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Gastroenterology, Irritable Bowel Syndrome, Food Sensitivities
Psychoneuroimmunoendocrinology describes the inter-relationship of mental, neurological, hormonal and immunological functions, addressing the impact of cognitive images of the mind (whatever its elusive definition) on the central nervous, endocrine and immune systems. It encompasses biofeedback and voluntary controls, impacts on physiology of thought, attitude and belief, past/present stress, placebos, social relationships and "energy medicine." This column highlights clinical applications of cogent studies from these arenas of holistic medicine in the new millennium.
Food Sensitivities and Hyperlipidemia
Seven hypercholesterolemia patients with known multiple food sensitivities went on a six-month diet eliminating sucrose, milk, and grains, obtaining a majority of their calories from beef from which browned and burned fat was trimmed. Fruits and vegetables were peeled or washed with soap and water, and subjects took supplements of vitamins A, B-complex, C, D, E, Ca, Mg, Se, and Zn, and 30 ml of PUFAs/d. Mean cholesterol fell from 263 to 189 mg/dl, mean triglyceride from 113 to 74 mg/dl and HDL-C rose from 21 to 32 mg/dl.
Newbold HL. Reducing the serum cholesterol level with a diet high in animal fat. South Med J. 1988;81:61.
Comment: This is a small uncontrolled study in which end-point measurements were compared to those at baseline. The gains are comparable to improvements that one could get from the use of HMGCoA reductase inhibitors (statins) or from red yeast rice. The ingestion of beef did not raise lipid levels, but browned and burned fat was removed. Since multiple interventions were instituted, it is uncertain which exhibited the most influence – the supplements, the beef, or the elimination of sensitizing foods. Since the study was not controlled, there is some possibility that there might have been a placebo effect of a highly proactive approach.
Duodenal Ulcer and Attitude
Mean positive life event scores were significantly lower in several score duodenal ulcer patients than in disease and healthy controls, and lower in patients with active ulcer than in those in remission. The positive scores and total life change scores fell significantly after six months in the control group and showed no significant variation in the duodenal ulcer group after six months. The authors conclude that the perception of life events, especially positive ones, is associated with duodenal ulcer.
Hui WM et al. Life events and daily stress in duodenal ulcer disease. A prospective study of patients with active disease and in remission. Digestion. 1992; 52:165.
Comment: The quality of perceptions is greatly influenced by attitude. One does not know here whether the presence of ulcer symptoms colored the attitudes, which in turn determined the quality of perceptions, or whether it was the quality of perceptions that instituted conditions leading to peptic ulceration. It is known that resistance to gastric erosion is diminished with unmanaged stress. Conversely, states of relaxation increase gastrointestinal peristalsis, resistance to digestive juices, and digestion and assimilation improve. The best treatment of gastric and duodenal erosions, then, must go beyond the prescribing of H2 blockers (e.g., famotidine, Pepcid), proton pump inhibitors (e.g., lansoprazole, Prevacid), and antibiotics to try to eliminate the presence of the associated bacterium, H. pylori. Stress is not even mentioned in the list of causes or contributors to gastric/duodenal ulcer in most textbooks. And it will take even longer for biofeedback and meditation to be listed as treatments for ulcers.
Functional Bowel Distress
Since hypnosis can be used safely to induce specific emotional states of considerable intensity, the effect on distal colonic motility of three hypnotically induced emotions (excitement, anger, and happiness) was studied in 18 irritable bowel syndrome patients age 20 to 48. Colonic motility index was reduced by hypnosis alone (mean change 19.1, p < 0.05) and this change was accompanied by decreases in pulse rate of 12/min (p < 0.001) and respiratory rate of 6/min (p < 0.001 for both). Induced states of anger and excitement increased the colonic motility index 50.8 and 30.4, respectively (p < 0.01 for both), pulse rate 26 and 28/min, respectively (p < 0.001 for both), and respiration rate 14 and 12/min, respectively (p < 0.001 for both). Happiness further nonsignificantly reduced colonic motility from that observed during hypnosis alone. Changes in motility were mainly due to alterations in rate than in amplitude of contractions. The observation that hypnosis strikingly reduces fasting colonic motility may partly explain the beneficial effects of this form of therapy in all functional bowel disorders.
Whorwell PJ et al. Physiological effects of emotion: assessment via hypnosis. Lancet. 1992;340:69.
