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IBS: Global Outlook
IBS Study in China: Epidemiology and Clinical Study
Wei-an Wang, MD, PhD, Department of Gastroenterology, The First Affilated Hospital, Sun Yat-sen University, Guangzhou , 510080, ChinaEmail: wangweian@IBSChina.com Email: wwa66@163.net
Website: www.IBSChina.com
In China, the history of functional GI disorders (FGID) may be traced back more than 2500 years, but it was not until 1987 that more attention began to be paid to FGID, especially IBS.
A 1996 randomized sampling study (2486 subjects randomly chosen from urban, suburban, and rural areas) showed a point prevalence of IBS of 7.01% (7% of the population at any given time presented with IBS symptoms).
- Urban areas had a higher prevalence rate (10.5%) than rural areas (6.1%).
- It was found to be slightly more common in women, with a 1.15:1 ratio (female to male).
- IBS was more common in people between 18-40 (51.6%) and among the "intellectual class."
- Risk factors included: history of dysentery, exposure to cold climate, and ingestion of cold food and raw foods.
Antidepressants have also been found to be effective in that symptom severity and frequency decreased significantly, along with anxiety and depression.
Traditional Chinese Medicine including herbs and acupuncture are still practiced and welcomed in some areas of China, although no conclusive scientific studies are reported. EPIDEMIOLOGY:
In China, the history of functional GI disorders (FGID) may be traced back more than 2500 years. In Huaungdi Neijing (The Emperor's Classic of Internal Medicine), a Chinese medical classic compiled between 800 and 300 BC, the features of FGID are described in detail. However, it was not until 1987 that more attention began to be paid to FGID, especially irritable bowel syndrome (IBS). Then, physicians trained in Western medicine in China, established clinical criteria and research criteria for IBS including the requirement of a 2-year clinical course.
According to those criteria, Dr Wen Bi-jun and Dr Pan Qi-ying (1988) reported their study on 233 apparently healthy Chinese of all ages, primarily consisting of hospital employees, students and cadres. They claimed that 22.8% of the subjects had more than six episodes of abdominal pain within one year, and the pain was relieved by defecation. This figure usually is cited as the prevalence of IBS in China though it is questionable whether this is the actual prevalence.
In 1996, Dr Pan Guo-Zong carried out an IBS survey in Beijing according to symptoms using both Manning (modified including constipation) and Rome criteria. 2486 subjects were studied by a clustered sampling of residential groups according to a stratified design of city, suburban and rural areas. The sample size of each area studied was in proportion to the population of the area. Selection of the residential groups was made by simple random sampling. Age of subjects enrolled in the study was 18-70. All subjects who fulfilled the selection criteria were requested to fill out a questionnaire, assisted by trained doctors or medical students during a visit to their families. Secondly, an aliquot of patients who fulfilled at least the Manning criteria were further selected according to their scoring series to undergo detailed clinical examination in the hospital including laboratory examination, abdominal ultrasonography, colonoscopy or/and barium enema to exclude organic disease of the colon.
The adjusted point prevalence of IBS in Beijing according to Manning criteria was 7.01%, and that according to Rome criteria is 0.82%. There was a higher prevalence rate in the city (10.50%) than in rural areas (6.14%) by stratified analysis (p<0.001). Male to female ratio was 1:1.15. IBS was more common in people of age between 18-40 (51.6%), and among the intellectual class. This study indicated that history of dysentery (OR 3.00), exposure to cool climate (OR 1.55) and ingestion of cold food and raw foods (OR 1.24) may be the most important risk factors (p< 0.001). Also, IBS patients had a higher tendency to have abnormal personalities. The data in Pan's Survey was reported in the Chinese Medical Journal 2000; 113(1):35-39. I think that Dr Pan Guo-zong's survey is a classical representation of China, although recently, some other surveys, using Rome II criteria for IBS were reported in south China (Dig Dis Sci 2002;47(11):2621-4; J Gastroenterol Hepatol 2002 Nov;17(11):1180-6).
Clinical Study & Treatment:
From 1990 on, more and more clinical reports in China have been published. But only a few randomized control trials have been presented.
