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Relationship between abdominal pain subgroups in the community and psychiatric diagnosis and personality - A birth cohort study
Abstract
It is unclear if there is a causal link between psychiatric disorders and unexplained chronic gastrointestinal (GI) symptomatology. The role of personality is also in dispute. We aimed to assess the association of these factors with functional GI symptoms in a birth cohort study.
The Dunedin birth cohort is well characterised and has been followed-up prospectively to age 26 (n=980). Measured were upper and lower GI symptoms over the prior year at age 26 using a validated questionnaire, psychiatric diagnoses at ages 18 and 21 by standardised interview applying DSM-III-R criteria, and personality at age 18 using the Multidimensional Personality Questionnaire (MPQ). Natural symptom groupings were identified using factor analysis and k-means clustering. The association of these clusters and psychiatric diagnoses or personality was assessed by logistic regression.
The k-means analysis produced a six-cluster solution, which was made up of a health group, and five "disease" clusters defined by higher than average scores on a single symptom. A diagnosis of depression at age 18 or 21 years was associated with increases in the odds of 1.69 (95% CI: 1.27-2.25) for all GI, of 2.16 (95% CI: 1.12-4.16) for dysmotility and of 2.07 (95% CI: 1.13-3.80) for constipation, but not with the other clusters. Similar results were observed with respect to anxiety disorders for the odds of GI overall (OR=1.42, 95% CI: 1.01-1.99) and constipation (OR=2.11, 95% CI: 1.17-3.79). The personality subscales were not strongly linked; membership of "any" diseased cluster was associated with a reduced odds of being in the fourth quartile for the well-being scale (OR=0.64, 95% CI: 0.46-0.88) but increased odds of being in the fourth quartile for the social potency scale (OR=1.64, 95% CI: 1.18-2.28).
In a young adult community sample, unexplained GI symptoms appear to be linked to psychiatric disorders but personality differences were minimal.
... HIT-6 is a well-recognized tool based on a questionnaire to measure the headache impact on patient's ability to function in normal daily life. The score is classified in different levels from 49 or less (little or no impact), 50-55 (some impact), 56-59 (substantial impact) and 60 or more (very severe impact), each of which needs specific management 19 . Patients who did not meet the migraine criteria were categorized as patients with headache other than migraine. ...
... Moreover correlation between the duration of IBD and migraine prevalence was not significant (r=-0.14, p=0. 19). Migraine occurred in 10 (58.8%) patients before IBD and in 7 (41.2%) ...
... These studies confirmed that abdominal complaints have been related to headache, depression, somatisation, and conversion disorders. [18][19] In Keeping with this hypothesis, in the current practice the frequency of anxiety in patients with IBD was significantly more than the control group. Moreover several studies revealed the role of inflammation in migraine. ...
BACKGROUND
It is hypothesized that migraine may be related to inflammatory bowel disease (IBD), therefore in this cross-sectional study we evaluated the prevalence of migraine in patients with IBD.
METHODS
In this cross-sectional study 80 patients with IBD and 80 patients without IBD referring to a private gastroenterology clinic from May to January 2014 were evaluated regarding the prevalence of migraine, severity of migraine based on Headache Impact Test (HIT-6), and habits related to headache.
RESULTS
160 participants with the mean age of 35 years were evaluated. The prevalence of migraine in the case group was significantly higher than the control (21.3% vs. 8.8%, p=0.027). Moreover, duration of each attack (hours) in IBD group was significantly higher than the control group (p<0.001) while the duration of migraine involvement (months) and number of attacks was higher in the control group (p=0.019 and 0.048, respectively). Headache other than migraine in the control group was significantly higher than the IBD group(p<0.001). Disability in the case group was more than the control group but the difference was not significant. The correlation between the severity of disability related to migraine (based on HIT-6) and severity of IBD (based on May oscore & Crohn’s disease activity index (CDAI)) was not significant (r=0.16, p=0.58). Moreover the correlation between the duration of IBD and migraineprevalence was not significant (r=-0.14, p=0.19).
CONCLUSION
We found that the prevalence of migraine in patients with IBD is significantly more than normal population. More studies are needed to highlight the correlation between migraine and IBD.
... Several studies conducted in adults with AP-FGIDs have reported some abnormal personality traits [6][7][8][9][10][11]. However, some other adult studies have failed to demonstrate a significant difference in personality traits in affected individuals [12]. Similarly, a previous study conducted in children has also failed to report abnormal mean personality scores in those with recurrent abdominal pain [13]. ...
... Other abnormalities observed in personality in adults with AP-FGIDs include detachment, neuroticism, conscientiousness, inferior coping strategies, low level of openness and agreeableness [6][7][8][9][10][38][39][40][41]. In contrast to this, some other studies conducted in adults with FGIDs [12] and children with recurrent abdominal pain [13] have failed to demonstrate significant differences in personality in affected individuals. However, all these previous studies have used different tools to assess personality in their study participants and therefore, a direct comparison was difficult. ...
Abstract Background Chronic abdominal pain is a common worldwide problem and known to be associated with psychological problems. This study evaluated the association between abdominal pain-predominant functional gastrointestinal disorders (AP-FGIDs), psychological maladjustment and personality traits in adolescents. Methods Adolescents aged 13–18 years were recruited from 5 randomly selected schools in Ampara district of Sri Lanka. AP-FGIDs were diagnosed using Rome III criteria. Translated and validated Rome III questionnaire (Child report form), personality questionnaire (PAQ) and PedsQL (Pediatric Quality of Life) inventory were used in data collection. Written consent was obtained from a parent and assent was obtained from every child recruited. The questionnaire was distributed in an examination setting to ensure confidentiality and privacy. Research assistants were present during data collection to assist on any necessary clarifications. Results A total of 1697 subjects were recruited [males 779 (45.9%), mean age 15.1 years, SD 1.6 years]. AP-FGIDs were present in 202 (11.9%). Those with AP-FGIDs had significantly higher mean scores for all personality traits (hostility and aggression, negative self-esteem, emotional unresponsiveness, emotional instability and negative world view), except dependency. Affected children had lower scores for all 4 domains of HRQoL (physical, emotional, social and school functioning), compared to controls (p
... Dementia and depression are considered possible secondary causes of constipation [9]. In addition, anxiety and depression have been widely associated with functional gastrointestinal disorders, especially irritable bowel syndrome [10][11][12]. When diagnosing depression, constipation is usually taken into consideration, however, not with other psychiatric diagnoses. ...
