Expert: Ivan Goldberg, M.D. - 5/5/2010

Question
Dr. Goldberg...
My husband has had bipolar our entire 38 years of marriage. Although we have been through a lot during the last four decades, I don't think I've had to face anything as trying and exhausting with him as now. My husband is addicted to caffiene as he drinks  between 2-3 liters of soda a day. Since his gastric bypass three years ago, (most weight gained back) he has a serious problem with IBS and incontinence. He doesn't give any thought at all to the negative impact his caffeine consumption has on his relationships. After two different episodes of IBSing on the front seat of a friends car, hub's comment is "It was an accident, I didn't do it on purpose." I have countless other experiences of the same type of situation. I know he doesn't do it on purpose, but the point is, he does NOTHING to do things differently. Although I've told him a million times how devasting his IBS and incontinence is on friends and family, for some reason, he just doesn't 'get it'. I'm working real hard to quit repeating my same pleas and lectures...no pay off. Hub's medicines are Abilify (10 mgs), Paxil (20 mg), Norvasc, Trazadone, Zocar, Prilosec, Metformin, Lisopril(sp?). Blood sugar over 300 most days. Has very sedendary life style. Everyday eats all the wrong foods, candy and caffeine.
Bottom line: Husband's incontinence and IBS have such a negative impact on anyone around him. Its gross and so very embarrassing to have my 58 year old husband with so little control or interst to do things differntly. His IBS and incontinence are directly related to his food choices and caffeine consumption. So my question is, Since drinking caffeine causes him to have IBS (yes, in public, all over pants, so sickening) would this be considered 'risky behavior'? Could all of his meds be clouding his thinking as to how serious and socially unacceptable this is? He does NOTHING to prevent his potential 'crisis'. He doesn't even give the horrific problem a seconds thought. After 40 years, I thought I'd seen it all. This is faily new to me and getting really old, really fast. I've been managing all IBS and incontinence situations with having him wear pull ups, taking extra pants in car, wrap sweatshirt around his waist to cover incontinence (yes, leaks out of pull up), reminders to change wet pants before someone knocks on door unannounced etc. to the point of sheer mental exhaustion for me. I've decided I won't be going anywhere with him anymore (unless emergency)as its too stressful for me to endure anymore IBS pouring down his pants, car seats etc...
I'm so sorry for the lenghty post. Thank you so much for reading it. Dr., I will be waiting for your reply.
Thank you kindly.
Anne

Answer
Hi Anne . . .

As I have never seen your husband I cannot tell you what role caffeine plays in his difficulty with bowel control. In some people caffeine makes IBS worse. See:

Inflamm Bowel Dis. 2007 Jan;13(1):91-6.

Treatment of irritable bowel syndrome in outpatients with inflammatory bowel disease using a food and beverage intolerance, food and beverage avoidance diet.
MacDermott RP.

Inflammatory Bowel Diseases Center, Division of Gastroenterology, Albany Medical College, Albany, New York 12208, USA. macderr@mail.amc.edu

Abstract
Irritable bowel syndrome (IBS) in the outpatient with chronic inflammatory bowel disease (IBD) is a difficult but important challenge to recognize and treat. It is very helpful to have effective treatment approaches for IBS that are practical and use minimal medications. Because of the underlying chronic inflammation in IBD, IBS symptoms occur with increased frequency and severity, secondary to increased hypersensitivity to foods and beverages that stimulate the gastrointestinal tract. This paper discusses how to treat IBS in the IBD outpatient, with emphasis on using a food and beverage intolerance, avoidance diet. The adverse effects of many foods and beverages are amount dependent and can be delayed, additive, and cumulative. The specific types of foods and beverages that can induce IBS symptoms include milk and milk containing products; caffeine containing products; alcoholic beverages; fruits; fruit juices; spices; seasonings; diet beverages; diet foods; diet candies; diet gum; fast foods; condiments; fried foods; fatty foods; multigrain breads; sourdough breads; bagels; salads; salad dressings; vegetables; beans; red meats; gravies; spaghetti sauce; stews; nuts; popcorn; high fiber; and cookies, crackers, pretzels, cakes, and pies. The types of foods and beverages that are better tolerated include water; rice; plain pasta or noodles; baked or broiled potatoes; white breads; plain fish, chicken, turkey, or ham; eggs; dry cereals; soy or rice based products; peas; applesauce; cantaloupe; watermelon; fruit cocktail; margarine; jams; jellies; and peanut butter. Handouts that were developed based upon what worsens or helps IBS symptoms in patients are included to help patients learn which foods and beverages to avoid and which are better tolerated.

