Download Anger and ego-defence mechanisms in non

Digestive and Liver Disease 38 (2006) 195–201
Alimentary Tract
Anger and ego-defence mechanisms in non-psychiatric
patients with irritable bowel syndrome
R. Zoccali a,∗ , M.R.A. Muscatello a , A. Bruno a , G. Barillà a , D. Campolo a ,
M. Meduri a , L. Familiari b , M. Bonica b , P. Consolo b , M. Scaffidi b
a
Department of Neurosciences, Psychiatric Sciences and Anaesthesiology, University of Messina, 98166 Messina, Italy
b Endoscopy Unit, Department of Medicine and Pharmacology, University of Messina, Italy
Received 22 May 2005; accepted 15 October 2005
Available online 11 February 2006
Abstract
Background. Irritable bowel syndrome is commonly accepted as a disorder closely influenced by affective factors, which can either trigger
the symptoms or contribute to their persistence, independently from their aetiology. It has been previously documented that irritable bowel
syndrome patients respond to a variety of emotional states (anger, fear and anxiety) with an increase in colonic motility.
Aims. The aim of this study was to evaluate the experience and the expression of anger and the prevalent ego-defence mechanisms in a
group of non-psychiatric patients with irritable bowel syndrome.
Subjects. Fifty-two patients with irritable bowel syndrome (18 males, 34 females) and 100 healthy volunteers from the community (44
males, 56 females) matched for age, level of education and social-status were enrolled.
Methods. Assessment was conducted using the State–Trait Anger Expression Inventory and the Defence Mechanism Inventory.
Results. No important differences between the two examined groups were found using the State–Trait Anger Expression Inventory and
Defence Mechanism Inventory.
Conclusions. It can be hypothesised that stable personality features and habits, such as anger disposition and defence mechanisms, play
only a marginal role in irritable bowel syndrome, while psychological and psychosocial influences may act as predisposing or precipitating
factors which contribute to the pathogenesis or expression of irritable bowel symptoms.
© 2006 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Keywords: Anger; Defence mechanisms; Irritable bowel syndrome
1. Introduction
Irritable bowel syndrome (IBS), affecting 10–20% of the
general population, is a chronic, functional disorder of the
gastrointestinal tract, which is characterised by abdominal
pain, disturbed defecation (constipation and/or diarrhoea)
and other minor symptoms such as bloating, abdominal distension, feeling of incomplete evacuation and urgency [1,2].
Although the causes of IBS are poorly understood, it
is commonly accepted as a disorder closely influenced
by affective factors, which can either trigger the symptoms or contribute to their persistence, independently from
∗
Corresponding author. Fax: +39 090 221 695136.
E-mail address: [email protected] (R. Zoccali).
their aetiology. Affective disorders and IBS may share
some common pathophysiological features: alterations in 5hydroxytriptamine (5-HT) have been documented both in
depressive disorders and in IBS [3].
Previous reports on IBS patients show that variations in
their intestinal motility pattern may follow emotional or significant environmental stimulation [4,5]; in fact, particularly
stressful events, fear, anxiety and anger increase intestinal
motility in IBS patients far more than in healthy controls
[6–10]. Moreover, Evans et al. [11] documented a relationship
between the tendency to control or repress anger, abdominal
pain and augmented post-prandial colonic motility, whereas
Welgan et al. [12] found that antral motor activity decreased
in IBS patients and increased in controls. Among the psychosocial features closely related to IBS, the literature widely
1590-8658/$30 © 2006 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dld.2005.10.028
196
R. Zoccali et al. / Digestive and Liver Disease 38 (2006) 195–201
examined the role of coping skills [13–15], while studies
directed to a better comprehension of the ego-defence mechanisms – defined by DSM IV as ‘automatic psychological
processes that protect the individual against anxiety and from
the awareness of internal or external dangers or stressors’ [16]
– are still lacking.
In 1936, Freud [17] defined ego-defence mechanisms as
mental functions which protect the individual from the excessive anxiety deriving from both stressful external events or
disruptive inner psychological states. The protective property
of the ego-defence mechanisms acts through the modification, distortion or removal of stressful thoughts, feelings and
perceptions.