... Among the young and middle-aged SMI patients, the strength of associations was much less and not statistically significant. The results of this first study on the association between psychiatric diagnosis and constipation are in contrast with clinical handbooks and previous studies that irritable bowel syndrome/constipation is more or less specifically related to depression and anxiety disorders [10][11][12]. Clinical handbooks do not report about the relationship between other psychiatric diagnoses and constipation [15]. ...
Objective
. Constipation is a prevalent problem in patients with psychiatric disorders; it reduces quality of life and may lead to severe complications. The prevalence distribution of constipation across all psychiatric diagnoses in patients with severe mental illness (SMI) has hardly been studied. The aim of this study is to estimate the association between psychiatric disorders and constipation in SMI inpatients.
Methods
. The strength of the association between constipation (based on use of laxatives) and DSM-IV psychiatric diagnosis was studied in a cross-sectional study with “adjustment disorders” as the reference group. The association was analyzed using logistic regression.
Results
. Of the 4728 patients, 20.3% had constipation. In the stratum of patients older than 60 years, all psychiatric categories except for substance related disorders were significantly associated with a higher prevalence of constipation (odds ratios ranging from 3.38 to 6.52), whereas no significant associations were found in the stratum of patients between 18 and 60 years (odds ratios ranging from 1.00 to 2.03).
Conclusion
. In the elderly, all measured psychiatric diagnoses are strongly associated with an increased prevalence of constipation. Physicians should be extra alert for constipation in SMI patients, independent of specific psychiatric diagnoses.
... According to this point of view, a more recent research has indicated an association between unexplained chronic gastrointestinal symptomatology and psychiatric disorders such as depression or anxiety disorder in a sample of young adults (Howell, Poulton, Caspi, & Talley, 2003). ...
Background: Despite the role of metacognition in psychopathology, no studies have explored this construct in the area of gastrointestinal disorders. Moreover, for many times there was a categorization between organic and functional gastrointestinal disorders. The aim of this study was to compare dysfunctional metacognitive beliefs between patients with functional bowel disorders and patients with organic bowel disorders. The purpose of this work was also to examine the relations between metacognitions, alexithymia and symptoms of the patients on the basis of diagnosis. Methods: A between-subject non parametric and correlational design was employed. We formed three clinical groups from a population of patients with gastrointestinal disorders and on the basis of the 'organic' and 'functional' diagnosis. All the participants underwent the Metacognitions Questionnaire 30, the Toronto Alexithymia Scale-20 and the Gastrointestinal Symptom Rating Scale. Results: There were no significant differences between the three clinical groups on MCQ-30 and TAS-20 scores. However, there were significant
... Abdominal complaints, regardless of their etiology, have been associated with depression, somatization, conversion disorders, and headaches. 26,27 The presence of abdominal complaints in both celiac disease and IBD may be a factor in the increased incidence of headache in these patient populations. The question still remains whether there are any mechanistic differences of migraine pathogenesis between celiac disease and IBD. ...
... Abdominal complaints, regardless of their etiology, have been associated with depression, somatization, conversion disorders, and headaches. 26,27 The presence of abdominal complaints in both celiac disease and IBD may be a factor in the increased incidence of headache in these patient populations. The question still remains whether there are any mechanistic differences of migraine pathogenesis between celiac disease and IBD. ...
Objective:
To assess the prevalence of headache in clinic and support group patients with celiac disease and inflammatory bowel disease (IBD) compared with a sample of healthy controls.
Background:
European studies have demonstrated increased prevalence of headache of patients with celiac disease compared with controls.
Methods:
Subjects took a self-administered survey containing clinical, demographic, and dietary data, as well as questions about headache type and frequency. The ID-Migraine screening tool and the Headache Impact Test (HIT-6) were also used.
Results:
Five hundred and two subjects who met exclusion criteria were analyzed - 188 with celiac disease, 111 with IBD, 25 with gluten sensitivity (GS), and 178 controls (C). Chronic headaches were reported by 30% of celiac disease, 56% of GS, 23% of IBD, and 14% of control subjects (P<.0001). On multivariate logistic regression, celiac disease (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.78-8.10), GS (OR 9.53, 95%CI 3.24-28.09), and IBD (OR 2.66, 95%CI 1.08-6.54) subjects all had significantly higher prevalence of migraine headaches compared with controls. Female sex (P=.01), depression, and anxiety (P=.0059) were independent predictors of migraine headaches, whereas age >65 was protective (P=.0345). Seventy-two percent of celiac disease subjects graded their migraine as severe in impact, compared with 30% of IBD, 60% of GS, and 50% of C subjects (P=.0919). There was no correlation between years on gluten-free diet and migraine severity.
Conclusions:
Migraine was more prevalent in celiac disease and IBD subjects than in controls. Future studies should include screening migraine patients for celiac disease and assessing the effects of gluten-free diet on migraines in celiac disease.
El objetivo general de esta Tesis Doctoral es analizar las relaciones entre personalidad y salud a partir del modelo de personalidad de Theodore Millon y sus posibles diferencias según las variables demográficas incluidas en la investigación (sexo/género, situación laboral y cultura/nación), dentro del marco teórico general de la Psicología de la Salud. La muestra total está compuesta por 1377 participantes de tres países (375 españoles, 466 portugueses y 536 brasileños). Las variables incluidas fueron: personalidad, salud percibida, dolencias físicas, ansiedad, autoestima y satisfacción personal. Los resultados demuestran que un estilo de personalidad desadaptado, definido por una tendencia a experimentar emociones negativas de forma pasiva, con una inestabilidad emocional de fondo, y por la tendencia a inhibir la expresión de estas emociones en la interacción social, esta última caracterizada por el aislamiento, la sumisión y la inseguridad, seria un terrero fructífero para una pobre salud y quizás para la aparición y desarrollo de posibles enfermedades. Por otro lado, el estilo de personalidad asociado a más salud se caracteriza por afrontar los hechos de la vida con optimismo y determinación, afrontándolos de forma activa, recurriendo a los demás como fuente de información y con unas relaciones interpersonales saludables, basadas en la seguridad en uno mismo. Además, se confirma la hipótesis secundaria, o sea, las variables sexo y situación laboral tomadas en conjunto modulan las relaciones entre personalidad y salud. Es decir, el lugar ocupado por las personas en el mercado laboral, y más allá de los datos, quizás el estrés percibido por mujeres y hombres según su condición de trabajo y los conflictos generados a partir de ello, sea la clave para que los rasgos de personalidad cobren importancia o no en el estado de salud de los sujetos.
