June 2008

Let the trumpets sound!  The National Institute of Clinical Excellence (NICE) has produced its guidelines for the diagnosis and management of Irritable Bowel Syndrome (IBS) in primary care.  It’s out and it’s big; more than five hundred pages.  No longer do doctors and practice nurses have to worry about what IBS is, what tests to do, what treatments work.  It’s all there!  But does it help?  Does it add one comma, one semi colon, a single word or illuminating sentence to the volumes that have already written about this condition?   No.  In Pythonesque style, trumpets collapse in a descending series of farts.   


It has been said that the amount we know about any subject is inversely proportional to how much has been written about it.  On that basis, it would seem that as the reports and guidelines accumulate, we know less and less about Irritable Bowel Syndrome.  This report is no exception.  Not only is there the customary tedious recanting of the mantra of Rome – , but any insights into how life events and situations may instigate IBS are suppressed in favour of what would not be out of place in a 1950’s copy of Good Housekeeping;  regular exercise, not taking bran and drinking eight cups of fluid a day.  Complementary therapies are afforded scant attention and idiosyncratic acceptance; hypnotherapy and homeopathy are in,  acupuncture and reflexology are out.  Doctors and nurses are advised to apply the General Practice Activity Questionnaire in order to discover whether patients are sedentary.  Whatever happened to common sense?         


The problem is that Irritable Bowel Syndrome does not exist as a discrete disease.  It has no pathological basis, no obvious physical cause, no diagnostic tests and no generally effective treatment. IBS is a medical invention, created in the 1970s to provide a name for the recurrent abdominal pains and bowel disturbances that cannot be explained by colitis, Crohn’s, coeliac disease, cancer or any known gastrointestinal disease.  It is one of a rash of new medically unexplained illnesses that include chronic fatigue syndrome, fibromyalgia syndrome,  functional dyspepsia,  non cardiac chest pain,  tension headaches, restless legs and irritable bladder. There are no typical symptoms of IBS.  Instead patients have a variety of symptoms, some affecting the bowel, many others the back, the head, the lungs, the legs, the bladder.  The symptoms of IBS are as individual as a fingerprint; some patterns are similar but no two patients present the same way.  Attempting to categorise such illness by committee is about as useless as trying to bottle starlight.      


It is not surprising that IBS overlaps with other medically unexplained illnesses.  They share the same epidemiological features.  They are more common in women, and in the young rather then the old, and there is a strong association with psychological disturbance.  In the past before medical specialisation,  there were all subsumed under the same overarching mind body diagnoses – hysteria, melancholia, neurasthenia, hypochondria, the spleen, irritable weakness.  We have always had medically unexplained illnesses, but they have changed their guise and attribution according to the culture. 


So how can we begin to understand illnesses like Irritable Bowel Syndrome?  Not by the mounting a stiff defence of the diagnosis by yet more guidelines – that’s for sure!  My experience as a specialist physician and psychotherapist for over 30 years suggests that IBS might be regarded as the visceral expression of intolerable emotional tension.  Over a hundred years ago, Freud and Breuer said that hysteria was a disease at the level of the idea.  The same applies to the latterday raft of medically unexplained illnesses.  What we believe in, what we imagine, our fears and dreads, the meaning we put on events have the capacity to make us as ill as the most virulent infection.  This notion is supported by the most recent research in neuroscience, which shows clearly how the abnormal activity of the emotional centres of the brain in medically unexplained illnesses can be suppressed together with the symptoms by psychological treatments. 


So instead of advocating research into different antidepressants, physical exercise and why don’t the committee suggest research into the commonality of medically unexplained illness and their relationship with life situations. 


So do these bulky guidelines have any value, besides providing a convenient doorstop that reassures overworked nurses and doctors.  Will they help patients with IBS?   They will if their advice about partnership with the patient communication, involvement of carers and family, and self management, are taken to heart,  but in all else the document reads as a didactic approach to medical management. 


In dealing with unexplained illness, it is more important to understand the patient than the disease.  There is no mention in this volume of the importance of the patient as an individual; how their life style, life situation, and life events, all impact to wrench their gut out of kilter. 


