FYIIRRITABLE BOWEL SYNDROME: ALTEREDNEUROLOGICAL ACTIVITY Irritable bowel syndrome (IBS) is a common disorder ofthe intestines that leads to pain, intestinal gas, bloating,and changes in bowel habits. People with IBS mayhave constipation or diarrhea and some people experienceboth. Other symptoms include the urge to movethe bowels but an inability to do so. The cause of IBS isnot known, and as yet there is no cure. IBS is classified asa functional disorder because there is no sign of diseasewhen the colon is examined. Although it does not causepermanent harm to the intestines and does not lead tointestinal bleeding of the bowel or to a serious diseasesuch as cancer, IBS patients suffer a great deal of discomfortand distress.The underlying physiologic cause of IBS is unknown.Ordinary events such as eating and distention from gas orother material in the colon can cause the colon to overreactin a person with IBS. Individuals with IBS seem tohave a colon that is more reactive and sensitive thanusual, so it responds strongly to stimuli that would notbother most people. Researchers have found that thecolon muscle of a person with IBS begins to spasm afteronly mild stimulation. Stress may also be a factor in themanifestation of disease symptoms.Patients with IBS also seem to have an enhanced awarenessof and sensitivity to normal gastrointestinal events,such as muscle contractions and the filling of the viscerafollowing a meal. This has led some researchers to speculatethat when the brains of persons with IBS receiveinformation from the visceral nerves in the intestines,they may process the information differently than personswithout IBS.To examine the possible role of information processingby the brain in causing IBS, researchers studied brainactivity in affected patients. In the experiment, the scientistsrecruited twelve people with IBS, as well as twelvehealthy volunteers, and inserted a catheter through therectum and into the volunteers� colons. Each cathetercontained two small balloons along its length that couldbe inflated to a precise pressure by the researchers.Inflation of balloons of this size is designed to producemild discomfort, but no serious pain or tissue damage.After the catheters were inserted and the patients had abrief recovery period, the researchers initiated a PositronEmission Tomography (PET) scan of the patients� brains.This scan permitted researchers to see relative rates ofmetabolism based on energy usage and blood flow within specific regions of the brain. The researchers theninitiated a three-part experimental phase, in which theytold patients that the balloons would or would not beinflated, but did not consistently inflate the balloons inthe manner stated. This experimental design allowed theresearchers to see responses to no inflation phase 1, anexpected and delivered inflation phase 2, and anexpected but undelivered inflation phase 3. During thisprocedure brain activity was monitored by PET scans.When the scientists analyzed the data generated by thePET scans, they found significant similarities between thenormal and IBS patients, but also noted important differences.Brain regions activated by actual and simulatedballoon inflations were similar in both groups; however,differences in three important areas of the brain could bedetected. First, patients with IBS exhibited enhanced activationof right prefrontal cortex in response to actual orexpected balloon inflation, whereas in normal patients,both sides of the brain reacted to a similar extent. Thisregion of the brain is thought to be very important forhigher cognitive functions, including concentration andjudgment. Second, within the anterior cingulate an areadeep within the brain thought to be involved in emotionssuch as sadness an enhanced reaction was seen in IBSpatients in a sub-region associated with the perception ofpain and unpleasantness. Third, the IBS patients demon-stratedan overall decreased activation of circuits in thebrain believed to activate fear and defense responses.All three of these observations indicate that IBSpatients show altered brain responses to rectal stimuli,regardless of whether these stimuli are actually deliveredor simply anticipated. This study provides solid evidenceof altered brain activity in patients suffering with this syndrome that is of unknown origin. To help fostermore research into the causes of IBS and its possibletreatmentsthe NIDDK is working with members of theIBS community to develop a conference on the topic offecal and urinary incontinence that is relevant to many ofthe quality of life issues that have an impact on peoplewith IBS.Naliboff BD, Derbyshire SWG, Munakata J, Berman S,Mandelkern M, Chang L, Mayer EA. Cerebral activation inpatients with irritable bowel syndrome and control subjectsduring rectosigmoid stimulation. Psychosomatic Med 63 3:365-375, 2001.
