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Irritable bowel syndrome is one of the best models of gastrointestinal disorders to use as a model for understanding placebo mechanisms. Several brain regions are inhibited by a placebo treatment in patients suffering from irritable bowel syndrome. In general, gastrointestinal symptoms can be conditioned, which indicates that learning may play an important role. Subjective symptoms are more affected than objective symptoms in genitourinary disorders. In addition, expectation is known to be crucially involved in sexual functions.

This chapter builds on a basic understanding of the central nervous system (CNS) as coordinator of regional gastrointestinal (GI) tract reflexes. The dorsal vagal complex in the CNS permissively governs the largely autonomous control by the enteric nervous system (ENS) of functions such as absorption, secretion and motility. The CNS actively coordinates voluntary and autonomic communication for complex behavioral functions, such as swallowing, emesis and defecation. The CNS and ENS communicate with inflammatory cells, endocrine cells and microbiota to maintain GI homeostasis and their dysfunction can give rise to clinical disorders. For example, stress or enteritis may predispose individuals to Irritable Bowel Syndrome in which altered bowel function is accompanied by visceral pain. Neural modulation of immune cells and release of inflammatory mediators may contribute to Inflammatory Bowel Diseases. Thus, the bi-directional brain-gut axis maintains GI health and its perturbation contributes to GI disorders.

This chapter describes some mechanisms in the gastrointestinal and genitourinary disorders, although little is known in this area. Irritable bowel syndrome is one of the best models of gastrointestinal disorders for understanding placebo mechanisms and several brain regions are inhibited by a placebo treatment in people suffering from irritable bowel syndrome. Gastrointestinal symptoms can be conditioned by means of a conditioning procedure, which indicates that learning may play an important role. Subjective symptoms are more affected than objective symptoms in genitourinary disorders. In addition, expectations are crucially involved in sexual functions.

Irritable bowel syndrome is one of the best models of gastrointestinal disorders to understand placebo mechanisms. Several brain regions are inhibited by a placebo treatment in patients suffering from irritable bowel syndrome. In general, gastrointestinal symptoms can be conditioned, which indicates that learning may play an important role. Subjective symptoms are more affected than objective symptoms in genitourinary disorders. In addition, expectation is known to be crucially involved in sexual functions. In spite of the widespread occurrence of placebo effects in both gastrointestinal and genitourinary disorders, little is known about the underlying biological mechanisms, and this may represent a promising area for future research.

“It’s a gut feeling.” Indeed, how and why do we get “gut feelings?” After the brain, the gut is the second most innervated bodily organ, diffusely interconnected with gastrointestinal afferent neurons. Whilst sensory neurons from the gut ascend by means of the spinal cord and vagal nerve to subcortical and higher cortical areas of the brain, caudally descending motor efferents from brain to gut seek to modulate gastrointestinal function. Such is the construct of the “brain–gut axis,” a bi-directional body nexus permitting constant information transfer between both brain and gut so as to provide us with visceral interoception. This chapter reviews the neurobiology of gut feelings and discuss their role in both physical and mental health and disease.

The plant Cannabis, which has been traditionally employed for the treatment of gastrointestinal ailments, contains both psychotropic phytocannabinoids, such as Δ‎⁹-tetrahydrocannabinol and nonpsychotropic phytocannabinoids (e.g. cannabidiol, cannabigerol, Δ‎⁹-tetrahydrocannabivarin, and cannabichromene). Such phytocannabinoids have been shown to modulate, through different mechanisms, a number of gastrointestinal functions, including gastric acid secretion, intestinal motility, visceral sensation, inflammation, and cell proliferation. This chapter focuses on the pharmacology and the potential therapeutic application of Cannabis-derived cannabinoids (phytocannabinoids) in gastrointestinal diseases, with a special reference to irritable bowel syndrome, inflammatory bowel disease, and colon cancer.

The concept of disability (including the WHO definition). Case example: disability cf ‘challenge’. Chronic pain, chronic fatigue, and spina bifida, Author’s keynote speech to New Zealand Disability Support Network. The experience of 100 people with different disabilities: system failure and ‘all some doctors see is my disability’. Author’s personal experience of disability resulting from osteoarthritis in both hips. Effect of aquajogging and gentle walking in easing pain, losing weight, and lifting mood. The experience of pain. Chronic pain syndrome and Professor Clifford Woolf’s (Harvard Medical School) 1983 definition of central sensitization. The role of the brain in the experience of pain. Central sensitization and case examples of carpal tunnel syndrome and low back pain. Regional pain syndrome, pain medication and the patient’s expertise with gabapentin. Number needed to treat of gabapentin is 6–8. Effectiveness of paracetamol. Medically unexplained symptoms explained, the example of fibromyalgia, irritable bowel syndrome. The concept of ‘curing’ compared with ‘healing’. The concept of homeostasis. The WHO’s ICD-11 (2018) and the new overarching concept of bodily distress disorder.

