26-01-23 – Psychosomatics - the example of Irritable Bowel Syndrome

Question 1

Learning outcomes

Answer 1

• Define the term psychosomatic disorder
• Describe the symptoms of irritable bowel syndrome
• Contrast differing treatments for patients suffering from irritable bowel syndrome

Question 2

What is the definition of Psychosomatics?

What is it a challenge to?

How does it link psychological and physiological wellbeing?

Answer 2

• Definition of Psychosomatics:
• ‘Psychosomatic disorders are disorders where emotional or psychological factors can impact on the symptoms’
• It is a challenge to the biomedical model of illness
• A person’s psychological state could impact on their physical state
• Psychosomatic = psycho-physiological

Question 3

What are 5 examples of psychosomatic disorders?

How common is each type?

Answer 3

• 5 examples of psychosomatic disorders:

1) Asthma
* 1 in 13 adults are being treated for asthma

2) Atopic dermatitis
* 2-10% of adults suffer from atopic dermatitis

3) Tension-type headaches
* 3% of people have a tension-type headache on most days

4) Chronic Fatigue Syndrome (CFS) - called by some pts & HCPs ‘Myalgic Encephalomyelitis’ (ME)
* CFS is thought to affect around 0.2 - 0.5% of the population

5) Irritable Bowel Syndrome (IBS)
* IBS is the most common functional gastrointestinal disorder encountered in primary & secondary care

Question 4

What are Functional GI Disorders (FGIDs)?

What is the Rome IV criteria used for?

Answer 4

• Functional GI Disorders (FGIDs):
• ‘Functional GI disorders are disorders of gut–brain interaction.
• It is a group of disorders classified by GI symptoms related to any combination of the following:
  1) Motility disturbance
  2) Visceral hypersensitivity
  3) Altered mucosal and immune function
  4) Altered gut microbiota
  5) Altered central nervous system (CNS) processing’
• Rome IV criteria is criteria used for categorising GI disorders

Question 5

What is Irritable bowel syndrome (IBS)?

How can symptoms vary over time?

How long does IBS last for?

What is a cure to IBS? What is the cause of IBS?

Answer 5

• Irritable bowel syndrome (IBS) is a common condition that affects the digestive system
• Symptoms tend to come and go over time, can last for days, weeks or months at a time
• Usually a lifelong problem - can be frustrating to live with, can impact significantly on everyday life
• No cure - but diet changes & medicines can often help control the symptoms
• Exact cause is unknown - linked to things like food passing through your gut too quickly/ too slowly, oversensitive nerves in your gut, stress, a family history of IBS

Question 6

What are 4 symptoms/signs of IBS?

What 7 symptoms can IBS also cause?

How many symptoms do people normally have?

How can they vary over time?

Answer 6

• 4 symptoms/signs of IBS:
  1) Abdominal pain/ cramps
  2) Bloating
  3) Diarrhoea
  4) Constipation
• 7 symptoms IBS can also cause:
  1) Flatulence (excessive wind)
  2) Passing of mucus
  3) Tiredness, a lack of energy
  4) Feeling sick (nausea)
  5) Backache
  6) Problems passing urine
  7) Bowel incontinence
• Normally there are 2 or more symptoms
• Symptoms tend to come and go over time, can last for days, weeks or months at a time

Question 7

What groups does IBS commonly affect?

Around what % of the population is affected by IBS?

What 4 symptoms can the main symptom of IBS vary between?

How does IBS affect QOL?

Answer 7

• IBS presents most often in 20–30-year-olds, and is more common in women than men (twice as likely to affect women than men
• Around 11% of the population is affected by IBS
• 4 symptoms can the main symptom of IBS vary between:
  1) Abdominal pain
  2) Diarrhoea
  3) Constipation
  4) Diarrhoea alternating with constipation
• IBS Is a major healthcare problem and significant impact on QoL

Question 8

What is the Rome IV criteria used for?

Describe the Rome IV criteria?

What additions were made to the criteria in the UK?

Why are doctors encouraged to diagnose IBS using this criteria?