Comment: The marked effects observed here would indicate that this approach could be very useful in other organ systems as well. Hypnosis is a wholly underused therapeutic approach for symptom relief and adjunctively for managing organic disease syndromes. And formal training need not be extensive. I was once asked to make a house call on a new patient who could not be awakened, although her respirations and breathing were quite normal. On arriving at the bedside, I found a young woman with eyes open, lying supine on her bed, unresponsive to requests to talk or respond to questions. Totally untrained in hypnosis, I calmly led her through a relaxation exercise somewhat like guided imagery, during which she closed her eyes in response to suggestion. In the middle of the relaxation exercise (about 7 minutes), I suggested that at the close of the exercise she would come to full wakefulness and be able to answer questions. At the close of the exercise, she opened her eyes, sat up and began to respond. Suggestions expressed in a calm voice can have a near-hypnotic quality in susceptible persons.
The Long Shadow of Childhood Abuse in Gastrointestinal Syndromes
In 206 university gastroenterology clinic women patients, 44% reported physical and/or sexual abuse in childhood. Only 17% had shared this with previous physicians. Versus those with organic gastrointestinal disease, those with irritable bowel syndrome were significantly more likely to have been abused. Odds ratio for reporting a history of forced intercourse was 2.08 (95% CI 1.03–4.21), 11.39 for frequent physical abuse (CI 2.22–58.48), 2.06 for chronic or recurrent abdominal pain (CI 1.03–4.12), and 2.7 for more lifetime surgeries (p < 0.03) vs. organic disease GI patients. Abused patients were more likely than nonabused patients to report pelvic pain (OR4.05; CI 1.41–11.69), multiple somatic symptoms (7.1 vs. 5.8 symptoms, p < 0.001), and more lifetime surgeries (2.8 vs. 2.0 surgeries, p < 0.01).
Drossman DA et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med. 1990;113:828.
Comment: All told, significantly increased risk of lifetime gastrointestinal and pelvic symptoms and/or surgery was present in abused women. In all histories without a clear explanation for painful symptoms beyond usual levels for given organic diseases, questions about physical, emotional, verbal, and sexual abuse are appropriate. Repression of memories of childhood abuse are common and bringing events to light so that they may be dealt with and resolved takes extra patience and establishment of a deep level of trust between practitioner and patient.
The Russek and Schwartz Study
This classic study of childhood influences involved 400 men and women who as college students had completed three psychological instruments. Thirty-five-year follow-up health assessments found that the number of college-age positive descriptors for mothers and fathers was very much higher in healthy vs. sick subjects in both women and men (p < 0.002). Positive parental descriptor scores were highly correlated with the 5-point Likert scale ratings of individual items, the most reflective of which were "loving," "just," "fair," and "hard-working" (p < 0.01). All four sick subgroups (cardiovascular disease, duodenal ulcer, alcoholism, and miscellaneous) had significantly fewer positive descriptors than the healthy group (p < 0.036). Sick subjects, whether smokers or not, had lower descriptors (p < 0.019). 15/51 sick subjects vs. 0/38 healthy subjects had experienced a parent’s death or divorce (p < 0.0004), although the number of positive descriptors was still significantly lower in those with and without a parent’s death and/or divorce (p < 0.004). Sick subjects also had lower descriptors whether or not they had experienced personal divorce (p < 0.022). The percentage of sick subjects who experienced excessive anger and anxiety was higher in those with low positive descriptors (p < 0.007). Both high vs. low positive parental descriptors and high vs. low ratings of parental love and caring were risk factors for later illness (p < 0.0001). 95% of those who both used few positive descriptors of their parents and rated them low in parental caring had diseases diagnosed in midlife, vs. only 29% of those who used positive descriptors and rated their parents high in caring.
Russek LG, Schwartz GE. Narrative descriptions of parental love and caring predict health status in midlife: a 35-year follow-up of the Harvard Mastery of Stress Study. Altern Ther Health Med.1996;2:55.
Comment: Duodenal ulcer was one of the prominent middle-age health problems in those who, at college age, had described their parents and childhoods with few positive statements. It is axiomatic that parental and childhood relationships play enormous roles in adult illness. The issue for the physician and health practitioner is to assist the patient in coming to terms with the devastating aftermath of this childhood negativity and begin to care for himself unconditionally from a freshly assumed positive attitude. The thirty-five year follow-up is one of the great strengths of this study.
Irritable Bowel Syndrome, Relaxation and Biofeedback
Eleven patients with irritable bowel syndrome were treated for 12 weeks with an integrated program including 6 thermal biofeedback sessions, education about normal intestinal function, teaching of progressive relaxation, and cognitive stress-coping techniques. The patients met in groups of 3 to 6 persons following 12 weeks of baseline monitoring, recording and observation. Diarrhea and abdominal pain improved significantly (p < 0.05), and 6 weeks later in follow-up, constipation and flatulence had improved significantly (p < 0.05).