But this is not unexpected. NICE guidelines are based on evidence obtained from populations.  When symptoms are as variable and idiosyncratic as those in patients with IBS,  what serves as statistical evidence becomes meaningless.  As doctors, we need to abandon our dependence on what serves as ‘evidence’ and adopt different perspectives.  Perhaps neuroscience will lead the way, perhaps novel psychological assessments, or perhaps we just need to view illness more from the life experience and psychosocial perspective of the ill person. 



Are intimate human relationships driven by sex or are they driven by security?     Jeremy Holmes, Professor of Psychotherapy at the University of Exeter and author of  ‘The Search for a Secure Base’, would support the latter.  His is a domesticated view of sexuality.   He argues that our most fundamental needs are for security,  and good sex can only take place within a stable partnership. Good sex, he asserts, is like good conversation or good therapy, a mutual inspiration, the creation of something new that either partner could not achieve alone.  That can only occur if both partners are relaxed and trusting.  Insecurity leads to defensiveness which closes up creative possibilities. 


Holmes is an advocate of attachment theory.  He opposes Freud’s assertion that the intimacy we enjoy with our mothers in infancy, rather confusingly termed ‘infantile sexuality’, drives and conditions our attachment with each other.  Holmes believes that our needs for attachment precede and set the secure base for sexual exploration.


Speaking last month at The West Yorkshire Playhouse for The Harry Guntrip Trust, Holmes explained how notions of attachment and sexuality are quite contrary to each other.  ‘Attachment is  about familiarity’, he asserted, ‘but sexual excitation is about the  strangeness of the other – the unknown.  Mother mirrors all aspects of an infant’s behaviour except those that are explicitly sexual.  This non gratification of sex leaves the infant with a hunger for sexual intimacy, which is only gratified when they meet their future sexual partner.’    


Holmes equates sexuality with exploration; a search for novelty and excitement. As the experiments by Mary Ainsworth so clearly showed,  children who feel secure in the love of their mothers,  will play quite happily when she leaves the room and welcome her with a smile and hug when she returns.  As those children grow up, they carry the consistency of their mother’s love in their minds, creating the confidence to explore and seek the excitement of genital sex with a novel partner.  Without a secure base, we cannot trust, cannot imagine, cannot explore and are unable to enjoy satisfying sex.     


The psychoanalyst, Lawrence Eagle, imagined an essential conflict between sexuality and attachment, writing that mature relationships are always a trade off between our needs for attachment and security and our needs for exploration, sexuality and excitement.  The challenge is how to negotiate these conflicting needs. If you have too much attachment, sex won’t last, he argues, but if you have too much excitation, the relationship won’t last.  


Eagle’s dichotomy appears to indicate that biologically, human beings are not created to be faithful to one partner for all of their lives – and marriages are only held together by social pressure.  Or maybe that is a male perspective; the imperative of the ‘hunter’ in whom sex plays out the metaphor of exploration and conquest.  Many women have a different imperative – the gatherer –  the creation of a stable home and investment in the children.  Sex is then seen as reaffirming, consolidating, reassuring and bonding.  But maybe these different roles were socially conditioned by much harsher environments.        


It is true that as couples become more ‘attached’ and familiar with each other, they make love less often, but that does not necessarily imply that the relationship has become boring.  There are other sources of excitation besides sexuality.  As they grow together in companionship, successful couples develop a shared enthusiasm for creating a home together and raising their children, and for mutual interests within and outside the community.  Indeed, it could be that as couples mature and become more confident with each other, sex is needed less as a source of reassurance.   We might even say that with ageing couples, if sex has to be co-opted to shore up the relationship, it must feel very insecure.      



While acknowledging the perspective of  The Lone Ranger,  human beings are a social species.  Our families and social groups supply meaning and purpose to our lives.  The theory that sexuality and attachment are somehow in conflict seems wrong, not only from a viewpoint of the family and society, but also from an evolutionary perspective.  Why would we have a built in libidinal drive that threatens the health and very existence of our children?    


