that hospital outpatients

with functional gastrointestinal disease have increased levels of neurosis and

Page 87: Orientation and Motivation

anxiety compared with controls. The reason suggested for this is that

psychologically distressed patients with bowel symptoms select themselves

for inclusion by presenting to physicians whereas others with similar

symptoms do not visit physicians. The question was also asked whether

somatoform disorder, a psychiatric disease manifest by abnormal concern

with bodily functions and associated with multisystem complaints, can be

confused with functional gastrointestinal disease. The research was to

determine whether patients with functional gastrointestinal disorders are

simply a subset of patients with somatization. They concluded that whilst

patients with functional gastrointestinal disease have an excessive tendency

to complain of bodily sensations, this is similar to patients who have organic

disease and this suggests that illness behaviour is a pattern associated with

illness regardless of whether it be functional or organic . But those who

suffered from somatoform disorder reported multisystem complaints which

was not characteristic of the functional gastrointestinal group.

The interesting question raised by Els et al. (1995); Camilleri and Ford (1994)

and Farthing (1995) amongst others in regard to the variety of interacting

factors implicated, is which comes first: do psychiatric symptoms develop as

a consequence of coping with the stressfulness of chronic gastrointestinal

conditions or is IBS a somatic and physical expression of psychiatric illness?

Devroede (1994) asks the question that when these two theories collide, could

it be that they both reflect a deeper problem? This is precisely the type of

question asked by an ecosystemic paradigm which seeks to ask deeper

questions as to what underlies and connects the mind and body. It might be

better to ask when and how all the interacting factors occur together? Whilst

some consensus appears to suggest that in the majority of cases the

psychiatric illness precedes the onset of gastrointestinal symptoms (Walker et

al., 1990; Whitehead et al., 1988), it may be that stress at times precipitates

and at other times mediates psychiatric disorder along with some of the other

interactive factors such as attitudes to illness, heightened perception or

autonomic involvement.

Page 88: Orientation and Motivation

3.2.2.8 Personality, stress and IBS

Although the search for a distinct personality type in IBS has and continues to

be propagated, summary of the research conducted to date has been unable

to isolate a distinct personality profile for IBS patients. In fact, historically, the

attempt to directly link specific personality traits or constellations of traits or

qualities to specific psychosomatic disorders has been shown to be too

simplistic (Keltikangas -Jarvinen, 1989) leading to a decline in this kind of

research.

In reviewing this research, West as early as 1970, attempted to distinguish a

specific personality profile for IBS patients from patients with conditions such

as ulcerative colitis, dermatological, gastrointestinal or muscular tension

disorders. IBS patients showed the greatest degree of ‘psychological

disturbance’. Esler and Goulson (1973) showed that IBS patients were

significantly higher on levels of introversion than were general medical

patients and controls. This finding was supported by Latimer (1981) and

Langeluddecke (1985). Latimer (1983) characterized IBS patients with a trait

of dependence. Greenberg and Bornstein (1988) concluded that dependent

persons are more likely to view their problems in psychosomatic terms and

seek professional help for physical symptoms. Esler and Goulson (1973)

also found that a diarrhea predominant group of IBS patients was more

anxious and neurotic than those who had predominantly abdominal pain and

who did not differ significantly from the control group in terms of their

personality profiles. Hill and Blendis (1967) and Langeluddecke (1985)

described IBS patients to be dependent, sensitive, guilty, unassertive and

overly conscientious. Latimer (1983) concluded that whilst these obsessive -

compulsive features, including conformity, rigid moral standards, obstinacy,

punctuality and orderliness have been revealed amongst IBS patients, these

findings have yet to be replicated.

Page 89: Orientation and Motivation

Suls and Rittenhouse (1990) proposed three models for examining personality

and illness, which emphasize the biopsychosocial perspective. In their view

there are three major routes by which a personality disposition may be

associated with increased illness risk. Their first model proposes that certain

persons by virtue of particular traits respond either on an acute or chronic

basis with exaggerated physiological reactivity to stressors which produce

elevated sympathetic and neuroendocrine responses. Two interpretations of

this model are, firstly that personality induces hyperreactivity to acute

stressors, or secondly, that certain dispositions create chronically high levels

of physiological arousal even when the stressor is low in effect. The second

model explains that personality dispositions associated with illness risk may

be the markers of some inborn constitutional predisposition to some inborn

physical weakness or abnormality that increases illness susceptibility. The

third model looks at personality traits as the basis for ‘dangerous behaviours’

and assumes that certain personality types create stressful lives, or riskier

behaviour patterns, leading to the assumption that personality and life stress

events are interactive. In other words, certain types of people make certain

kinds of events more likely to happen (Swann, 1983).

