When the Body Says No: The Cost of Hidden Stress (22 page)

Tim says he is very critical of others and of himself—one more trait for which he ends up judging himself. “I am a perfectionist, so I don’t think I have that natural human sympathy. I’m more cold. In fifteen years I’ve never missed work, even when I was running to the toilet twelve or fifteen times a day, with bleeding. An employee yesterday took the day off—his dog died the night before. I was like ‘What are you saying—he’s not here because his dog died? It was just a dog. Why can’t he come to work?’ Some of the staff said, ‘Haven’t you ever owned a dog? Are you heartless or what?’ I just couldn’t relate.”

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Dr. Douglas Drossman is an internationally known gastroenterologist, and a professor of medicine and psychiatry at the University of North Carolina at Chapel Hill. He is an associate editor of
Gastroenterology
, the official journal of the American Gastroenterology Association. Dr. Drossman has been a leading advocate of seeing intestinal diseases as expressions not only of disturbed physiology but also of stressed lives. He wrote a seminal article on the subject in 1998. “On the basis of clinical reports, on appraisal of the existing research literature, and clinical experience, I believe there is at least indirect evidence that psychosocial factors do affect disease susceptibility and activity. The most likely mechanism for this to occur would be through psychoimmunological pathways.”
⁵

The inflammation of IBD is the result of disordered immune activity in the gut. Beyond their functions of digestion and absorption, the intestines are also one of the body’s major barriers to invasion. Whatever is in the gut is simply passing through and still belongs to the external world. Only after penetrating the bowel lining do substances and organisms enter the body proper. Since this protective function of the gut tissue is critical to well-being, it is generously supplied with its own local immune system, one that works in coordination with the body’s general immune defences.

Inflammation is an ingenious process invoked by the body to isolate and destroy hostile organisms or noxious particles. It does so by tissue swelling and the influx of a host of immune cells and antibodies. To facilitate its defensive function, the lining, or mucosa, of the bowel is in a “state of perpetually controlled or orchestrated inflammation.”
⁶
That is its normal state in healthy people.

The powerful destructive forces of the immune apparatus must be minutely regulated and kept in such a balance that they are able to carry out their policing duties without harming the delicate body tissues they are charged with defending. Some substances promote inflammation; others inhibit it. If the balance is upset, disease can result. A diminished capacity by the gut to mount an inflammatory response would invite life-threatening infections. On the other hand, an inability to dampen inflammation exposes the gut tissue to self-injury. The central abnormality in inflammatory bowel disease would appear to be just such an imbalance of what one journal article calls the “pro-inflammatory and
anti-inflammatory” molecules in the bowel lining. Emotional influences acting through the nerve and immune pathways of the PNI super-system could tip the balance in favour of inflammation. As Canadian researchers have pointed out, “many, if not all, aspects of gut physiology may be regulated by neuroimmune factors.”
⁷

The nervous system is deeply influenced by emotions. In turn, the nervous system is intimately involved in the regulation of immune responses and of inflammation. Neuropeptides, protein molecules secreted by nerve cells, serve to promote inflammation or to inhibit it. Such molecules are found in heavy concentration in the intestines, in the areas most vulnerable to IBD. They are implicated both in the regulation of local inflammation and in the body’s stress response. For example, a neuropeptide called
substance P
is a powerful stimulator of inflammation because it induces certain immune cells to release inflammatory chemicals such as histamine and prostaglandins, among many others. In the gut, immune cells are closely associated with nerve cells. Chronically stressful emotional patterns could induce inflammatory disease in the gut, through the mediation of the PNI super-system and the activation of pro-inflammatory molecules by stress.

The gut, or intestinal tract, is much more than an organ of digestion. It is a sensory apparatus with a nervous system of its own, intimately connected to the brain’s emotional centres. Everyone intuitively understands the meaning of the phrase “gut-wrenching” as a description of emotionally upsetting events. Many of us can recall experiencing the sore tummy of the anxious child. Gut feelings, pleasant or unpleasant, are part of the body’s normal response to the world—they help us to interpret what is happening around us and inform us whether we are safe or in danger. Nausea and pain or a warm, comforting feeling in the tummy are sensations that orient us to the meaning of events.