Freud’s notions of infantile sexuality make more sense if we transpose the term ‘intimacy’ for sexuality.  Freud said that ‘ultimately the ego is a body ego’. Attachment is physical before it is psychological.  We emerge from our mother’s body and attach to the breast.  We are reassured by cuddling,  kissing and stroking. Our mothers feed us, clean us, keep us warm, hold us.   If this is sexuality, it is not as we as adults know it; it is a whole body intimacy.  It is a physical attachment and as such, the nature of this early physical attachment cannot fail to set the template for  intimate and less intimate attachments later in life.  If it is confident and trusting, then, unless something happens to undermine that early experience, we will form confident and trusting adult relationships.  But if it is ambivalent or worse, even hostile, our adult relationships will lack trust and continue to be challenging and difficult.     


I would accept entirely the notion that secure attachment is a prerequisite for loving and confident sexual intercourse,  but that attachment is fundamentally a bodily attachment. We are physically attached to our mother before we are emotionally attached.  Our emotions, after all, are physical feelings put into context. 


Throughout life, physical intimacy is the foundation of good attachment. When couples fall in love, their intense physical desire fuels an intimacy, that dismantles defences and creates the bodily and emotional trust for lifelong attachment.  I wonder whether Holmes is right when he implies that good sex only occurs in the context of secure attachment.  His view is predicated on what he means by ‘good’.  Is this good sensation, morally right, or life enhancing?   Many couples have told me that their best sex occurred during the risky time of courtship, serving to consolidate trust and fix memories. 


Sex is not just a pelvic experience – like defaecation,  it is imbued with layers upon layer of memory and meaning.  It is those representations that make it ‘good’ or not.  ,  But the sexual experience itself emphasises and consolidates meaning by biological mechanisms.  Brain scanning has shown that orgasm can dissociate the hippocampus, releasing oxytocin (the attachment hormone) and reducing anxiety.  Couples relax and talk more openly, more freely, after sex. 


But it’s not just sexual intercourse that creates bonds, any type of physical relationship can do it.  The pain of natural childbirth and the intimacy of breast feeding also releases the love hormone oxytocin, which affirms the close bond between mother and child necessary to maintain the provision of care until maturity.  The physical intimacy of soldiers, the mutual fear, the pain of injury  creates life long friendships.  The same kind of bonding takes place in sports teams.  Families that are close and intimate stay together throughout life undeterred by geographical distance.  All of these examples suggest to me that within healthy relationships, sexuality, like other aspects of physicality is not in conflict with attachment, it is an essential part of an iterative interaction.        


Indeed I would go so far to say that if attachment and sexuality are separated, it is a recipe for disaster.  Love affairs offer the physical excitement of being in love without the possibility of resolution into trusting life-long relationships.  But when disconnected from attachment and used instead to gratify narcissistic requirements, sex can become a weapon in a struggle for dominance, deployed to manipulate, exploit and humiliate.  Lacking a satisfactory resolution, the romantic make believe must inevitably disintegrate into a grievous power struggle.  Selfish and debased, the physical relationship becomes by stages, addictive, sado-masochistic and hostile and may, in a climate of deception and betrayal, release forces that are terribly destructive, even lethal.   


If sexuality without attachment can be lethal, then attachment without sexuality can be moribund. If physical intimacy threatens the relationship by creating a dangerous dependence or releasing the fury emanating from a previous betrayal, then it is avoided and the relationship dies.     


But in many couples, attachment and sexuality are not so much disconnected as  unstable.  When attachment is insecure, sex is so often employed in the service of security – and herein lies the problem.  Just as an insecure, anxious child, becomes fretful if left and clings to its mother, so an insecure man or woman may only be able to feel secure after sexual intimacy.  Sex then becomes a rite of passage, a ticket to security.  We’ve fucked; therefore we must love each other. We’re safe – for the moment.  This insecurity can, however,  be exploited.  Some women learn to excite their partner’s jealousy in order to feel needed and then administer sex as an anxiolytic.  



To my mind, the distinction between sexuality and attachment is false dichotomy in healthy relationships and a dangerous one in those that are insecure.  Far from being an impossible combination,  physical intimacy is the magnetic force that bonds loving couples together and maintains the lifelong attachment necessary to raise their family  and then assist the children raise their families in turn.    But in the absence of a secure attachment or the prospect of a secure attachment, the magnets are reversed.  Then sexuality can be deployed to manipulate and control, keeping suspicious couples in a destructive division.