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. 

 

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