It is much better, people think, for the nerves than the mind to be ill. The nerves are physical structures, and heal in the way that all organs of the body heal naturally. Disorders of the mind are frightening because they are so intangible, and, we think, may well lead to insanity rather than recovery. From time out of mind, people have privileged nervous illness over mental illness. From time out of mind, societies have had expressions for the varieties of frets, anxieties, and dyspepsias to which the flesh is heir. In France and England in the seventeenth and eighteenth centuries, one term was “vapours,” a reference from humoral medicine to supposed exhalations of the viscera that would rise in the body to affect the brain. A major apostle was London physician John Purcell, writing in 1702, of “those who have laboured long under this distemper, [who] are oppressed with a dreadful anguish of mind and a deep melancholy, always reflecting on what can perplex, terrify, and disorder them most, so that at last they think their recovery impossible, and are very angry with those who pretend there is any hopes of it.” He emphasized melancholia and anguish, and for him the “vapours” were something more than a mild attack of the frets. But this was not for everyone. Lady Mary Wortley Montagu, now 60 and living in exile in Italy, described to her estranged husband in 1749 Italian health care arrangements, and how physicians visited rich and poor alike. “This last article would be very hard if we had as many vapourish ladies as in England, but those imaginary ills are entirely unknown here. When I recollect the vast fortunes raised by doctors amongst us [in England], and the eager pursuit after every new piece of quackery that is introduced, I cannot help thinking there is a fund of credulity in mankind . . . and the money formerly given to monks for the health of the soul is now thrown to doctors for the health of the body, and generally with as little real prospect of success.”

The main characteristics of generalized anxiety disorder (GAD) are chronic pathological worry, other manifestations of nonphobic anxiety, and various symptoms of tension. Physical symptoms of anxiety are usually less prominent in GAD than in panic disorder, but they can still be an important component of clinical presentation. Behaviors that are often seen in other anxiety disorders, such as overt avoidance, are conspicuously absent. Unlike all other anxiety disorders, it is more likely for GAD in clinical setting to co-occur with a primary condition for which help has been sought–usually depression or other anxiety disorder–than to be the main reason for seeking professional help. Generalized anxiety disorder is one of the more controversial members of the family of anxiety disorders: it seems that almost every aspect of GAD has provoked debates that do not show signs of abating. Paradox, disagreement, debate, and controversy are the words most commonly associated with GAD. It is small wonder then that the list of ‘‘hot topics’’ related to GAD could be very long indeed. Listed below is a selection of issues thought to represent adequately a more comprehensive list…. 1. What are the characteristic features of GAD that would help in its conceptualization? Pathological worry, other cognitive aspects of anxiety, manifestations of tension, and/or (some) symptoms of autonomic arousal? What combination of these features would ensure that GAD is diagnosed adequately and recognized in clinical practice? 2. What is the relationship between pathological worry and GAD? 3. How can different views on what constitutes the essence of GAD be reconciled? Is GAD a single entity or are there two or more ‘‘types’’ of GAD with distinct clinical characteristics? 4. How is GAD related to depressive disorders, other anxiety disorders, and personality disturbance? Where are its boundaries? In view of its close relationship with depression, should GAD be classified along with depression and perhaps renamed accordingly? 5. Can GAD exist on its own, without depression or other anxiety disorders? What could be features specific enough for GAD that would allow it to establish itself as an independent and valid psychopathological and diagnostic entity? 6. What are the pathophysiological correlates of pathological worry and other aspects of chronic anxiety in GAD? 7. What are the underlying mechanisms and purpose of pathological worry in GAD? What is the meaning of chronic anxiety?