- Symptom-targeted Drugs Anti-muscarinics have been traditional drugs for IBS in recent years. Otilonium (SPASMOMEN) and Pinaverium Bromide are the main drugs used in the treatment of IBS in China. Other drugs such as Loperamide and polyethylene glycol also are used in IBS.
- Cognitive therapy Dr Wang Wei-an was the first in China to investigate the procedure and tactics used in cognitive therapy for patients with IBS, and to evaluate its efficacy. (Wang W, Pan G, Qian JM. Cognitive therapy for patients with refractory irritable bowel syndrome. Chin J Intern Med,2002;41:156-159). A self-controlled study of cognitive therapy in 22 patients with refractory IBS symptoms (according to Rome II criteria) was performed at Peking Union Medical College Hospital from 1998 to 2000. The cognitive therapy procedure included five steps, health education, patients' questioning, relaxation training, desensitization training, and homework for enforcing the effect of the former four steps. The effects of cognitive therapy for IBS were evaluated by instruments of symptom-related-anxiety index of symptoms, IBS-specific quality of life (IBS QoL) and coping.
All 22 cases completed cognitive therapy and the first follow-up evaluation. At that point, clinical symptoms in all patients improved (p<0.05). 81.8% improved significantly (p<0.001). At 12-month follow-up, clinical symptoms had achieved complete remission in 72.7% (8/11) patients. Comparing the scores of symptom-related-anxiety, index of symptom, IBS QoL and coping at the end of the first follow-up period with that at basal level, the scores of anxiety indexes of the severity and frequency of symptoms decreased significantly (p<0.001); the scores of depression and anxiety in SCL-90 also decreased significantly (p<0.001,respectively). The scores of active coping rose significantly (P=0.001) and IBS-QoL improved significantly (p<0.05). Dysphoria, body image, and food avoidance improved very significantly (p<0.001, respectively). - Antidepressants. To investigate the effect of antidepressants on IBS, Dr Wang Wei-an performed a self-controlled study on sub-clinical dosage of antidepressants for 9~12 wks in 46 patients with refractory IBS symptoms according to Rome II criteria (Wang W, Qian JM, Pan G). Treatment of refractory irritable bowel syndrome with sub-clinical dosage antidepressants. (Acta Academiae Medicine Sinice, 2003; 25(1): , in press.) The clinical outcomes were evaluated by scale changes of symptom-related-anxiety, severity index of symptom, and IBS QoL, as well as general psychiatric health by SCL-90 during treatment and follow-up periods.
All 46 cases completed therapy and first follow-up period (12wks). At that time, clinical symptoms in all patients improved (p<0.01), Comparing the scores of symptom-related-anxiety, index of symptom, and IBS QoL at the end of the first follow-up with that at basal level, indexes of the severity and frequency of symptoms decreased significantly (p<0.01, respectively); the scores of symptom-anxiety questionnaire including body anxiety (p<0.001), cognitive anxiety (p<0.001), fear (p<0.001) and avoidance (p<0.001) also decreased significantly. In the meantime, IBS-QoL improved significantly (p<0.05), with dysphoria, body image, interference with activity, health worry, social reaction and overall scores improving significantly (p<0.01,respectively). The status of general psychiatric health also improved significantly (p<0.001). - Of course, Traditional Chinese Medicine, including herbals and acupuncture remain welcome in some places and among some peoples in China, especially in South China and the countryside.
CONCLUSION:
To improve and enhance the understanding of IBS throughout all the country, Chinese Journal of Gastroenterology & Hepatology will be paying more and more attention to functional gastrointestinal disorders. Every year will have a special issue about FGID. From 2000 through 2002,there were three FGID special topics, especially IBS, compiled and edited by Dr Wang Wei-an. Other main Chinese academic journals on GI have also had an eye on FGID.
Chinese guidelines for diagnosis and treatment for IBS are being establishing by a few active researchers and clinical gastroenterologists in China. China's first national IBS conference will be held on 14~16, March,2003, in Guangzhou, China. All issues mentioned above, undoubtedly, will result in more public recognition of IBS. Dr Wang feels certain that, along with colleagues from other countries, China's clinical gastroenterologists will be making great progress in the field of FGID.