Ego-defence mechanisms are different from coping skills,
although both processes are thought in terms of adaptative
functions protecting the individual from the emotional consequences of unfavourable life events.
In 1998, Cramer [18] stressed the necessity to maintain a distinction – on the basis of specific characteristics
– between defence and coping mechanisms. As stated by the
author, coping skills require full awareness and the decision
to manage and resolve a problematic situation, whereas egodefence mechanisms act without conscious awareness and
can only interfere with the inner psychological state, producing a distortion of reality. Moreover, coping skills depend on
situations, while ego-defence mechanisms reflect relatively
stable, enduring characteristics of individuals.
To deal with stress, people use both intentional, consciously willed behaviours (coping) and also unconscious
mechanisms (defences). Thus, behind coping skills, egodefence mechanisms play a critical role in influencing both
the meaning ascribed to particular life events and the functioning at daily life, diminishing negative affects without
conscious effort in a direct way, independent of awareness.
The aim of this study is to evaluate the experience and the
expression of anger and the prevalent ego-defence mechanisms in a group of non-psychiatric patients with IBS. Among
the emotions, we elected to study the effect of anger on IBS
because, as opposed to anxiety, anger has not been studied in
as much depth in its connection to IBS, and moreover, it is an
emotional state widespread in the general population. Other
factors commonly investigated in IBS, such as depression
and stressful life events, are clearly involved in psychiatric
disorders. We also started from the hypothesis that specific
defensive styles may interfere with the management of stressors, emotions and anger but can also influence the functional
bowel disorder, mainly its onset, symptoms severity and outcome.
2. Methods
2.1. Inclusion and exclusion criteria
Patients between 18 and 70 years old with IBS were
selected for the study. IBS was established according to the
Rome II survey criteria [19], after full evaluation by a gastroenterologist and colonoscopic examination. The Rome II
criteria include self-report of continuous or recurring symptoms of abdominal pain or irritation associated with at least
two symptoms of defecation relief, change in stool frequency
or in stool consistency over the preceding three months.
Exclusion criteria were the organic pathogenesis of the disease, a history of severe somatisation or psychotic disorders,
the presence of any psychiatric disorder included in Axes I
and/or II of the Diagnostic and Statistical Manual of Mental
Disorders (DSM) IV at the time of colonoscopy and during
a six-month period prior to the study.
2.2. Subjects
Sixty-four IBS outpatients of the Endoscopy Unit of the
Department of Medicine and Pharmacology of the Policlinico
Universitario of Messina were consecutively selected after
an examination by a gastroenterologist and a colonoscopy.
Afterwards, within two days, they underwent a clinical interview conducted by a psychiatrist with at least five-years
clinical experience in order to exclude the presence of concurrent psychiatric disorders classified on Axes I and/or II of the
DSM IV. The psychometric examination was conducted at the
conclusion of the psychiatric interview. Twelve patients were
excluded from the study because, at the psychiatric interview,
the presence of a concurrent psychiatric disorder emerged
(four patients were affected by Major Depressive Disorder,
six patients by Generalised Anxiety Disorder and the last two
by Personality Disorders Not Otherwise Specified).
The control group consisted of 100 healthy volunteers (44
males, 56 females) matched for age, level of education and
social status, recruited among general population. All control
subjects underwent a psychiatric interview and were screened
for mental disorders. They also underwent a clinical examination to exclude those subjects with symptoms of IBS. The
control subjects had no history of gastrointestinal problems
or, for the six-month period prior to the study, a psychiatric
disorder defined by Axes I and II of DSM IV.
Both clinical and control subjects gave written consent
prior to their participation in the assessment study.
2.3. Instruments
All the patients underwent the following tests:
• State–Trait Anger Expression Inventory (STAXI) [20]
The STAXI is a 44-item self-report questionnaire, which
measures the experience and expression of anger. It consists of six primary scales and two subscales:
(1) State Anger (S-A): measures anger as a transitory condition that varies in intensity from mild annoyance to
intense fury.
(2) Trait Anger (T-A): measures individual differences in
the disposition to experience anger. The Trait Anger
scale is further divided into two subscales:
R. Zoccali et al. / Digestive and Liver Disease 38 (2006) 195–201
• Angry Temperament (T-A/T): assesses a general
tendency to experience and express anger without
specific provocation.
