M.A. / Irritable Bowel Syndrome is defined as a chronic relapsing functional bowel disorder of unknown causes (Weber & McCallum, 1992). IBS is characterized by attacks of abdominal pain and change of bowel habit resulting in diarrhoea, constipation or both, where no structural alteration of the colon is found (Varis, 1987). The symptoms appear to result from a dysfunction of the intestine and are therefore said to be “functional” (Heaton & Thompson, 1999). The prevalence of IBS in the general population of Western countries is 14-24% of women. It is the most common cause of gut symptoms, and the most common reason that people go to their family doctor with a gut complaint. Despite all of this, physicians are still groping to understand the pathogenesis of IBS. The secret of success with IBS is to recognize it quickly and confidently. This is done primarily from the history, as there are no clinical tests that may be done to diagnose IBS. Once the diagnosis has been made it is of utmost importance that the sufferer is told, the syndrome is explained, and a good relationship is established with the health-care giver. Thereafter it becomes important to search for unspoken agendas in the life of the sufferer. According to the literature, stress can exacerbate IBS, and sexual, physical and emotional abuse can pose complex problems that require the assistance of a skilled counsellor. These problems, if left, may lead to the intensified symptoms of IBS. Society is becoming increasingly abusive and women and children often bear the brunt of physical, emotional and sexual abuse. Studies in America of women who present at medical facilities as well as those sampled from the community have found abuse rates that range from 20-76%. There is no reason to believe that these figures would be that different for South Africa. These studies have also found that abused women report a significantly higher number of medical problems and health-care system usage. A number of researchers have also found that there was a significant association between IBS and sexual abuse and physical abuse in childhood and adulthood. For the counselling psychologist the challenge is to unravel the mechanisms behind the symptoms, and to provide a rationale for therapy. The role that abuse may play in the development of IBS forms the cornerstone of the present study.

M.A. / The disorder known as Irritable Bowel Syndrome (IBS) is a clinical conundrum. Of chronic magnitude, this disorder of the gastrointestinal system affects up to 20% of the population in developed countries. Yet, it remains elusive in terms of its accurate definition and diagnosis, while its origins and etiology are unknown. To date, clinical confirmation of this disorder is complex and uncertain, while medical intervention has proven to be largely unsuccessful. Symptomatology relating to IBS varies widely and is not confined to the gastrointestinal tract. Diagnoses are made on the grounds of the manifestation of certain physical symptoms such as constipation, diarrhoea, abdominal pain and distension and disordered bowel habits. The role of psychological factors in the manifestation of IBS is controversial, although many clinicians postulate IBS to be a psychosomatic disorder due to the presence of many concomitant psychological features such as anxiety and depression. By all appearances, one of the most dramatic psychosocial concomitants of IBS is stress. Research has indicated that factors such as income, social support, life stress, psychological status, coping styles and personality all play a role in terms of whether the disorder develops and how successfully or adaptively the sufferer copes with his/her disorder. In terms of a research project undertaken by the Counselling and Research Centre for Gastroenterology under the auspices of the Department of Counselling Psychology at the Rand Afrikaans University, an exhaustive investigation into the physiological and psychological concomitants of IBS was conducted. As part of this endeavour to bring IBS to the attention of the medical profession, the public at large, and the individuals who suffer from this disorder, a number of individual studies were undertaken by MA (Psychology) students as part of the larger project. These researchers attempted to highlight various essential aspects associated with IBS, the focus of which included psychopathological features, stress, abuse, coping styles and strategies, defence mechanisms, personality factors and eating disorders. A second phase of this research project is currently in operation in order to provide remediation in the form of psychotherapy and stress management to the subjects who participated in the initial research project. The focus of the present treatise aims to provide an all-encompassing integration of the various research studies referred to above. Thereafter, on the basis of the data obtained from these studies, attention turns to the identification of a psychological profile with respect to the typical patient suffering from IBS. In accordance with the scientific demands of psychosocial research, a thorough review of the literature and various theoretical explanations of IBS were conducted as part of the integrative process. A number of theoretical models were considered in terms of their application to IBS, including the Digestive Disease model; the Psychiatric model; the Psychophysiological model; a Behavioural iii model; a Biopsychosocial model and a relatively recent newcomer, the Salutogenic Orientation proposed by Antonovsky, that offers an unusual approach to health and disease. In terms of the psychological profile mentioned above, the data demonstrated interesting findings. It was ascertained that the large majority of IBS patients are women, a finding that has been internationally verified. These women tend to be married with children, well-educated and employed on a full-time basis. The emotional status of the typical IBS patient reflects varying degrees of psychopathological tendencies, while her interpersonal relationships are characteristically unstable. Demonstrating high stress levels, the IBS patient tends to utilize inadequate coping skills, while these women also report using a maladapative defence mechanism to cope with the difficulties of their lives. Furthermore, personality traits such as introversion and neuroticism have been observed in these women. Lastly, it has been noted that the typical IBS patient exhibits certain aberrant eating patterns that are characteristic of women who are diagnosed as anorexic and/or bulimic. The IBS patient experiences her physical symptoms as severely disruptive and debilitating. Living in a very stressful and demanding world, she is lonely and isolated and shows the tendency to somatize her problems in the form of a disorder that is neither life-threatening, nor results in other more serious diseases, but which causes major distress in her life.

