08: Trauma, Part III: Antibiotics to IBS to Depression — A Cycle of Despair
A closed-eye journey surfaced a vision of my dysbiosis, which I’ve attempted to transcribe here via watercolor.
Before I recount my experience with ayahuasca, I need to share a story. A story of my body. And my emotions. It covers some topics our society has largely deemed “inappropriate” or “crude” — like bodily functions, IBS, flatulence, acne. I want to change that. Not feeling comfortable talking about these issues in my early life led to alcoholism, depression, and nearly suicide, later in life.
Preface
In January, prior to my ayahuasca retreat, I posted the following “poem,” a meditation insight:
This is what happens when you are broken.
When, despite every privileged advantage you’ve been blessed with, your life lacks any sense of meaning.
When your chosen career has been an utter failure, and you’ve been fired or burned out of every job you’ve ever held.
When every romantic partnership you’ve been in has crashed and burned, leaving deep and painful emotional scars.
And after all that, when the one thing you’re left clinging to is one of your best and closest friendships, when that too breaks apart.
Only then — when there is nowhere else to look, no one around to console you, nowhere else to cast blame, or even assign a logical reason for the wake of sorrow in the rear view mirror of your life — only then
You look inside yourself and ask, tears streaming down your face, what is so wrong with me?
“WHAT IS WRONG WITH YOU?”
“Oh my god that is heinous.”
“Did something die inside of you!?”
Throughout my life I’ve heard all of these — from friends, acquaintances, or other people who had the misfortune of being in the vicinity of my offensive flatulence, on the occasions I simply couldn’t control it. In these situations I felt embarrassment and shame. Even sitting here now writing this, I can feel my face flushing with embarrassment.
The truth is, nothing “died inside of me.” No, on the contrary, something was very, very alive. A thriving colony of dysbiotic bacteria, feasting on and mis-digesting my food intake, themselves belching sulphorous, malodorous gases that caused intense discomfort inside me.
What is Irritable Bowel Syndrome?
From the Mayo Clinic: “Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. Signs and symptoms include cramping, abdominal pain, bloating, gas, and diarrhea or constipation, or both. The cause of irritable bowel syndrome isn't well understood.” IBS is generally regarded to come in two varieties: diarrhea-dominant “IBS-D,” and constipation-dominant “IBS-C,” although it isn’t uncommon for an individual to experience both. There is no known cure for IBS.
Who is affected by IBS?
“Irritable bowel syndrome is a common health problem affecting a substantial proportion of the population; point prevalence estimates usually range from 12–30%. Prevalence rates vary significantly between countries and depend on the diagnostic criteria used,” however, “...many individuals with symptoms of IBS do not not seek medical attention or have stopped consulting because of disillusionment with current treatment options.” [1]
The following post will be one of my most personal to date. Uncomfortably personal for me, in fact. But it’s an important part of my story, and the knowledge that nearly 1-in-3 suffer from IBS and don’t know where to turn for treatment and healing is spurring me forward in writing on this topic.
“IBS causes reduced quality of life and has been reported as resulting in the same degree of impairment as congestive heart failure. People with IBS are more likely to be unable to work and to have visited their doctor than the general population.” [1]
To fully understand what all of this has to do with ayahuasca, we need to go back to my childhood.
Chapter 1: Antibiotics
“Jonathan’s getting his annual cold”
It was common knowledge in my family that I would get sick every year, usually when the weather changed in November or December. These colds followed a pattern — seasonal allergies leading to post-nasal drip, followed by sore throat, and then sinus infection — and lasted one to two weeks.
As a kid I was driven to succeed both academically and athletically. I had school, and after school, soccer, baseball, or basketball practice. I wouldn’t let a cold keep me in bed, and never stayed home to rest and recover. And so the response to these infections followed the standard protocol: a visit to the family doctor, and the resulting prescription for a pharmaceutical antibiotic. Almost every year, from about age 6 to 15, I took these broad-spectrum antibiotics, never knowing the ravages they were having on my microbiome.