Answer 8

• Rome IV criteria is criteria used for categorising GI disorders
• Rome IV Criteria:
• That in the last 3 months, with symptom onset at least 6 months prior to diagnosis the individual experiences recurrent abdominal pain at least 1 day/week in the last 3 months associated with two or more of the following:

1) Related to defecation

2) Associated with a change in frequency of stool

3) Associated with a change in form (appearance) of stool

• In the UK:
• • 2 of the following:

1) A change in how you pass stools (urgency, not emptied bowels)

2) Bloating, hardness or tension in abdomen

3) Symptoms worse after eating

4) Passing mucus from rectum

• Doctors are encouraged to diagnose IBS using this criteria as it avoids the need for tests

Question 9

What is diagnosis of IBS often based on?

In what 4 situations can tests be run for diagnosis?

Why do some patients find the diagnosis of IBS difficult?

Answer 9

• Diagnosis of IBS is often based on symptoms alone
• 4 Situations tests can be run for diagnosis:

1) Blood tests to rule out other conditions (Coeliac)

2) Stool sample to rule out other conditions (Calprotectin – marker present in inflammatory bowel disease (IBD))

3) When there is unexplained weight loss

4) When there is a history of bowel cancer

• Some patients find it difficult to cope with a diagnosis of IBS as there is no cure

Question 10

What are 4 major impacts of IBS on a patient’s life?

Answer 10

• 4 major impacts of IBS on a patient’s life:

1) Work?
* Patients often have to take time off work at some point due to their symptoms
* Some patients cant work at all

2) Visits to health professionals
* Patients with IBS have to visit more often

3) Health Related Quality of Life (HRQoL)

4) Psychological health
* Patients with IBS more likely to suffer from anxiety and depression

Question 11

What are 3 different types of potential causes of IBS?

Answer 11

• 3 different types of potential causes of IBS:
  1) Biological
  2) Psychological
  3) Social
• Likely to be an interaction of these potential causes which results in a patients experience of IBS
• These causes are putative as they generally believed to exist or be something specified, but not definitely the case

Question 12

What are 4 biological causes of IBS?

Answer 12

• 4 biological causes of IBS:

1) Abnormal muscle contraction
* With little stimulation, and usually lasting longer

2) Serotonin receptors
* Serotonin is thought to be involved in modulation of contraction of the smooth muscle wall
* Sign patients have exaggeration of serotonin after food

3) Infection

4) Food intolerance

Question 13

Psychological causes of IBS.

What % of patients dealing with psychiatric disorders attend FGID clinics?

What are 2 common psychiatric disorders that can cause IBS?

What is an example of a social factor that can lead to a psychological cause of IBS?

Answer 13

• Psychological causes of IBS
• Psychological disorders e.g. depression and anxiety – may be present before the IBS occurs
• 40-60% of patients attending FGID clinic have psychiatric disorders
• 2 common psychiatric disorders that can cause IBS:
• Hyper-reactivity in the brain-gut interface:

1) Hyper-sensitivity
* Patients are hypersensitive to rectal pain or gut stimuli

2) Hyper-vigilance
* Patients focus more attention on bodily stimulation
* Stressful life events is a social factor that can lead to a psychological cause of IBS (in picture)

Question 14

What are 2 social causes of IBS?

Answer 14

• 2 social causes of IBS:

1) Adverse Childhood Experiences (ACEs)
* Sexual, physical or emotional abuse

2) Social learning
* Impactful in interpreting and responding to symptoms e.g growing up with a parent that deals with the same condition

Question 15

9) Describe Common-sense model (CSM): Irritable bowel syndrome

Answer 15

• Leventhal’s common sense model (CSM) is used to understand people’s responses to illness.
• The model proposes that illness perceptions directly influence coping strategies, which in turn influence outcomes.
• Illness perceptions are lay interpretations of information and personal experiences the patient has acquired.
• They are posited to include 5 main cognitive domains: 1) identity (label and symptoms), 2) timeline, 3) consequences, 4) cause, and 5) perceived controllability or curability, plus 1 noncognitive domain: emotional perceptions
• The model posits parallel-processing of cognitions and emotions
• Research indicates youth do conceptualize disease dimensions similarly to adults, but these conceptualizations vary in sophistication and number

Question 16

When should we try management of IBS.

