When the Body Says No: The Cost of Hidden Stress (24 page)

The three women interviewed for this chapter described similar pain experiences, though it is only Patricia whose constellation of symptoms meet the full diagnostic criteria for IBS. Unlike the majority of patients in the North Carolina studies, none of these women suffered sexual or physical abuse either as children or as adults. How, then, can we explain their lowered pain thresholds?

The downward calibration of the nervous system’s pain “thermostat” does not require abuse; chronic emotional stress is sufficient to diminish the pain threshold and to induce hypervigilance in the brain. While abuse would be a major source of such stress, there are other potential stresses on the developing child that are subtle, less visible, but harmful nonetheless. Such strains are present in many families, with parents who love their children and would be horrified by any thought of hurting them. Experiences that affect the physiology of pain perception and of intestinal functioning may happen to children who were not abused in any sense of that word and who even felt loved and protected.

The immediate stressors for Magda’s severe abdominal pains were related to her job. At the time she was working in a New York hospital. The director of her laboratory had recently resigned, and Magda was not on good terms with his replacement. “The new boss had it in for me from the beginning. In retrospect, I think she was looking for ways to get rid of me from the day she arrived. It was an extremely unpleasant, tense, miserable situation where I loved my work but I hated the environment.

“I worked incredible hours. I was in at seven in the morning. I usually left on time at four, on principle, unless there was some kind of meeting, which happened quite often. I never stopped for lunch. I never took a break. I took work home; I’d work on weekends. I never added it up, but a lot of hours non-stop with tremendous pressure and dirty, dirty politics and a terrible fear—there were no jobs to go to in my
field, which was a dying specialty. I never wanted to do general practice, and I didn’t want to go back and do another residency.

“Even with all the pain, I appeared at seven on Monday morning and never dropped the ball—ever. I was never sick. I wasn’t going to give them a way to get rid of me. They were never going to find anything wrong. I didn’t know what I was going to do with my life. I desperately wanted to leave, but I didn’t know what I was going to do.”

Magda was born in an East European refugee camp after the war. As the daughter of Holocaust survivors from Poland, she became secondarily traumatized by their experience. She has always carried a heavy burden of guilt and responsibility for the sufferings of her parents and for difficulties they continued to face. Her decision to enter the medical field did not arise from her own inclinations. It was motivated by her perception of the needs and expectations of her parents and by her concern to ease their anxieties for her future security.

“If you look at my natural skills, I’m very good at languages, and I’m very good at explaining things. I would never have gone into medicine if I had been free to choose. In fact, I hated a lot about medicine, but I had to deny it to myself.

“I hated much of the course material. I came within a millimetre of failing anatomy. It was an absolute nightmare. I couldn’t do calculus. I couldn’t do physics. I don’t have that kind of mind. I was never good at clinical work. I don’t know if I ever heard a diastolic murmur in my life! I just don’t have that kind of skill. I don’t think I ever felt a spleen—I just pretended. Those were just not things I was good at or inclined to do.

“I thought that being a doctor was what I wanted. My parents never said I should I do it, or that I shouldn’t do something else. They just mentioned enough times that it was so good to be able to help other people, and how even the Nazis needed the doctors.”

“Yes, I used to hear that too. And the security that you always carry your knowledge with you in a bag.”

“That’s right, and nobody can take that away. No matter what kind of times, no matter what happens, doctors are always needed. You can be your own boss and how nice that is. My parents brainwashed me from a very young age.

“Then I became a laboratory researcher and I wasn’t a ‘regular’ doctor the way my parents imagined. My mother never really understood
what I did and never really was satisfied. What I do is kind of second rate. I don’t put the stethoscope on the patient and I don’t write prescriptions, and I don’t do all those things real doctors do. I just look at specimens and slides. She doesn’t say it to my face, but to some extent she is always disappointed.”

As she realized that conventional medical treatment had little to offer her, Magda began psychotherapy. Repressed since childhood, her deep anger toward her parents began to emerge. “I was short-circuiting my visceral experience of anger—at my dad because he yelled and screamed and frightened me so much as a child.