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IBS in Israel
Ami Sperber, M.D., Soroka Medical Center, Gastroenterology Unit, Beer-Sheva 84101 IsraelE-mail: amy@bgumail.bgu.ac.il
In recent years there have been important developments in the area of IBS and other functional gastrointestinal disorders (FGID) in Israel. These developments include increased awareness and understanding of the disorder on the part of gastroenterologists and primary care physicians, updated assessments of its prevalence, nationwide dissemination of educational material for patients, and growth of research into the mechanisms of disease and its treatment.
Epidemiology: Both Jews and Arabs Have IBS
Since stress has been related to IBS and residents of Israel (Jewish, Arab and Bedouin) live under extremely stressful circumstances, one might assume that the rate of IBS in Israel would be higher than in other countries of the world. We are nearing the completion of a large epidemiological survey of the prevalence of IBS and other FGIDs in Israel among the above three population groups. We have completed our analysis of the data from the Jewish population, have completed surveying the Arab population and are starting to analyze the data, and are in the middle of our survey of the Bedouin population. The study in funded by the Israel Ministry of Health and the results will be published in the future.Interestingly, the rates of IBS among Israeli Jews are similar or slightly lower than in other countries, ranging from 4.1% (using strict Rome II criteria) to about 11% if the criteria are slightly relaxed. This result suggests that stress is not a cause of the disorder. Overall, close to 30% of the population reported symptoms compatible with any functional lower bowel disorder (functional constipation, functional diarrhea, functional bloating, etc.).
Physician and patient education
The Israel Gastroenterology Association has established a committee of physicians who are particularly interested in motility and functional disorders of the GI system. The committee and its affiliated physicians have embarked upon a program to educate physicians and patients on these disorders. Several symposia have been conducted at the semi-annual IGA meetings and others are being planned in the near future for family physicians, surgeons, gynecologists, psychiatrists and psychologists, nurses, nutritionists, etc.Twice a year the Israel Gastroenterology Association (IGA) publishes an IBS newsletter (with the support of Novartis) that includes original articles by Israel physicians, translated articles from the IFFGD "Partipate" newsletter (with their written permission), news on IBS research projects in Israel and news from pharmaceutical companies on developments in the area of therapy for IBS. The newsletter is distributed by mail to registered readers and put on prominent display in the waiting rooms of all GI hospital and ambulatory clinics throughout the country. The response to the newsletter has been very positive and gratifying.
Patient meetings with questions and answer sessions have been held for IBS patients in the Beer-Sheva region of Israel for the past few years. The meetings are well attended and very well received. This activity will be expanded to other regions of Israel. We are now in the process of planning a nationwide network of IBS workshops to be conducted in hospitals throughout Israel. The workshops will be for small groups of patients and their significant others. We hope to begin these workshops within the coming 6-12 months.
Research
As awareness of the importance of IBS grows among Israeli physicians and scientists, so does the body of research devoted to the subject, including studies on epidemiology (see above), pathophysiology, clinical manifestations (the coexistence of IBS and Fibromyalgia, sleep disorders, psychological disorders, etc.), and treatment. We recently participated in a cross-cultural study of IBS patients conceived and centralized by Drs. Charles and Mary-Joan Gerson of the Mind-Body Digestive Center in New York and we await final analyses and publication of the results of the study.Several studies have been published on co-morbidity with Fibromyalgia. These studies show that 32% of IBS patients also meet the criteria for Fibromyalgia and a similar rate of women with Fibromyalgia meet diagnostic criteria for IBS. Patients with both disorders generally have more severe symptoms and more impaired quality of life than those with only one of them.
Another study on sleep disturbances among IBS patients was recently completed and will soon be published. This study shows that IBS patients have objective evidence (sleep laboratory studies) of repeated arousals and awakenings during sleep that lead to what is termed sleep fragmentation or non-restorative sleep. This may have a cause-and-effect relationship with IBS symptoms, although the direction is unclear (i.e., does impaired sleep cause more symptoms or do increased symptoms cause impaired sleep?).
A multicenter study is being conducted on genetics and IBS, and several centers have conducted studies on treatment modalities for IBS, including hypnosis, acupuncture, biofeedback, etc. Studies are now being conducted on probiotics as a treatment modality for IBS.