“The gut microbiome, the roughly 10 trillion to 100 trillion bacteria and other microorganisms that live in the digestive tract, contributes to health by synthesizing vitamins, metabolizing drugs and fighting pathogens. Anything that disrupts the balance of microorganisms, such as antibiotics, which can kill both “good” and “bad” bacteria, has the potential to cause disease. [2]
—from The New York Times article: “Does the Gut Microbiome Ever Fully Recover from Antibiotics?” (December, 2018)
Scorching my intestines
of “good” bacteria made space for dysbiotic microbes to take root — a colony of bad-acting flora that fomented in my gut, growing inside my intestines throughout my childhood, adolescence, and persisting even today. In fact, “data from a 2016 study suggest that exposure to antibiotics in infancy can alter the gut microbiome and weaken the immune response for years to come.” [3]
And so for a majority of my young life, I was caught in an immuno-compromising cycle. Antibiotics to treat the illness, weakening my body’s innate immunity, followed by illness arising from a deficient immune response. Rinse. Repeat.
“The effect of antibiotics on the natural microbial communities may consequently modulate the immune function and promote illness associated with dysfunctional immune system. This might be especially true in the case of antibiotics administered in early childhood, a period during which the immune system is developing in coordination with the nascent microbial colonization. Indeed, use of antibiotics during childhood has been correlated with increased risk of allergy, asthma, various infections and Irritable Bowel Disease.”
— from “Antibiotics in early life: dysbiosis and the damage done,” FEMS Microbiology Reviews [3]
Chapter 2: Dysbiosis
Irregular bowel movements were a feature of my childhood. Now, it may not be unusual for a child of 7 to have to suddenly pull his pants down to defecate in an aisle at K-Mart. Or need to use so much toilet paper due to loose stool, that he clogged the toilet and flooded the house at age 8. Or at age 10 to lose control of his bowels at his best friend’s birthday party, and need to be taken home by his friend’s mom in shame and embarrassment. But my gut issues followed me into adolescence.
By the time I was 11 or 12, I did learn to control my bowels, but only by virtue of extreme clinching of my sphincter, causing immense discomfort at frequent “urge” moments throughout my day, on an almost daily basis, for the entirety of my young life.
First period English class.
Hanging out with friends playing video games.
Stepping on to the soccer field for practice or a game.
It happened so often, it became a discomfort I integrated as a normal fact of life. This frequent “urge and restraint” cycle, and the bodily and psychological stress that came with it, had a damaging and lasting impact on my nervous system.
“This is the GI stress cycle,”
as University of Michigan clinical psychologist Megan Riehl, PsyD., M.A., one of just a handful of psychogastroenterologists in the US, has termed it. She explains that for IBS-sufferers
“their brains mistakenly interpret a simple need to go to the bathroom in the grocery store as a catastrophic event, which engages the “fight or flight” response, especially if a bathroom is far away. That can cause the GI tract to clench, tense and spasm, which worsens GI symptoms. It also leads to pain and fatalistic thinking — assuming, for example, that a person will have an accident in the middle of the store.” [4]
“Fight or flight” is an activation of the sympathetic nervous system I’ve explored before, a process that causes our adrenal glands to secrete stress hormones like cortisol and adrenaline, allowing us to spring into action and escape danger. However, when constantly activated, this is known as “chronic stress.”
“Chronic stress can wreak havoc on your mind and body… the long-term activation of the stress-response system and the overexposure to cortisol and other stress hormones that follows can disrupt almost all your body's processes. This puts you at increased risk of many health problems, including anxiety, depression, digestive problems, headaches, heart disease, sleep problems, weight gain, memory and concentration impairment.” [5]
—The Mayo Clinic
While chronic stress was wreaking havoc in my physiology, the moments of shame and ridicule from others were puncturing my mental health as potential emotional and transpersonal traumas.
But the antibiotic abuse continued
even into college. My first semester of freshman year—a delicate and formative moment in one’s young social life—I developed large dime- to quarter-sized, bright red, inflamed boils on my face and chest. This disfiguring cystic acne was yet another consequence of decimating my microbiome of good bacteria. Skin, our body’s largest organ, is intimately connected to our gut, and even has its own microbiome. The response? A visit to the dermatologist, and more broad-spectrum antibiotics.
The skin condition subsided, but left lasting scarring and pigmentation. Inflammatory skin breakouts have occurred regularly, a few times each year, every year since then. I have been to more than a dozen different dermatologists, and none have been able to treat, or even diagnose my issue (although many have offered antibiotics, which I have categorically refused for the past four years).