Cerebral activation in IBS
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Tom, I just want to make it clear these Dr's are neurogastroenterologist's and gastroenterologist's studying why we have IBS and not psychologists. This is important information and some of this is also part of the dysregulation of the neurotransmitters, between the brain and the gut and back and what is happening in IBS to generate the symptoms.
Tom, I just want to make it clear these Dr's are neurogastroenterologist's and gastroenterologist's studying why we have IBS and not psychologists. This is important information and some of this is also part of the dysregulation of the neurotransmitters, between the brain and the gut and back and what is happening in IBS to generate the symptoms.
eric, my point is the same no matter how many syllables are in the title. nobody ever explains these things from a patient's point of view. Actually as a psychologist with my neuropsychological background i would be considered medically competent to interpret neurogastroenterological findings to a patient, but these studies as wonderful as they are and as long as the titles of the authors are never are published in a form that is understandable and useful for someone who has IBS.tom
eric, my point is the same no matter how many syllables are in the title. nobody ever explains these things from a patient's point of view. Actually as a psychologist with my neuropsychological background i would be considered medically competent to interpret neurogastroenterological findings to a patient, but these studies as wonderful as they are and as long as the titles of the authors are never are published in a form that is understandable and useful for someone who has IBS.tom
I think it helps to confirm the importance of doing relaxation techniques, cbt, hypnotherapy, taking antideppresants, and a host of other methods and the factits worth treating the brain and gut in IBS.It also helps to confirm where the pain comes from in IBS, how its modulated and what part of the brain this is all effecting.One of the major issues in IBS at this time they are working on getting to the bottom of is hypersensitivity of the gut.I am not sure about you but I been studying this long enough I am actaually starting to understand a small percentage of it. I also believe information is power and change comes from within. and we just have to keep changing until we find the right combinations.On a side note this one actually had more of an explanation to some of it then the others.This I believe is important although it all is."Second, within the anterior cingulate an area deep within the brain thought to be involved in emotions such as sadness an enhanced reaction was seen in IBS patients in a sub-region associated with the perception of pain and unpleasantness."
I think it helps to confirm the importance of doing relaxation techniques, cbt, hypnotherapy, taking antideppresants, and a host of other methods and the factits worth treating the brain and gut in IBS.It also helps to confirm where the pain comes from in IBS, how its modulated and what part of the brain this is all effecting.One of the major issues in IBS at this time they are working on getting to the bottom of is hypersensitivity of the gut.I am not sure about you but I been studying this long enough I am actaually starting to understand a small percentage of it. I also believe information is power and change comes from within. and we just have to keep changing until we find the right combinations.On a side note this one actually had more of an explanation to some of it then the others.This I believe is important although it all is."Second, within the anterior cingulate an area deep within the brain thought to be involved in emotions such as sadness an enhanced reaction was seen in IBS patients in a sub-region associated with the perception of pain and unpleasantness."