An unexplained epidemic of obesity is occurring but the relationship between obesity and gastrointestinal (GI) tract function is unclear. We aimed to evaluate the association between body mass index (BMI) and specific GI symptoms.
A birth cohort in Dunedin, New Zealand, aged 26 yr (n = 980, 94% of total original sample) was evaluated using a validated GI symptom questionnaire. Categories of GI symptom complexes were defined a priori. The association of reported GI symptoms with BMI (kg/m(2)) was assessed adjusting for gender.
The prevalence of obesity (BMI > or = 30 kg/m(2)) was 12%; 30% were overweight. There was a significant univariate positive association between increased BMI and diarrhea (>3 stools/day, loose stools, or urgency); the sex adjusted odds ratio for obese versus normal weight was 1.8 (95% CI 1.1, 2.9; p= 0.02). Abdominal pain associated with nausea or vomiting was positively associated with increased BMI (OR 2.0, 95% CI 1.0, 2.9; p= 0.04). Being overweight was negatively associated with abdominal pain and constipation (OR 0.4, 95% CI 0.2, 0.9; p= 0.02). Irritable bowel syndrome and reflux symptoms were not significantly associated with increased BMI. Waist-to-hip ratios were not significantly associated with GI symptoms. No study members were taking antiobesity medications. Hemoglobin A1c levels were not associated with any of the GI symptoms.
In a general population sample of young adults, increasing BMI was associated with diarrhea and abdominal pain with nausea/vomiting.
Functional gastrointestinal disorders (FGID) are a group of disorders characterized by recurrent gastrointestinal distress for which no structural or biochemical cause can be discerned. Irritable bowel syndrome (IBS) is an FGID estimated to affect 10% to 25% of the United States population. IBS occurs in over 40% of individuals with panic disorder, and in patients with IBS, 25% to 30% have panic disorder, which has led to speculation about possible shared pathophysiology between the two. Less is known about the prevalence of other FGID in individuals with panic disorder.
The purpose of this study was to examine the prevalence of IBS and all the other FGID in patients with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) panic disorder.
We assessed FGIDs in 73 treatment-seeking DSM-IV panic disorder patients via the Diagnostic Interview Questions for Functional Gastrointestinal Disorders and made descriptive comparisons with a large convenience sample from an already-completed United States Household Survey (USHS), which employed the same diagnostic criteria.
The prevalence of IBS and other FGIDs in both men and women with panic disorder were substantially higher than in the USHS respondents. Women with panic disorder had significantly more functional chest pain than men, but there was no gender difference in IBS. With the exception of functional anorectal and biliary disorders, the FGID prevalences were comparatively higher in panic disorder versus the USHS respondents.
This survey supports earlier reports of a high prevalence of IBS in individuals with panic disorder and also suggests that the prevalence of several other FGIDs were comparatively high as well. Methodological limitations precluded direct statistical analysis. It may be that commonly overlapping psychiatric and often-painful FGIDs, and extra-intestinal disorders increase the risk for comorbidity in already-affected individuals via shared pathophysiology. One potential model for which there is some evidence for a role in stress, panic disorder, FGIDs and several extra-intestinal functional conditions is dysregulation of corticotropin-releasing factor function.
The prevalence of FGIDs in DSM-IV panic disorder was comparatively higher than in USHS respondent community sample, which used similar FGID diagnostic criteria. The cause for the apparent close association of panic disorder with FGID may represent shared pathophysiology. Increased understanding of the mechanism of the overlap may allow for improved treatment of the significant proportion of the population suffering from comorbid psychiatric and functional medical conditions.
We administered the Multidimensional Personality Questionnaire (MPQ) to 217 monozygotic and 114 dizygotic reared-together adult twin pairs and 44 monozygotic reared-apart adult twin pairs. A four-parameter biometric model (incorporating genetic, additive versus nonadditive, shared family-environment, and unshared environment components) and five reduced models were fitted through maximum-likelihood techniques to data obtained with the 11 primary MPQ scales and its 3 higher order scales. Solely environmental models did not fit any of the scales. Although the other reduced models, including the simple additive model, did fit many of the scales, only the full model provided a satisfactory fit for all scales. Heritabilities estimated by the full model ranged from .39 to .58. Consistent with previous reports, but contrary to widely held beliefs, the overall contribution of a common family-environment component was small and negligible for all but 2 of the 14 personality measures. Evidence of significant nonadditive genetic effects, possibly emergenic (epistatic) in nature, was obtained for 3 of the measures. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
In outpatients and the community, an association between abuse (particularly sexual abuse) and irritable bowel syndrome (IBS) has been observed, but whether there is a causal link continues to be disputed.
To test the hypothesis that psychological factors explain the apparent association between abuse and IBS.
A sample of residents of Penrith (a Sydney suburb sociodemographically similar to the Australian population) selected randomly from the electoral rolls (that by law include the entire population of age 18 years and above) was mailed a validated self report questionnaire. Measured were gastrointestinal (GI) symptoms including the Rome criteria for IBS, abuse (including the standardised Drossman questions), neuroticism (Eysenck Personality Questionnaire), and psychological morbidity (General Health Questionnaire).
The response rate was 64% (n = 730); 12% fulfilled the Rome criteria for IBS. Overall abuse in childhood (odds ratio (OR) = 2.02, 95% confidence interval (CI) 1.29 to 3.15) but not adulthood (OR = 1.39, 95% CI 0.88 to 2.19) was associated with IBS univariately. Neuroticism and psychological morbidity were also univariately associated with abuse in childhood, abuse in adulthood and IBS, respectively. However, by logistic regression, abuse in childhood was not associated with IBS after controlling for age, gender, and psychological factors (OR = 1.34, 95% CI 0.83 to 2.17). The results were not altered by restricting the analyses to more severe forms of abuse, and were not explained by interactions between abuse and psychological variables.
There is an association between abuse and IBS in the community, but this may be explained in part by other psychological factors. Based on a path analysis, we postulate that abuse may induce the expression of neuroticism that in turn leads to IBS.