We can never know who committed the first murder with arsenic or even who discovered the deadly nature of arsenical compounds. Although the natural arsenic minerals orpiment and realgar are poisonous, they are not particularly effective as murder weapons because they are insoluble and highly coloured, so that feeding them undetected to the intended victim would not be easy. The most reliable form in which to administer arsenic, knowing that it would succeed in killing someone, would have to be as the oxide. This is not a naturally occurring substance but it was easily obtained. When copper ores that had arsenic as an impurity were smelted, the arsenic was oxidized and emitted as white smoke, some of which sublimed (changed directly from a solid to a vapour) onto the walls of flues and chimneys of the smelter, from where it could be gathered. When people talk of ‘arsenic’ they are almost invariably referring to its oxide, whose chemical formula is As2O3, with arsenic atoms bonded to oxygen atoms. Over the centuries this has had many names such as white arsenic, arsenious oxide, arsenious acid (because it dissolves in water to form an acidic solution), arsenic trioxide, and its proper chemical name, arsenic(III) oxide. I shall call it by the name which is still in common use even among chemists: arsenic trioxide. Some murderers used solid arsenic trioxide, stirring it into foods like stews, porridge, or rice pudding to disguise it, but the more usual method was to dissolve it in something that the victim would drink. Not only is arsenic trioxide soluble, but the solution in which it is dissolved does not betray its presence because it is colourless and almost tasteless; if anything it imparts a slightly sweetish taste to the water. Yet even with such advantages favouring the would-be poisoner, it was still possible to fail to kill, either by not understanding arsenic trioxide’s simple chemistry or misjudging the dose required. Sometimes the ignorance and incompetence of murderers worked in their favour because repeated small doses of the poison gave the impression that the victim was suffering from some deep-seated illness, so that when a final fatal dose was administered the end was not unexpected.

We might have thought that the concept of nerves ended in 1957 when the United States Post Office Department initiated a fraud proceeding against John Winters of New York City, who had been promoting a product called Orbacine containing bromide and niacin for “every-day nervousness and its symptoms.” Although Winters’ claims went a bit beyond nerves, the Post Office wanted an end to the whole business and Orbacine disappeared. But the concept of nerves had enemies other than the Post Office. Three in particular had tried to do away with it: psychoanalysis, psychopharmacology, and the DSM series. All failed to kill it completely, and the concept lingers on because of its obvious face value: Our patients clearly have a nervous illness or something resembling it. They do not have a “mood disorder.” In medicine the nervous syndrome, the condition that dare not speak its name, has taken on various allures. Once upon a time, hysteria was the equivalent of a nervous diagnosis in women. There were physicians who had little patience with calling their former hysteric patients “depressed”: They remained hysteric! Jacques Frei, a member of the department of psychiatry of the University of Lausanne in Switzerland, noted in 1984 “the importance that depressive symptomatology has taken today as a call for help among female hysterics. . . . It seems that the hysterical woman today has a better chance of a hearing if she presents with a depressive picture, even evoking suicidal ideas.” Although hysteria today is discredited as a diagnosis, it is interesting that older clinicians such as Frei saw it as a diagnosis that trumped depression; he even argued that his patients at Cery Hospital were modeling their symptoms to conform to the new diagnoses. The 1950s and 1960s saw alternative diagnoses to the nervous syndrome come and go, fragments of clinical experience that seemed to make sense to individual physicians but were not more widely taken up because their originators did not have prestigious academic appointments. Take “the housewife syndrome” that Palma Formica proposed in 1962.

When our patients are diagnosed with fibromyalgia, their initial reaction generally is “What?” At this point, we provide them with literature from fibromyalgia support groups and the Arthritis Foundation and explain what this condition means. Often we meet with family members to reinforce the educational process. In mild cases, this creates a sense of relief. Some patients who have seen several physicians and been given various diagnoses have differing reactions: “Are you just trying to put me off?” “My last rheumatologist said the same thing, told me he could do nothing for it, and sent me back to my family doctor.” “Are you sure it’s not lupus or Lyme disease or cancer?” Once our patients have accepted the diagnosis and read about the syndrome, we examine their behavior patterns and try to find ways to help them deal with the diagnosis in a constructive manner. This chapter reviews some of the emotional reactions our patients display and problems they have to deal with, gives practical advice on how to surmount obstacles, and describes community resources that help patients overcome the syndrome. It’s hard enough to get through the day when feeling unwell. In fibromyalgia, the sense of being unwell is manifested by fatigue, pain, spasm, poor sleeping, lack of stamina or endurance, and sometimes difficulty concentrating or focusing. Fibromyalgia patients frequently react to these sensations with specific attitudes, emotions, and other behavioral responses, including anxiety, anger, guilt, loss of self-esteem, depression, and fear. There are no physical markers of fibromyalgia that reveal the syndrome to others. Fibromyalgia patients have no deformities, don’t have an X marked on their fore head, look healthy, and seem able to be active. While this is good for the patient in one sense, friends, employers, and loved ones often have difficulty believing that they have so many complaints. Therefore, it’s important to be open and frank with those who care. You need to have their trust to help them understand the limitations imposed by fibromyalgia. Patients do not need to be coddled or treated like invalids; they crave and need understanding and respect.