Irritable Bowel Syndrome and Digestive Health Support Forum banner
1 - 7 of 7 Posts

·
Registered
Joined
·
23,983 Posts
Discussion Starter · #1 ·
FYI:Symptom Expression in Pain-Predominant Functional Bowel Syndrome: Is Visceral Hyperalgesia the Whole Truth? Michael S. Shapiro, M.D.a and Kevin W. Olden, M.D.a Ever increasing socioeconomic pressures have elevated cost-effective management of patients with irritable bowel syndrome (IBS) and related functional disorders as a high priority in gastroenterology practice. The illness of these patients produces an enormous cost to society related to absenteeism and use of medical resources (1). Although most individuals with IBS go about their daily lives without need for medical care, about 30% of IBS sufferers seek assistance for their disorder (2). IBS patients pursue consultation mainly because of their abdominal pain (3). The severity of abdominal pain reported by patients with functional bowel syndrome to their physician often drives the aggressiveness of a workup in the attempt to identify "serious disease." This results in higher risk to the patient and greater expense. However, what is uncertain is whether, in IBS patients, painful symptoms directly reflect pathophysiological mechanisms involved in pain production such as visceral hyperalgesia, or whether they are a consequence of psychosocial factors. In this issue of the Journal, Drossman et al. address the question of what factors influence severity of the pain reported in pain-predominant functional bowel disorders (4). Patients considered in this study were sufferers of moderate to severe painful functional bowel syndrome as identified by a validated Functional Bowel Severity Index. A total of 83.3% of subjects in the study fulfilled standard Rome criteria for IBS. Psychosocial and behavioral parameters were compared between moderate and severe groups. Psychological factors were considered as potential modulators of pain expression based on the high prevalence of psychiatric disturbance detected in patients who present with functional bowel complaints, in the range of 42-61% (1). Visceral hyperalgesia also is considered to be a major mechanism involved in symptom production in functional bowel syndrome, and can be demonstrated in up to 94% of IBS patients by rectal distention (5). For this study, visceral hypersensitivity was assessed by barostat balloon rectal distention to detect differences in pain perception. The results show compelling evidence that psychosocial and behavioral elements are the crucial and predominant factors that distinguish moderate from severe functional bowel syndrome. Major factors associated significantly with the severe pain-predominant group included depression, reduced perception of quality of life, impaired coping skills, and increased health care use. Of 19 psychosocial variables entered into a regression model to predict pain severity, four factors were identified as highly predictive of severe functional pain: physical dysfunction, eating dysfunction, days in bed for GI symptoms, and number of times the physician was called for GI symptoms. These factors are characteristic of "learned illness behavior" (6), in which patients are preoccupied with multiple somatic complaints and adopt a behavioral pattern to reflect this preoccupation. Although heighted visceral hypersensitivity was suggested in the severe pain-predominant group, the differences between this group and the moderate group were not substantial, and regression analysis did not find sensitivity to rectal distention to be a good predictor of pain severity. This study illustrates the crucial role of psychosocial and behavioral disturbance in how pain is perceived and reported in IBS and other painful functional GI disorders. Visceral hypersensitivity has been the focus of intense investigation as a possible mechanism of symptom generation in IBS and the functional GI disorders (2, 7). Although the data of Drossman et al. do not reject a role for visceral hypersensitivity in painful functional bowel syndrome, they suggest that visceral hyperalgesia alone is not sufficient to explain how pain is communicated by patients with functional GI disorders. In particular, somatization disorder has been found to correlate with reduced pain threshold (8) in IBS and is prevalent in functional bowel syndrome sufferers who seek medical care (6). The mechanism by which psychological factors modulate pain reporting and perception is not known. Some attention has been directed to chronic stress as a factor, which is highly prevalent in patients with functional bowel syndrome (9) and is associated with increased intensity of symptoms reported (10, 11). Stress may influence the threshold to painful distention (8). A possible biochemical basis for these effects may involve, at some level, corticotropin-releasing factor, which is an important player in the stress response and which has been demonstrated to influence symptoms in IBS (12). Whitehead and Palsson have proposed a model of pain perception and reporting in IBS that incorporates a dynamic interplay of physiological and psychosocial factors leading to how symptoms ultimately are described by the patient (8). Illness behavior plays a pivotal part in this model and is directly linked to health care use. The results of Drossman et al., appearing in this issue of the Journal, lend support to the "biopsychosocial" model of functional GI disorder. Their findings also emphasize the importance of modification of illness behavior patterns as the most effective means of enacting a favorable outcome for these most challenging patients. How can these findings be applied? There is a need to heighten awareness of the clinician involved in the care of these patients regarding the recognition of important psychosocial factors in functional bowel patients. Symptoms must be interpreted as a complex manifestation of brain-gut interaction and not merely as gut dysfunction. Establishing an effective patient-physician relationship is a crucial step in successfully sorting out such patient issues (1). Once contributing psychological features are identified, effective therapy can be offered, which may include use of psychotropic drugs, cognitive-behavioral therapy, dynamic psychotherapy, hypnotherapy, or other behavioral techniques that have been shown to benefit these patients (1). Thus, we are reminded that effective medical care for these patients requires a thoughtful blend of art and science, based on insightful interview, knowledge of the complexity of factors involved in symptom expression, and the ability to persuade, with sensitivity, patients as to the most helpful intervention. ------------------ http://webpotential.com/ericibs/index.htm
 

·
Registered
Joined
·
142 Posts
I hope some of the physicians people have talked about here take note of that line about establishing an effective physician/patient relationship. JeanG: Not to mention cognitive/behavioural therapy.
 

·
Registered
Joined
·
1,174 Posts
Eric,These are my doctors! This certainly fits in with what we've been talking about.Quote:Their findings also emphasize the importance of modification of illness behavior patterns as the most effective means of enacting a favorable outcome for these most challenging patients.I haven't been in to see Dr. Olden since I started hypnotherapy. I will have to see him soon and explore his views. AZ
 

·
Registered
Joined
·
107 Posts
Thanks for posting Eric. I see they uncovered the "learned illness behavior" associated with the severe pain group. Seems to me from the many stories on this BB that a study is needed on the learned treatment behavior of some Drs.
 
1 - 7 of 7 Posts
This is an older thread, you may not receive a response, and could be reviving an old thread. Please consider creating a new thread.
Top