In this multivariate analysis of the irritable bowel syndrome (IBS) we describe the symptomatic and psychologic features of the condition and their possible contributions to health care seeking. We studied 72 IBS patients, 82 persons with IBS who had not sought medical treatment, and 84 normal subjects. All subjects received complete medical evaluation, diary card assessment of abdominal pain and stool habit, and standard psychologic tests of pain, personality, mood, stressful life events, illness behavior, and social support. Pain and diarrhea were the most important symptoms associated with patient status. When controlling for these symptoms we found that (a) IBS patients have a higher proportion of abnormal personality patterns, greater illness behaviors, and lower positive stressful life event scores than IBS nonpatients (p less than 0.001) and normals (p less than 0.001); (b) IBS nonpatients, although psychologically intermediate between patients and normals, are not different from normals (p less than 0.21); and (c) IBS nonpatients have higher coping capabilities, experience illness as less disruptive to life, and tend to exhibit less psychologic denial than patients. These factors may contribute to "wellness behaviors" among people with chronic bowel symptoms. We conclude that the psychologic factors previously attributed to the IBS are associated with patient status rather than to the disorder per se. These factors may interact with physiologic disturbances in the bowel to determine how the illness is experienced and acted upon.
The authors assessed the relation between personality and mental disorder in a representative birth cohort of 897 men and women. Personality was assessed at age 18 with the Multidimensional Personality Questionnaire (MPQ; A. Tellegen, 1982), and 4 types of mental disorder (affective, anxiety, substance dependence, and conduct disorder) were assessed at ages 15, 18 and 21, using age-appropriate standardized diagnostic interviews. All disorder groups had MPQ profiles that were very different from those of controls. When comorbid cases were excluded, fewer significant differences between diagnosed cases and controls remained. Relations between personality and mental disorder were not affected by the measurement of disorder as continuous versus discrete, gender, or the age at which disorder was diagnosed. Relations between personality and mental disorders appear to be robust, and individual personality differences may be particularly relevant to understanding the most severe (comorbid) expressions of psychopathology.
A new interview schedule allows lay interviewers or clinicians to make psychiatric diagnoses according to DSM-III criteria, Feighner criteria, and Research Diagnostic Criteria. It is being used in a set of epidemiological studies sponsored by the National Institute of Mental Health Center for Epidemiological Studies. Its accuracy has been evaluated in a test-retest design comparing independent administrations by psychiatrists and lay interviewers to 216 subjects (inpatients, outpatients, ex-patients, and nonpatients).
• A new interview schedule allows lay interviewers or clinicians to make psychiatric diagnoses according to DSM-III criteria, Feighner criteria, and Research Diagnostic Criteria. It is being used in a set of epidemiological studies sponsored by the National Institute of Mental Health Center for Epidemiological Studies. Its accuracy has been evaluated in a test-retest design comparing independent administrations by psychiatrists and lay interviewers to 216 subjects (inpatients, outpatients, ex-patients, and nonpatients).
Objective: We aimed to determine whether psychiatric disorders and psychological symptoms are associated with the irritable bowel syndrome, and whether childhood sexual abuse is reported more often by patients with irritable bowel syndrome, as these issues continue to be controversial.
Design: Prospectively, 32 symptomatic married outpatients with irritable bowel syndrome completed selected portions of the Structured Clinical Interview for DSM-III-R psychiatric diagnoses, a standardized interview for childhood abuse, and a series of self-report psychological symptom inventories. Controls comprised 20 currently symptomatic married outpatients who had undergone a partial colectomy or ileectomy for organic disease, the spouses of the patients with irritable bowel syndrome, and the spouses of the organic disease controls.
Results: Current psychiatric disorders were reported significantly more frequently by patients with irritable bowel syndrome compared with controls, although 69% of these patients were not affected. Childhood abuse was reported more frequently by patients with irritable bowel syndrome, but after adjusting for age and gender, a significant association with diagnostic group was not detected. However, psychiatric disorders were significantly more frequent in those with a history of childhood abuse. Self-report psychological symptom inventories did not discriminate between patients with the irritable bowel syndrome and controls.
Conclusion: Our findings suggest that while standardized psychiatric interviews give more information than self-report rating scales, psychopathology may not be the major explanation for at least a subset of patients with the irritable bowel syndrome.
(C) Lippincott-Raven Publishers.
Background: Individuals with irritable bowel syndrome (IBS) are reported to experience more symptoms compatible with psychopathologic disorders, abnormal personality traits, and psychological distress. Conversely, individuals with psychiatric disorders report higher levels of gastrointestinal (GI) symptoms compatible with IBS. Thus, psychological distress may contribute to GI symptoms in individuals with IBS.
Objectives: To examine psychological distress in women with IBS, women with similar GI symptoms but not diagnosed (IBS nonpatients, IBS-NP), and asymptomatic Control women.
Methods: The women (N = 97) were interviewed, completed questionnaires, and maintained daily diaries for 2 months. Across-women and within-woman analyses were used to calculate the results.
Results: The IBS and IBS-NP groups had a higher percentage of lifetime psychopathology and recalled psychological distress. At least 40% of the women in the IBS and IBS-NP groups had positive relationships between daily psychological distress and daily GI symptoms.
Conclusions: Psychological distress is an important component of the IBS symptom experience and should be considered when treatment strategies are designed.
High rates of psychiatric disorder have been documented in patients with functional bowel syndromes sampled from physicians' offices. Lifetime psychiatric disorders and/or current psychiatric symptoms are thought to be much more highly associated with current gastrointestinal bowel symptoms in clinical settings than in the community. The relationship of lifetime functional gastrointestinal symptoms to lifetime psychiatric disorders has not been examined systematically in randomly selected samples of general community populations. The current study reports findings from existing data on a large, randomly selected population sample that may help to clarify these associations. Epidemiologic Catchment Area (ECA) project data were analyzed to examine relationships of functional gastrointestinal symptoms and psychiatric diagnoses in the community. Individuals with two or more medically unexplained gastrointestinal symptoms had high rates of psychiatric disorders. This was also true for the subgroup in which abdominal pain was one of the two symptoms. The overwhelming majority of subjects reporting medically unexplained gastrointestinal symptoms said they had consulted physicians for those symptoms. General population ECA data indicate that women in the community report more functional gastrointestinal complaints than men, that individuals with lifetime gastrointestinal complaints have high rates of lifetime psychiatric disorders (not necessarily currently symptomatic), and most have contacted a physician regarding their gastrointestinal symptoms. These data complement studies showing that patients with current gastrointestinal symptoms often do not consult a physician, or when they do, such behavior is associated with active psychiatric symptoms. The present data are consistent with the hypothesis that patients with recurrent symptoms are those who routinely seek medical help and who have high rates of psychiatric disorders, whereas those with symptoms that resolve or are improved by a medical intervention do not maintain treatment-seeking behavior.
