Doctors have not got a good press in managing patients with IBS. In a recent conference organised by The IBS Network, Professor Peter Whorwell reported that most doctors are not interested in IBS; they see it as a nuisance, a trivial psychological condition that does not threaten patients’ lives. Even gastroenterologists have little time for it. They see their role to exclude ‘serious’ illness and they rarely follow patients up. ‘IBS is the last stigmatised disorder”, Whorwell declared. ‘I advise patients to keep it to themselves’.
Many patients are so afflicted by pain, bloating and bowel upset that they feel desperate and regard their doctors as their only source of relief. Nevertheless, after the first two consultations, when the doctor is keen to identify or exclude any treatable condition, they may detect a lack of interest in the absence of eye contact and lack of attention. They may then complain that their doctors don’t understand IBS, never listen to them, are always short of time and seem too eager to end the consultation by prescribing pills that never seem to work or handing them another diet sheet.
But this is not necessarily the fault of a doctor, who doesn’t understand and has lost interest; nor can it just be blamed on a patient who is too neurotic and needy. It’s the relationship that is not working. This is best understood as a disturbance of attachment.
Attachment is the psychological term that refers to the bonds that allows us to understand each other, work together and regulate each other’s emotions and behaviour, particularly with regard to the processing of negative experience. Attachment plays a key role in the acquisition of emotional intelligence and development of resilience.
The psychiatrist and psychoanalyst, John Bowlby explained how for the first few years of life, parents regulate their infants’ emotions and bodily functions by a delicate balance of containment and graduated freedom; showing them how to behave in certain circumstances but allowing them appropriate opportunity to learn for themselves. Situations that induce anxiety and distress will cause an infant to seek proximity and reassurance, but repeated successful interaction with a parent or caregiver leads to the development of a sound internal working model for self regulation; a secure base, which encourages curiosity, exploration and trust. People, who have internalised a secure model of attachment, are confident enough to manage themselves without becoming ill but can seek help when difficult things happen that are outside their usual experience.
Unfortunately, in as many as 40% of people, particularly those with unexplained or long term illness, this can go wrong and attachment can be insecure, provoking reactions to change or stress that may be either overly needy, chaotic and disorganised or avoidant and controlled. This, Bowlby proposed, is dependant on the quality of parenting. If a child’s main caregiver is overanxious, stressful situations can feel overwhelming and induce the kind of chaotic reactions that were at one time regarded as ‘hysterical’. If, on the other hand, parents are absent or neglectful, then the child may repress their feelings, resulting in more avoidant reactions.
Insecure attachment is often brought about by adverse childhood experience very early in life. As the psychiatrist, Peter Levine, has explained, this can be stored in a child’s implicit (emotional and bodily) memory, where, when rekindled by association, it activates the autonomic nervous system and is expressed in bodily symptoms and behaviour that represent the emotion. Thus as far as IBS is concerned, diarrhoea can seem to express a more chaotic and disorganised reaction while constipation is more repressed, avoidant and controlled. These may, however, alternate according to circumstances. Thus, the usual sympathetic (flight or fight) or parasympathetic (freeze or faint) nervous system reactions do not resolve the perceived threat; instead, they play it out in emotional and bodily reactions. These will persist as a long term illness such as IBS unless the patient can understand the possible origin of the symptoms and change their life style, life situation or the way they think about the illness.
Stress can be the cause of illness and the result of it. Disorders of attachment can not only induce or exacerbate chronic illness by increasing the impact of life events on the autonomic nervous system, they also determine how a patient appraises their illness, whether they react with anxiety or depression, health care seeking or avoidance, how much control they feel they have over their illness, how they interact with family and friends and how much they trust health care providers and can respond to medical, dietary and psychological treatments. Those with a suspicious negative view of others are less likely to seek support, are less trusting and more likely to experience care givers as uninterested and unhelpful. Those with a more needy disorganised style of attachment may return to their GPs very frequently, express extreme anxiety, and are difficult to help or reassure they don’t have a serious illness.
Experience of illness in childhood affects patterns of illness behaviour in later life. Patients may learn that they will only get attention, care and love if they are sick. Doctors are trained to treat physical expressions of illness and do not always recognise patients’ emotional needs and their bodily reactions to those. It’s a mismatch, but, like their patients response to their illness, they have also been influenced in their career choice by their childhood attachments.
Many young people are drawn into medicine because they want to help people, make a difference and do something good and worthwhile; others because being a doctor gives them power and status over others. Both may be regarded as a reaction to feelings of not being accepted for who they are, but more for what they can do. They may have found that hardworking and caring behaviour allowed them to get their needs for love and attention met in early life. Being able to ‘make’ people better is central to their self efficacy and self esteem. As doctors, they may see themselves as especially knowledgable and understanding. Why else, you might think, would they go into a profession where they are surrounded by illness and death?
So it seems that between a doctor with a deep seated psychological need to treat illness successfully and a patient who is so needy or suspicious they cannot be helped you have a recipe for frustration and failure. No wonder neither party finds it a rewarding relationship.