Now, at age 33, I am just beginning to learn that my skin has been trying to tell me something — a story I haven’t been willing to hear, its origins beginning in my gut, and conclusion held in a locked vault, deep within my psyche.
“In the USA, antibiotics account for 25% of all the prescriptions written to the pediatric population… However, numerous pieces of evidence have begun to indicate that there may also be a price for such frequent antibiotic use. With the development of microbiome research and recognition of the essential roles of microbiota in overall health, concern has been raised regarding the effects of antibiotics on the healthy microbial components residing within our bodies. It has indeed been shown that antibiotic treatment dramatically alters both adult and infant microbiome compositions... it has been demonstrated that even brief antibiotic treatments can have long-term effects on microbiota composition. Such changes in microbiota are termed dysbiosis, a microbial imbalance that is correlated with impaired health. Dysbiosis has been associated with many disease states including autoimmune diseases, metabolic diseases, malnutrition and others.” [3]
Chapter 3: Despair
This is what happens when you are broken...
Suffering from IBS for so long, it never sunk in that something indeed was very, very dysfunctional. It wasn’t until I was in my mid-20s that I started to realize just how abnormal I really was. Being in a series of long-term relationships illuminated how the same foods affected me differently, and how much my bathroom schedule deviated from my more ‘regular’ partners.
Finally at the age of 30, I went to see a gastroenterologist, who denied my request for a microbiome analysis, and told me: “Some people just have IBS. You can’t overdose on Immodium.” Not satisfied with that answer, I sought out a second opinion from another GI doctor, and was left literally speechless when I received almost the exact same answer.
I walked through the medical center parking lot back to my car. I felt defeated. I realized I had pinned high hopes on getting some kind of hint, some clue as to what was wrong with me, and maybe, just maybe, a path forward to normalcy. My phone was buzzing, but I didn’t need to look. I had taken the afternoon off for this appointment and emails were pouring in from work. I tried to start the car. But I fumbled the keys, and as they dropped to the floor, I broke. I began sobbing — big, heaving, difficult sobs, as if something was compressing my sternum, disallowing my emotions to fully release.
My phone buzzed again. I snapped out of it, and felt foolish for letting such a small thing get to me. But I now realize the emotion I felt was not simple frustration and work stress. It was despair; the welling up of 30 years of cumulative physical and emotional pain. Thirty years of mistreatment by modern medicine. Underpinning it all is the western medical philosophy of putting a “band-aid” on the symptoms, rather than addressing the root cause. It’s the “just-give-them-the-pill-and-send-them-on-their-way” attitude that destroyed my microbiome and immune system, again and again and again, throughout my young life.
But there was no one to blame. It wasn’t the malpractice of one doctor—doctor’s today only get to spend an average of 15 minutes with each patient. They don’t have the time for microbiome analyses and poring through patient history. Furthermore, they are often pressured into prescribing the most efficacious, “evidence-based” medications, by the threat of malpractice lawsuits and aggressive pharmaceutical salespeople.
It wasn’t one pharmaceutical company — pharmaceutical companies were simply doing their best to succeed in a capitalist model: they created products to meet demand, and their products were approved for market by the FDA. Plus, microbiome research is a nascent field, no one knew the long-term, unintended consequences of antibiotic use back then. Even today relatively few healthcare companies and practitioners understand the implications of their actions on our microbial community.
No, it was an entire system at fault — and it all culminated, for me, in a major depressive episode and suicidal ideations.
“We're about five, six decades into this journey of killing bacteria in force through the medical environment. We plateaued as doctors back in the 1990s, and yet we still prescribe an amazing 7.7 million pounds of antibiotics a year. That's a pretty gross number. It equates to 833 prescriptions per 1000 persons, 833 prescriptions per every 1000 persons in the US is how much antibiotic we prescribe. It's literally impossible to distribute more antibiotic prescriptions than we do in the US.”
- Dr. Zach Bush, MD
What is normal bowel function?
It took me 25 years to realize my bowel function was abnormal, in large part, because it’s something our society has deemed inappropriate to talk about. Rather than listing all the ways one might not be normal, I believe it’s more helpful to describe what is normal, in case anyone reading this might fall outside of this range.