What are 4 parts of the management of IBS?

Answer 16

• We should try management of IBS before conducting loads of tests
• 4 parts of the management of IBS:

1) Diet / lifestyle (physical activity) changes approach

2) Drug treatments approach

3) Psychological approaches

4) Complementary therapies approach

Question 17

What are 2 parts of the management of IBS using diet / lifestyle (physical activity) changes approach?

Answer 17

• 2 parts of the management of IBS using diet / lifestyle (physical activity) changes approach:

1) Food diary
* Food intolerances e.g spicy foods, fruit, tea, coffee, fizzy drinks
* Dieticians can provide exclusion diets
* Healthy diet – might want to eat health, drink water, and have regular meal times
* Oats can be helpful for IBS patients

2) Assess activity levels
* Can improve gut motility

Question 18

What are first line drugs used for in IBS?

What are 3 drugs types used in the first line treatment of IBS?

What are second line drugs used for in IBS?

What are 2 examples of antidepressants used for IBS?

What is an example of second line laxative used to treat IBS?

Answer 18

• The first line drug treatment of IBS is used to treat symptoms
• 3 drug types used in the first line treatment of IBS:

1) Antidiarrheal (Loperamide)

2) Laxatives (not Lactulose)

3) Antispasmodics
* Can slow contraction of bowl to reduce diarrhoea and pain

• Second line drugs for IBS are antidepressants or laxatives
• 2 examples of antidepressants used for IBS:

1) Tricyclic antidepressants (TCAs) (if first line ineffective)

2) Selective serotonin reuptake inhibitors (SSRIs) (if TCAs ineffective)

• Laxatives used in second line treatment of IBS – Linaclotide, only if previous laxatives have not worked

Question 19

What are 3 examples of complementary therapies used in the treatment of IBS?

What are 2 examples of complementary theories not that are not recommended?

Answer 19

• 3 examples of complementary therapies used in the treatment of IBS:

1) Nutraceuticals
* E.g plant extracts such as peppermint oral capsules
* Though to relax smooth muscle in the gut

2) Chinese herbal medicine

3) Probiotics
* Live bacteria and yeasts

• 2 examples of complementary theories not that are not recommended:

1) Acupuncture

2) Reflexology
* The application of pressure to areas on the feet (or the hands).
* Reflexology is generally relaxing and may help alleviate stress

Question 20

When should psychological approaches to the management of IBS be used?

What are 3 examples of psychological approaches used in the treatment of IBS?

Answer 20

• Psychological approaches should only be used n the management of IBS if after 12 months other treatments are not effective
• 3 examples of psychological approaches used in the treatment of IBS:

1) Cognitive behavioural therapy
* Aims to change thoughts a patient has about their health, symptoms and health behaviours
* Challenges patients unhelpful cognitions and beliefs and changes them to more useful ones e.g waiting some time after feeling the need to go to the toilet
* Can show that perceptions were not correct, and can reduce symptoms and anxiety

2) Hypnotherapy
* Improves physical relaxation and perceptions

3) Psychological therapy
* Allows patient to discuss previous and current interpersonal differences and resolving them

Question 21

What effect does the doctor-patient relationship have on psychosomatic disorders?

Answer 21

• Doctor-patient relationship is very important in the treatment of psychosomatic disorders and is paramount to effective diagnosis and management
• IBS patients with good doctor-patient relationship make fewer return visits, are more satisfied with their visits and often have reduced symptoms

Question 22

How should we communicate with those with psychosomatic conditions?

What are 3 potential targets for IBS patients?

When should we listen to our patients?

Answer 22

• When talking to those with psychosomatic disorders, be need to be optimistic but realistic
• Ensure they understand that the goal is to manage symptoms and improve QOL, and that cure is very unlikely
• 3 potential targets for IBS patients:
  1) Reducing disability
  2) Improving coping
  3) Reducing dependence on health care
• We should listen to our patients not only to gather information, but to understand their cognitions, beliefs and health beliefs