A cooperative study (with Dr. Drossman from UNC), funded by the US-Israel Binational Science Foundation, has now gotten under way to look into the possible development of IBS following gynecologic surgery. The study is planned to continue for 3-4 years and hopefully will produce important new insights into IBS.
This short report of activity in Israel related to IBS provides a glimpse of our dedication to this area of patient care and research. Hopefully, we will be able to update this report in the future with positive news on ongoing and new projects.
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A Perspective on Characteristics of IBS in a Mexican Population
Richard A. Awad, MD, MSc, Experimental Medicine and Motility Unit, Mexico City General HospitalDr. Balmis #148, Col. Doctores, 06726 MÈxico, D.F., MÈxico
Phone and fax: 52.55.5588.8036
e-mail: awadrichard@iserve.net.mx
Do characteristics of IBS vary considerably from country to country?
In Mexico:- The age onset of IBS can vary from 17-53 years old.
- Symptoms are usually present an average of 2.5 years before diagnosis.
- Symptoms are either diarrhea or constipation-predominant or alternating periods of diarrhea and constipation (the majority of sufferers show this pattern).
- 93% of IBS sufferers are women at the author's center.
- A number of studies have been conducted in Latin America with a variety of medications, from peppermint oil to sophisticated calcium channel blockers and serotonin antagonists and partial agonists. Results are promising from the serotonin related studies, but more research needs to be conducted on a worldwide level.
- Physiologic studies show a number of differences between IBS patients and controls with regard to pelvic-floor mobility and small and large bowel motility (rectal function).
- IBS symptom characteristics are similar from Mexico to other countries; however, the predominance of women sufferers is notable.
In this regard and based on my observations acquired over the last 15 years working with basic, clinical, and epidemiological research protocols in subjects with IBS, I estimate that the characteristics of IBS can vary considerably from country to country. Perhaps the Rome working group should take this into consideration. I have studied, in diverse protocols since 1989, more than 350 patients with IBS under criteria of Manning, Rome I, and Rome II.
From the epidemiological point of view, our patients with IBS present at an age range between 17 and 53 years. Symptoms are present 2 5 years before diagnosis. Ninety three percent are present in women. 12.5% are diarrhea-predominant, 27.5% are constipation-predominant, and 60% have alternating periods of diarrhea and constipation.
We have systematically assessed symptom patterns in our Mexican patients. Typically, they display 4.8 periods of abdominal pain per week, which are moderately severe (score 4.3 0.1, score 0 6 for an individual item), and last approximately 1 hour. In 54%, abdominal pain is relieved by defecation. Abdominal distension is a major symptom (score 5.2 0.1). Consistency of bowel movements is hard in 40%, semi-formed in 27.5%, loose in 21%, and occasionally loose in 1.25%. On the other hand, laboratory parameters, air contrast barium enema and recto-sigmoidoscopy are normal.
Since I direct a Motility Laboratory, my main interest has been how rectal function in IBS differs from normal. We have identified a number of abnormalities. This may or may not be unique to our Mexican population.
Physiologically, although many studies have identified motor abnormalities of the small and large bowel, data are often conflicting. Our physiological results in a Mexican population indicate several changes in recto-anal motility. We have observed greater amplitude in rectal spike while fasting and in response to food. We have also shown greater frequency, duration, and amplitude of inhibition of spontaneous recto-anal inhibitory reflex, both at rest and in response to food. In addition, studies have suggested that approximately two thirds of patients with IBS have heightened sensitivity to rectal distension. We have been able to confirm this concept (Awad RA, et al. Gastroenterology 2000;118:A1161; Awad RA, et al. Gastroenterology 1999;116:A954).
Pelvic floor characteristics in our Latin American patients with IBS also have been studied. Defecography showed that patients with IBS were unable to widen the anorectal angle during defecation, in contrast to healthy volunteers. In addition, it appeared that patients with IBS had less perineal descent during simulated defecation than healthy subjects. Our results suggest that patients with IBS as a whole, whether constipation-predominant or not, have changes in pelvic-floor mobility (Awad RA, et al. Int J Colorectal Dis 1997;12:91 94). Furthermore, ultrasonography demonstrated that total thickness of rectal wall and muscle thickness of internal anal sphincter at rest are reduced in patients with IBS (Awad RA, et al. Int J Colorectal Dis 1998;13:82 87). So we have documented a number of abnormalities in rectal function in our IBS population.