[Disclaimer: Opinions on what’s “normal” vary among health care practitioners, but having read definitions and descriptions from over a dozen respected GI experts, I believe I’ve found a good, median description of what is normal human bowel function, which I’ve summarized here]
First, it’s important to understand that assessing bowel movement is a function of quantity—amount and frequency; and quality—objective characteristics of stool and the feeling of passing said stool.
Quantity
“It’s common for people to empty their bowel once a day, although it’s still normal to be more or less often. Being regular really means that soft yet well-formed bowel motions are easily passed and that this happens anywhere from 1–3 times a day to 3 times a week. The bowel usually wants to empty about 30 minutes after a meal (commonly breakfast), but this can vary from person to person.” [7]
Additionally, you should be able to:
hold on for a short time after you feel the first urge to go to the toilet
pass a bowel motion within about a minute of sitting down on the toilet
Quality
The Bristol Stool Scale was developed as a clinical assessment tool in 1997, and classifies human feces into 7 categories. “Every person will have different bowel habits, but the important thing is that your stools are soft and easy to pass – like types 3 and 4 below.” [7]
Type 1–2 indicate constipation
Type 3–4 are ideal stools as they are easier to pass, and
Type 5–7 may indicate diarrhoea and urgency
Other qualitative measures around bowel function include feeling and completion. For example, you should be able to:
pass a bowel motion easily and without pain - ideally, you shouldn’t be straining on the toilet or struggling to pass a bowel motion which is hard and dry, and
completely empty your bowel when you pass a motion - meaning you don’t have to go back to the toilet soon after, to pass more. [7]
Image use under Creative Commons: Attribution
Chapter 04: Depression
As I chronicled in 04: Trauma Part 1 my depression came roaring back in November with suicidal ideations.
I wrote in that piece:
“While trauma warps our experience of reality in a negative way, for many, it completely takes over. The cerebral and hormonal changes... have been linked to depression, anxiety, addiction, schizophrenia, psychosis, eating disorders, and other clinical psychological diagnoses, but also to physiological ailments like irritable bowel syndrome (IBS), Crohn’s, symptoms of chronic pain/inflammation like sciatica, rheumatoid arthritis and fibromyalgia, neurodegenerative diseases like Alzheimer’s and ALS, autoimmune disease, and even certain types of cancer.”
While emotional trauma set the stage for depression, antibiotics may have been a potent sidekick. A 2015 study in the Journal of Clinical Psychiatry found that the more courses of antibiotics a person had over their lifetime, the more likely they were to have depression and anxiety. And the findings were actually quite startling: just one course of antibiotics was linked with a 25% higher risk of a major depressive episode in the next six months. Two courses took the risk up to 40%, and more than five courses involved a 56% higher risk. [8]
Microbes in our gut can make us depressed?
The research on this microbe-gut-brain connection is very new, and the extent (and quantity) of the links are just emerging. However there are a number of hypothesized connections, some or all of which may be behind the antibiotic-depression correlation:
GABA: or gamma-aminobutyric acid, is the “chief inhibitory neurotransmitter in the mammalian central nervous system. It plays the principal role in reducing neuronal excitability throughout the nervous system. This can be the reason why the gut microbiome seems to affect mood, as low levels of GABA are linked to depression and mood disorders. Several categories of gut bacteria have been shown to produce GABA, including members of the Bifidobacterium and Lactobacillus genera.” [9]
Serotonin: 90–95% of our body’s serotonin resides in the gut. This chemical is involved in “regulating numerous physiological processes, including respiration, vasoconstriction, behavior, and neurological function.” [9]
Dopamine and Norepinephrine: “Dopamine is one of the major neurotransmitters in reward-motivated behavior, and is a precursor for other catecholamines, like norepinephrine and epinephrine. Norepinephrine is historically known for its role in arousal and alertness in the waking state as well in sensory signal detection, but more recent work has found it is also involved in behavior and cognition, like memory, learning, and attention… Several bacteria have been also shown to produce dopamine and norepinephrine in vitro” [9]
In addition to these neurochemical imbalances, “IBS patients report higher levels of difficulty in a broad range of daily activities when compared to healthy controls; that IBS negatively affects both mental and physical functioning; and that the reported effect of IBS on daily living is almost as high as that of the flu.” [10]
The distress then, for IBS sufferers, comes not only from daily experiences like the “urge and restraint” cycle, and resulting “fight or flight” chronic stress, but is compounded by a phenomenon known as “visceral hypersensitivity.” Visceral hypersensitivity is feeling pain, from normal stomach and intestinal processes, like digestion. This frequent pain is yet another psychological burden for those with IBS, and it’s a feeling implicated in depression and suicidal ideations.
