Bowel trouble could be all in the mind: Singapore experts

A 66-year-old housewife suffers from irritable bowel syndrome (IBS) as well as anxiety and a few other psychological issues.

With the help of a gastroenterologist and psychologist, the woman, who wanted to be known only as Madam Theresa, traced the cause of her psychological issues to when she suffered abuse as a child at a boarding school in another country.

She had not expected to discover that her bowel condition was probably caused by her psychological issues.

She had been suffering from IBS for years before a doctor suggested that a psychologist might be able to help.

Her physical symptoms include an intense pain between her ribs, bloatedness and gas. As a result, she eats very little.

She also suffers from low moods which have affected her relationship with her husband.

Recently, over the past year or so, she has been seeing a psychologist at National University Hospital (NUH) for her psychological symptoms.

Increasingly, doctors are associating psychological disorders with people who have IBS.

To detect mental issues early, doctors at Singapore General Hospital (SGH) have started to screen IBS patients for psychological disorders, while at NUH, a gastroenterologist and a psychologist both see IBS patients together.

IBS is one of the most common conditions that patients seek help for at NUH and SGH specialist clinics for gastrointestinal disorders.

A local study published about 10 years ago estimates the population prevalence at about 8 to 10 per cent, said Dr Reuben Wong, a consultant at the department of gastroenterology and hepatology at NUH.

Doctors are now working on making IBS a notifiable condition and having a registry on it, he said.

Madam Theresa's case is not atypical, he said.

The early studies published by his mentor, Dr Douglas Drossman, from the University of North Carolina at Chapel Hill School of Medicine in the United States, describe a history of childhood abuse and issues in IBS patients.

"No one believed him years ago when he first presented his results, but it is now well established that there is a significantly higher history of abuse, neglect and trauma in IBS patients compared with healthy individuals," said Dr Wong.

After studies overseas proved that there is a link between IBS and psychological disorders, Singapore has done its own study.

Doctors at SGH found that almost half of 345 IBS patients screened from November 2010 to October 2011 also had psychological disorders.

In comparison, the 2010 Singapore Mental Health Study found that 12 per cent of people here will be stricken by mental illness in their lifetime.

The IBS patients found to have psychological disorders in the SGH study were then offered psychological consultations.

However, only half of them opted for them.

Of these, half recovered from their psychological disorders and their quality of life improved.

This shows the importance of psychological intervention in the management of IBS patients with psychological disorders, said Dr Wang Yu Tien, a consultant at the department of gastroenterology and hepatology at SGH. He is the principal investigator of the study, which was submitted for SGH's Annual Scientific Meeting this month.

Commonly affects younger adults

Although IBS is not life-threatening, it can negatively impact a patient's lifestyle and quality of life as well as that of his partner's.

Unlike diabetes or hypertension, it is not a disease which becomes more common with age. Instead, it commonly affects younger adults in the prime of their life - the most productive members in society - Dr Wong added.

There is also much overlap between IBS and other functional gastrointestinal disorders, so the diagnosis is not always clear cut.

The other challenge now, as the SGH study shows, is to get more IBS patients who have psychological issues to seek psychological help.

Much of the resistance such patients put up against seeking help is the perceived stigma of having a psychological or psychiatric disorder.

Dr Victor Kwok, an associate consultant at the department of psychiatry at SGH, said some IBS patients tell doctors that they are "not mad" when psychological help is suggested.

"People still think it is a weakness, character failing or within a person's control. But it is a medical condition just like diabetes or high blood pressure," he said.

Many patients also do not accept that their bowel symptoms have anything to do with their brain, said Dr Wang.

"They tell us it's two completely different things, two different organs. This stems from a lack of knowledge," he said.

But researchers are finding evidence that dysfunction along pathways running between the brain and the intestines may be contributing to the symptoms of IBS, which include abdominal pain, constipation and diarrhoea.

Nerves in the intestines that are experiencing excessive sensitivity can trigger changes in the brain.

Thoughts, feelings and activation of parts of the brain that have to do with anxiety or arousal can stimulate exaggerated responses from the gut.

What is not known is which comes first, said Dr Wang.

"It could be that the gut is not feeling well, then the brain feels depressed. Or the person is depressed, which then affects the gut," he said.

The more common psychiatric conditions that DrKwok has diagnosed in IBS patients are depression, dysthymia (low mood that has persisted for at least two years), generalised anxiety disorder, panic disorders and somatisation disorders in which the patient experiences multiple physical symptoms that are not explained by disease and primary insomnia.