Similar to other countries, treatment has been a challenge. In our Latin American patients with IBS, we have conducted a number of studies with various medications. In 1988 we showed that peppermint oil was superior to placebo in decreasing ano-rectal electrical and mechanical gastro-colonic response to food. Later, we tested the calcium channel blocker pinaverium bromide, which diminished pain duration from several hours to a few minutes. It also decreased rectal spike amplitude and frequency as well as spontaneous recto-anal inhibitory reflex frequency after meals. Subsequently, we performed a random, double-blind, placebo-controlled trial of 2-agonist Lidamidine HCL, with results showing that abdominal distension and frequency, severity and duration of pain diminished after Lidamidine HCL. However, results were not different from placebo. Recently, polyethylene glycol was tested in constipation-predominant patients with IBS. We assessed rectal visceral sensitivity with an electronic barostat. Constipation was improved but there was no effect on rectal physiology. At present, promising therapies related to serotonin such as the 5-HT3 antagonist alosetron and the 5-HT4 partial agonist tegaserod have been studied in our laboratory, and supervised in other countries in South America. Results, while very promising, still await worldwide validation.
In summary, IBS symptom characteristics in our Mexican population are similar to other countries. The marked predominance of women is notable. Our physiologic studies have demonstrated a number of differences between IBS and controls. Hopefully, our observations will assist another in regard to the future development of IBS medications.
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Ten Years of IBS
Christine P. Dancey, Ph.D., Psychology Department, University of East London, Romford Road, London, E154LZ- Ten years ago, IBS was virtually unknown among the UK public, and many health professionals had not even heard of the disorder.
- In 1991, Dr. Dancey helped to co-found the IBS Network, which, while providing support and information to people with IBS through an informative newsletter and self-help groups, also helped to publicize the disorder which then led to better health care and understanding of IBS.
- The psychological problems that accompany IBS (anxiety, depression, self-blame, stigmatization) are not addressed through common IBS medications, but can be significantly helped by psychologists.
- IBS patients who have sought factual knowledge about the disorder and/or a social support network (comprised of other IBS sufferers) showed significantly reduced anxiety and depression levels when compared with IBS sufferers who did not learn about IBS.
- Treatments that help alleviate worry and stress (relaxation training, self-help groups, hypnotherapy, social support networks) have been found to significantly help alleviate IBS symptoms.
In 1991 I co-founded the IBS Network, which exists to provide support and information to people with IBS. It publishes a quarterly journal (Gut Reaction) which is sent to thousands of subscribers. When my co-founder (Sue Backhouse) and I had produced the first copy of Gut Reaction (only a two-page newsletter in 1991), we printed one hundred copies. A few lines about Gut Reaction were published in a national newspaper- we had 10,000 letters delivered in sackfuls to our doors! During the past ten years the amount of publicity given to IBS has increased enormously- in the papers, on the radio and TV. Health professionals treat the disorder far more seriously than in the past. There are numerous books on the subject as well as audio and video tapes, a network of self help groups and many more scientific papers.
As the sub-editor and contributor to Gut Reaction over the past ten years, I have spoken to many people who work within the area of IBS. One expert is certain that all IBS is due to diet. Another believes it is due to childhood trauma. Others state it may be a diagnosis encompassing different disorders and sub-types. As a psychologist, my position is that do not know enough to say with any certainty what causes IBS. The IBS Research Team here tries to discourage patients from seeking causes. We do know that having IBS leads to a reduced quality of life. Because of IBS, between 8 and 11% of patients are non employed.
As a psychologist, my position is that we need to help people cope with the condition. This doesn't just mean the symptoms themselves, but the psychological problems that come with it- anxiety, depression and a feeling of blaming themselves. People with IBS sometimes feel ashamed of having IBS, and feel that others perceive them as dirty or shameful. That is, they feel stigmatized because of their IBS. This may lead to restriction of activities- going out less, stopping hobbies and interests. As psychologists, we can help them have a better quality of life by addressing their feelings of stigma. Information about IBS, convincing people it is nothing to be ashamed of, that it can affect any type of person etc, can lead to people being more open about IBS. Interestingly the research that UEL IBS Research Team carried out found that the deleterious effects of stigma were worse for men than women, maybe because IBS is still often thought of as a women's problem.
