Gastroenterology
Understanding of IBD-IBS from a Biopsychosocial Perspective By Douglas A. Drossman, M.D.
As providers we often struggle to understand
visceral sensitization may occur from prior
the patient’s illness experience in relationship
inflammation leading to abdominal pain and
to their disease, i.e. the observable data from
diarrhea in up to 20 percent of patients treated
X-ray, endoscopy or histopathology. With
with these potent agents.
structural disorders, such as inflammatory bowel disease or peptic ulcer disease, we
The chronic pain of illnesses like IBD-IBS is a
often assume that the patient’s symptoms
biopsychosocial, multidimensional process,
correlate highly with the evident disease
with sensory, emotional and cognitive
activity. However, a patient’s illness or their
contributions to the experience that relates to:
perception of ill health may vary considerably
1) Ascending visceral pain transmission
from their disease or the externally verifiable
2) Peripheral amplification of visceral signals
evidence of a pathological state.
3) Reduced inhibition by the central nervous system (CNS) of ascending pain signals at
An important example of this possible incongruity can be noted in inflammatory bowel disease (IBD), ulcerative colitis or
the level of the dorsal horn 4) Central amplification via psychological distress
Crohn’s disease. Some patients with active and ulcerating IBD may have few symptoms
Thus, chronic pain involves dysregulation of
and may not even present for treatment until
neurophysiological processes at spinal and
a complication, such as bleeding, obstruction
supraspinal levels. Furthermore, with chronic
or abscess, arises. That is because mucosal
pain, increased afferent visceral stimuli do not
inflammation alone is not sufficient in many
contribute as much as CNS upregulation of
cases to cause pain or other gastrointestinal
incoming visceral afferent signals, which can
symptoms. The pain of IBD relates to
bring even regulatory (normally subliminal)
penetrating ulcers that reach neural plexi,
signals to a point of conscious awareness and
fistulas, obstruction or severe inflammation.
distress.
In contrast, it is not uncommon for us to see
Dr. Douglas Drossman graduated from Albert Einstein College of Medicine and was a medical resident and gastroenterology fellow at the University of North Carolina. He was trained in psychosomatic (biopsychosocial) medicine at the University of Rochester and recently retired after 35 years as professor of medicine and psychiatry at UNC, where he currently holds an adjunct appointment. Dr. Drossman is president of the Rome Foundation (www.theromefoundation. org) and of the Drossman Center for the Education and Practice of Biopsychosocial Care (www.drossmancenter.com). His areas of research and teaching involve the functional GI disorders, psychosocial aspects of GI illness and enhancing communication skills to improve the patientprovider relationship. Drossman Gastroenterology P.L.L.C. (www.drossmancenter.com) specializes in patients with difficult-to-diagnose gastrointestinal disorders and in the management GI disorders, in particular severe functional GI disorders. The office is located at Chapel Hill Doctors, 55 Vilcom Center Drive, Suite 110 in Chapel Hill. Appointments can be made by calling (919) 929-7990.
patients with IBD who report marked pain and
Our understanding of IBD-IBS pain in terms of
diarrhea, but with endoscopic or radiological
both peripheral (gut) and central (brain and
mild or microscopic disease, a similar
spinal cord) acting factors leads to important
phenotype to that of post-infectious irritable
therapeutic implications for the treating
bowel syndrome (PI-IBS). We now call this
physician. The management of centrally
entity IBD-IBS.
driven chronic pain may evoke more centrally
syndrome, in which opioids paradoxically
targeted treatments in addition to or instead
increase pain.
Both IBD-IBS and PI-IBS share similar
of anti-inflammatory agents, for example.
pathophysiological origins with evidence for
Antidepressants, including selective serotonin
References
mucosal inflammation (more so in IBD), often
reuptake inhibitors to tricyclic antidepressants,
Grover, M.; Herfarth, H.; Drossman, D.A. The
in response to infection, which then leads to
and psychological treatments, including
functional-organic dichotomy: Post-infectious
loss of mucosal membrane integrity, cytokine
cognitive behavioral therapy and hypnosis,
irritable bowel syndrome and inflammatory
activation and upregulation of myenteric
are examples of centrally targeted therapies
bowel disease-irritable bowel syndrome. Clinical
nerves, causing pain. The dissociation
for chronic pain as might occur in IBD-IBS.
Gastroenterology and Hepatology 2009;7:48-53
between illness and disease in IBD is most
Narcotic use should be avoided as continued
evident since the use of potent biological
use can escalate gastrointestinal symptoms,
Grover, M.; Drossman, D.A. Pain management
anti-TNF (tumor necrosis factor) agents that
leading to opioid induced constipation or
in inflammatory bowel disease; IBD Monitor
can literally wipe out observable disease, yet
the infrequently recognized narcotic bowel
2009;10:1-10
September 2014
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