The gut secretes its own neurotransmitters and is influenced by the body’s general hormonal system. The gut also forms an important part of the body’s barrier against noxious substances and plays a major role in immune defence. Its functioning is inseparable from the psychological processing that each moment gauges and reacts to the stimuli presented to us by the environment. The ability of gut tissue to maintain its integrity is heavily influenced by psychological factors, and its resistance to inflammation and even to malignant change is also vulnerable to
emotional stress. A species of New World monkey, the cotton-topped tamarin, develops ulcerative colitis and cancer of the colon when captured and caged.
⁸
A 1999 Italian study showed that in ulcerative colitis, “long-term perceived stress increases the risk of exacerbation over a period of months to years.”
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In 1997 Dr. Noel Hershfield, the Calgary gastroenterologist whose timely letter to the editor sparked my own interest in psychoneuroimmunology some years ago, published an article in the
Canadian Journal of Gastroenterology
. He pointed out that in clinical trials of medications for inflammatory bowel disease, there have been instances of placebo response in the range of 60 per cent and that in others comparing narcotics with placebo drugs for pain control, the number of patients who obtained the placebo effect was consistent at 55 per cent of the response. The 55 per cent figure has been seen in trials of anti-depressant drugs as well. It has been called “the 55 per cent rule.”

Most people think of placebo as a simple matter of imagination, a case of “mind over matter.” Although induced by thought or emotion, the placebo effect is entirely physiological. It is the activation of neurological and chemical processes in the body that serve to reduce symptoms or to promote healing.

Dr. Hershfield proposes that it could be useful to study what is different about the people who improve on placebos. “What kind of people are they? What kind of environment do they live in? Is there something from their past experience that produces their response? What kind of lives do they lead? Are they content with their existences, upbringings, marriages and relationships with society?” These are questions that few doctors ever ask their patients, either those who recover or those who do poorly. When such questions are posed, the answers are uniformly revealing. Dr. Hershfield’s article concluded with a sensible suggestion, radical though it may seem in today’s medical climate: “Perhaps we should include instruction to our colleagues and fellows in the psychosocial aspects of illness, the psychodynamics of recovery and the biochemistry of healing, and teach them that all ills of humanity cannot be solved by yet another endoscopy, another biopsy and another ‘high tech’ procedure that only confirms but does not heal.”
¹⁰

A friend of mine, Tibor, suffered an episode of ulcerative colitis—the first and only significant episode he would have—during a time
when he was experiencing “a frantic feeling of hopelessness, fear and apprehension.” In his early twenties, shortly after the death of his father, he was unexpectedly confronted with the responsibility of having to support his mother and care for his younger sister. His mother, who was in poor health, had been dismissed from her job and appeared to have little prospect of finding another. “I didn’t know how I might ever have a life of my own,” Tibor recalls. He was rushed to hospital with high fever and bleeding from the colon.

“They gave me a steroid. I was in the hospital for three weeks, but as soon as they started the treatment I began to feel better and enjoy the nurses around me. This was before hospital cutbacks when nurses had time for patients. The doctors made all kinds of dire predictions of what can happen in the long term—illness, cancer, whatever. I said, ‘Well, I’m not going to have that happen to me.’ I read up on the subject and saw that there were suggestions that ulcerative colitis was psychologically induced and stress related. I got a book on relaxation techniques. I’d lie down and follow the instructions—you know, just relax your toes, relax your legs, relax your whole body.

“I wasn’t on medication for long, only in the hospital. They were telling me to follow this diet or that. I thought, I’m not going to live my life that way. For whatever it was worth, I decided I was going to take control of this situation. I also decided that I would not let external stresses get to me and consciously did what I could do to minimize stress in my life. In the thirty years since, I have been fortunate to have no more than the occasional minor episode of diarrhea or bleeding. None have required medications or medical care.”

This is not to suggest that the cure for IBD is to lie down and relax one’s toes. But significant in my friend’s experience was his immediate decision to take charge.