“The much bigger problem was my relationship with my mother. I thought it was wonderful and we were best buddies—she was my friend and my supporter and ally and the one who listened to me for hours when I came home from school, and the one that I felt close to and understood by and all the rest. It took many, many sessions to uncover the fact that this was actually a very poor-quality relationship. With all her protection of me, she undermined me. She left me feeling quite inept socially and within myself, and she didn’t help me grow up and become my own person. She kept me—with good intentions—very immature.

“Other things too—she told me stories of the Holocaust. Other kids were told fairy tales, and I was told stories of the Holocaust … many inappropriate things.”

“Do you feel it was inappropriate for you to find out about that?”

“It was inappropriate at age three and four, when she started telling me. And I don’t know what age it was, but I cannot remember a time when I didn’t hear the accounts of how the whole family nearly got killed because of me when we crossed the border to escape Poland—about how I cried with everybody except with my mother, but I was heavy and she tripped and fell and dropped me in the river, and in order to save me from drowning, they almost all got shot yelling for help. Then she dislocated her shoulder and it’s never been right since.

“My parents never said life would have been easier without a child. They wanted a child—they loved me. But I still took on this sense that I was the problem.”

Given the trauma her parents had endured and the circumstances surrounding her developing years, Magda’s choice to ignore her own inclinations was almost inevitable. That choice also left her perilously
vulnerable to stress. Believing herself to be trapped in a job where she felt rejected by her new laboratory chief was a natural trigger for the excruciating abdominal pains she experienced. In this situation, she could no more assert herself than she could have as a child in her family home. The origin of her pain, as she came to realize, was connected with her unconscious repression of anger.

We have noted that gut feelings are an important part of the body’s sensory apparatus, helping us to evaluate the environment and assess whether a situation is safe. Gut feelings magnify perceptions that the emotional centres of the brain find important and relay through the hypothalamus. Pain in the gut is one signal the body uses to send messages that are difficult for us to ignore. Thus,
pain is also a mode of perception
. Physiologically, the pain pathways channel information that we have blocked from reaching us by more direct routes. Pain is a powerful secondary mode of perception to alert us when our primary modes have shut down. It provides us with data that we ignore at our peril.

Fiona, whose abdominal pains were ascribed first to a “spastic colon” and finally to IBS, had a childhood less dramatically charged than Magda’s. However, there is a strong emotional resonance in her chronic fear that she was not accepted for who she was.

“I honestly believe now that I’m an adult and I know my dad as an adult that he never intentionally judged me for anything I did, but he was always critiquing and evaluating. I said to a girlfriend of mine in Calgary when I was seventeen that I haven’t even had a real job yet and I already felt like my resumé didn’t measure up to my sister’s and brother’s. With Dad it always feels like you’re building a resumé instead of just doing what you like to do.”

“As a child, did you ever tell your parents when you felt bad?” I inquire.

“Physically, yes. Never emotionally. I’ve never been good about talking about that. I don’t know why. I think it’s just too personal and private. I’m better at it now. I would never have talked to you five years ago.”

At the time of our interview, the immediate stresses in Fiona’s life stemmed from her marriage. She had been in the relationship eight years and there were two children. “My husband suffers from depression and panic attacks. He gets these really anxious moments—he’s
been like that as long as I’ve known him. He’s a great guy and I love him dearly. He’s a kind-hearted person, but it has been so exhausting to look after him. I’ve been his mother. I have three children—a thirty-nine-year-old, a six-year-old and a two-year-old.”

“These are problems you are aware of. Is it possible that the pains you get reflect something else you haven’t been paying attention to? Rather than seeing the pains as a problem, perhaps they really are gut feelings that are telling you something. When you don’t pay attention to emotional signals, your body says, ‘Okay, here are some physical signals for you.’ If you don’t pay attention to them either, you really are in deep trouble.”

A week after that conversation, Fiona called me back. Her husband, she revealed, had a serious drug addiction problem that she had been ignoring for a long time. She had suppressed her anxiety and anger, wanting to hold on to a childlike hope that he would quit. In consequence of our interview, she began to rethink her situation.