that's the kind of thing I was getting at. it might mean something like some IBS patients have a strong reaction to sadness (sometimes so strong they block it completely)and this sadness might be associated with pain.The other whole area of this is I think related to perception of the physical aspects of colon transit and, for example, people with IBS might perceive an urge to move when there is really no realbasis for this.tomtom
that's the kind of thing I was getting at. it might mean something like some IBS patients have a strong reaction to sadness (sometimes so strong they block it completely)and this sadness might be associated with pain.The other whole area of this is I think related to perception of the physical aspects of colon transit and, for example, people with IBS might perceive an urge to move when there is really no realbasis for this.tomtom
FYI"Brain Physiology Stress reproducibly alters gastrointestinal motility and sensation. The release of corticotropin releasing factor from the hypothalamus may mediate the stress response. Brain centers important in mediating visceral pain include the thalamus (general sensory), insular cortex (visceral sensory), anterior cingulate cortex (general pain awareness), and prefrontal cortex (general pain processing). Visceral pain in IBS is associated with increased prefrontal cortex activation. The normal correlation between subjective pain intensity and activation of the anterior cingulate and insula cortices is lost in IBS. The limbic system is involved in emotion, mood, and visceral autonomic control. Limbic abnormalities are seen in depression and IBS. Thus, this system is a possible site of convergence where emotional disturbance provokes intestinal dysfunction. " http://www.fdhn.org/html/education/gi/ibs_nosology.htm
FYI"Brain Physiology Stress reproducibly alters gastrointestinal motility and sensation. The release of corticotropin releasing factor from the hypothalamus may mediate the stress response. Brain centers important in mediating visceral pain include the thalamus (general sensory), insular cortex (visceral sensory), anterior cingulate cortex (general pain awareness), and prefrontal cortex (general pain processing). Visceral pain in IBS is associated with increased prefrontal cortex activation. The normal correlation between subjective pain intensity and activation of the anterior cingulate and insula cortices is lost in IBS. The limbic system is involved in emotion, mood, and visceral autonomic control. Limbic abnormalities are seen in depression and IBS. Thus, this system is a possible site of convergence where emotional disturbance provokes intestinal dysfunction. " http://www.fdhn.org/html/education/gi/ibs_nosology.htm
Tom, one of the doc's was a Psychologist sorry.
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Bruce D. Naliboff, PhD, Clinical Professor of Medical Psychology in the Dept. of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine; Co-director, UCLA Center for Integrative Medicine; and Chief of the Psychophysiology Research Laboratory, West Los Angeles VA GLA Health Care.perception is big and one good reason distraction techniques work I believe.
Tom, one of the doc's was a Psychologist sorry.
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Bruce D. Naliboff, PhD, Clinical Professor of Medical Psychology in the Dept. of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine; Co-director, UCLA Center for Integrative Medicine; and Chief of the Psychophysiology Research Laboratory, West Los Angeles VA GLA Health Care.perception is big and one good reason distraction techniques work I believe.
Thanks for the article, Eric. It's fascinating to see where the brain fits into all this. And I agree with you that it becomes clearer and clearer as time goes by why hypnotherapy, cbt and relaxation benefits IBS patients.Keep on posting these articles. I'm too lazy right now to look them up myself.
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JeanG
Thanks for the article, Eric. It's fascinating to see where the brain fits into all this. And I agree with you that it becomes clearer and clearer as time goes by why hypnotherapy, cbt and relaxation benefits IBS patients.Keep on posting these articles. I'm too lazy right now to look them up myself.