As Dr. Hershfield implies, not the latest technology or miracle drug but encouraging the patient’s capacity to heal may provide the ultimate answer to inflammatory bowel disease. The 55 per cent solution.

  P
ATRICIA’S ANGER SEEMS FRESHLY ROUSED
. “I’m furious at the doctors. I’ve been condescended to. I’ve been patronized. I’ve been told to my face that I’m faking. I’ve been told that I have to stop going for second opinions. I’ve been told that I’m not feeling pain.”

The gallbladder of the salesclerk was removed in 1991, when she was twenty-eight, but she continued to have abdominal pain. “I had what I called phantom gallbladder attacks. I had more of that you’ve-been-pumped-full-of-air pain. It would expand, and then I’d throw up, and then I’d feel better for a bit. I’d go to emergency. They would ignore me or say, ‘You’ve got no gallbladder, so you can’t be having these symptoms.’ Then I started to develop sensitivities to certain foods, and I had diarrhea more often.”

After many doctors’ visits and tests Patricia was diagnosed with irritable bowel syndrome (IBS). Medical terminology calls IBS a
functional
disorder.
Functional
refers to a condition in which the symptoms are not explainable by any anatomical, pathological or biochemical abnormality or by infection. Doctors are accustomed to rolling their eyes when faced with a patient who has functional symptoms, since
functional
is medical code for “all in the head.” There is truth in that. The patient’s experience is, in part, in her brain—but, as we will see, not in the pejorative and dismissive sense that the phrase “all in the head” implies.

Fiona’s medical history and her experience of emergency wards are remarkably similar to Patricia’s. In 1989, in her early twenties, she also had gallbladder surgery, with no resolution of her abdominal distress.

“Ever since then, I’ve had these pains. It’s just a mind-boggling, sharp spasm, a pain that they’ve done every test in the book for and have come up with nothing. So they’ve diagnosed this IBS. There are no problems with diarrhea or constipation, just pain. The pain is way up here.”

“That’s not IBS, strictly speaking,” I note.

“That’s what I’ve said all along. The diagnosis was made back when they called it spastic colon, and then it’s been called IBS. It was a doctor in Toronto who diagnosed it. I’ve had the stomach scopes, the barium X-ray, and they’ve given me all the medications. They’ve tried me on three or four of the different meds for it. The pills have never done anything for me.

“I’ve gone months without having any of these attacks, and then there may be days where I’ll have them. Sometimes they last two minutes, and other times they are debilitating and last for hours. They are sharp, absolute, spasm-type pains. It takes my breath away—a really intense pain. These days they’re pretty bad. I may have an attack that lasts an hour, but it feels like a year.

“When I was in Toronto, they didn’t know what was wrong with me. They’d put me in hospital and connect me to a Demerol drip, so every time I had an attack I could medicate myself. I had nurses tell me I was just there for the attention and so that I could get more narcotics—that I was hooked on them. My response was ‘Then stop giving it to me. All it does is make me sleep—that’s the only way it helps with the pain.’ I hate the stuff.”

Although abdominal pain is a prominent feature of irritable bowel syndrome, by the current definition of the disorder, pain itself is not sufficient for the diagnosis. A person is considered to have IBS if, in the absence of other pathology, she experiences abdominal pains along with disturbances of bowel function, such as diarrhea or constipation.
¹
The symptoms may vary from person to person, or even for the same individual from time to time. Patricia’s disturbed bowel habits, for example, do not follow any single pattern.

“It swings between constipation and diarrhea. There’s not much in between. I can go days without going to the bathroom, and when I do go, it’s diarrhea. Sometimes it’s several times a day, and sometimes I could be in the bathroom for three hours at once. The only consistent
thing is that there is no consistency. It is sometimes explosive, sometimes not.”

Although they are not essential for the diagnosis, there are other symptoms commonly noted. It is not unusual for IBS patients to describe stool that is lumpy or small and pellet-like or, on the other hand, loose and watery. They may find themselves having to strain and feeling they have not completely evacuated their bowels. They frequently describe passing mucus with their stool. A sensation of bloating or abdominal distension is also common.