Further Discussion of the Relationship of IBS to Stress and Other Psychological Conditions and the Dynamics of Psychotherapy
 The Psychology of IBS Talking Psychotherapy
Mark Egit Ph.D. (Psychoanalyst)

Specifically the focus here will be on Irritable Bowel Syndrome (IBS) for those individuals, who have not benefited sufficiently from medical interventions. These individuals account for 15% of the IBS population. As is clear, symptoms are exacerbated by dystonic conditions in the emotional environment, can they be ameliorated by tending to vulnerable emotional mechanisms? The first level of treatment is, if possible the removal of emotionally toxic circumstances, the relieving of stress. This can be accomplished through environmental or pharmacological means. Such intervention, are limited. Symptoms reappear.
Gastroenterological and psychiatric, research view psychotherapy cautiously, yet lean to it as the treatment of choice, one that works with a different model of cure. It attempts to buttress the mechanisms which defend against the conditions toxic to the individual. Conditions necessary to trigger psychosomatic discomfort are a feature of daily life, yet affect only some of those exposed. There is something in the constitution and experience of these patients which sets them apart and makes them vulnerable.

What is Somatization ?

It is the physical expression of a psychological state. A patient described it well 'My mind may not remember but my body keeps score'. But a score of what? It is generally understood that what is being "kept" is the experience of trauma, and it is the reflection and bodily memory of the trauma which generates the physical symptoms. This leads to a "tendency to experience and communicate psychological distress in the form of physical symptoms and to seek medical help for them". It is also the inability to see and experience the triangular relationship between past experience, psychological distress and physical well-being. We often feel that distress is the result of the physical condition, often the opposite is true.

Examining the differences in behaviour between IBS and IBD (Inflammatory Bowel Disease) is instructive. The latter is not a somatoform disorder and in comparative studies... " the [IBS] group had significantly higher prevalence rates of lifetime major depression, current panic disorder, generalized anxiety disorder and agoraphobia as well as childhood rape and molestation. These findings suggest that psychological distress plays a fundamental role in the ongoing adjustment that patients make to physical symptoms" (Psychological Medicine) v 25 p.1259 1995 )

In these instances, it is sensible to look at the variety of somatoform disorders as amenable to psychological treatment or as an adjunct to medical interventions.

What Happens in Psychotherapy?

We begin with the clinical understanding that a traumatic episode occurred. This is not a discreet event, rather a series of interactions surrounding and including the actual event.

We want to differentiate between alarming and traumatic events. The former do not take hold within the inner life of the individual to wreak their influence throughout a lifetime. Traumatic episodes do just that. The experience enters undifferentiated and unaddressed, into that inner life and calls out to itself because the suffering had not been undone, it had not been articulated. We assume that a traumatic episode can be undone only in a self object milieu. Only then can it be demoted to an alarming event which becomes a painful memory and, as all memories of pain, fades to become only a memory. It is this self object interaction which occurs in the psychotherapeutic space. Cure comes through the countless repetitions and therapeutic adjustments in the clinical setting. Bacal puts it well "Patients want to re-experience the special quality of relationship between a particular child and a particular parent, and to re- examine that relationship within a therapeutic setting". In the case of somatoform disorders, that re-examination is about the interaction which did not take place, which did not turn the traumatic incident into an alarming one. That is the work of the psychotherapeutic encounter with the somatoform patient.

How do we address and treat The condition of stress in our patients? Sometimes stress is situational and just clears up. But more often, it is long standing and cumulative We face stress on the job, at home, stress with children, spouses bosses subordinates stress with bills and the internet. We are stressed because we work too much or not enough because our partners do not really understand us and with that accuse us of not understanding them. We want just to be left alone when with people and want to be with people when alone. We despair that its been a long time since we've been in a warm embrace and may never be in one before we die. In short in a significant part of our life we do not feel affirmed, on the contrary we feel our circumstances grating against us not allowing us to fulfil our adult obligations. How can stress be assuaged and how can patients be treated?

Stress, like all distonic inner states is a psychological red flag which allows patients to look into themselves and ask the uniquely human question, What's going on outside and inside of me? Or to say this with more insight, what is it about my social relationships with others and what is it about my inner turmoil that results in my feeling "stressed"?
Why am I stressed, How come others in similar circumstances seem to be doing fine? What is it about me what can I do about this can I be helped? Stress allows for the possibility of introspection. But at the same time it accentuates for us as all disease does, our aloneness our , vulnerability our "human condition"

Stress is not a diagnostic category, it is neither PSTD nor acute stress disorder, rather like "I'm not feeling very well"it is a marker for a dystonic mental condition, a need to talk about oneself and ones circumstances.

Walking into a physicians office the issue for the patient is the hope of relief but in the short term the possibility to open up to a dispassionate but interested party. The wish is for genuine relief. By genuine I mean mirrored empathically, shared genuinely and resulting a feeling of having been understood. Unlike a rash which has no emotional root, the resolution of the issue of stress is not "fixing it" but to walk away feeling that another person, could empathize and therefore in a genuine way join with us in understanding the difficult place we are in and in that way engendering a feeling of not being alone.

A Few Words About Depression

What is depression and how does it come about?
We are encouraged to think of depression primarily as a chemical imbalance to be treated medically, at its chemical root.

Indeed depression does have a chemical profile but it is not about chemistry. It is, in clinical experience, about unfulfilled longing, frustrated ambitions, it is about not being loved, the lack of connectedness or lack of affirmation, it is about feeling alone in a world filled with people.

It results from the desperation about our continued inability to effect change in areas most profoundly impinging on our daily lives. It is the belief that we will grow old without ever having been truly loved and that we will die being neither long nor well remembered.

Depression is about not mattering enough to those who matter to us. Often and paradoxically, people despair when they have accomplished life long goals, when they have been rewarded for their efforts, when they have surmounted lifelong obstacles, when their dreams have come true. It is at those times when all the obstacles we have always been prepared for are suddenly withdrawn from the psychic field that despair can descend. And this is not just about brain about chemistry. It often comes from behind the curtain that has always fluttered while we chose not to pay it attention.

The playwright gets it right….

J Saunders quoted by Tom Stoppard in the New York Review of Books Sept. 13 1999

There lies behind everything, and you can believe this or not as you wish, a certain quality which we may call grief. It's always there, just under the surface, just behind the facade, sometimes very nearly exposed, so that you can dimly see the shape of it as you can see sometimes through the surface of an ornamental pond on a still day, the dark gross inhuman outline of a carp gliding slowly past; when you realize suddenly that the carp were always there below the surface,even while the water sparkled in the sunshine, and while you patronized the quaint ducks and the supercilious swans, the carp were down there unseen. It bides its time this quality. And if you do catch a glimpse of it, you may pretend not to notice or you may turn suddenly away and romp with your children on the grass, laughing for no reason. The name of this quality is grief. carp

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