Iran Journal of Nursing

1. Introduction
Irritable bowel syndrome is one of the most common gastrointestinal disorders that significantly affects patients' Quality of Life. One of the significant 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. This disease has been introduced as a stress-related disorder, and psychological factors play a critical role in its control and prognosis. The results of studies show that the more severe the symptoms of IBS, the more significant 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 to hide their negative emotions than healthy people. 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 related to emotional suppression can be valuable in IBS treatments. 
The patients' QoL may improve by suppressing emotions that bring more psychological burden, increase anxiety, exacerbate symptoms, and worsen the disease. Expressing feelings in writing and enhancing a person's emotional state can be easily taught and practiced. It is done spontaneously, without face-to-face and continuous referrals, with less interference. Considering the benefits of written expression and the importance 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 expression on the severity of gastrointestinal symptoms in patients with Irritable bowel syndrome.
2. Materials and Methods
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 by continuous method. Participants were randomly (permuted block randomization) assigned into 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. 
The inclusion criteria were as follow: 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 (IBS-SI) 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. 
The exclusion criteria included: 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 the collaboration; 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 worsening of gastrointestinal symptoms during the study. 
By obtaining the Ethics Committee's permission, the researcher referred to the research environments, selected people with IBS who met the inclusion criteria, and explained the research objectives to these people and if they wished to participate in the research. The informed consent form Completed by them. Participants in both groups answered a questionnaire on demographic characteristics and symptom severity index (IBS-SI). The internal correlation coefficient of the Symptom Severity Index Questionnaire is 0.86, and Cronbach's alpha is 0.69. In the intervention group, in addition to routine care, a white booklet with a particular format was given to each participant to express their emotions in writing. 
A weekly written expression of the patient's feelings for 15 to 30 minutes, based on the topics in the booklet, was done at home for one month. During the intervention, 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. After attending the clinic training class, the researcher collected patients' notes. After the researcher viewed the booklet regarding 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, 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 v. 16 and descriptive statistics (Mean±SD, frequency, and percentage) and inferential statistics (independent t-test, paired t-test, and Mann-Whitney).
3. Results
The results showed that the experimental and control groups were homogeneous demographic characteristics. Before performing the written expression, the Mean±SD of symptom severity in the experimental group was 262.36±104.74, and the Mean±SD in the control group was 263.48±118.74. The independent t-test showed that the experimental and control groups were not statistically significant in terms of symptom severity before the intervention and were homogeneous (P=0.966). One month after the written expression, the Mean±SD of symptom severity in the experimental group was 218.75±116.11, and the Mean±SD in the control group was 239.51±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 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 one month after the intervention (P=0.438). The study of changes in gastrointestinal symptoms of patients with irritable bowel syndrome in the experimental and control groups also showed that the decrease in scores in the two groups was not statistically significant (P=0.295).
4. Conclusion
Although written expression in this study did not cause a statistically significant difference in the score of gastrointestinal symptoms in patients with irritable bowel syndrome, it was associated with a decrease in the severity of gastrointestinal symptoms in the experimental group. A significant improvement in the severity of gastrointestinal symptoms was observed in patients with severe symptoms and reduced their symptoms to moderate and even improved. This non-pharmacological intervention can be considered a practical and easy method and pharmacological treatment for patients with irritable bowel syndrome. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Council and the Ethics Committee of Iran University of Medical Sciences (IR.IUMS.REC.1398.326). And the study was registered in the Iranian Clinical Trial Registration Center (IRCT20200831048567N).

Funding
This study was extracted by MA. thesis of the first author at the Department of Internal Surgery, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran.

Authors' contributions
Research: Marzieh Borjian Boroujeni, Mehdi Nikkhah, Mehrnoosh Inanloo; Project supervision and management: Alice Khachian; Analysis: Shima Haqqani; Drafting, editing and finalizing: Marzieh Borjian Boroujeni, Mohammad Heidari. 

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We would like to thank the members of the Research Council of Iran University of Medical Sciences, the professors of the School of Nursing and Midwifery.


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