There is much that psychologists can do to help people with IBS, by finding out the psychological factors which influence the course of the disorder. People who have knowledge about IBS may be less anxious. Research has found that people with IBS, as well as the general public, have a lot of misconceptions about the disorder. A common misconception is it can lead to bowel cancer.
Any treatment which helps people feel less worried and stressed (such as relaxation training, self help groups or hypnotherapy) should help IBS symptoms. Here in the UK, the IBS Network set up local self help groups throughout Britain, where people with the disorder could meet and support each other, as well as exchange information. People found such groups very useful. As an extension of this, the IBS Network co-operated with Holistic Resources (a charity which aimed to bring complementary medicine within the state health system) to provide a comprehensive therapeutic package to groups of IBS patients. This included social support (via group and facilitator), relaxation techniques, cognitive-behavioral therapy, and exchange of illness-related knowledge. In group meetings, topics included trigger factors, the role of diet, stress and medical treatment, and management of symptoms and anxiety. Negative thought patterns, assertiveness training and gut directed hypnotherapy were also included. Participants had written information and audio tapes to help them practise learned techniques for dealing with IBS at home. Initial analysis shows positive results for these groups, and more information will be available on their effectiveness once the full results are analyzed.
Psychological help can be a useful adjunct to any medications people are taking to relieve their symptoms. The more we know about the psychological concomitants of IBS, the more effective our interventions will be. Although it might seem depressing that the causes of IBS are still unclear, steady progress has been made and we remain confident that treatment will be even more effective, as our understanding increases.
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Sexual Abuse and IBS
Piero Porcelli, Ph.D., Clinical Psychologist, Psychosomatic Unit, IRCCS "S. de Bellis" Gastrointestinal Hospital, Bari, Italy- A history of physical and sexual abuse is associated with functional GI disorders, particularly IBS.
- A study done in the US in 1996 found that 67% of IBS patients and 56% of "organic GI disease" (i.e. inflammatory bowel disease) patients had experienced sexual abuse.
- A study in France also found that a significantly higher percentage of French IBS sufferers (32%) also suffered prior physical or sexual abuse than patients with organic GI diseases or healthy control subjects.
- A Canadian study showed that women with IBS reported higher levels of emotional abuse, self-blame, and self-silencing than patients with an organic GI disease.
- Studies in Italy have shown a high prevalence (up to 66%) of "alexithymia" (difficulty in identifying and communicating feelings; i.e. inhibition of self-expression) in patients with IBS and other GI disorders.
- Thus, abuse may lead to inhibition of self-expression, suppression of communication (especially about painful feelings), and shouldering responsibility for negative events, which may be a contributing factor in IBS.
In the last decade several studies have shown increasing evidence that a history of physical and sexual abuse is associated with functional gastrointestinal disorders (FGID), particularly irritable bowel syndrome (IBS). In a 1990 study on the Annals of Internal Medicine, Douglas Drossman and his associates were the first to report high prevalence of past physical and sexual abuse in women with IBS referred to a tertiary care center. They found that 53% of IBS patients experienced sexual abuse in the FGID sample and only 37% in women with organic GI diseases. In a larger study, published by Drossmanís research group six years later, the authors found a much higher prevalence rate, both in FGID (67%) and organic female patients (56%). Although the subjects were drawn from the same clinic as the previous study, differences were attributed by the authors to the greater sensitivity of a new structured interview they developed in order to identify abuse experiences. One of the few European studies, published in 1997 in the European Journal of Gastroenterology and Hepatology, found that 32% of French subjects with IBS reported physical and sexual abuse. This was significantly higher than patients with organic GI diseases and healthy control subjects consulting for check-ups.