M.A. / Irritable Bowel Syndrome (IBS) can be described as a bodily idiom - a nonverbal language which may have its roots in unspeakable dilemmas (Griffiths & Griffiths, 1994). The splitting of languages and silencing of the body may be the soil in which such symptoms grow. Unutterable conflicts lead to the symptoms being trapped within the body until the body itself begins to "speak" (Griffiths & Griffiths, 1994). In essence, this study seeks to evaluate the effects of attaching language, feelings and awareness to these symptoms and communicating this with other IBS subjects within the group context. Psychiatric illness is often found in IBS health care seekers (Drossman & Thompson, 1992). The specific aim of this study was to ascertain the effects of a holistic short-term group intervention in the treatment of IBS with comorbid depression and anxiety. The sample consisted of 24 South African women who had been positively diagnosed with severe IBS by either a gastroenterologist or a general practitioner. Furthermore, each subject had to have associated moderate to severe depression and anxiety. Four questionnaires were utilised, namely the Biographical Questionnaire, the Irritable Bowel Syndrome Client Questionnaire, the Personality Assessment Inventory (PAI) and the Functional Bowel Disorder Severity Index (FBDSI). The Biographical Questionnaire mainly requested personal details and sought a family history of psychological disorders. The Irritable Bowel Syndrome Client Questionnaire, based on the standardised Rome Criteria (Drossman, 1994; Drossman, Zhiming, Toner, Creed, Thompson, Read et al., 1995; Talley, Phillips, Melton, Mulvihill, Wiltgen & Zinsmeister, 1989), verified a positive IBS diagnosis, while the Functional Bowel Disorder Severity Index rated the severity of the subject’s IBS. Lastly, the depression score was rated on the depression scale of the Personality Assessment Inventory (PAI) and the anxiety score was rated on the anxiety scale of the PAI. The subjects were divided into two groups of twelve members each - Group 1 was the experimental group and Group 2 was the control group. The group design was a pre-test, post-test control group design where subjects in Group 1 (the experimental group) received group intervention and subjects in Group 2 (the control group) were placed on a waiting list and received no intervention. The subjects in the control group were offered individual therapy once the post-tests were completed. All the subjects completed the IBS Severity Index Questionnaire and the Depression and Anxiety subscales of the Personality Assessment Inventory before commencement of group therapy for Group 1 and again one month after completion of this intervention. The effect of the intervention was determined utilising comparative statistics with reference to the pre-test versus post-test scores. The t-test for the equality of means for between group variance was utilised for two analyses. Firstly, it was used to determine the variance regarding the pre-test scores between Group 1 (the experimental group – who received intervention) versus Group 2 (the control group – who received no intervention) (Hypothesis 1). Secondly, it was utilised to determine the between group variance in terms of the post-test scores for Group 1 (the experimental group) versus Group 2 (the control group) (Hypothesis 2). The paired samples t-test was also used for two analyses. Firstly, it was used to determine the within group variance regarding the pre-intervention test scores versus the post-intervention test scores for Group 1 (the experimental group)(Hypothesis 3). Secondly, the paired samples t-test was also utilised to determine if there were statistically significant differences in terms of the pre-test scores versus the post-test scores of Group 2 (the control group) who did not receive the intervention (Hypothesis 4). A short-term holistic group therapy model was applied based on the work of Broom (1997), Crafford (1985), Pretorius (1996) and Yalom (1970). The results of the study showed that there was a statistically significant improvement in the anxiety scores of Group 1 (the experimental group) after completion of the intervention when compared with Group 2 (the control group) who received no intervention. The within group depression and anxiety scores in the experimental group also revealed a statistically significant improvement after the intervention. However, the IBS symptom severity remained unchanged. Thus, it is concluded that holistic short-term group therapy is indicated in the treatment of severe IBS with comorbid depression and anxiety even if the IBS symptoms are unaltered. It is recommended that further research be conducted to ascertain whether holistic group therapy of a moderate duration (approximately eight to ten weeks) has a greater impact on the IBS symptom severity.