• Angry Reaction (T-A/R): assesses the disposition
to express anger when criticised or treated unfairly
by others.
(3) Anger-Out (AX/Out): measures the expression of
anger toward other people or objects in the environment.
(4) Anger-In (AX/In): measures the extent to which angry
feelings are held in or suppressed.
(5) Anger Control (AX/Con): assesses the frequency with
which individuals effectively control or reduce the
expression of anger.
(6) Anger Expression (AX/EX): derived from the previous three scales, it provides a general index of the
expression of anger, independently from its direction
(in, out).
Using 4-point scales, participants assess either the intensity or frequency of their experiences and results are
expressed as T scores. Higher scores indicate a greater
level of anger, its suppression or its expression. The STAXI
has been validated on a variety of normal and clinical populations, and has good psychometric properties
[21].
• Defence Mechanism Inventory (DMI) [22]
The DMI is a pencil and paper test which assesses five
major groups of defence mechanisms which are manifested in behaviours, fantasies, thoughts and feelings. The
test consists of 12 brief stories, followed by four questions. The questions are: What would your actual reaction
be? What would you impulsively (in fantasy) want to do?
What thought might occur to you? How would you feel
and why? Five choices are given for each question, each
corresponding to one of the defence styles being measured.
The subject has to select the most representative answer for
each question, and the one least representative of his/her
way of reacting. The answers to the four questions indicate, respectively, the response to frustration, the control
over impulses, the associated ideas and feelings.
This test consists of hypothetical responses to real life
situations and it is produced on the basis of typical psychometric schemes and has been validated on the Italian
population.
In DMI, five defensive styles are identified:
(1) Turning Against Object (TAO) deals with conflicts
through attacking a real or presumed external frustrating object. Such classical defence mechanisms as
displacement and identification with the aggressor can
be included in this category.
(2) Projection (PRO) consists in the attribution of negative
characteristics or intent to an external object without
unequivocal evidence.
(3) Principalisation (PRN) deals with conflicts through
the splitting of thought content from affect which is
repressed. Defence mechanisms such as rationalisa-
197
tion, intellectualisation and isolation fall in this category.
(4) Turning Against Self (TAS) includes those defence
mechanisms that handle conflicts through directing aggression toward the subject him- or herself.
Masochism is an example of defence mechanism in
this category.
(5) Reversal (REV) deals with conflicts responding in a
positive or neutral way to a frustrating object that
might rather evoke a negative reaction. Reaction formation, denial and repression are defence mechanisms
included in this category.
Scores ranging from 0 to 2 are assigned to each item and
the total score for each defence style may range from 0 to
80. Results are expressed as T-scores.
The DMI has been used in broad samples, both clinical [23] and non-clinical [24]. To the best of our knowledge, the use of the DMI in clinical samples of subjects
affected by organic illnesses has been limited; however,
the validity of a shortened form of the DMI has been
examined in different clinical populations such as adult
females undergoing abdominal surgery, infarct patients
and females affected by migraine [25–27]. The instrument,
however, shows good test–retest reliability, internal consistency, content, concurrent and discriminative validity,
and it has a factor structure which is relatively uniform
across different populations.
2.4. Statistical analysis
Data obtained from the study underwent check and quality
control and, subsequently, to descriptive and inferential statistical analysis. The Normality test and the Levene test for
equality of variances were applied for all the variables, then
we applied non-parametric tests for two independent samples. Continuous data were expressed as mean ± S.D. and
significant differences between groups was assessed using
the Mann–Whitney non-parametric test for two independent
samples; non-continuous data were expressed as percentages
and the comparison between the two groups was performed
by using the χ2 -test. The significance level for the test was
p < 0.01. The statistical analysis was performed with Statistical Package for the Social Sciences – SPSS 11.5 software
(SPSS Inc, Chicago, IL, USA).
3. Results
The final clinical sample consisted of 52 individuals (18
males, 34 females) between 19 and 68 years of age (mean
age: 32.21 years; DS: 12.20). The duration of disease varied
from a minimum of 1 year to a maximum of 30 years (mean
duration: 7.75 years; DS: 6.79).