It has often been stated that personality hardiness has a buffering effect on

stressfulness. Certain stressful factors contribute through the mediation of

personality to IBS leading to the promulgation of the notion of a ‘distress-

prone’ personality. Stone and Costa (1990), and Friedman and Booth -Kewley

(1987) provided evidence that link negative affect to nervous system arousal

combined with introversion and associate these factors with a variety of

physical illnesses. They hypothesize that it is possible to speak of a ‘distress -

prone’ personality. From the evidence above it may be worth considering this

style of personality as mediating the relationship between stress and IBS.

Stanley (2000) appears to reiterate this in her study of IBS and personality

when she makes an explicit reference to the biopsychosocial dimensions

inherent in the relationship between IBS and personality. She drew her

Page 90: Orientation and Motivation

conclusions from her own research and that done by the wider RAU project

using a sample of white middle-class women. Stanley (2000) concluded that

the IBS sufferer probably has a constitutional vulnerability that predisposes

her to gastrointestinal dysfunction. Temperamentally, she experiences more

emotional distress and negative emotions such as fear, anxiety, anger,

hostility and sadness; and is also more prone to the irrational and disturbed

thoughts and behaviours that accompany this distress. Her higher levels of

reactivity, including greater resistance to change, suggest higher emotional

rigidity resulting in extreme suppression or expression of emotion that have

substantial repercussions in both her psychological and social domains of

functioning. Her tendency to focus exclusively on her bodily functions and

symptoms at the expense of her psychological needs means that she is more

likely to somatize her emotional distress and hence to be more prone to

psychosomatic or functional conditions like IBS. She is predisposed to

perceive and to respond to life stress in a way that involves more loss and

chronic difficulties. Researchers link this more to how she ‘perceives’ stress

and the meaning she attaches to it, together with utilization of unhealthy

defense mechanisms and conflict-avoidant coping styles or passive reactions,

wherein she tends to blame herself (Mayer, 1997), rather than to the stressors

themselves. In terms of the social dimension of functioning, she usually has a

more restricted social support network. Stanley (2000) concludes that IBS is

one of the many ways in which personality manifests through the body-mind

and reflects the interaction between the physical, psychological and social

domains of functioning.

3.2.2.9 Social resources

Resources to counteract or ‘buffer’ stress, are not only internal as previously

described in this chapter, but also come from the external social environment.

More recent ‘stress’ theories view human beings as embedded within

networks of relationships and bonded to deeply significant persons in the

social environment (Bowlby, 1969; Weiner, 1992). Louw (1991) claims that

Page 91: Orientation and Motivation

disruptions in attachments or relationships in adulthood can result in

psychosomatic disturbances. Low levels of social resources have been

associated with psychological distress, psychosomatic complaints,

physiological indices and stress (Billings & Moos, 1981). The stress theory of

the past did not predict that human relationships are crucial to the

maintenance or the restoration of health, or that social isolation increases

morbidity and mortality (House, Landis & Umberson, 1988). However the

links are not as straightforward nor as linear as this, as at times the degree to

which an individual is connected to others may have positive as well as

negative effects. Two resources which will be discussed are social support

and recreation.

3.2.2.9.1 Social support

Objective measures of social support studied include the number of

individuals in the social network, degree of social integration and social

isolation; and subjective measures are; ‘perceived’ support from others,

including the type and degree of support (Adler & Matthews, 1994).

Lazarus and Folkman (1984) make a distinction between the number of types

of relationships a person has, which are referred to as social networks, and

the ‘perception of the value of social interactions’ as social support. Social

network measures make the assumption that having a relationship is

equivalent to getting support from it. No attention is paid to the social

demands and hence the stressful aspect of the relationship. Such studies

support the idea that having a large social network is valuable in protecting

health. In contrast social support refers to the nature of the interactions

occurring in social relationships and how these are evaluated by the person

as to their supportiveness and is therefore more of an interpersonal variable.

