We have all experienced it; an important interview, the fear of being out of control, an unfair accusation, shocking news; they can all trigger an urge to evacuate our bowels. But some people feel under threat all the time and may not be able to leave their house until they are sure their bowels are completely empty.
The physiology of stress related diarrhoea.
When the ethologist and Nobel laureate, Konrad Lorenz, startled his pet geese in his study at Altenberg, they evacuated the bright green contents of their paired caeca all over his Persian rug. Also sheep and cattle frequently urinate and defaecate if you approach them too closely. A similar phenomenon occurs in us. During stress, the computer in our brain that controls our bowels may be reprogrammed for evacuation, and this may be enhanced by an associated increase in bowel sensitivity.
Stress, whether this is emotional stress, physical trauma or infection causes the release of corticotrophin releasing factor from the hypothalamus which acts on the dorsovagal nucleus in the to cause gastric stasis and colonic evacuation. This would explain why stress of any kind may induce diarrhoea and vomiting. The effect of psychological stress on the gut recruits the same brain gut mechanisms that empty the gut during food poisoning. There is also evidence to suggest that psychological stress can induce changes in the immune system of the gut resulting in hypersensitivity, increased permeability, changes in the microbiota, all of which might feed back to enhance the defaecation response.
Studies have suggested that when gastroenteritis occurs together with anxiety, depression and/or an upsetting life situation or event, it is more likely to lead to persistent diarrhoea. It is as if the context anchors a stressful situation to the gut. If that can occur after an attack of gastroenteritis, how much more powerful it is if the attack of diarrhoea is induced by a life trauma or upsetting situation? Both can sensitise the gut so that any change, however seemingly insignificant, may induce the same gut reaction.
What does it mean to be sensitive?
There is a strong association between Irritable Bowel Syndrome and symptoms of anxiety and depression. How we feel about what happens can upset our bowels, but the bowel upset also affects how we feel. It’s a ‘vicious cycle’. Whatever the original cause, it seems that sensitive bowels occur in sensitive people.
Sensitivity is in many ways a gift; it implies a greater awareness. Sensitive people see things more clearly, hear the nuances in music, perceive the hidden messages in conversation, pick up on change in tone and attitude, see possibilities in situations, understand the connections between things. Life, one could argue, is richer, but it comes at a cost. Sensitive people are wary of change, they perceive potential threat in everything and can react excessively. They are unsure of how they should be in a new situation. Sensitivity can imply a fragile sense of personal identity, which can affects every aspect of behaviour and physiology. Sensitive people find it difficult to regulate their emotions and their physiology. They may react to change with pain and bodily reactions. People often report that that they feel more insecure and out of control when they have diarrhoea.
But stress can also cause constipation.
How can that be? In my previous post, I have suggested that constipation may be associated not so much with expression of emotion, but with suppression. Constipation is often accompanied by depression and denial, and sublimation. The motility of the colon tends to delay or inhibit faecal evacuation and in many cases sensitivity may be reduced. So colonic physiology is a metaphor for emotional expression; anger and anxiety is more commonly associated with diarrhoea and rapid transit while suppression and depression is associated with delayed transit and constipation. A study conducted in the nineteen eighties showed a strong association between bowel habit and personality. People who tended to score highly on the extroversion scale passed large, soft and frequent stools whereas those who were introverted and defended struggled to squeeze out a few pellets. So it would seem that people suffering with IBS diarrhoea may find it as difficult to contain their emotions as they do their motions. Although most people tend to have a predominant psychosomatic expression but in some constipation and diarrhoea can alternate depending on what is happening.
An expression of who you are.
If IBS is related to an insecure or fragile sense of identity, at least in some people, it begs the question why. To paraphrase the medical philosopher, Sir William Osler: ‘A man (or a woman) may inherit an irritable nervous system, a confident one may be spoiled by bad training or shocked out of action by the blows of circumstance.’
Some people with IBS, but certainly not everybody, can identify a particularly traumatic episode that has shocked their bowel and made it very sensitive. However, some people can withstand the same circumstance better than others. So could lack of ‘good enough’ parenting, because of relative neglect on the one hand or overprotection on the other have impaired the development of a confident and robust sense of self. Childhood is a process of learning; children need to be shown but then given the space to do it themselves.
Some sensitive people may be able to compensate for a deficient self regulation by finding an identity in some role or activity. Many artists, actors, musicians and writers are highly sensitive people. Others use their finely tuned sense of intuition and judgement to be successful in business or professions. Others may be lucky enough to ‘hook’ up with somebody else who is more robust and confident. It is when they are alone in an unfamiliar situation where they have to be spontaneous that they may feel helpless and develop symptoms.
Sensitivity needs managing.
People who are sensitive constantly worry about what may happen. They find it difficult just to be. In the last twenty years, the concept that has captured the imagination of patients and health care professionals is ‘Mindfulness’, an application of age-old Buddhist philosophy. Mindfulness is about living in the ‘here and now’ instead of the ‘there and then’; it removes you from the frustrations and worries of life, quietens the inner turmoil and soothes the discomfort. It encourages self reflection, which allows you to get things in perspective and provides insight. This helps you gain control of your body reactions and gives you health confidence.
There are many routes to mindfulness, but perhaps the best is to immerse yourself in something you enjoy doing, like for example, writing, drawing, walking in the country, or even cooking or helping your children or grandchildren focus on something that captures their interest. No matter what is wrong with you, what illness you may have, these very basic aspects of healthy living will make you feel better.
This post is based on an article published in this month’s issue of Gut Reaction, the magazine of The IBS Network. To see more articles on Diarrhoea, this month’s themed topic or to get your own regular copies of Gut Reaction, join The IBS Network today.