Conditioning Model

This is supplemental information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection, by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview Publishing, 2002). Click here to learn more about the book and/or to purchase it.

Howard Brody, M.D. is a physician from Michigan State University who is an expert on the expectancy model, conditioning model, and the placebo/nocebo effect.

Click here to learn more about his book (with Daralyn Brody), How You Can Release the Body's Inner Pharmacy for Better Health (New York: HarperCollins, 2000).

 


 

Counting Blessings

This is supplemental information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection, by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview Publishing, 2002). Click here to learn more about the book and/or to purchase it.

Click here to visit Dr. Neimark's website: The Body/Soul Connection.

 


 

Dietary Guidelines for Americans (DGA)

This is supplemental information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection, by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview Publishing, 2002). Click here to learn more about the book and/or to purchase it.

Click here to read Dietary Guidelines For Americans, 2000, 5th Edition, USDA

 


 

Dr. Drossman’s Biopsychosocial Model of IBS

This is supplemental information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection, by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview Publishing, 2002). Click here to learn more about the book and/or to purchase it.

 

Douglas A. Drossman, M.D. is Co-Director of the University of North Carolina Center for Functional GI & Motility Disorders. Click here to visit this web site. Dr. Drossman has pioneered application of the multidimensional biopsychosocial model for explaining and understanding IBS and other functional GI disorders.

Click here to view a conceptual model of irritable bowel syndrome.

Click here to read "Biopsychosocial assessment important in diagnosis and management for GI patients" (including quotes from Dr.’s Drossman and Salt).

Several of Dr. Drossman’s medical journal articles are included here:

 


 

Dr. Mayer’s Disease Model of IBS

This is supplemental information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection, by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview Publishing, 2002). Click here to learn more about the book and/or to purchase it.

 

Emeran Mayer, M.D. is a gastroenterologist at UCLA, director of the UCLA/CURE Neuroenteric Disease Program and chair of the UCLA Mind Body Collaborative Research Center. He has developed a disease model for irritable bowel syndrome and other functional gastrointestinal syndromes:

Dr. Mayer’s model is similar to that proposed for fibromyalgia and chronic fatigue by Dan Clauw, rheumatologist at Georgetown University Medical Center:

Note that these models are built upon Dr. Bruce McEwen’s concepts of allostasis and the good stress response, allostatic load and the bad stress response, and Dr. Joseph LeDoux’s model of the emotional brain.

Other medical references of interest include:

 


 

Exercise

This is supplemental information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection, by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview Publishing, 2002). Click here to learn more about the book and/or to purchase it.

 

Click here to visit the website of the National Institutes of Health Exercise and Your Heart: A Guide to Physical Activity.

Click here to visit the website of MEDLINEplus Health Information: Exercise/Physical Fitness.

Kenneth H. Cooper, M.D., M.P.H., is recognized as the leader of the international physical fitness movement and has been credited with motivating more people to exercise in pursuit of good health than any other person. He is known as, "The Father of Aerobics." His message is direct: "It is easier to maintain good health through proper exercise, diet, and emotional balance than it is to regain it once it is lost." Click here to visit the website of the Cooper Aerobics Center.

 


 

Expectancy Model

This is supplemental information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection, by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview Publishing, 2002). Click here to learn more about the book and/or to purchase it.

Howard Brody, M.D. is a physician from Michigan State University who is an expert on the expectancy model, the conditioning model and the placebo/nocebo effect.

Click here to learn more about his book (with Daralyn Brody), How You Can Release the Body's Inner Pharmacy for Better Health (New York: HarperCollins, 2000).

 


 

Functional Gastrointestinal Syndromes

This is supplemental information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection, by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview Publishing, 2002). Click here to learn more about the book and/or to purchase it.

 

Functional Gastrointestinal Symptoms

The medical term "functional" means that the cause of symptoms cannot be explained by currently available diagnostic studies, including blood tests, x-rays, endoscopy (esophagogastroduodenoscopy and colonoscopy), biopsy, or surgical findings. Instead, there is an altered physiological function (the way the body works). The most common functional digestive symptoms are listed in Table 1.