M.A. / The purpose of this study was to ascertain whether patients suffering from irritable bowel syndrome (IBS) differed from non-IBS clients in terms of their coping styles. Gastrointestinal disorders are among the most common of all illnesses; half of the population suffers from acute gastrointestinal illnesses every year (Read, 1985). More than 10% have chronic illnesses, and these illnesses are a major cause of absenteeism from work. In view of this it is surprising that there is such a faucity of psychological and psychophysiological research focusing on gastrointestinal activity. Perhaps one reason for this is that investigators conceptualise the gastrointestinal tract as a system that is unresponsive to psychological intervention. Another reason may be the widespread belief that adequate techniques are not available for studying gastrointestinal psychology and psychophysiology (Haynes & Gannon, 1981). Today there is consensus that IBS is a psychosomatic disorder that accounts for between 40 to 70% of referrals to gastroenterologists. Unfortunately, this is a very misunderstood disorder. Sufferers are often misinformed or poorly educated by their physicians. Misunderstanding and lack of patient education often results in increased anxiety and physical distress. There are cases in which unnecessary surgery, expensive diagnostic procedures and addictive pain killers are mistakenly employed. In addition, IBS patients represent an expensive group because they use up a considerable amount of medical resources in money and time (Moser, 1986).

M.A. (Counselling Psychology) / Please refer to full text to view abstract

M.A. / The purpose of the study was to ascertain whether patients suffering from irritable bowel syndrome (IBS) differed from non- IBS clients in terms of their defense mechanisms. Although irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders encountered by primary care physicians and gastroenterologists, it is one of the least well understood. Part of the reason for this is the lack of real consensus of opinion regarding the nature of the complaint (Read, 1985). Today it is widely agreed that irritable bowel syndrome is a psychosomatic disorder, that is, a disorder of physiological functioning and anatomical structure, which are determined for most part by psychological factors (Lachman, 1972; Moser, 1986). Evidence linking psychological variables to gastrointestinal disorders is surprisingly sparse, and all too often confusing and contradicting. Such conflicting results probably reflect the many methodological weaknesses common to all areas of study (Bennett, .1989). Although evaluation of the impact of psychological interventions on both symptomatic and psychological relief has been pursued, its findings provide tangential support for the importance of psychological disorders. Nevertheless, these studies have shown a consistency of positive results not found in the etiological research (Read, 1985). Using a variety of techniques, most with the therapeutic goal of stress reduction, psychological therapy has been shown to produce. symptomatic relief, increase periods of remission, and to reduce the impact of stress resulting from severe symptomatic flare ups in IBS (Bennett, 1989). In .addition, most IBS patients may not identify their gut symptoms in psychological terms. Therefore, they inappropriately and repeatedly subject themselves to unnecessary, expensive and harmful medical procedures in search of an organic cause. Further research into the psychological factors of IBS, including the defense mechanisms underlying it may lead to a reduction in type of anxiety (Folkman, Lazarus, Gruen & DeLongis, 1986). The ways in which people cope with intense emotions may have a significant effect on their psychological and physical health. StresS factors and the suppression of emotions, for example through defense mechanisms, are thought to be especially relevant in the etiology and exacerbation of psychosomatic illness (Ogden & Von Sturmer, 1984). The role that defense mechanisms play in the development of IBS forms the cornerstone of the present research.

M.A. / Irritable bowel syndrome [IBS] has been described as a chronic relapsing condition, characterised by a change in bowel habit and abdominal pain, that cannot be explained by an organic disease. Some research indicates that IBS may be psychogenic in origin, however, the aetiology of this complex syndrome is still unclear. Some researchers have postulated that IBS is primarily a motility disorder of the gut, while others have indicated that the symptoms of IBS are mediated by the central nervous system. Thus it is not surprising that the care of patients with IBS poses a particular challenge to physicians, especially because of its biologic and symptomatic heterogeneity and, particularly for patients with refractory symptoms, its association with psychological disturbances. The literature study indicates that there that there may be a possible connection between the ingestive disorders, the menstrual cycle fluctuations associated with premenstrual dysphoric disorder and IBS. All three of these disorders also appear to be mediated, to some extent, by the neurotransmitter serotonin. In terms of these suggested correlations one of the aims of this study was to determine whether blood-serotonin levels significantly influence the symptomatology of IBS. Extensive literature exists documenting the potential role that serotonin plays in gastrointestinal functioning. However, none of the existing studies refer specifically to blood-serotonin levels. Thus the present study attempted to address this problem. A second aim of the present study was to determine the possible serotonergic connection in the ingestive disorders and premenstrual dysphoric disorder in women with IBS. All the subjects were required to go for a blood test in order to determine whether their serotonin levels were low, normal, or high. In addition, three self-report questionnaires were used in this investigation. The Irritable Bowel Syndrome Client Questionnaire; The Eating Disorder Inventory -2, of which four subscales out of 11 subscales were included, namely the Drive for Thinness, Bulimia, Body Dissatisfaction and Introceptive Awareness subscales; and the Premenstrual Assessment Form, of which six subscales out of 18 were included, namely Endogenous Depressive Features, Atypical Depressive Features, Signs of water Retention, General Physical Discomfort, Autonomic Physical Changes and Miscellaneous Physical Changes. In order to address the above mentioned aims, research was conducted at the Research and Counselling Centre for Psychogastroenterology at the Rand Afrikaans University. The Research and Counselling Centre for Psychogastroenterology is a facility developed to investigate the psychological constituents of IBS. Researchers at the centre are aiming to explore the multidimensional components of IBS with the purpose of gaining some understanding into the development and maintenance of this syndrome. A variety of topics are being investigated at the Research and Counselling Centre for Psychogastroenterology, including the role that stress, depression and coping styles play in IBS. Initially a sample group of (N = 60) women with IBS were selected for this research from a population of South Africans who were referred from gastroenterologists and general practitioners to the Centre for Gastroenterology at the Rand Afrikaans University. A number of women (N = 40) without IBS, from the north eastern suburbs of Johannesburg, were also asked to participate in this study in order to compile the comparison group.

