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;

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
mans 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).
however

IBS

constitutes

Many do not seek medical attention,

25-50%

of

referrals

to

gastroenterologists

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

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 th at 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 clients illness that integrates the mind and body.

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 si 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

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 (OConnor & 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.

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 disord ers, 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

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

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 emergenc e of a more recent quantum, holistic scientific worldview can be
seen.

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

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 cons ciousness in our psyche or the patterns of relationship in our
social systems (Bateson, 1972; Capra, 1997; Keeney, 1983).

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 n

i 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

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

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 illhealth 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). Selyes (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

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 n
i 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.

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 tis 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

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 Ad aptation 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

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 Selyes (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
Cannons and Selyes 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 Cannons 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

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 goaloriented;

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.

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 multidimensional, 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 individuals 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

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,

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

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 organisms 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

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).

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 als. (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

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.
hormones are activated as well.

Other

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 morphinelike 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

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, glu cose,
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 patients 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

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
systems 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 te rm 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).

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, ones 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 individuals
life will result in a process of biological embedding wherein the individuals
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

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

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

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 Associations 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

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

necessity for discrete categorization in research and the practice of medicine

where practitioners feel that they need to do something to relieve their clients
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
worlds 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,

ODonnell, 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

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).
syndrome

is

probably

the

most

Furthermore, the irritable bowel

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

- 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)

- 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

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.
select

specific

narrowly

Research diagnostic criteria would

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

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 noncolonic 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,

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

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

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

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 ones susceptibility to IBS symptoms, or at least
ones 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

Demographic

Personality

Early Environment

Social Support
Coping
No IBS

Chronic
Patient

Early Life
Patient

IBS

Non
Patient
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 biops ychosocial 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.

Hypothalmic / Pituitary
Stress hormones

Background
Characteristics
of Individual

Perceived
Stress

Immune
System
Autonomic Nervous
System Activity

Mediators:
Supports
Selfconcept
Coping

Figure 2.2:

2.6.4

Health
Behaviours

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

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 persons functioning has been researched and given
attention by Benson (1996); Dossey (1993); Levin, Larson and Puchalski
(1997) amongst others.

Benson (1 996) 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.

Health

2.6.5

Network mode l

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.
peptides.

The gut or intestines are richly lined with gut

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.

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 mindbody 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.

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

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

Conceptual systems like those proposed in the models which were described
briefly in chapter tw o, 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

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 doctors 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

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:
predominant, diarrhea-predominant and pain-predominant.

constipation-

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

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 re sponds 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 stress ors 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

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 volunteers 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. (1 988) 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

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
systems modulation of the enteric nervous systems 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.

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.

What is of partic ular 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

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

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).

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 Thomps on (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 vis ceral

hyperalgesia reported so frequently by patients suffering from IBS.

Their

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 perio ds 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

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 record ed 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.
effect.

Stress interferes with this inhibitory

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

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 conc epts 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

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 persons 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.

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

persons 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.

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 individuals 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 individuals internal processes which
include: an intactness of cognitive functions such as orientation, capacity for
arousal, memory, concentration and affective stability.

Implicit in Kimballs

(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

ongoing research is being done in studying the bodys 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 ke eps 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, OKeane, OBoyle, 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

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

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);
effects

Weiner (1992) both indicate that life events will vary in

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.

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 persons 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 persons 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,
doesnt 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

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 escapeavoidance 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 ones 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.

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 depres sion.

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.

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

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

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 betw een psychological events, emotions, brain

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 evidenc e 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 ones own capabilities, Higgins, Vookles and Tykocinski (1992)

found s upport 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 dejectionrelated 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 sympto ms
which were found in the IBS symptom clusters. The first is the sympathoadrenomedullary system (SAM) essentially found in the defensive fight or

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 individuals

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

depressed as measured on the Becks 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

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 1800s 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
experience.

inner and outer

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.

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
Relationships

Physical and
Mental Illness
Survival
A
W
A
R
E
N
E
S
S

Repetition Compulsion
Weakened
Immune System

Projection and
other defenses

postponed processing & grieving

Stored
Painful Energy

Loss of Memory
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 n
i the

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 brains perception and sensation of

uncomfortable symptoms like those experienced in IBS.

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 persons 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

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/p elvic 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 c ommon 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 s uch

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

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 th ree 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

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

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 exp ression 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.

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.
disturbance.

IBS patients showed the greatest degree of psychological

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.

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 distressprone 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

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

disruptions in attachments or relationships in adulthood can result in

psychosomatic disturbances. Low levels of social resources have been
associated

with

psycholo gical

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

(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 persons responses to stressful events, it is necessary to

simultaneously consider both the available social resources as well as the
individuals coping process and strategies.
In addition to appraisal and coping, Cohens (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

support but do not perceive their social support as helpful to their condition
(Bayne, 1 997).
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 a nd 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

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.