Table 1

Functional Gastrointestinal Symptoms

(Affect Two of Every Three People in the United States)

Lump in the throat

Chest pain

Swallowing trouble

Heartburn

Indigestion

Dyspepsia

Upper abdominal pain

Nausea

Vomiting

Chronic abdominal pain

Attacks of abdominal pain

Abdominal bloating/distention

Gas

Belching

Flatulence

Chronic/recurrent diarrhea

Chronic constipation

Anus or rectal pain

 

Scientific studies show that these symptoms are extremely common and that most people experience one or more of them from time to time. The most common functional symptoms are chest pain, dyspepsia (pain or discomfort in the upper abdomen), and abdominal pain or discomfort associated with a disturbance of bowel function (diarrhea, constipation, or alternating diarrhea and constipation). A recently conducted scientific study by Robert Sandler and colleagues from the University of North Carolina concluded that 40.5% reported one or more digestive symptoms within the month before the interview, including abdominal pain or discomfort 21.8%, bloating or distension 15.9%, and diarrhea or loose stools 26.9%. Click here to read an abstract of this medical journal article.

Functional Gastrointestinal Syndromes

Many people with functional gastrointestinal symptoms decide to consult with a doctor, especially if the symptoms include severe pain, raise concerns about a serious disease like cancer, interfere with life's activities (including work, social life, and personal relationships), or become associated with anxiety and/or depression. These recurrent symptoms begin to dominate people’s lives and troubling thoughts about these symptoms can remain constantly in mind. The original symptoms—along with the secondary anxiety they produce—can sap one’s energy, interfere with sleep, and lead to chronic anxiety, depression, fatigue or inner discord.

Many people with functional symptoms who consult with a doctor are diagnosed with one or more functional gastrointestinal syndromes. Any portion of the digestive tract can be involved, including the esophagus, stomach, duodenum, small intestine, colon, abdomen, bile duct, rectum, and anus. Patients with functional gastrointestinal syndromes make up 12% of all patients seen by primary care doctors and 40% of all patients seen by gastroenterology specialists. Click here for more information about functional gastrointestinal disorders from the International Foundation for Functional Gastrointestinal Disorders. A multinational group of doctors and other professionals led by gastroenterologist, Douglas A. Drossman, M.D. has developed a symptom-based, diagnostic classification system called the ROME Criteria for the functional gastrointestinal disorders, or syndromes (see Table 2). Click here to visit the official website of the ROME criteria where scientific and medical publications can be ordered.

Table 2
ROME II Functional Gastrointestinal Disorders (Syndromes)

Esophageal Disorders

Globus

Rumination Syndrome

Functional Chest Pain of Presumed Esophageal Origin

Functional Heartburn

Functional Dysphagia

Unspecified Functional Esophageal Disorder

Gastroduodenal Disorders

Functional Dyspepsia

Ulcer-like Dyspepsia

Dysmotility-like Dyspepsia

Unspecified (nonspecific) Dyspepsia

Aerophagia

Functional Vomiting

Bowel Disorders

Irritable Bowel Syndrome

Functional Abdominal Bloating

Functional Constipation

Functional Diarrhea

Unspecified Functional Bowel Disorder

Functional Abdominal Pain

Functional Abdominal Pain Syndrome

Unspecified Functional Abdominal Pain

Functional Disorders of the Biliary Tract and the Pancreas

Gallbladder Dysfunction

Sphincter of Oddi Dysfunction

Anorectal Disorders

Functional Fecal Incontinence

Functional Anorectal Pain

Levator Ani Syndrome

Proctalgia Fugax

Pelvic Floor Dyssynergia

Functional Pediatric Disorders

Vomiting

Infant Regurgitation

Infant Rumination Syndrome

Cyclic Vomiting Syndrome

Abdominal Pain

Functional Dyspepsia

Ulcer-like Dyspepsia

Dysmotility-like Dyspepsia

Unspecified (nonspecific) Dyspepsia

Irritable Bowel Syndrome

Functional Abdominal Pain

Abdominal Migraine

Aerophagia

Functional Diarrhea

Disorders of Defecation

Infant Dyschezia

Functional Constipation

Functional Fecal Retention

Functional Non-retentive Fecal Soiling

The three most common functional gastrointestinal syndromes with their ROME II Criteria are listed in Table 3.

