What's New in the Literature

Summaries of Recent Research Articles

Psychological Differences between IBS and IBD

It is unclear what role psychological individual differences play in the development and profile of symptoms in inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). Although the causes are not definitively known, the development and trajectory of symptoms seems to differ in IBD and IBS. However, it appears that both can be influenced by life event stressors as well as chronic stress via the ‘gut-brain axis.’ For instance, anxiety and depression, disorders that are both related to stress, are found with greater frequency in IBD and IBS populations compared to healthy individuals. Alexithymia which is characterized by difficulty understanding and expressing one’s emotions, as well as coping strategies have been found to overlap in IBD and IBS patients.

However, overall, IBS compared to IBD patients have a greater level of anxiety and have more dysfunctional attitudes. Likewise, healthcare professionals perceive and engage with IBD and IBS patients differently, indicating the need for increased research to further understand the differences between IBD and IBS and what role these differences play in disease pathogenesis, which were the purposes of the current study.

Seventy-four IBD patients and 81 IBS patients participated in the current study. Ages ranged from 21 to 66. Participants completed several different questionnaires. The Rosenberg Self-Esteem Scale (RSES) was used to examine self-image, or global self-esteem. The Toronto Alexithymia Scale was used to measure the degree to which one is able to understand and express their emotions. The experiences in close relationships (ECR) scale was used to examine anxious and avoidant attachment styles in adults (how people relate to those around them). The sense of coherence scale was used to measure coping abilities in the face of life stressors. Disease activity was also assessed in both groups. For instance, IBS patients reported how much their symptoms, such as abdominal pain and constipations, concerned them.

Results revealed that there were no significant differences between the IBD and IBS patients, except for self-esteem and attachment scales. IBS patients exhibited more anxious attachment style compared to IBD patients when controlling for gender and age and lower self-esteem. However, avoidant attachment style did not differ between the groups.. The authors speculate that this increased attachment anxiety amongst IBS patients may be related to the fact that an organic cause is unknown for IBS, which may have implications for how healthcare professionals relate to IBS patients. Indeed, previous research has shown that IBS patients feel more stigmatization from their doctors than IBD patients.

Source: Bengtsson, M., Sjöberg, K., Candamio, M., Lerman, A. & Ohlsson, B. Anxiety in close relationships is higher and self-esteem lower in patients with irritable bowel syndrome compared to patients with inflammatory bowel disease. European Journal of Internal Medicine, 24, 266-272.

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A Cross-Cultural Investigation of Attachment Style, Catastrophizing, Negative Pain Beliefs and Symptom Severity in Irritable Bowel Syndrome

The purpose of this study was to examine attachment style and two other psychological factors related to Irritable Bowel Syndrome (IBS) (catastrophizing and negative pain beliefs) across different cultures.

What is attachment? It describes the manner in which people feel comfortable or not on their relationships with others. Attachment style, secure or insecure, is a reflection of a child’s need for protection from a caregiver and may be manifested in four profiles of adult attachment style: 1) secure which is well-regulated, 2) anxious preoccupied which is characterized by a desire for closeness but protection is comprised due to worry about availability of others, 3) dismissive avoidant which is characterized by a discomfort with closeness, and 4) fearful avoidant which is related to a desire for closeness that is compromised by fear. It is important to study attachment in illness domains, particularly IBS, because it has been related to health maintenance and chronic pain syndromes. Attachment has been studied in chronic illness, but not in IBS.

In the current study, 50 IBS patients and 20 healthy controls at nine different international sites completed the IBS symptoms severity scale, and attachment questionnaire, catastrophizing and negative pain belief questionnaires as well as questions regarding healthcare visits. The nine sites were: the New York, NY, USA; Los Angeles, CA, USA; Mexico City; Mexico; Rome, Italy; Bari, Italy; Cluj, Romania; Teheran, Iran; Lucknow, India; Beijing, China. IBS is a global condition so it is important to assess different geographic areas.

Results revealed that anxious and avoidant attachment styles were significantly higher in IBS patients than healthy controls. Fearful-avoidant attachment was the most common style in the IBS patients.

The other interesting finding in this study was the significant differences in all three psychological variables, attachment, catastrophizing and negative pain beliefs from one site to another. The largest variance was in China and Romania. This may represent the stressful political and social changes that have occurred in both countries.

Path analysis, a statistical method that assesses direct and indirect relationships, showed that attachment anxiety and attachment avoidance had an indirect effect on IBS symptom severity through their highly significant effects on catastrophisizing and negative pain beliefs.

Finally, attachment anxiety was higher in patients who reported having 2 or more healthcare visits compared to those who reported 1 or fewer while, in contrast, attachment avoidance was higher in patients who reported having 1 or fewer healthcare visits than those who reported 2 or more. These findings are consistent with other reports that describe the effects of attachment style on various aspects of the doctor-patient relationship. Recognizing that patients are insecurely attached, either anxious or avoidant, may help physicians to be more effective.

In conclusion, these findings are important because they show that attachment styles are systematically different between IBS patients and healthy controls. Additionally, attachment styles and the other psychological measures in IBS that were studied differ across different cultures, an observation that requires further investigation.

Source:CD Gerson, MJ Gerson, L Chang, ES Corazziari, D Dumitrascu, UC Ghoshal, P Porcelli, M Schmulson, W-A Wang, M Zali Neurogastroenterol Motil, 27: 490-500, 2015

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Expressive Writing as a Therapeutic Tool

Research exploring the effectiveness of expressive writing began in 1986 when Pennebaker and Beall first investigated whether expressive writing about a traumatic life experience had positive consequences for physical health. However, there has been much variability in the results of the research. This may be due to the fact that expressive writing may function differently (e.g., more effectively) in different contexts. Thus, additional research was needed to explore which contexts maximize the effectiveness of the expressive writing paradigm.

Methods: Through recruitment at the University of California, Los Angeles, 116 individuals participated in the study whose ages ranged from 18 to 35. Fifty nine were randomized to the expressive writing group while 57 were randomized to the control condition. Participants in the experimental condition wrote for 20 minutes on four separate occasions about their deepest thoughts on the most stressful experiences in their life within the last five years. Participants in the control group also completed four 20 minute writing sessions in which they were instructed to explain how they typically spend their time, without expressing emotions. Outcome measures included depressive symptoms, physical symptoms, and anxiety symptoms. The study also determined whether results were affected by feelings about coping with emotions, expressing emotions and ambivalence over expressing emotions.

Results: The overall effect of expressive writing on outcomes was not significantly different from the control group, but writing did affect anxiety level. Participants who were highly anxious at baseline had less anxiety after expressive writing while participants who were low in anxiety at baseline had more anxiety afterwards. This finding suggests that the effect of expressive writing depends on different psychological characteristics of the individual. Professionals should take this into account when implementing expressive writing as a therapy. Future research is needed to uncover additional moderators that may target populations that may benefit from expressive writing.

Source: Niles, A. N., Haltom, K.E., Mulvenna, C. M. Lieberman, M. D., & Stanton, A. L. (2013). Randomized controlled trial of expressive writing for psychological and physical health: The moderating role of emotional expressivity. Anxiety, Stress, & Coping: An International Journal.

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