Patricia, who suffered from irritable bowel syndrome and esophageal reflux, had the most emotionally difficult childhood of the three women introduced in this chapter. She grew up with a perception not only of being unacceptable as she was but of being unwanted in the first place.

“I know I wasn’t wanted. I’m not sure when I first realized it, whether as a teenager or as an adult. I’ve thought about things that my mom has said to me, and I realized the signs were there since I was a child. I didn’t recognize them then. I just knew I felt uncomfortable. She always said, ‘You know, I don’t think you belong in this family. I think they gave us the wrong baby.’ And she’d say it with a smile on her face. But, of course, people often pretend to joke when they say something serious.”

Irritable bowel patients are more likely than others to have symptoms elsewhere in the body. Susceptibility to pain—migraines, for example—is a problem many IBS patients are prone to, a fact we can readily understand if we grasp the concept of nervous-system sensitization by stressful experience. Heightened perception of pain can be generalized, as Patricia’s medical history illustrates. In addition to IBS and esophageal reflux, Patricia suffers from other conditions, including interstitial cystitis and fibromyalgia.

In the North Carolina study that found a majority of women with IBS to have suffered abuse, it was also learned that in only 17 per cent of the abuse cases was the patient’s physician aware of the traumatic history. The practical exclusion of people’s life histories from the medical approach to illness deprives doctors of powerful healing tools. It also leaves them vulnerable to grasping at the latest pharmacological miracle. A case in point is the sobering example of a recent “wonder drug” for irritable bowel syndrome.

On October 24, 2000,
The Medical Post
, a weekly publication read by many Canadian physicians, carried an enthusiastic headline: “New Drug Relieves IBS Symptoms in Women.” The article reported that a new medication, alosetron, “has been proven in clinical trials to be safe and well-tolerated, and to rapidly and significantly relieve pain and bowel function in patients with IBS, particularly in women with diarrhea-prominent IBS.” A leading Canadian authority was quoted endorsing the drug and hoping for others like it to follow: “Physicians are going to potentially have therapies for IBS that are useful…. IBS patients have a sense of frustration that we really don’t understand what is causing the symptoms. Some of the patients don’t get a lot of relief.”

Another expert, the head of the department of medicine at a Canadian university, echoed that positive assessment of the newly available medication: “It’s a very exciting breakthrough…. There is nothing else for them out there. None of the other drugs work. This is it.”

Four months earlier,
The Medical Letter
, a respected weekly bulletin on medications, had already reported that there was no evidence alosetron offered any advantages over standard treatment. For those patients who did experience improvement with the medication, the benefits disappeared after one week of stopping the drug.
The Medical Letter
also noted that some women taking it had developed ischemic colitis, a potentially catastrophic condition in which bowel tissue is damaged by a lack of oxygen caused by the constriction of blood supply.

In the United States, too, alosetron had been greeted with much fanfare. It was approved by the Food and Drug Administration in February 2000. At the end of November, only a month after the publication of the enthusiastic article in
The Medical Post
, the FDA forced the manufacturer to withdraw the drug. More women had been hospitalized with ischemic colitis, several of whom required surgery. It was
reported that in at least one case the patient’s entire colon had to be removed. There were also reports of deaths.

If medications are prescribed in a chronic condition like IBS, they usually have to be taken for months or years. It is always risky to commit to a new drug whose long-term safety cannot have been demonstrated by the time it first appears on pharmacy shelves. Doctors and patients do not have to reach for the pharmacopia when the impact of psychological factors on a disease has so abundantly been demonstrated. There is encouraging research evidence that even minimal psychological intervention can be of benefit: “In one controlled study of cognitive-behavioural treatment for patients with irritable bowel syndrome, eight 2-hour group treatment sessions over a 3-month period led to an increase in the number of effective cognitive and behavioural strategies and concurrent reduction in abdominal complaints. Furthermore, improvement continued at 2-year follow-up examinations.”
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