This study compared daily gastrointestinal symptoms and stool characteristics across two menstrual cycles, and recalled bowel symptoms and psychological distress in women with irritable bowel syndrome (IBS,N=22), IBS nonpatients (IBS-NP,N=22), and controls (N =25). Daily reports of abdominal pain, bloating, intestinal gas, constipation, and diarrhea did not differ significantly between the IBS and IBS-NP groups but both groups reported significantly higher symptoms than the control group. Stool consistencies was significantly looser in the IBS group relative to the control group. Menstrual cycle effects on symptoms were noted in all the groups. There were no significant differences in psychological distress between women with IBS, and IBS-NP, but both groups reported significantly higher global distress than the control group. The lack of difference between the IBS and IBS-NP groups in contrast to the results of others, can be understood in terms of differences in recruitment strategies.
OBJECTIVE:Psychiatric morbidity is high among patients who present to referral centers with irritable bowel syndrome (IBS). However, few studies have investigated the relationship between psychiatric disturbance and IBS in community samples. We hypothesized that psychiatric disorders are linked to IBS in the general community, but this is influenced by the criteria used to establish a diagnosis of IBS.METHODS:The data were collected from a birth cohort born in Dunedin (New Zealand) between April 1972 and March 1973. This cohort consisted of 1037 members (52% male), who were assessed at ages 3, 5, 7, 9, 11, 13, 15, 18, 21, and 26 yr. GI symptoms were recorded at age 26 yr, using an abbreviated version of the Bowel Symptom Questionnaire; psychiatric history was obtained at ages 18 and 21 yr, using a modified version of the Diagnostic Interview Schedule.RESULTS:The prevalence of IBS was 12.7% according to the Manning criteria and 4.3% according to the Rome II criteria. The IBS was not significantly related to a diagnostic history for psychiatric illness overall, nor to a history of anxiety disorders, depressive disorders, and substance dependence. These results were independent of the IBS criteria used; there was no association between psychiatric history and IBS when IBS was defined according to the Manning criteria (p = 0.11 to 0.98) or the Rome criteria (p = 0.18 to 0.92); Rome and Manning criteria subjects did not significantly differ from each other in terms of psychiatric history (p = 0.16 to 0.89).CONCLUSION:In a cohort of young adults with IBS from New Zealand, IBS appears to not be related to psychiatric disorders.
Patients with irritable bowel syndrome (IBS) (n = 121) were compared to 46 patients with inflammatory bowel disease (IBD), and to 45 nonpatient controls on a variety of psychological tests and on symptomatology. The most consistent finding was the ordering of group psychological test means such that, on 11 of 14 measures, IBS patients scored higher than IBD patients, who in turn scored higher than the nonpatient controls. The two patient groups differed significantly only on measures of anxiety with the IBS patients scoring significantly higher on all three measures. IBS patients also reported significantly more severity of abdominal pain than the IBD patients; while IBD patients reported more episodes of diarrhea, they did not rate them as significantly more severe than did the IBS patients. Various other parameters of the IBS population are also explored and implications for treatment and future study are discussed.
Ninety-six patients complaining of recurrent or persistent abdominal pain were referred consecutively to a surgical clinic and a medical clinic, respectively. They were examined psychiatrically after their initial physical investigation. The psychiatric examination included rating scales for depression and anxiety, a personality inventory, life-events schedule, scale of verbal expressivity, and family and personal patterns of pain and invalidism. Only 15 patients (15-6%) had organic disorders that could be responsible for their symptoms. In the remainder, psychiatric factors were considered primarily responsible for their abdominal pain: 31 were depressed; 21 had chronic tension; in 17 hysterical mechanisms were prominent; and 12 were found to be unrecognised alcoholics. Follow-up at three and six months and recognition by 80% of the psychogenic group that a psychological explanation was plausible, confirmed the diagnoses, and over half responded favourably to psychiatric management. Features distinguishing the organic and psychogenic groups were delineated. Psychiatric assessment has a place among the investigations of non-acute abdominal pain; certainly it should not be condisered simply as "a last resort."
The purpose of this investigation is to determine if the high prevalence rates of major depression, panic disorder, and agoraphobia found in tertiary-care studies of irritable bowel syndrome and medically unexplained gastrointestinal symptoms are also found in the general population. Structured psychiatric interviews on 18,571 subjects from the NIMH Epidemiologic Catchment Area (ECA) Study were reviewed for prevalence of gastrointestinal distress symptoms and selected psychiatric disorders. Medically unexplained gastrointestinal symptoms had a high prevalence in the general population (6-25%). When compared with those reporting no gastrointestinal symptoms, subjects who report at least one of these symptoms were significantly more likely to have also experienced lifetime episodes of major depression (7.5% vs 2.9%), panic disorder (2.5% vs 0.7%), or agoraphobia (10.0% vs 3.6%). Subjects with two gastrointestinal symptoms had even higher lifetime rates of depression (13.4%), panic (5.2%), or agoraphobia (17.8%). Lifetime rates of affective and anxiety disorders in the general population are higher in subjects with gastrointestinal symptoms compared with subjects without gastrointestinal symptoms. An even higher prevalence of affective and anxiety disorders is found in patients with medically unexplained gastrointestinal symptoms in tertiary-care clinics. Future studies are needed in primary-care populations where prevalence rates of psychiatric illness are probably intermediate between those of the general population and tertiary care.
Forty patients with a diagnosis of irritable bowel syndrome (IBS) and 32 patients with peptic ulcer disease underwent a full psychiatric assessment. All were rated using the Gastrointestinal Symptom Rating Scale (GSRS), the Comprehensive Psychopathological Rating Scale, the Life Experiences Survey and the Eysenck Personality Inventory. The 2 groups were not distinguishable on total GSRS scores or rates of DSM-III diagnosed mental disorder. However, greater trait scores for neuroticism and introversion were found in the IBS group, together with a greater reporting of life events perceived as negative.