“Like other chronic and functional disorders, medical treatments for IBS are suboptimal and the overall illness burden is high. Patients with IBS report high rates of psychopathology, low quality of life, and increased suicidal ideation… up to 38% of IBS patients in tertiary care settings have contemplated suicide as a result of their symptoms.” [10]
—from “Psychosocial impact of irritable bowel syndrome: A brief review.” World Journal of Gastrointestinal Pathophysiology
• • •
In 2015 two Princeton economists noticed that, despite the recovering economy, the U.S. was seeing a dramatic rise in deaths from suicide, overdose and self-poisoning—what they came to call “deaths of despair” in a paper published in the Proceedings of the National Academy of Sciences. [11]
The paper was so well-received, the duo — Angus Deaton and Anne Case — went on to write a NY Times bestseller on the subject entitled “Deaths of Despair and the Future of Capitalism” in which they identified an unexpected culprit behind the trend: “...our complicated and costly health-care system.” [12]
Upon learning this I suddenly saw the truth of my reality: I was stuck, wedged between the physical and emotional pain of IBS, and an ineffectual, callous healthcare model. Caught here in this vice grip, slowly tightening; squeezed to the point where the idea of suicide wells up, and becomes an enticing escape from this powerless and meaningless life. And this place is called despair.
Despair, is the loss of all hope.
Despair, was that feeling of my chest being compressed, of being crushed after I left my doctor’s appointment, as I sobbed and gasped for air.
Despair, is what I meant when I wrote:
Only then — when there is nowhere else to look, no one around to console you, nowhere else to cast blame, or even assign a logical reason for the wake of sorrow in the rear view mirror of your life — only then
You look inside yourself and ask, tears streaming down your face, what is so wrong with me?
I am so fortunate to have the means to look inside myself. In Part IV, I will share the results of a microbiome analysis, and describe my initial foray into treating my dysbiosis outside the allopathic paradigm of healthcare in the U.S.
Until then, I offer encouragement to those who are suffering from IBS, dysbiosis, depression, or who have been failed by the U.S. healthcare system and our western medical model:
Do not give up.
You deserve wellness.
Even if you can’t see it now, your path to health and wholeness is just around the corner.
Keep the faith, keep your head high, and keep moving.
Don’t be afraid to stop and ask for help, for you may be many things — in pain, in hopelessness, in despair.
But you are not alone.
References:
1. Wilson, Sue et al. “Prevalence of irritable bowel syndrome: a community survey.” The British journal of general practice : the journal of the Royal College of General Practitioner.
2. “Does the Gut Microbiome Ever Fully Recover from Antibiotics?” The New York Times. 21 December 2018.
3. Hadar Neuman, Paul Forsythe, Atara Uzan, Orly Avni, Omry Koren, Antibiotics in early life: dysbiosis and the damage done, FEMS Microbiology Reviews, Volume 42, Issue 4, July 2018, Pages 489–499
4. Riehl, S. “Why IBS Causes Emotional Stress.” University of Michigan.
5. “Chronic Stress.” The Mayo Clinic. 4 July 2020.
6. Hadar Neuman, Paul Forsythe, Atara Uzan, Orly Avni, Omry Koren, Antibiotics in early life: dysbiosis and the damage done, FEMS Microbiology Reviews, Volume 42, Issue 4, July 2018, Pages 489–499
7. Bristol stool chart. Continence Foundation of Australia. 2020
8. Lurie I, Yang YX, Haynes K, Mamtani R, Boursi B. Antibiotic exposure and the risk for depression, anxiety, or psychosis: a nested case-control study. J Clin Psychiatry. 2015.
9. Strandwitz P. (2018). Neurotransmitter modulation by the gut microbiota. Brain research, 1693(Pt B), 128–133.
10. Ballou, Sarah et al. Psychosocial impact of irritable bowel syndrome: A brief review. World journal of gastrointestinal pathophysiology vol. 6,4 (2015): 120-3.
11. Deaton A, and Case A. “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century.” Proceedings of the National Academy of Sciences.
12. “Why Americans are Dying from Despair.” The New Yorker. 23 March 2020.