Table 3

The Three Most Common Functional Gastrointestinal Syndromes

Functional chest pain

(At least 12 weeks, which need not be consecutive, in the preceding 12 months of pain or discomfort in the middle of the chest that is not of a burning quality)

Functional dyspepsia

(At least 12 weeks, which need not be consecutive, in the preceding 12 months of pain or discomfort centered in the upper abdomen)

Irritable bowel syndrome.

Irritable Bowel Syndrome (IBS)

(Affects one in every five people in the United States)

If you have experienced abdominal discomfort or pain for at least 12 weeks (not necessarily consecutive weeks) in the last year, and if your discomfort or pain is accompanied by two or more of the following features, then you may have IBS:

Based upon ROME II Criteria and Thompson, W.G., et. al., "Functional bowel disorders and functional abdominal pain." Gut Vol. 45 Supplement II, 43-47, 1999.

Other symptoms of irritable bowel syndrome may include:

A discussion of irritable bowel syndrome is available on the Internet in the Patient Resource Center at UpToDate's home page (www.UpToDate.com) where it will be updated as needed every four months. Click here to read UpToDate’s patient educational information on Irritable Bowel Syndrome.

You can learn more about functional gastrointestinal disorders/syndromes:

 


 

Functional Gut Symptoms and Syndromes

This is supplemental information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection, by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview Publishing, 2002). Click here to learn more about the book and/or to purchase it.

 

Click here for functional gastrointestinal symptoms and syndromes.

 


 

Functional Gastrointestinal Syndromes

This is supplemental information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection, by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview Publishing, 2002). Click here to learn more about the book and/or to purchase it.

An entire issue of a prestigious medical journal, The Annals of Internal Medicine, was recently devoted to symptoms (Ann Intern Med. 1 May 2001, volume 134, supplement number 9). Click here to read the abstracts of this medical journal issue.

Symptoms are part of the human condition and experience. One survey of more than one million people found that 40% to 55% were having headaches, 33% to 46% fatigue, and 15% sore throat at the moment that they were being surveyed (Hammond ED. Some preliminary findings on physical complaints from a prospective study of 1,064,004 men and women. Am J Public Health. 1964;54:11-23).

Sometimes a person considers a symptom or symptoms to be troublesome enough to constitute an "illness." JH Dingle prospectively followed 443 persons for 10 years, for a total of 970,036 person-days (The ills of man. Sci Am. 1973;229:76-84). There were 9.4 instances per person-year in which the participants reported symptoms that caused impairment sufficiently severe to be described as illnesses. But participants sought medical care for only a minority of the "illnesses." So most people do not regard symptoms as being illnesses or most illnesses as necessitating a visit to the doctor.

The symptoms of "minor" illnesses result in huge expenditures, even when people do not see a doctor about them. The multiple billions of dollars spent on over-the-counter medications that do not require a prescription are part of the evidence for this observation. Every year in the United States, respiratory infection symptoms result in more than 100 million days of lost productivity. The symptoms of irritable bowel syndrome are the second most common cause of missing work (the common cold is first).

However, many patients do decide to consult a doctor about symptoms, and many to most symptoms cannot be explained by convention medical tests. The medical term "functional" means that the cause of symptoms cannot be explained by currently available diagnostic studies, including blood tests, x-rays, endoscopy (esophagogastroduodenoscopy and colonoscopy), biopsy, or surgical findings. Instead, there is an altered physiological function (the way the body works). Kurt Kroenke, M.D. is renowned for scientific investigation of symptoms. In a widely quoted medical report, he showed that in a study of 1000 patient visits for any of 14 different common acute symptoms, doctors could only establish a clear diagnosis in 16% of cases (Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med. 1989;86:262-6). Click here to read an abstract of this medical journal article.

