Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders, affecting around 10-20% of the population in Western countries and around 5-10% of the population in Asia.
Although the etiology of the disease is not completely known, several hypotheses have been proposed. For example, there are recognized associations between the development of IBS and psychosocial factors, especially anxiety and stress, or traumatic events such as psychological trauma or abuse, particularly before the age of 18.
- Up to 80% of IBS patients have psychiatric comorbidities, especially depression and anxiety disorders, somatization, and substance use disorders, which affect patients’ treatment-seeking behaviors.
- Additionally, antidepressants and a variety of psychological interventions, such as mindfulness and analytical and interpersonal psychotherapy, play an important role in the treatment of the disease.
- There is a relationship between the desire to control or repress anger with abdominal pain and exacerbated colon movements after eating.
- There is also a significant relationship between anger and immature defense mechanisms in several types of functional gastrointestinal disorders, including IBS.
Defense mechanisms , as defined in the DSM-5, are factors that mediate people’s responses to emotional conflicts and external stressors.
These mechanisms are divided into three groups :
- Normal people use mature defenses to cope with various stressors and are considered normal unless they are excessive.
- Neurotic defenses are common in the healthy population, however, they may be correlated with some psychiatric disorders, especially anxiety disorders.
- Immature defenses are not frequently used by healthy adults and can cause psychic disorders and are correlated with personality disorders and other psychiatric conditions.
The purpose of the present study was to compare the defense mechanisms used by patients with IBS and the control group and also to investigate the relationship between these mechanisms and the severity of the disease and the quality of life of the patients.
| Methods |
Forty-five IBS patients (mean age 37.1 years; 14 men) and 45 controls (mean age 38.0 years; 13 men) were evaluated.
The diagnosis of IBS was determined based on the Rome III criteria and the predominant pattern of the disease was determined based on the patient’s history (13 predominantly diarrhea, 16 predominantly constipation, and 16 mixed IBS).
The Defense Styles Questionnaire 40 (DSQ-40), the IBS severity scale, and the IBS quality of life questionnaire were used.
| Results |
Among the different types of psychiatric comorbidities, the frequency of obsessive-compulsive disorder in the IBS group was significantly higher than that in the control group.
Severity of IBS symptoms
39 IBS patients (86.7%) suffered abdominal pain when completing the questionnaires and 42 (93.3%) had abdominal bloating. The mean number of days the person had pain in the month (± SD) was 4.7 ± 2.7.
The mean pain intensity in these subjects was 49.2 ± 22.0 mm, the mean abdominal distension was 62.3 ± 19.7 mm, the mean discomfort from bowel habits was 60.5 ± 24.4 mm, and the mean amount of IBS interference with daily life was 52 ± 0.29 mm.
Thus, the average severity of IBS (sum of the four dimensions mentioned) was 224.0 ± 58.5 mm. Overall IBS symptom severity was not significantly different between subgroups (F = 1.784; p = 0.181).
The mean quality of life score (± SD) was 90.6 ± 25.2. The average quality of life score in the three groups of diarrhea-predominant, diarrhea-predominant, and mixed IBS patients was 79.9 ± 25.2, 96.4 ± 23.0, and 93.1 ± 26.1, respectively, which did not show statistically significant differences ( F = 1.614; p = 0.212).
> Defense mechanisms
The mean score of projection, acting, somatization, autistic fantasy, passive aggression, and reaction formation in the IBS group was significantly higher than the control group. However, the mean mood and anticipation score was higher in the control group.
Furthermore, the use of immature defenses in the SII group was significantly greater than the control group, while the intensity of the use of mature defenses in the control group was significantly greater than in the other group.
The severity of the immature, mature and neurotic defensive mechanisms did not depend on the existence of other somatoform disorders (F = 1.014, p = 0.317; F = 0.326, p = 0.570; and F = 0.008, p = 0.927, respectively) and the interaction of IBS and any other somatoform disorder was not statistically significant (F = 0.416, p = 0.521, F = 3.144, p = 0.080 and F = 1.648, p = 0.203, respectively).