These data lead one to wonder whether physical and sexual abuse may cause IBS. However, there are issues worth considering before concluding a direct, causal link. First, studies were based on patients referred to tertiary care settings. As severe abuse, functional GI symptoms, and psychopathology have been found to be positively associated with each other, the link between abuse and IBS should be replicated in subjects from the general population. The base rate (i.e., the frequency with which certain conditions or events occur in a setting or a given population) for physical and sexual abuse in the U.S. has such a wide range that there may be overlap in different subgroups. Furthermore, opinions about what "abuse" means can differ. Definitions of abuse range from being exposed to otherís sex organs to being forced to have sex with one or more persons, from single episodes to long-lasting relations with a parent. Also, methods to detect past sexual abuse may under- or over-estimate the events. Some individuals may feel more at ease about talking about it in a face-to-face interview with a skilled, empathic observer while some others when leaving alone answering to a self-report questionnaire.
Estimates of prevalence of sexual abuse in Italy are approximate. Only data from regional areas are available. In a survey of 1,088 cases referred to centers for child abuse, 33.5% had been sexually abused. In two community surveys, rates of sexual abuse ranged from 5 to 12%. There are no available controlled data on the prevalence of sexual abuse in an Italian IBS population. However, from a chart review of 256 adult outpatients with functional GI disorders (most of them with IBS alone or IBS and functional dyspepsia) who were referred to the Functional GI Disorders Outpatient Unit of my tertiary care hospital in Southern Italy and who were asked for past traumatic experiences, including sexual abuse, only 18 (7%) subjects (15 females and 3 males) reported sexual abuse during childhood and adolescence and none in adulthood. This is within the base rate for abuse in Italy.
Although local and uncontrolled, why are Italian figures so different from U.S. data? Surely, no firm answer is possible without a sound investigation. However, some tentative explanations may be suggested. Without sociodemographic stratification, epidemiologic prevalence data are not conclusive because of wide variability in reported figures. Also, sexual abuse has been demonstrated to be highly dependent on family context. Abused children are more likely to live in families whose adult members have been assaulted and victimized. Therefore, abuse and assaults tend to be transmitted from one generation to another. An Austrian study published on Psychotherapy and Psychosomatics in 1995 on university students found that girls with a history of sexual abuse were at higher risk of somatoform symptoms only if they lived in multiproblematic families.
In Italian culture, family has a very high ethical value. So Italian people may be more guarded in reporting traumatic events that occurred to them within their family. Therefore, the problem may lie in the way people are willing to share their painful history with an unknown interviewer. Finally, the reported association between abuse and IBS may be due to a third variable which may account for the association. For instance, the relationship between abuse and IBS has been found mediated by neuroticism - a personality trait characterized by exaggerated responsivity to physiological changes - and higher general psychological morbidity by Talley and colleagues (Gut, 1998).
An interesting finding comes from studies investigating the link between sexual abuse and the ability to identify and communicate oneís own feelings, emotions and inner world. A Canadian study (published in Psychosomatic Medicine in 2000) showed that IBS women reported higher levels of emotional abuse, self-blame, and self-silencing than patients with an organic disease (inflammatory bowel disease). So women who experience emotional abuse may be more likely to inhibit self-expression, take responsibility for negative events and be less prone to talk about other painful experiences like sexual abuse. The difficulty in identifying, differentiating, and communicating feelings is called "alexithymia", which means "no words for feelings." Alexithymia have been found to be significantly more prevalent in rape victims, suggesting that alexithymia may develop as a means of avoiding painful affect. Also, Berenbaum (Journal of Psychosomatic Research) showed that alexithymia was significantly correlated with personality disorders and childhood abuse.
In some previous studies in Italy (published on Psychotherapy and Psychosomatics since 1999), my collaborators and I found high prevalence of alexithymia in patients with IBS and other functional GI disorders, up to 66%. Therefore, it may be that IBS alexithymic patients may prefer to avoid talking about painful, traumatic experiences and appear to have a lower rate of abuse. I may quote a young female patient of mine, who suffered from severe chronic pelvic pain and dyspareunia during sexual intercourse, who denied any abuse in childhood. At home, while in deep relaxation for therapeutic exercises, she suddenly recalled an event she had completely forgotten: when she was a little child, in a summer afternoon at her country home, no one was awaking (a sort of siesta-like phase of the day during summer in Italy) and she saw a man (perhaps one of her uncles) exposing his sexually excited organ to her; she was very frightened, did not talk with anyone of this episode, and did not recall it until now.
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