IBS: Working with Complexity
I was taught medicine from the bottom up, First understand the components, anatomy, physiology, biochemistry, pathology and then put these together to understand the whole patient, but human life doesn’t work like that. It is a much more complex system of interconnections, there is no one single cause or effect, no one single treatment, no one single model. The Irritable Bowel, for example, is not a disease. It is a syndrome that incorporates a number of other complex systems: the microbiome, neural interconnectivity, gut physiology, genetics, the gut immune system and social interaction. A small perturbation in any of these may have a large effect on the expression or phenotype of the illness.
It would be more logical to see it all top down – how does my reaction to this situation work through these other systems to result in my unique illness? But in order to appreciate this we still have to understand the mechanics of the component systems: how they can adapt and evolve. These components and the microsystems, from which they are constituted, have a limited repertoire. Think of the functionality of an individual neurone, a bacterium or an immune cell, but put them together, connect them up and you have limitless reactions to change. And as far as illness is concerned, intervene with a specific treatment with all of its complex effects on the body and you have a multiplicity of outcomes. Statistics tell us about the probabilities of reactions within a population, but they cannot tell us how the individual will react; that is infinitely variable.
Complex systems can easily be knocked out of kilter by a small change in the environment, leading to a new state of equilibrium or to no equilibrium at all. They do not work on simple negative feedback which feeds back to damp down a reaction and stabilises the system, they work on chains of positive feedback which can take things in an unpredictable direction into a state of disequilibrium or chaos. We may try to bring the system under control by another intervention but the chances are we do not see the consequences and may well make it worse. I am reminded of the introduction of myxomatosis to control the rabbit populations, the introduction of the Cane Toad in Queensland and countless medical interventions from thalidomide to overuse of antibiotics.
Living in society for a lifetime, we each develop an intuition about what might happen in certain given circumstances. We may not always be able to analyse that, but as healers, whether of ourself or others, we must keep hold of that gut feeling and not be diverted by dogma or evidence based on individual components, incomplete understanding or a particular limited experimental context. The models scientists build are inherently simplistic; they do not look at the whole picture and can lead us down unhelpful tracks. There was a time when doctors believed that coarse wheat bran was the answer to IBS. Now we have probiotics, the low FODMAP diet, and a range of new drugs and supplements. All of these contain part truths; they may be helpful to some people some of the time, but they never suit everybody and are never the complete answer for IBS. Connectivity via social media and the sheer diversity of causes, tests and treatments, has made the system we call IBS much more unstable. What suits one person for a time may not suit others.
To understand an individual illness like IBS, we need to understand the narrative: under what circumstances did the illness first arise?; what reduces the symptoms?; what makes it worse;? , how do people lead their lives?; what food do they eat?; how active are they?; what has happened in their lives?; what treatments have they taken? IBS is a holistic illness. One answer does not suit all or even most. Treating one component is unrealistic; it leads to misunderstandings and confusion. Evidence base can not be equated with understanding.
My experience has taught me that an illness usually makes perfect sense when seen from the perspective of a person’s life story. It’s when things don’t fit with the narrative, that I need to investigate the possibility of a specific disease. Years ago, one of my patients told me. ‘You know, the pain I get in my bottom is my alarm bell, it tells me when my life is not going well’. This prompted the response, ‘well, why are you spending all this time and money trying to investigate whether the alarm is not working well. The chances are it is working fine, but you need to find out what is setting it off.
The Sensitive Gut 