A Very Complex Illness
There was a time when physicians used to group all illnesses that did not have definitive structural features or an obvious physical cause under the same all –embracing title. For 2000 years, this was hysteria, but there were other terms such as melancholia, the spleen, the vapours, hypochondriasis, irritable weakness and neurasthenia.
‘The frequency of hysteria is no less remarkable for the multiformity of shapes that it puts on: violent headaches, occasionally followed by vomiting, violent coughing or spasms of the colon, continuous diarrhoea, pain in the jaws, shoulders, hands, legs and particularly the back and polyuria (frequent passage of urine)…..’ Thomas Sydenham, 1668.
The current model of medical practice came in with the discovery of germs little over a hundred years ago. Diseases that once had to run their course could be cured! It was just a matter of taking a careful history, conducting a clinical examination, confirming your suspicion with tests and applying a specific treatment. Within little more than a generation, it appeared that for every ailment, there was a cause and a treatment; a linear model of cause, effect and cure. Advances in medical science allowed more and more diseases to be understood, diagnosed and treated. What was once a single medical textbook now fills a library, but the model has hardly changed. Despite the miracles of medical science, about 50% of doctors’ appointments are for illnesses that have no obvious cause nor any specific treatment – and they all tend to overlap with each other. Among these is the ailment we call The Irritable Bowel Syndrome (IBS).
But IBS cannot be conveniently understood by a linear model. There are so many possible causes: infection, trauma, stress, diet, depletion of colonic bacteria (microbiome), immunological activation, bile acid malabsorption, dysmotility, alternations in the brain gut axis, visceral sensitivity, though all are interconnected and may be more accurately viewed as different perspectives. And there is a multiplicity of treatments, all of which at least some people find efficacious.
Despite extensive research over many years, it now seems unlikely that clinical scientists are ever likely to find the definitive cause of IBS; they can’t even agree as to what it is. This has led a few to consider IBS as a re-setting of a state of brain gut sensitivity or reactivity, a disorder of regulation, a common destination of a number of possible routes.
It seems that a combination of factors may bring about IBS in any individual patient and there may be many successful treatments. It all depends on the nature and life experience of the patient. IBS is a very individual illness and often requires a very individual treatment. This idea resonates with Thomas Sydenham’s (1668) notion of a combination of overordinate actions of the body and over-ordinate commotions of the mind or Ian Deary’s concept of a state of dysphoria affecting mind and body.
Last year, Professor Michael Hyland from Plymouth used an analogy from control engineering to propose that IBS is like a machine with its gain set too high, causing increased intestinal sensitivity and an oscillation (hunting) between diarrhoea and constipation. This is an interesting inasmuch as overlapping conditions can also oscillate or ’hunt’ in synchrony with IBS (viz: anorexia and binge eating/bulimia; fibromyalgia and lethargy (ME/CFS); agitation and depression) and reducing gut sensitivity with alosetron or ondansetron is as near as we get to any effective drug treatment for all the symptoms of IBS, while psychological treatments also reduce sensitivity and are very effective.
Professor Hyland and his research student Sarah Bruckgraber, are seeking volunteers to fill in an on line questionnaire to investigate the links between IBS and ME/CFS. Click on the following link. https://www.psy.plymouth.ac.uk/onlineresearch/FunctionalDisorders/default.aspx?Code=xhd9G146mL
Deary I, 2001. A taxonomy of medically unexplained symptoms.J.Psychosomatic Research 47, 51-59.
Hyland, M, 2011. The Origins of Health and Disease. Cambridge University Press
Manolakis AC, Kapsoritakis AN, Tiaka EK, Tsiompanidis I, Potamianos SP. Irritable bowel syndrome: has the psychosomatic “affliction” grown into an inflammatory disorder? In:Kiyomizu G, Rin H, eds. Constipation and irritable bowel syndrome: causes, treatments and prevention. New York: Nova Science; 2012:85-108.
Read, NW 2015 (in press) Recent Advances in IBS. Chapter 3. Recent Advances in Gastroenterology
Sydenham, T (1668) Observationes medicae.
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