Similarly, the diagnosis of obsessive-compulsive disorder (which had a different frequency between the two groups) did not show a significant difference in the use of immature, mature and neurotic defense mechanisms (F = 1.063, p = 0.306; F = 2.409 , p = 0.124 and F = 0.144, p = 0.725, respectively) and there was no significant interaction with the main group (IBS or control) (F = 1.133, p = 0.290; F = 0.005, p = 0.941; F = 0.201, p = 0.201, respectively). The IBS subgroups did not have a significant statistical difference in this regard.
Quality of life (higher scores mean lower quality of life) had no significant correlation with immature, mature, and neurotic defensive mechanisms. Furthermore, there was no significant correlation between disease severity and defense mechanism scores.
| Discussion |
Psychological and psychobiological factors play an important role in the incidence and persistence of functional gastrointestinal disorders, including IBS.
The present study examined the use of defense mechanisms as a group of psychological factors in patients with IBS.
In our study, the intensity of the use of projection, acting out, somatization, autistic fantasy, passive aggression, and reaction formation was higher in the IBS group. l
he main defense mechanisms used in patients with IBS were more common in immature defenses than in the control group. Some of these defense mechanisms, such as somatization and passive aggression, are obviously associated with anger and anxiety against the patient himself.
It has been shown that patients with IBS had more escape avoidance mechanisms in their coping strategies than those in the control group. The researchers concluded that IBS patients were consciously trying to avoid or escape the problem, rather than deal with it effectively.
Some of these stresses are internalized in the gastrointestinal tract. The use of such immature defenses makes it possible for the person to use his anger against himself instead of turning to a tense agent to deal with it effectively and, according to Ehilevich and Gleser, use it as a kind of self-punishment.
Some of these mechanisms are different from the mechanisms of turning against oneself. For example, based on Ihilevich and Gleser’s classification, acting is a type of defensive mechanism that distorts reality towards the object.
Reaction formation is a type of reversal defense mechanism, and projection is within a separate category of defense mechanisms.
Since somatoform disorders have a psychological view of proximity to IBS and the frequency of obsessive-compulsive disorder in the patient group was higher than the control group, we considered these disorders as the possible interfering factors. Overuse of immature mechanisms was also observed in patients with obsessive-compulsive disorder.
In our study, the use of defense mechanisms had no connection with the dominant pattern of the disorder nor did it show a significant correlation with disease severity or quality of life. To our knowledge, no other study has addressed this issue. In fact, the discrepancy between the three disease patterns may be attributed to the limited sample size of the study.
The incidence of IBS, such as central amplification of pain and a decrease in cognitive flexibility, may be a common factor in all types of IBS.
However, the reduction of inhibitory feedback in the emotional arousal network and the impairment in the control of autonomic function of the gastrointestinal tract and intestinal motor activity between different types of syndrome can be thought to be different. The relationship between these clinical findings and the psychological mechanisms of the field needs further investigation.
Finally, it should also be noted that in addition to the limited number of samples, the present study experienced other limitations. The lack of control, among other functional gastrointestinal disorders, makes it unclear whether the difference in the use of defense mechanisms is a common factor between all types of functional gastrointestinal disorders or is only attributed to IBS.
The common complication of psychological disorders is also restricting the ability to carefully examine the mediating role of these disorders. To evaluate this role, we need to review and then compare patients without a psychiatric disorder with patients who do. Furthermore, although analytic psychotherapy is useful in the treatment of IBS, the role of these defense mechanisms in the treatment of IBS is unclear.
| Conclusion |
According to the findings of the present study, IBS patients use more immature defense mechanisms and less mature mechanisms compared to healthy people.
These findings may play an important role in psychodynamic and supportive psychotherapy of patients with IBS. However, the importance of using these mechanisms and their exact role in the formation of interruptions in complementary studies are essential.