Blanchard EB, Schwarz SP. Adaptation of a multicomponent treatment for irritable bowel syndrome to a small-group format. Biofeedback Self Regul. 1987;12:63.
Comment: The experience of stress, affecting mental and emotional factors, plays an enormous role in gastrointestinal symptomatology. Physical factors notwithstanding, relaxation training nearly always will be beneficial, even as diet, probiotics and multiple biomedical factors are being addressed in an integrative holistic approach, as illustrated in the following study.
Irritable Bowel Syndrome/Relaxation-Psychotherapy
One hundred and two patients with irritable bowel syndrome of less than 1 year's duration and unimproved with 6 months of medical treatment were randomized to (1) a medical treatment group (high fiber diet and antispasmodic drugs) or (2) psychological treatment including an initial >2-hour interview followed by regular therapeutic interviews using the conversational model of Hobson. Each patient received a relaxation tape to use at home on a regular basis with no psychotropic medication. At three months, the psychotherapy group was significantly better off than the medical-only group, with improvement in therapist observations of discomfort (p < 0.01) and diarrhea (p < 0.05), and in subjective patient observations of decreased pain (p < 0.001), distension (p < 0.01), and diarrhea (p < 0.05). At three months, there was also significant correlation with improvement in the Psychiatric Assessment Schedule, the Hamilton Rating Scale and the Clinical Anxiety Scale and the degree of decrease in abdominal symptoms (p < 0.001). Symptom scores, improved overall, were highly significantly improved in women (p < 0.01 to 0.001) but not significant in men. In the following year, clinic visits were reduced 75% compared with the previous year (p < 0.001). The psychiatric improvement on HRS and CAS scores was significantly better than controls (p < 0.001 and p < 0.01 respectively).
Guthrie E et al. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterol. 1991;100:450
Comment: Cognitive psychotherapy engendered greater improvement than the medical-only group. Although not done here, the best approach would seem to be to employ the best of the biomedical and psychotherapeutic techniques. A holistic approach in which a thorough investigation of the mental, emotional, nutritional, attitudinal, and physical activity of the patient are explored greatly increases the chances for successful outcomes. Even intentions may need to be included in patient discussions, as highlighted in the following study.
Intention and Outcomes
Sixty-one individuals were assigned to one of four groups and asked to record their moods each day for a week by using the Profile of Mood States. On days 3, 4, and 5, each subject consumed a half-ounce of dark chocolate twice a day at prescribed times. Three groups in double-blind fashion received chocolate that had been intentionally "treated" by Tibetan monks and Mongolian shamans. The intention expressed in each case was that people who would consume the chocolate would experience an enhanced sense of energy, vigor, and well-being. The fourth group blindly received "untreated" chocolate as a placebo control. On the third day of eating chocolate, mood had improved significantly more in the three intention conditions than in controls (p = 0.04). A subset of individuals who habitually consumed less than the mean of 3.2 ounces of chocolate/wk showed a stronger improvement in mood (p = 0.0001). Primary contributors to the mood changes were the declining in fatigue (p = 0.01) and increasing vigor (p = 0.002).
Radin D et al. Effects of intentionally enhanced chocolate on mood. Explore (NY). 2007;3:485.
Comment: If the conclusion of this controlled study is valid and extrapolated, our intention needs to begin to be factored into many aspects of lifestyle. The mood-elevating properties of chocolate appeared to be enhanced with positive intentions focused from the actions of shamans and monks. It is very difficult for most Western and conventional scientists and observers to wrap themselves around the parameters of "energy medicine." Understanding homeopathy requires such thinking. Understanding the many energy therapies such as therapeutic touch, healing touch, quantum healing, and Matrix Energetics also requires a quantum leap beyond conventional physics. William Tiller, professor emeritus of materials science at Stanford University, has explored the new physics aspects of the theory of energy medicine in Psychoenergetic Science: A Second Copernican-Scale Revolution (Walnut Creek, CA: Pavior Publishing; 2007). While much of what Tiller presents is theoretical, his clinical experimental work on quantifying the effect of intention is extraordinary.
Robert A. Anderson, MD, FAAFP, FACPM, ABIHM
614 Daniels Drive NE
East Wenatchee, Washington 98802-4036
Robert Anderson is a retired family physician who has authored several major books, Stress Power!, Wellness Medicine, Clinician's Guide to Holistic Medicine, and The Scientific Basis for Holistic Medicine. Anderson founded the American Board of Integrative Holistic Medicine, is a past president of the AHMA, past assistant clinical professor of family medicine at the University of Washington, and present instructor in The Art of Primary Care at Bastyr University.