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JeanG
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Interesting thread once again clearly demonstrating that the board certification(s) of the investigators determine the perspective from which the data of an investigation are interpreted. Also demonstrates that speculation is often interpreted as fact in the retelling. Also demionstrates that the failure to assay datapoints which have a direct bearing on the observed neurologic activity disallow any conclusions to be formed beyond speculation. ___________________________________Naliboff:“IBS is classified asa functional disorder because there is no sign of diseasewhen the colon is examined. “ __________________________________But if you examine the ileocecal junction tissue abnormalities are found (increased mast cell density). If you examine the SMALL Intestine by jejunal isolation, abnormal lymphocytic accumulation can be seen, and cell mediated inflammatory reactions provoked in vivo. Also ins some patients humoral inflammatory reactions can be provoked and quantitified. This calls to question the entire concept of “functional disease” especially as defined in the article as “ no sign of disease in the colon”. ______________________“The underlying physiologic cause of IBS is unknown.” _______________________However the integrated CNS, ENS, Immunologic and Endocrinologic mechanisms of symptom generation can be quantified….the mechanisms can be quantified the etioliologic basis remains speculatory for the moment, as either there are multiple etiologies OR there is mass-misdiagnosis worldwide as subpopulations of people diagnosed with IBS can be shown to develop symptoms in response to specific mechanisms…ergo is this part of IBS or should these patients be deselected? This discussion is likely to become more open in the next several years. _________________________“Individuals with IBS seem tohave a colon that is more reactive and sensitive than usual, so it responds strongly to stimuli that would not bother most people. Researchers have found that the colon muscle of a person with IBS begins to spasm after only mild stimulation. “ __________________________The specific mediators which elicit these responses (upregulation of motor and sensory functions, and smooth muscle contractility) can be and have been isolated in some IBS studies and include immunologic and endocrinologic sourced mediators which are already known to upregulate the neuromuscular functions observed to be upregulated. The specific things which can and do provoke them are known, and have been isolated in individual studies on different patient groups, but not analyzed together on the same patients at the same time to be able to determine which mechanism is primary and which is secondary and under what conditions. ____________________________________“Stress may also be a factor in the manifestation of disease symptoms.” ___________________________________As are immunoendocrine dysfunctions which are easily quantified. How these interract to cause symptom generation is understood, as they are interdependent and multidirectional. No single mechanism of the three can be shown to be wholly primary in all patients diagnosed with IBS, nor has anyone yet attempted to integrate the study of an integrated system.Each studies the element of the system which is of interest to them based upon their specialty, which determines their perspective thus what data they study and thus what theories they set forth as maybes and possibilities.______________________________________“This has led some researchers to speculatethat when the brains of persons with IBS receive information from the visceral nerves in the intestines,they may process the information differently than persons without IBS.” __________________________________And speculation it is, when one merely observes the electrical activity and bloodflow, not the causal basis for said aberrations which are multiple possibilities. Any extended logic based on that speculation remains as valid as the speculatory source. Indeed information “processing” appears aberrant, but the mechanisms by which this can occur have been quantified only in separate studies, by other investigators, on different patients, so how they apply to the patients examined in another study can also only be theorized. _____________________________“This scan permitted researchers to see relative rates of metabolism based on energy usage and blood flow within specific regions of the brain. “ ______________________________In studies where immunologic activation is elicited in IBS patients, the specific mediators released are known, Among Many Other Affects, to affect intracranial blood flow, blood-brain barrier permeability, cerebral blood flow and flow to other brain areas, and specific and direct effects upon specific areas of the brain….and the same can be said bidirectionally of endocrinologic factors. None of these dozens of variables is accounted for in these studies as the researchers area of interest is not from that perspective. Besides it is also damn expensive to try to do so. LOL _______________________________“All three of these observations indicate that IBS patients show altered brain responses to rectal stimuli,regardless of whether these stimuli are actually delivered or simply anticipated. “ ______________________________This has been shown many times. But it does not explore the various Mechanisms which can result in this observation, nor what may provoke or activate those mechanisms. ___________________________________“This study provides solid evidenceof altered brain activityin patients suffering with this syndrome that is of unknown origin. “ ____________________________________And that is all it provides. It provides no evidence as to what Causes the observed alterations, and the possibilities are at the very least multiple. ________________________From Tom:“..it's clear our brains don't connect right but the problem is these psychologists never tell us what's not working right from our point of view so we can