Regarding social and demographic features, no significant differences between IBS patients and healthy controls
were documented (Table 1). These observations presumably
R. Zoccali et al. / Digestive and Liver Disease 38 (2006) 195–201
198
Table 1
Socio-demographic features of IBS patients and controls
IBS
Controls
Mann–Whitney test
M (S.D.)
M (S.D.)
U
p
Age (years)
Level of education (years)
32.21 (12.21)
13.17 (3.33)
31.82 (11.20)
13.58 (3.07)
.974
.420
Marital status (%)
• Single
• Married
• Divorced
• Widower
2591.5
2413.5
Chi-Square
χ2
26.9
40.4
32.7
–
27
38
35
–
.103
.950
p
Table 2
STAXI mean scores in IBS patients and controls
IBS pts.
State anger
Trait anger
Angry temperament
Angry reaction
Anger in
Anger out
Anger control
Anger expression
Controls
Mann–Whitney
M
S.D.
M
S.D.
U
p
54.23
54.54
40.13
56.33
64.52
54.60
44.08
62.31
8.33
9.98
8.86
7.65
12.69
12.08
8.86
10.55
54.50
54.06
43.27
53.46
61.43
52.77
44.29
61.34
8.38
10.72
9.30
9.49
12.16
12.11
9.99
14.00
2560.5
2585.5
2107.0
2131.0
2263.5
2380.5
2571.5
2501.5
.877
.955
.054
.068
.188
.393
.912
.700
Scores have been compared by Mann–Whitney U-test for two independent samples.
Table 3
DMI mean scores in IBS patients and controls
IBS
Turning against object
Projection
Principalisation
Turning against self
Reversal
Controls
Mann–Whitney
M
S.D.
M
S.D.
U
p
49.31
52.81
50.10
44.44
54.02
12.14
7.92
10.46
10.49
13.07
48.53
50.63
49.16
47.30
53.54
11.28
7.82
9.73
11.04
11.84
2496.0
2231.0
2483.0
2236.5
2552.5
.686
.151
.649
.158
.854
Scores have been compared by Mann–Whitney U-test for two independent samples.
indicate that social and demographic characteristics do not
influence the successive comparison of the various levels of
anger and defence styles between groups.
Tables 2 and 3 show the descriptive statistical analyses
and the Mann–Whitney U-test for two independent samples
based on the STAXI and DMI variables for IBS patients and
controls; even considering these variables, no relevant differences between the two examined groups were found.
4. Conclusions
IBS is considered a chronic disorder of the colonic function, often associated with a number of diagnosable psychiatric conditions such as anxiety, depression, panic disorder,
agoraphobia and somatisation [28–31]. It has been previously
documented that IBS patients respond to a variety of emo-
tional and environmental events with an increase of colonic
motility [4,5]. Regarding emotional triggers, anger, fear and
anxiety determine an increase of the intestinal motility of
the large bowel both in IBS patients and in normal subjects,
although IBS patients respond to these emotions with greater
motor activity [9,10]. Recently, Blomhoff et al. [32] have
shown a discrete influence of the emotional state, caused by
stress or a psychiatric disorder, on the intestinal reactivity;
they consider gut motility as a dynamic indicator of level of
stress and of the intensity of the individual’s affective involvement.
In a study based on the experimental induction of emotions, when considering anger, Welgan et al. [12] reported that
IBS patients, as opposed to the controls, showed an increased
motility in response to anger-induction experimental events,
and this almost exclusively in the colon. As reported by the
authors, anger levels registered in both groups were similar
R. Zoccali et al. / Digestive and Liver Disease 38 (2006) 195–201
and the documented difference might be due to a qualitative
aspect of anger rather than to a quantitative one.
Based on the evidence found in the literature, this present
study aimed to investigate, in a group of patients affected
by IBS, possible relationships between anger and the egodefence mechanisms which may modulate the experience and
the expression of the same emotion.