Psychiatric disorder is reported to occur in a large proportion of patients with irritable bowel syndrome (IBS) and psychological treatment methods have been advocated for this patient group. In a sample of 25 out-patients with intractable IBS, only four patients with psychiatric disorder were identified. The majority did not have elevated levels of anxiety or depression nor was there evidence of significant abnormal illness behaviour. Electrodermal activity did not show the extremes of responding and habituation associated with anxiety, depression or chronic pain. It is suggested that, when accurate diagnostic criteria are employed, a specific relationship between IBS and psychopathology is no longer evident.
This paper describes the prevalence and incidence of psychiatric disorders in IBS patients using a standardized psychiatric interview, and proposes a psychological model for investigating one aspect of IBS. Forty-four IBS patients and 28 nonclinical participants received a psychiatric interview (Diagnostic Interview Schedule) and completed the Lie Scale of the Eysenck Personality Inventory (L-EPI). Results indicated that a significant percentage (59%) of the IBS group met DSM-III criteria for a psychiatric disorder within the last year, far more than occurred in the matched nonclinical comparison group. Relative to the comparison group, the IBS group also had significantly higher lie scores on the EPI indicating a response style of social desirability. On the basis of these findings, together with earlier work by Latimer's group, a conceptual model was formulated on the notion that some IBS patients may have a self-schema (i.e. knowledge of self, stored in memory) characterized by social desirability. We suggest that the construct of self-schema may be helpful in differentiating IBS from psychiatric groups both conceptually and therapeutically.
The importance of personality traits in nonulcer dyspepsia and irritable bowel syndrome is a controversial issue. We wished to assess the distribution of abnormal personality traits in nonulcer dyspepsia and the irritable bowel syndrome, define any relation among personality and symptoms, and determine whether personality factors discriminate among patients with functional, psychiatric, or organic gastrointestinal diseases. Patients with nonulcer dyspepsia (n = 31), irritable bowel syndrome (n = 67), organic gastrointestinal disease (n = 64), somatoform disorder (n = 36) and healthy controls (n = 128) were studied. Before diagnostic evaluation by an independent physician, all patients completed the Minnesota Multiphasic Personality Inventory and a symptom questionnaire. Symptom scores for abdominal pain and the Manning criteria, which is considered to be diagnostic for the irritable bowel syndrome, were evaluated. Personality scales in patients with nonulcer dyspepsia, irritable bowel syndrome, and organic disease were very similar. However, patients in the other groups differed from somatoform disorder on nearly all scales. In nonulcer dyspepsia, irritable bowel syndrome, and organic disease, hypochondriasis weakly correlated with pain. Subgroups of irritable bowel syndrome patients with predominant constipation and those with predominant diarrhea had similar personality traits, although hypomania was minimally increased in constipation. Patients who fulfilled the Manning criteria for irritable bowel syndrome had more psychological distress than those who did not. The Minnesota Multiphasic Personality Inventory correctly classified somatoform disorder and health 81% and 75% of the time, respectively, but it classified nonulcer dyspepsia and irritable bowel syndrome correctly in only 32% and 34% of cases. Our results suggest that psychopathology may not be the major explanation for functional gastrointestinal disorders.
In spite of the fact that both laymen and clinicians have pointed out their relevance, the psychological aspects of gastrointestinal disorders, especially their influence on etiology and pathophysiology, have been a matter of controversy and challenge to researchers. Difficulties in this field arise from several sources, for instance, the sampling methodology in the selection of patients and the heterogeneity of the disorders studied. When the irritable bowel syndrome (IBS) is compared with peptic ulcer disease (PUD), the personality features of IBS have not been described with the same consistency as the dependency traits of PUD. Also, IBS patients have been regarded as more neurotic and depressed than PUD patients. In this study of 101 IBS and 103 PUD patients, our overall impression was that mental symptoms and personality profiles were essentially the same in IBS and PUD, but that both groups differed from a normal population. We conclude that from a psychosomatic point of view IBS and PUD may be looked upon as different facets of the same underlying psychogenic mechanism. Although conclusive evidence of how psychological factors affect physiological processes and contribute to the clinical picture in gastrointestinal disorders is still lacking, it seems reasonable to state that they are often significant and must be considered in treating individual IBS and PUD patients.
Background:
Antidepressant agents may have a therapeutic role in functional gastroenterologic disorders, but controlled investigations in irritable bowel syndrome (IBS) have not provided satisfactory practice recommendations. To help with future study design, we reviewed a five-year clinical experience with antidepressant agents in out-patients with IBS.
Methods:
Presenting features, treatment course, and clinical outcome were determined from a chart review of 138 patients attending a university-based gastroenterology practice.
Results:
Patients were treated with up to five antidepressants in separate, consecutive trials if a satisfactory end-point had not been reached. Tricyclic antidepressants were utilized 130 times, newer antidepressants 39 times, and anxiolytic-antidepressants 47 times. Improvement and complete remission in bowel symptoms occurred in 89% and 61% of patients, respectively, during antidepressant therapy. Median dosages being prescribed when remission occurred were less than those conventionally used in clinical psychiatry (50 mg/day for several tricyclic antidepressants). Age, gender, symptom duration, and presence of psychological symptoms did not discriminate those who remitted from those who did not, whereas a pain predominant symptom pattern was more commonly associated with symptom remission (P < 0.05 comparing symptom patterns). Symptom remission was more likely during the first antidepressant treatment than with subsequent trials in the group with continued symptoms (P = 0.01), but nearly half of the patients with side effects or no benefit from the first agent who went on to subsequent trials remitted during treatment with an alternative antidepressant.
Conclusions:
The design of this retrospective review is not capable of determining the efficacy of antidepressants for IBS. Our observations in conjunction with other available data suggest that future trials should employ low daily dosages, carefully assess pain response, include patients with and without active psychiatric symptoms, and utilize a second agent for subjects intolerant or unresponsive to the first.
Antidepressants are used in the treatment of irritable bowel syndrome but it is unclear whether any symptomatic improvement is due solely to correction of an associated affective disorder, or whether these drugs have effects on bowel function which may be of therapeutic benefit. Intestinal transit is known to be abnormal in some irritable bowel syndrome patients.