Furthermore, such medically unexplained symptoms can cause functional impairment in life that is as significant as that seen in patients who have well-defined organic diseases (Kroenke K. Studying symptoms: sampling and measurement issues. Ann Intern Med. 2001;134:844-53).

In another study, Dr Kroenke and his colleagues found that many patients with symptoms of minor illnesses do not benefit significantly from their encounter with the health care system (Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and adequacy of therapy. Arch Intern Med. 1990;150:1685-9). 410 of 500 outpatients who were prospectively interviewed indicated that they currently had symptoms, which they regarded as "major problems." Only 39% of patients with presenting symptoms of fatigue, shortness of breath, dizziness, insomnia, sexual dysfunction, depression, or anxiety reported any benefit from the visit or from the treatments prescribed at the physician visit. Approximately one third of patients who seek care for symptoms are dissatisfied with the outcome (Jackson JL, Kroenke K. The effect of unmet expectations among adults presenting with physical symptoms. Ann Intern Med. 2001;134:889-97).

Medically unexplained symptoms are also frustrating for doctors. Hahn found that physicians are more likely to label patients with unexplained symptoms as "difficult," independent of any concurrent psychiatric or organic disorders (Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. 2001;134:897-904).

There is considerable medical evidence that psychiatric distress and disorders (especially anxiety and depression) are found more often in patients with medically unexplained symptoms (Kroenke K. Studying symptoms: sampling and measurement issues. Ann Intern Med. 2001;134:844-53; Barsky AJ. Palpitations, arrhythmias, and awareness of cardiac activity. Ann Intern Med. 2001;134:832-7; Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med. 2001;134:917-25).

Katon and colleagues argue that many symptoms, although medically unexplained, are not necessarily unexplainable or imaginary (Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med. 2001;134:917-25). They state that "many medical symptoms without identified pathology may actually be caused by psychophysiologic or brain-body pathways, such as abnormalities in smooth muscle tone in the gastrointestinal tract during stress in patients with irritable bowel syndrome … Recent research also suggests that links between perturbations in brain physiology and physical symptoms are bidirectional." Sharpe and Carson say the same thing and advocate a "paradigm shift" in which unexplained symptoms are remedicalized around the notion of a functional disturbance of the nervous system" (Sharpe M, Carson A. "Unexplained" somatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Ann Intern Med. 2001;134:926-30). Click here to read an abstract of this medical article.

Barsky proposes an idealized model in which symptoms are studied by independently and simultaneously measuring various neural components of symptom perception and formation (Barsky AJ. Palpitations, arrhythmias, and awareness of cardiac activity. Ann Intern Med. 2001;134:832-7). These components are 1) the peripheral abnormality (for example muscle spasm) that triggers afferent sensory fibers, 2) the ascending pathways carrying sensory messages to the brain and the descending pathways that influence them, 3) the reception of the sensory message in the brain, 4) the activation of perceptual and emotional centers in the brain in response to the received sensation, and 5) the impact of an individual’s emotional state and socially determined belief systems on the perception of the sensation. We may be able to approach this ideal with new scientific techniques and technologies, such as functional brain imaging with positron emission tomography (PET) scanning.

In a medical journal article entitled, Symptoms: In the Head or In the Brain? (Ann Intern Med. 2001;134:783-785), Harvard’s Anthony Karmaroff, M.D. says, " While some patients seek medical care for ‘symptoms’ that are fabricated to achieve secondary gain, most patients who seek medical care for symptoms almost surely have what Sharpe and Carson call a ‘functional disturbance of the nervous system.’ We need to explain this to patients, while also recognizing the important role that a patient’s emotional state can play in augmenting the pathology. Taking this approach is likely to make us (doctors) more effective physicians. What will always remain ineffective therapy, in dealing with the patient who has unexplained symptoms, is saying, in so many words, ‘There’s really nothing wrong with you. It’s all in your head.’"