The effect of written emotional expression on severity of gastrointestinal symptoms in patients with Irritable bowel syndrome

Irritable bowel syndrome is one of the most common gastrointestinal disorders that significantly affects the quality of life of patients. One of the salient features of this disease is that most of the patients are young adults who, in addition to gastrointestinal symptoms, are involved with various physical symptoms and suffer from extensive extra intestinal symptoms. The chronic nature of the disease is such that it disrupts a person's lifestyle and causes degrees of psychiatric disorder by interfering with underlying health. Several studies have shown a high prevalence of concomitant mental disorders among people with irritable bowel syndrome. It is worth mentioning that this disease has been introduced as a stress-related disorder and psychological factors play a very important role in its control and prognosis. The results of studies show that the more severe the symptoms of IBS, the greater the contribution of psychological variables in these conditions, and in moderate to severe cases of the disease, especially in patients with psychosocial problems, it is better in addition to drug treatment, psychotherapy should also be used. Written emotional expression is a non-pharmacological intervention that has been studied in several studies on its effect on physical and mental health and the prognosis of chronic diseases. The results of some studies suggest that there is a link between emotional repression and emotional inhibition with IBS. Psychological inhibition, which means the inability to express thoughts, feelings, and behaviors related to an experience, occurs when people think they cannot easily talk about their experience with others. Patients with irritable bowel syndrome are more likely than healthy people to hide their negative emotions. Embarrassment about the symptoms of the disease may lead to secrecy and reluctance to discuss the emotional problems associated with the disorder. Accordingly, encouraging patients to express emotions and change behaviors associated with emotional suppression can be valuable in IBS treatments. Doing so may improve the quality of life of sufferers, as suppressing emotions brings more psychological burden and, by increasing anxiety, exacerbates symptoms and worsens the disease. Expressing emotions in the form of writing, in addition to the effect it has on improving a person's emotional state, can be easily taught and practiced, and it is done spontaneously, without face-to-face and continuous referrals, and with less interference from the intervener. Considering the benefits of written expression and considering the importance of the role of psychological variables in aggravating the symptoms of this syndrome and the educational-supportive role of nurses, this study aimed to determine the effect of written emotional expression on severity of gastrointestinal symptoms in patients with Irritable bowel syndrome.

This clinical trial study was conducted in 2019, on 71 patients with Irritable bowel syndrome who were referred to the gastrointestinal clinics of Firoozgar and Hazrat Rasoul Akram hospitals in Tehran. Patients were selected using a continuous sampling method. Participants were randomly (permuted block randomization) assigned to two groups: the control group (n=35) and the intervention group (n=36). The sampling process started in November 2019 and continued for 8 months until the completion of the sample size until May 2020. Inclusion criteria include: IBS according to the doctor's diagnosis, at least 3 months have passed since the diagnosis, having symptoms based on the severity of symptoms of irritable bowel syndrome (SI-IBS) in the mild, moderate or severe range, having Literacy, having sufficient physical and mental ability to write, age 18 to 65 years, no acute mental disorders based on physician diagnosis and record, no use of anti-anxiety drugs during the last 3 months according to patient reports and no infection At the same time, participants had other functional or structural gastrointestinal disorders based on patient reports. Exclusion criteria also include: diagnosis of any disease during the study by the treating physician who has symptoms similar to the symptoms of irritable bowel syndrome, the patient does not have the necessary cooperation or unwillingness to continue cooperation, the patient does not attend pre-test or post-test evaluations , Not writing in the booklet more than 2 times or 4 sessions in total and hospitalization of the patient due to exacerbation of gastrointestinal symptoms during the study. After obtaining permission from the ethics committee, the researcher referred to the research environments, selected people with IBS who met the inclusion criteria, and after explaining the objectives of the research to these people and if they wish to participate in the research, the informed consent form Completed by them. A questionnaire on demographic characteristics and symptom severity index (IBS-SI) were answered by participants in both groups. The Symptom Severity Index Questionnaire was designed in 1977 by Francis et al. The Persian version of this questionnaire was translated into Persian in the study of Afshar et al by the standard method of linguistic validation. The internal correlation coefficient of this scale is 0.86 and Cronbach's alpha is 0.69. In the intervention group, in addition to routine care, a white booklet with a special format was given to each participant to express their emotions in writing. A weekly written expression of the patient's feelings for a period of 15 to 30 minutes, based on the topics in the booklet, was done at home for one month. During the intervention, the process of writing patients was followed by a researcher by phone at the end of each week. At the end of the intervention, by phone call and at the invitation of the researcher, the research samples were referred to medical centers again and after the presence of test subjects in the clinic training class, patients' notes were collected by the researcher. After the researcher viewed the booklet in terms of the patient's written expression each week, the booklet was returned to them. Also, all subjects in the experimental group answered the symptom severity index questionnaire again and in the same session. The control group received only routine care by clinic staff after the pre-test. In this group, telephone follow-ups were performed every week, in which the researcher answered the questions of the sample people regarding their health status and the training they received from health care providers. In this group, after one month, the subjects returned to the medical centers on the dates agreed by the researcher and completed the IBS-SI tool. Finally, in order to observe the ethical points, a written guide to the written emotional expression was provided to this group. Questionnaire data were extracted and analyzed using SPSS software version 16 and descriptive statistical methods, independent t-test and analysis of variance with repeated measures.

The two groups were homogeneous in terms of demographic characteristics. Before performing the written expression, the mean score of symptom severity in the experimental group was 262.36 with a standard deviation of 104.74 and the mean in the control group was 263.48 with a standard deviation of 11.874. The results of independent t-test showed that before the intervention, the experimental and control groups were not statistically significant in terms of symptom severity and were homogeneous (p = 0.966). One month after the written expression, the mean score of symptom severity in the experimental group was 218.75 with a standard deviation of 116.11 and the mean in the control group was 239.51 with a standard deviation of 107.67. After the intervention, there was no statistically significant difference in the severity of symptoms in the control group (p = 0.134). The severity of gastrointestinal symptoms in the experimental group decreased significantly compared to before the intervention (p = 0.016). However, there was no statistically significant difference between the mean scores of gastrointestinal symptoms in the experimental and control groups 1 month after the intervention (p = 0.438).

Execution of written emotional expression in this study, although did not cause a statistically significant difference in the score of gastrointestinal symptoms in patients with irritable bowel syndrome, but was associated with a decrease in the severity of gastrointestinal symptoms in patients in the experimental group, so that significant improvement in gastrointestinal symptoms. Patients with severe symptoms and mild to moderate symptoms were observed. This non-pharmacological intervention can be considered as a practical and easy method along with pharmacological treatments for patients with irritable bowel syndrome.