We have studied the effects of imipramine, a tricyclic antidepressant with mixed pharmacological properties, and paroxetine, a selective 5-hydroxytryptamine re-uptake inhibitor, on intestinal transit times.
Median (range) whole gut transit time was lower in 10 diarrhoea-predominant irritable bowel syndrome patients, 22.2 (3.6-51.6) h, compared to 28 control subjects 39.6 (7.2-68.4) h, (P < 0.05). Similarly, orocaecal transit time was shorter at 55 (30-90) min in diarrhoea-predominant irritable bowel syndrome patients compared to 75 (40-150) min in controls, (P < 0.05). Four days' administration of imipramine increasing to a daily dose of 100 mg prolonged both orocaecal and whole gut transit times in 12 control subjects and six diarrhoea-predominant irritable bowel syndrome patients. In contrast, 30 mg paroxetine daily for 4 days reduced orocaecal transit time in ten controls and eight irritable bowel syndrome patients, but had no effect on whole gut transit time.
Short-term administration of antidepressants alters intestinal transit, but the selective 5-hydroxytryptamine re-uptake inhibitor, paroxetine, has different effects to the tricyclic drug, imipramine. These effects on transit precede any effects on mood. Although there is a high prevalence of affective disorder in irritable bowel syndrome clinic patients, these drugs may have additional therapeutic actions on the gut. These actions might be taken into account when prescribing antidepressants in irritable bowel syndrome.
The one-year prevalence and correlates of selected DSM-III-R disorders were determined in a sample of 930 18-year-olds. Using both diagnostic and impairment criteria 340 individuals (36.6%) were considered to have disorder. The most prevalent disorders were major depressive episode (16.7%), alcohol dependence (10.4%) and social phobia (11.1%). There was a high degree of co-morbidity among disorders; 46% of those with disorder had two or more. The prevalence of disorders was greater for females, with the exception of conduct disorder and alcohol or marijuana dependence. A variety of characteristics were associated with disorder, including poor social competence, disadvantage and self-rated health status. A third of those with disorder had their problems recognised by a "significant-other". The results are presented within the context of a perceived need for research in the area of adolescent and early adult mental health in order to minimise the toll of mental disorder in later life.
Clinical experience and recent reports suggest that there is a high prevalence of gastrointestinal symptoms in patients with panic disorder and that there is a high prevalence of panic disorder in patients with irritable bowel syndrome, a functional gastrointestinal disorder. To assess gastrointestinal symptoms in a nonpatient, community-based sample, the authors surveyed the prevalence of gastrointestinal symptoms in individuals with panic disorder and other or no psychiatric disorders obtained in a national community survey.
Subjects were 13,537 respondents at four sites of the National Institute of Mental Health (NIMH) Epidemiological Catchment Area project. DSM-III diagnoses were determined by using the NIMH Diagnostic Interview Schedule (DIS). Gastrointestinal symptoms were assessed from the somatization disorder section of the DIS.
Individuals with panic disorder had a significantly higher rate of endorsing gastrointestinal symptoms, including those typically associated with irritable bowel syndrome, than those with other or no psychiatric diagnosis.
Findings suggest a diagnostic overlap between panic disorder and irritable bowel syndrome, with similar demographic and clinical characteristics of patients. Limitations of the study are discussed in terms of medical assessment and self-report inventories. Practical and theoretical implications are discussed.
In a survey of bowel patterns and anxiety on 1264 health maintenance organization (HMO) members undergoing health assessment, I found (a) Stool frequency increased with age (p = 0.001), was greater in men than women (p < 0.00001), and was greater in whites than blacks (p = 0.07); (b) Fecal incontinence increased with age in women (p < 0.001) but was not age-related in men (p > 0.10); (c) Laxative use was greater in women than men at all ages (p < 0.01), and there was an age effect on use in women (p < 0.025) but not in men (p > 0.20); (d) Bowel pattern change and abdominal pain were frequently caused by stress, and both effects declined with age in each gender (p < 0.05); (e) More women than men at all ages reported stress effects (p < 0.001), and subjects who reported either stress effect scored higher on both parts of the State-Trait Anxiety Inventory (p < 0.00001) than other people. Bowel patterns and their relation to anxiety have demographic characteristics.
Chronic gastrointestinal (GI) symptoms are believed to be common in the general population, but Australian data are lacking. A valid instrument is required to assess GI symptoms adequately and determine their prevalence in the community.
To test the feasibility, reliability and concurrent validity of a self-report Bowel Symptom Questionnaire (BSQ) as a measure of GI symptoms, and obtain preliminary data on the prevalence of symptoms in an Australian population-based sample.
Outpatients (n = 63), volunteers (n = 163) and a random sample (n = 99) of the Penrith population, Sydney, completed the BSQ. Feasibility was evaluated in 264 subjects. Reliability was measured by a test-retest procedure (n = 43), while concurrent validity was documented by comparing self-report data with an independent interview (n = 20). The response rate in the population mail survey was 68%. Prevalence data on bowel symptoms in the community sample (n = 99) were age and gender standardised to the Australian population.
The majority of subjects found the BSQ easy to complete (97%) and understand (97%); 90% completed the questionnaire in half an hour or less. Reliability (median kappa 0.70, interquartile range 0.20) and concurrent validity (median kappa 0.79, interquartile range 0.26) of GI symptoms were both very acceptable. The internal consistency of all GI symptom scales was good (Cronbach's Alpha range 0.51-0.74). The prevalence of the irritable bowel syndrome (defined as abdominal pain and disturbed defaecation based on two or more of the Manning criteria) was 17.2% (95% CI: 10-25%).
The BSQ was well accepted and easy to understand; it provided reliable and valid data on GI symptoms and should prove useful in large scale epidemiological studies in Australia.
It is not known whether irritable bowel syndrome (IBS) fluctuates with the seasons. We aimed to determine whether seasonal changes in symptoms occur in IBS and to examine the relationships between IBS, seasonality, and psychological factors.
A random sample of the community (n = 99) and hospital staff volunteers (n = 163) in Sydney, Australia, completed a previously validated questionnaire that measured bowel symptoms, psychosocial factors, and seasonality.