M.A. / The overall objective of the global research project of which the present study is a part, is to create a greater awareness and understanding of the association between physiology and psychology, specifically with regard to IBS. Investigations are being conducted into the contribution of such factors as stress, anxiety, depression, somatization, psychopathology. early sexual abuse and physical abuse to the development and management of IBS. The present study aims to assess the incidence of co-morbid psychopathology in patients with IBS as compared to the general population. 1.3.2 Specific Aims. The aim of the present study is to compare the incidence of concurrent psychopathology in a sample of white, female patients, aged from 25-55 years and diagnosed to have IBS, with the incidence of psychopathology in a sample of white female non-IBS controls aged 25-55 years. Of initial concern will be whether the results of this study confirm the findings of the numerous research projects which attest to the high incidence of comorbid psychopathology in patients with IBS (Chaudhary & Truelove, 1962; Liss et al., 1973; Young et al., 1976), or add support to the limited evidence that disputes these claims (Talley, Kramlinger et al., 1993; Thornton, McIntyre et al., 1990). The study then aims to consider whether the variable of gender has a significant effect on the incidence of co-morbid psychopathology in patients with IBS. As will be discussed in Chapter 3, most of the studies do not differentiate between male and female subjects even though this may well prove to be an important determining factor. As mentioned in section 1.2.1, there is a dearth of research in South Africa into IBS and, more specifically, into the incidence of co-morbid psychopathology and IBS. By restricting participants in this study to those of the white race, the aim of this study is to initiate a process in which the incidence of co-morbid psychopathology in IBS patients of all races will be assessed and compared. In addition, the present study aims to assess whether age and level of education are significant variables in determining the incidence of co-morbid psychopathology in patients with IBS. Inter-group comparisons will be made between three groups of patients with IBS divided first according to age and then according to level of education. Finally, the present study aims to be more methodologically sound than certain of the earlier research projects as reported in the literature. As will become clear in Chapters 2 and 3, a common thread running through much of the literature is the concern that the validity of results may be questionable due to methodological flaws in the design of certain research projects. Small sample size has been a problem in some studies (Liss et al., 1973; Young et al., 1976) whilst in others, the absence of a control group has limited the relevance of data (Liss et al., 1973). Furthermore, a diversity of measuring instruments have been used in the past with little if any standardisation or control of specific variables being assessed. The measuring instrument used in this study, namely the Personality Assessment Inventory (PAI), allows for an accuracy and comprehensiveness of assessment not found in many previous studies (see Chapter 6, section 6.2.1.4). The PAI assesses psychopathological trends in personality functioning. The word "psychopathology" will be used in this study as substitute for the phrase "psychopathological trends in personality functioning".

M.A. / Irritable bowl syndrome (IBS) is one of the common conditions referred to gastroentorologists, but one of the least understood. Part of the reason for this is the real lack of consensus of opinion regarding the nature of the complaint. The problem is confounded by the absence of objective disease makers, as well as the variation in symptom presentation. The term (IBS) describes a cluster of symptoms which include chronic abdominal pain and altered bowel habits (diarrhoea, constipation, or alternating diarrhoea and constipation) in the absence of a known structural cause for the symptom (Toner, Garfinkel, Jeejeebhoy, Scher, Shulhan & Di Gasbarro, 1990). The symptoms of IBS mimic those of many other gastrointestinal diseases and the challenge to medical doctors is to establish a confident diagnosis based on the symptomatology of the individual, without the need to carry out multiple investigations to eliminate organic disease of the bowel. The pathogenesis of a condition remains a mystery. Most doctors would not consider IBS to a 'proper" disease at all, but view it as a physiological alteration in intestinal function brought about by psychological disturbance (Read, 1985).