IBS: How can diarrhoea and constipation coexist in the same illness
Heraclitus of Ephesus
This is one of the biggest mysteries of IBS. Alternating diarrhoea and constipation is a well known subset of IBS, but it is not always balanced. Many people with diarrhoea predominant IBS can have constipation on occasions. Equally constipation predominant IBS can be punctuated with episodes of diarrhoea that are not necessarily provoked by laxatives. So how can the same condition change its character so dramatically from day to day or even within the same day?
Bowel habit is not the only thing. Other physiological functions may change too. For example, eating behaviour may switch from restricted eating, which may coexist with constipation and binge eating, that may be associated with diarrhoea. There may also be differences in mood. Diarrhoea is frequently associated with anxiety and irritation; constipation with depression and inertia. And social behaviour; gregariousness can alternate with isolation. Such fluctuations represent different states of being.
Neural Control
The brain is a master computer of incredible complexity, controlling our thoughts, behaviour and bodily function. So when our bowels, our sleep, our moods and eating behaviour play up for no obvious reason, it is more than likely that our central nervous computer has been reset by some change in our environment or some thought or memory.
As far as the bowels are concerned, the autonomic nervous system is a key mediator. For example the parasympathetic nervous system facilitates colonic peristalsis, colonic secretion and defaecation while the sympathetic nervous system inhibits colonic motility and increases anal sphincter tone. The relative tone in these two systems can change from moment to moment. Look at how unexpected changes cause our pulse to race, our respiration to deepen and our skin to change colour and perspire. Long term measurements of intestinal motility also show constant fluctuations.
Our brain is programmed by what happens to us. Our emotional and bodily responses are conditioned by an amalgam of influences from the time we were born and probably before. Our parents and caregivers, schoolteachers, friends, tutors, sexual partners, children all programme our operating systems, helping to make us the people we are.
The Effect of Trauma
Trauma may wipe our autobiographical memory system, causing us to reconfigure it to compensate for the damage. This might result in a system that is so sensitive it exhibits extreme oscillations.
Tanya’s alternating diarrhoea and constipation fluctuated on a weekly basis. This was her story: ‘I am a good time girl. I like to go out and party, drink and eat too much and enjoy casual sexual encounters. That’s when I get diarrhoea. After a few days of riotous living, I get fed up with myself and resolve to get back in control. So I stay in, work, watch television, eat sensibly, get some sleep and become constipated. But it’s no life and so a few days later, I arrange to go out and the cycle starts again’. I asked her about her parents. ‘My father is a hedonist; he loves life. It’s my mother who keeps everything in control.’ So Tanya had a conflict of identity; she oscillated between chaos and control and her bowels followed suit.
Gemma was different. For most of the time and with considerable hard work, she kept herself under control and was mildly constipated, but when change threatened her sense of who she was, she would experience a surge of emotion and develop diarrhoea.
Heraclitus and The Unity of Opposites
Two and a half thousand years ago, the pre-Socratic philosopher, Heraclitus of Ephesus, coined the term ‘the unity of opposites’ to describe how things constantly shift and can exist in two seemingly opposing forms that may be thought of as control and chaos. We cannot enjoy happiness unless we have experienced sadness, love is always accompanied by the risk of loss and on a less sublime level, the dialectic of diarrhoea and constipation. It is not just that things are actually changing, it could be that our perception of them alternates depending on our shifting perspective. Decisions can be good or bad depending on how we view them. Brexit comes to mind. Diets or treatments make us better or worse depending on the conditions. It’s all relative.
To remain well and content, we need to be flexible enough to adjust to a changing environment. Fixed rituals of exercise, diet, treatment don’t always work. Adhering rigidly to the same safe option may only cause conflict between what we may want to do and we feel we ought to do. Sensitive people are never quite sure and worry about it. Illness can imply a lack of physiological regulation that stems from the lack of flexibility and a resistance to change. Heraclitus distrusted dogma and laws (logos); they attempted to fix things and led to a rigidity of thought. He rated knowing that comes from intuition and what we might now call mindfulness. He was a free thinker and didn’t have much regard for his fellow human beings and their institutions. ‘Men fail to notice what they do while they are awake and they forget while they are asleep.’ Wisdom comes from having time to reflect on the way things are.
From ancient Greece to the present day, there is nothing new under the sun as regards human nature, only a different perspective.
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