IBS (n = 60; 23%) was significantly associated with somatization (by the Psychosomatic Symptom Checklist) and lifetime depression but not neuroticism (by the Eysenck Personality Questionnaire) or psychological morbidity (by the General Health Questionnaire). A seasonal variation in behavior score (measuring sleep, eating, including carbohydrate craving, weight gain, socializing, energy level, and mood by the Seasonal Pattern Assessment Questionnaire) was associated with somatization (p < 0.001) and IBS (p < 0.05) in a stepwise multiple regression model. Of those with IBS, 23% reported moderate or greater seasonal change in bowel symptoms. Subjects with IBS (vs subjects with some bowel symptoms) were significantly more likely to report seasonal changes in pain and/or disturbed defecation (odds ratio = 3.2; 95% CI = 1.25-8.23); the latter was significantly associated with somatization but not the other psychological variables.
A subset of IBS may be seasonally determined, and this is explained in part by somatization.
High rates of psychiatric disorder have been documented in patients with functional bowel syndromes sampled from physicians' offices. Lifetime psychiatric disorder and/or current psychiatric symptoms are thought to be much more highly associated with current gastrointestinal bowel symptoms in clinical settings than in the community. The relationship of lifetime functional gastrointestinal symptoms to lifetime psychiatric disorders has not been examined systematically in randomly selected samples of general community populations. The current study reports findings from existing data on a large, randomly selected population sample that may help to clarify these associations. Epidemiologic Catchment Area (ECA) project data were analyzed to examine relationships of functional gastrointestinal symptoms and psychiatric diagnoses in the community. Individuals with two or more medically unexplained gastrointestinal symptoms had high rates of psychiatric disorders. This was also true for the subgroup in which abdominal pain was one of the two symptoms. The overwhelming majority of subjects reporting medically unexplained gastrointestinal symptoms said they had consulted physicians for those symptoms. General population ECA data indicate that women in the community report more functional gastrointestinal complaints than men, that individuals with lifetime gastrointestinal complaints have high rates of lifetime psychiatric disorders (not necessarily currently symptomatic), and most have contacted a physician regarding their gastrointestinal symptoms. These data complement studies showing that patients with current gastrointestinal symptoms often do not consult a physician, or when they do, such behavior is associated with active psychiatric symptoms. These present data are consistent with the hypothesis that patients with recurrent symptoms are those who routinely seek medical help and who have high rates of psychiatric disorders, whereas those with symptoms that resolve or are improved by a medical intervention do not maintain treatment-seeking behavior.
In a preliminary study using only self-report measures, university students completed questionnaires about their bowel symptoms and trait anxiety. Results showed that students with irritable bowel syndrome (IBS) reported higher trait anxiety than asymptomatic controls. Among the students with IBS, there were no significant differences in trait anxiety between those who had sought medical care for IBS mostly from a primary care physician, and those who had not sought care for IBS. Students who had sought medical care for IBS reported being more bothered by the symptoms and were more concerned about their meaning than those students who had not sought care. The results are compared to other research with IBS patients referred to specialist clinics, and a distinction is made between initial vs. continued care seeking for IBS.
Objective:
There is increasing interest in using noninvasive H. pylori testing rather than endoscopy in determining the management of younger patients presenting with dyspepsia. However, there is concern that this approach may result in missing potentially curable malignancy. The aim of the study was therefore to assess whether concern over occult malignancy is valid in patients aged <55 yr presenting with uncomplicated dyspepsia.
Methods:
A predetermined questionnaire was used to review the case notes of patients aged <55 yr who had presented with esophageal or gastric cancer between 1989 and 1993 within the Greater Glasgow Health Board population of 940,000.
Results:
A total of 169 patients aged <55 yr were diagnosed to have gastroesophageal malignancy over the 5-yr period, representing an incidence of about 1 per 28,000 total population/yr. There were only five patients who were found to have upper GI malignancy when undergoing upper GI investigation in the absence of sinister symptoms. This represents an incidence of underlying malignancy in patients of <55 yr with uncomplicated dyspepsia of 1.06 per million total population/yr. Of these five patients, all had lymph node metastases at diagnosis and four had died between 2 months and 3 yr of follow-up.
Conclusions:
Upper GI malignancy is extremely rare in patients <55 yr presenting with uncomplicated dyspepsia and, when found, is usually incurable. Consequently, concern about missing underlying curable malignancy is not a valid indication for endoscoping patients <55 yr presenting with uncomplicated dyspepsia.
It is unknown whether distinct functional GI (GI) symptom groupings occur in the general population and whether these are similar across different cultures. Although symptom-based diagnostic criteria have been developed for upper and lower GI syndromes (the Rome criteria), the classification is controversial. We aimed to identify whether independent symptom-based subgroups exist in four countries consistent with the Rome criteria.
Random samples of the community were mailed a validated questionnaire based on the Bowel Disease Questionnaire in Rochester, MN (n = 2,220), in Sydney, Australia (n = 1,135), and in Essen, Germany (n = 500). A different validated questionnaire was mailed to a random sample in Osthammar, Sweden (n = 1,517). Only the common questions (n = 22) were used in the current analysis, and these were essentially identical in wording. The underlying structure of the item responses was examined using factor analysis. Initial factors were extracted using principal components analysis and then rotated using Varimax. Clustering of symptoms among individuals was examined though cluster analysis, using the factors as the basis for clustering.
Response rates varied from 64% to 80%; responders and nonresponders were similar sociodemographically. All four studies yielded similar factor structures. All countries reported symptom groupings consistent with the irritable bowel syndrome (IBS), dyspepsia and/or gastroesophageal reflux, and constipation; all except Sweden also had a diarrhea group. The cluster analysis yielded slightly more disparate results but a healthy group was present in all populations. All four populations had an IBS and/or bowel dysfunction cluster identified; a gastroesophageal reflux cluster was also present in all countries.
The similarity of factor and cluster structures found in these four nations suggest that patterns of GI symptoms and groupings of individuals are similar across these Western cultures. These results are consistent with the current international Rome classification for separate upper and lower functional GI disorders.
From child to adult: the Dunedin Multidisciplinary Health and Development Study
- Pa Silva
- Stanton
- Wr
Silva PA, Stanton WR, editors. From child to adult: the Dunedin Multidisciplinary Health and Development Study. Auckland: Oxford Press, 1996.
The irritable bowel syndrome and psychiatric disorder in the community: is there a link?
- Talley