Differently from previous reports, this study did not evaluate anger by experimental methods of induction, as it seems
quite clear that ongoing emotional states such as anger and
anxiety have a direct effect on gut motility. We chose a
self-report questionnaire, the STAXI, that assesses both the
experience of anger and its ways of expression, since we were
more interested in exploring the role of anger as a stable component of the personality structure (trait versus state) and the
possible role of defence mechanisms which are involved in
emotional modulation.
The results show no significant differences in anger and
defensive profiles between IBS patients and the controls.
Thus, anger experience and expression as well as defensive
styles considered as stable personality features, do not seem
to play a critical role in the functional colonic disorder in
IBS patients who do not manifest a concurrent psychiatric
disorder or emotional disturbances.
Our results, however, show a number of limitations; first,
the relatively small sample size raises the possibility that the
statistical power is low and might give rise to a type II error,
possibly leaving the existing differences undetected. Second,
a prospective design would be more suitable than the current cross-sectional design to support the conclusions. Third,
considering that our sample of IBS patients were unaffected
by diagnosable mental illnesses, it would be interesting to
investigate the same variables on a sample of IBS subjects
with a comorbid psychiatric disorder.
Although the relationship between emotional states and
the intestinal motility, both in IBS as in control subjects, is
well documented in the literature, the results obtained from
the present study seem to indicate that trait anger and defensive profiles do not differ between IBS subjects unaffected
by mental illnesses, and the controls. As reported by Blanchard and Scharff [33], there are significant correlations of
same-day measures of stress and gastrointestinal symptoms,
but there is no evidence of stressful events on one day leading
to an exacerbation of IBS symptoms the next. According to
this observation, it can be hypothesised that stable personality features and habits, such as anger disposition and defence
mechanisms, play only a marginal role in IBS, while it is
widely accepted that psychological and psychosocial influences may act as predisposing or precipitating factors which
contribute to the pathogenesis or expression of irritable bowel
symptoms. Further studies are needed to expand our knowledge and comprehension of this complex and multifactorial
disease.
Conflict of interest statement
None declared.
199
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Commentary
Irritable bowel syndrome: What is the role of the psyche?
K.W. Olden∗
Division of Gastroenterology, University of South Alabama, 5600 Girby Road, Mobile, AL 36693-3398, USA
Received 17 November 2005; accepted 23 November 2005
Available online 19 January 2006
One interesting aspect associated with the study of functional gastrointestinal disorders, and particularly irritable
bowel syndrome (IBS), is the relationship between psychosocial factors and the disease. Early analytic thinkers,
such as Alexander [1], felt that IBS as well as other functional gastrointestinal disorders represented defects in ego
functioning and inadequate ‘defence mechanisms.’ These
findings are based on observational research, without the
use of control groups. The methodology was further negatively impacted by the fact that valid diagnostic criteria
and validated psychometric instruments for measuring various psychosocial factors for IBS did not exist at the time of
those studies.
We have come a long way since then. In the last 30
years, numerous studies have documented the presence of
significant comorbid levels of mood and anxiety disorders
in association with IBS [2]. These findings focused, by and
large, on specific psychiatric diagnoses, using standardised
psychometric instruments to look for specific psychiatric
∗
Tel.: +1 251 660 5555; fax: +1 251 660 5559.
E-mail address: [email protected]
diagnoses. The advent of the Rome criteria for IBS has led to
a reasonably sensitive, specific, and most importantly, common definition for this disorder to be used in the research
setting [3]. Using contemporary methodology, the incidents
of psychiatric disorders, particularly mood and anxiety disorders, as mentioned above, have been reasonably well studied in the IBS patient population. Likewise, this has led to
recommendations on how to best detect and integrate their
treatment to optimise outcomes for these patients [4]. These
findings have led to significant improvements in treatment.
Recent studies have documented the efficacy, and indeed in
some studies, superiority of behavioural as opposed to medical or even psychopharmacological treatment for patients
with functional gastrointestinal disorders, including IBS
[5].
However, lost in this rapidly advancing body of knowledge has been the issue of underlying personality structure
due to the poor quality and dubious results of early research
done in the area of personality structure and ego-defence
mechanisms as they relate to IBS. This area, by and large,
has been ignored over the last 30 years. Zoccali et al.
[6] present an interesting and high quality study investigating the relationship of ego-defence mechanisms, and