Patients with psychological problems can develop counter-productive or unsuitable behaviour to do with eating or passing motion which may make the IBS worse, said Dr Kwok.

Others may tend to seek medical help more often, which can also worsen their condition.

"The more anxious patients may ask for more tests and need a lot more reassurance from doctors. This can aggravate the IBS and reduce their quality of life, said Dr Kwok.

Once it is established that the patient has psychological symptoms, he should get psychological help.

The belief is that reduction of psychological symptoms leads to the reduction of bowel symptoms.

Such treatment for IBS has good scientific evidence and is endorsed by many institutes including the American College of Gastroenterology, said Dr Kwok.

Psycological screening

Since 2009, SGH has started an early intervention programme for anxiety and depression among IBS patients.

Since then, all IBS patients have the option of getting a free screening to detect depression and anxiety that might otherwise have gone undetected and untreated.

The psychological screening is done by an IBS coordinator, who goes through a few questionnaires with each IBS patient.

If a patient is suspected of having anxiety disorders or depression, he is given the option of seeing a psychiatrist or psychologist, and attending a support group for IBS patients, said Dr Kwok.

The support group, which holds meetings once every month at SGH, helps especially those who are afraid of the stigma of seeing a psychiatrist, he said.

Underscoring the importance of psychological help for patients, psychiatrists and psychologists at SGH will soon be working in much closer proximity to the gastroenterologists, in the same clinic.

An integrated multi-disciplinary IBS clinic will be run from next month, said Dr Wang.

This is already being done at NUH.

In the Gastrointestinal-Psychology Collaborative Service, started in 2009, a psychologist sits in a clinic next to the gastroenterologist in case any IBS patient with psychological disorders wants a consultation.

Dr Wong started this together with the department of psychiatry at NUH, in a collaboration with psychologists from James-Cook University Singapore.

At the time, he had just returned from his fellowship at the University of North Carolina Centre for Functional GI Disorders & Motility Disorders.

There, he found that there were dedicated psychologists who were on-site at the clinic, seeing the patients together with the doctors.

"This team-based approach allowed patients to be treated holistically by a gastroenterologist and psychologist working together," he said.

Holistic treatment approach

With psychiatrists and psychologists on board, doctors are also trying to change the way IBS is treated.

Medication is only part of the solution, and in the case of a functional gastrointestinal disorder such as IBS, holistic treatment means addressing all aspects of the disorder, including from the psychological perspective, said Dr Wong.

Psychological interventions that have been used on IBS patients and proven to work through research studies include cognitive behaviour therapy - which helps patients explore how their thinking and emotions are linked - hypnotherapy and a few other modalities, he said.

Stress management, assertiveness training and relaxation exercises, such as progressive muscle relaxation, can also help, said Dr Kwok.

He added that medication, including selective serotonin reuptake inhibitors such as prozac, can help by modifying gut movements and pain sensations, besides reducing anxiety and improving mood.

But not all hospitals have brought the psychologist or psychiatrist on board to see IBS patients.

At Tan Tock Seng Hospital, for example, doctors find that most of their patients respond well to lifestyle modifications and medication.

Dr Robert Lo, a consultant at the department of gastroenterology and hepatology at TTSH, said that once diagnosis of IBS is confirmed, doctors will explain and reassure patients that it is not a life-threatening condition, does not cause damage to the bowel and does not cause cancer.

"Knowledge and awareness are important as they help IBS sufferers to be less anxious, which may help their symptoms," he said.

Dietary advice will be given. Eating a healthy diet with enough fluid and fibre can reduce IBS symptoms. For some people, certain food items, such as alcohol, caffeine, milk products, wheat, citrus fruit and onions, can trigger symptoms.

"IBS sufferers may find it helpful to keep a food diary to identify their food triggers," Dr Lo said.

Exercise is recommended as it can alleviate IBS symptoms. Although the precise cause is not clear, it is thought that exercise relieves stress, which, in turn, reduces IBS symptoms, Dr Lo added.

Only the few who remain symptomatic despite treatment are referred to TTSH psychiatrists.

"We do not see IBS patients routinely with the psychiatrist or psychologist," Dr Lo said.

For Madam Theresa, after she started seeing the psychologist, her physical and mental health has improved.

"I didn't think at first that going for psychological counselling and talking to a psychologist would help me. I also didn't want people to think I was mad. But I am glad t hat I did because psychotherapy has lessened my IBS pain," she said.

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