change!” _____________________________That is because, Tom, they cannot as of yet since they did not investigate what may cause this at all. They only made observations of a specific activity or activities. So that is whay everything is qualified as speculation beyond the specific observed activity. ________________________________From Eric:"Tom, I just want to make it clear these Dr's are neurogastroenterologist's and gastroenterologist's studying why we have IBS and not psychologists. " _______________________________Dr. BRUCE Naliboff, the head investigator, is not, he is a psychiatrist. The investigation is that which would be performed by, and the perspective is that of, one with that specialty as his point of reference. It is not right or wrong, good or bad, it merely is a fact which must be taken into account as with reading any investigators conclusions. __________________________________“This is important information and some of this is also part of the dysregulation of the neurotransmitters, between the brain and the gut and back and what is happening in IBS to generate the symptoms.” ________________________________It is important for certain, but it sheds no light on the etiology, nor on the specific mechanisms of the aberrations observed. You cannot draw any conclusions from the data since there are too many variables which will “dysregulate neurotransmitters”. It also shows one piece of a complex mechanism of symptom generation but leaves out several other proven sources of symptom generation which occur directly within the small bowel itself._______________Further,“I think it helps to confirm the importance of doing relaxation techniques, cbt, hypnotherapy, taking antideppresants, and a host of other methods and the factits worth treating the brain and gut in IBS.It also helps to confirm where the pain comes from in IBS, how its modulated and what part of the brain this is all effecting.” ____________________________________It does not confirm nor disprove the value of any treatment modality as no outcome assessment of any modality is part of the study.However it would be correct to state that it remains true that the most widely accepted protocol for IBS would be that a multi-modality Disease Management Program which includes:1. Dietary therapy specific to the patients needs2. Stress reduction therapy in the form of HT or CBT3. Pharmacotherapy as required after outcome assessment of #1 and #2This will produce the best outcomes overall when applied to a population of patients with IBS symptoms. _____________________________“One of the major issues in IBS at this time they are working on getting to the bottom of is hypersensitivity of the gut.” ______________________________"They" includes numerous investigators In more than one place and in more than one country, and from more than one perspective. It is unfortunate that the investigative protocols cannot somehow be integrated so that all the assays are included, and that they are performed on the exact same patients. This sure would speed things up. But each group is driven by both different perspectives and different funding sources, which have an effect on the study protocols and the investigative goals.I think this is part of the Point Tom is trying to make. ______________________________“I am not sure about you but I been studying this long enough I am actaually starting to understand a small percentage of it.” ______________________________I have had enough interchanges with Tom over time think that the same is true of Tom, and myself, and many other members and indeed ALL researchers studying IBS. Everybody has been studying what they study, and everyone understands that portion which they understand. Some portions of knowledge are larger and some smaller but no one understands the whole thing yet. Not even close. So I do not think that there is any single person anywhere who holds the high ground. If there were, then the research would be better and more comprehensively integrated and things would be moving along more quickly and comrpehensively in more areas than they presently are. ________________________________“I also believe information is power and change comes from within. and we just have to keep changing until we find the right combinations” _________________________________Absolutely in agreement with that. I also beleive information should be studied in entirety, not just in parts, from all investigational perspectives, if one is to grasp the whole picture concerning any disease entity or any syndrome...this is true of everything in life however.And further ________________________________"Tom, one of the doc's was a Psychologist sorry. Bruce D. Naliboff, PhD, Clinical Professor of MedicalPsychology in the Dept. of Psychiatry and BiobehavioralSciences, UCLA School of Medicine; Co-director, UCLACenter for Integrative Medicine; and Chief of thePsychophysiology Research Laboratory, West Los AngelesVA GLA Health Care." __________________________________Oop, sorry, someone found out already…that’s what happens responding in order of the statements in real time.As was stated in a recent tutorial on current standards of therapy in IBS: ______________________________“However, it is not likely that one single treatment will help every IBS patient and many of them will need a more complex approach with multidisciplinary therapy (diet, psychotherapy, medications). “ _________________________________This remains the universal truth. The best outcomes are realized when the most currently available tools are used to optimize the diet to the patients specific reactivities (allergic comorbidities, sensitivities, and intolerances), the psychotherapy is chosen on the basis of what is shown to be efficacious when used AND which the patient will actually accept and follow as instructed, and the medication is titrated against the outcomes of dietary therapy and HT or CBT provided concurrently.Eat well. Think well. Be well. off to Cleveland. See you all from the Rock and Roll Capital of The Universe!MNL
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