Schaefer, Coyne and Lazarus (1982) distinguished three types of functions of

social support. These are: emotional support (including attachment,

reassurance, being able to rely on and confide in another person); tangible

support (involving practical and direct aid); and informational support

Page 92: Orientation and Motivation

(providing information or advice and giving feedback about how a person is

doing).

One of the ways that social support may protect people from the potentially

harmful effects of exposure to stress is through its mediating effect of

appraisal and coping processes (Lazarus & Folkman, 1984), as previously

discussed. Billings and Moos (1981) consider that to comprehensively

evaluate a person’s responses to stressful events, it is necessary to

simultaneously consider both the available social resources as well as the

individual’s coping process and strategies.

In addition to appraisal and coping, Cohen’s (1988) stress -centred approach

to support includes various systems levels which may intervene between

stress and illness outcome, by reducing or eliminating the affective reaction,

by directly suppressing physiologic processes such as the neuroendocrine

and the immune response and by altering maladaptive behaviour responses.

He further proposes that study of the relations between social support and

physical illnesses are by nature interdisciplinary. Both medical assessment of

pathogenic processes and disorder are required, as well as that of the

psychologist who is uniquely qualified to provide insight into the mechanisms

through which social environments influence cognition, affect, behaviour and

physiological response. Psychology, he says, has the theory, data and

perspective necessary to propose plausible models that suggest when and

why social networks and/or perception of support influence health.

One study specifically measuring the links between stress and IBS (Bayne,

1997) found that a group of IBS subjects when interpreting the objective

measure of social support, did not utilize support as a means of buffering their

stress. IBS patients do not typically discuss their symptoms with others and

may feel isolated as a consequence (Dancey & Backhouse, 1993). However

when their subjective responses to the questionnaire are analyzed in terms of

the ‘perceptive’ view of social support, it would appear that they have some

Page 93: Orientation and Motivation

support but do not ‘perceive’ their social support as helpful to their condition

(Bayne, 1997).

3.2.2.9.2 Recreation Engaging in recreational activities is considered to be an effective mediator of

stress (Kaplan et al., 1993). Bayne (1997) found that a group of IBS sufferers

make less use of recreation than a control group without IBS. She

hypothesized that the physical symptoms of IBS may have more debilitating

effects which make them reluctant to move beyond their home environment to

unfamiliar places where they may have to get to a bathroom quickly (Dancey

& Backhouse, 1993).

3.3 Summary and conclusion

The psychosocial role of stress and IBS has not been researched as

thoroughly as the physiological, and when researched, it has been conducted

by the medical profession who do not have the necessary theory and insight

into the psychological processes being elucidated (Cohen, 1988; Devroede,

1994; Scarinci et al., 1994; Van Dulmen et al., 1994). This gives a more

specific place to psychologists as scientist-practitioners to contribute to both

theory and etiology in this complex subject.

Research has been virtually unanimous in characterizing IBS patients as

psychologically distressed (Schwarz et al., 1993). Some researchers continue

to search for the biological mechanisms and pathways in IBS (Lind, 1992);

others are convinced of the psychosomatic nature of the disorder where

physical symptoms are a manifestation of psychological mechanisms (Talley,

Phillips, Bruce, Twomey, Zinsmeister & Melton, 1990). Yet others have

argued, and perhaps more voices are being added to this argument, that it is

impossible to distinguish between physical and psychosocial factors as both

Page 94: Orientation and Motivation

are usually interactive throughout the process of this disorder (Latimer, 1981;

Weiner, 1992), as is proposed by this thesis.

Therefore, if the IBS/stress relationship is truly biopsychosocial as proposed

by the general systems theory and ecological paradigm, when searching for

solutions in how to alleviate the pain and suffering experienced by persons

with IBS, the treatment strategies adopted will of necessity turn towards

holistic options. In the next chapter a review of the literature on treatments as

well as the proposal of a holistic stress management therapy programme will

be elucidated so that the tenets of whole-person care can be both respected

and embraced.