PMID: 17206644 [PubMed - indexed for MEDLINE]

I have seen a number of people with bowel behavior similar to your husband's. More often than not their incontinence was the product of a passive-aggressive personality problem rather than being caused by a physical condition. Here is some info on passive aggression:

Passive Aggressive Behavior, a Form of Covert Abuse
By Cathy Meyer, About.com Guide

Passive Aggressive (adj.) Of, relating to, or having a personality disorder characterized by habitual passive resistance to demands for adequate performance in occupational or social situations, as by procrastination, stubbornness, sullenness, and inefficiency.

Covert (adj.) Not openly shown, engaged in, or avowed : VEILED

Passive Aggressive Behavior Defined:
Passive Aggressive behavior is a form of covert abuse2. When someone hits you or yells at you, you know that you've been abused. It is obvious and easily identified. Covert abuse is subtle and veiled or disguised by actions that appear to be normal, at times loving and caring. The passive aggressive person is a master at covert abuse.

Passive aggressive behavior stems from an inability to express anger in a healthy way. A person's feelings may be so repressed that they don't even realize they are angry or feeling resentment. A passive aggressive can drive people around him/her crazy and seem sincerely dismayed when confronted with their behavior. Due to their own lack of insight into their feelings the passive aggressive often feels that others misunderstand them or, are holding them to unreasonable standards if they are confronted about their behavior.

Common Passive Aggressive Behaviors:

Ambiguity: I think of the proverb, "Actions speak louder than words" when it comes to the passive aggressive and how ambiguous they can be. They rarely mean what they say or say what they mean. The best judge of how a passive aggressive feels about an issue is how they act. Normally they don't act until after they've caused some kind of stress by their ambiguous way of communicating.

Forgetfulness: The passive aggressive avoids responsibility by "forgetting." How convenient is that? There is no easier way to punish someone than forgetting that lunch date or your birthday or, better yet, an anniversary.

Blaming: They are never responsible for their actions. If you aren't to blame then it is something that happened at work, the traffic on the way home or the slow clerk at the convenience store. The passive aggressive has no faults, it is everyone around him/her who has faults and they must be punished for those faults.

Lack of Anger: He/she may never express anger. There are some who are happy with whatever you want. On the outside anyway! The passive aggressive may have been taught, as a child, that anger is unacceptable. Hence they go through life stuffing their anger, being accommodating and then sticking it to you in an under-handed way.

Fear of Dependency: From Scott Wetlzer, author of Living With The Passive Aggressive Man. "Unsure of his autonomy and afraid of being alone, he fights his dependency needs, usually by trying to control you. He wants you to think he doesn't depend on you, but he binds himself closer than he cares to admit. Relationships can become battle grounds, where he can only claim victory if he denies his need for your support."

Fear of Intimacy: The passive aggressive often can't trust. Because of this, they guard themselves against becoming intimately attached to someone. A passive aggressive will have sex with you but they rarely make love to you. If they feel themselves becoming attached, they may punish you by withholding sex.

Obstructionism: Do you want something from your passive aggressive spouse? If so, get ready to wait for it or maybe even never get it. It is important to him/her that you don,t get your way. He/she will act as if giving you what you want is important to them but, rarely will he/she follow through with giving it. It is very confusing to have someone appear to want to give to you but never follow through. You can begin to feel as if you are asking too much which is exactly what he/she wants to you to feel.

Victimization: The passive aggressive feels they are treated unfairly. If you get upset because he or she is constantly late, they take offense because; in their mind, it was someone else's fault that they were late. He/she is always the innocent victim of your unreasonable expectations, an over-bearing boss or that slow clerk at the convenience store.
Procrastination: The passive aggressive person believes that deadlines are for everyone but them. They do things on their own time schedule and be damned anyone who expects differently from them.

The Passive Aggressive and You:11

The passive aggressive needs to have a relationship with someone who can be the object of his or her hostility. They need someone whose expectations and demands he/she can resist. A passive aggressive is usually attracted to co-dependents, people with low self-esteem and those who find it easy to make excuses for other's bad behaviors.

The biggest frustration in being with a passive aggressive is that they never follow through on agreements and promises. He/she will dodge responsibility for anything in the relationship while at the same time making it look as if he/she is pulling his/her own weight and is a very loving partner. The sad thing is, you can be made to believe that you are loved and adored by a person who is completely unable to form an emotional connection with anyone.

The passive aggressive ignores problems in the relationship, sees things through their own skewed sense of reality and if forced to deal with the problems will completely withdraw from the relationship and you. They will deny evidence of wrong doing, distort what you know to be real to fit their own agenda, minimize or lie so that their version of what is real seems more logical.
Source: http://divorcesupport.about.com/od/abusiverelationships/a/Pass_Agg.htm

If passive-aggression is involved, only psychotherapy is likely to lead to some improvement.

Best regards . . .

Ivan
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