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Daily gastrointestinal symptoms in women with and without a diagnosis of IBS
Abstract
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.
... Whitehead et al. studied GI complaints associated with menses in women with IBS, and found that those patients were more likely to experience increased flatulence, diarrhea, or constipation during menses than controls [50]. Similarly, Heitkemper et al. reported that IBS patients experienced more stomach pain, nausea, and diarrhea during menses than controls [51]. In a retrospective study, Kane et al. reported that women with IBS had an increase in abdominal pain, diarrhea or constipation during pre-menses and menses [52]. ...
... In a retrospective study, Kane et al. reported that women with IBS had an increase in abdominal pain, diarrhea or constipation during pre-menses and menses [52]. Many of the studies described have relied on symptom recall, in which women were asked about their experiences of GI symptoms in various phases of their menstrual cycle [8,[49][50][51][52][53][54][55] (Table 2). Obviously, this approach might have resulted in recall bias. ...
... Obviously, this approach might have resulted in recall bias. To mitigate recall bias, other investigators have used daily dairies to prospectively study the pattern of GI symptoms throughout the menstrual cycle [8,51]. Most studies that involved prospective recordings using a symptoms dairy also found that GI symptomatology was more severe during both menses and pre-menses in IBS patients, further supporting the association between the menstrual cycle and IBS symptoms. ...
Gender-related physiological variations in gastrointestinal (GI) symptomatology have been observed in women of reproductive age. Many women experience cyclical changes in GI symptomatology during their menstrual cycle, particularly alteration in their bowel habits. Physiological studies of healthy women during the menstrual cycle showed a prolonged GI transit time during the luteal phase, either in the oro-cecum route or in the colon. Worsened GI symptoms, such as abdominal pain, bloating or diarrhea are observed in patients with irritable bowel syndrome (IBS) during menses. This may be due to elevated prostaglandin levels during menses, with an enhanced perception of viscera-somatic stimuli resulting in nausea, abdominal distension and pain. Also patients with IBS or IBD demonstrate a cyclical pattern more closely related to their bowel habits than healthy controls. Women with inflammatory bowel disease (IBD) also have exacerbated symptoms during menses; however, it is unclear whether this relates to physiological variation or disease exacerbation in IBS or IBD. Studies examining the association of the menstrual cycle and GI symptomatology in patients with IBS or IBD, have not yet clarified the underlying mechanisms. Moreover medications-such as non-steroidal anti-inflammatory drugs and oral contraceptive pills used for dysmenorrhea and menstrual migraine in those patients have not well been controlled for in the previous studies, which can contribute to further bias. Understanding changes in GI symptomatology during the menstrual cycle may help to determine the true extent of disease exacerbation and proper management strategy.
© The Author(s) 2015. Published by Oxford University Press and the Digestive Science Publishing Co. Limited.
... and without IBS may vary with phases of the menstrual cycle. [14][15][16][17] Based on limited data, menstruating women with IBS appear to have more severe GI symptoms, looser stools, 18 and increased visceral hypersensitivity 17 during the late luteal and early menses phases, which are periods characterized by low or declining levels of estrogen and progesterone. Women with IBS also frequently report a coexistence of other menstrual cycle-associated conditions, including dysmenorrhea and premenstrual distress syndrome. ...
... Previous studies in premenopausal women with IBS have suggested that more severe symptoms, looser stools, and increased visceral hypersensitivity may occur during the late luteal and early menses phases, periods that are characterized by low levels of estrogen and progesterone. [14][15][16][17]52 However, because we did not observe any menstrual cycle variations in GI symptoms during the follicular and luteal phases, we can conclude that our findings of decreased IBS symptom severity and higher physical QOL in premenopausal women compared to postmenopausal women were unlikely to have been influenced by symptom fluctuations during the menstrual cycle. ...
Background
Although irritable bowel syndrome (IBS) is more common in women, little is known about the role of hormonal changes and menopause in IBS. This study aimed to evaluate for differences in gastrointestinal (GI) and psychological symptoms between pre‐ and postmenopausal women with IBS compared to age‐matched men with IBS.
Methods
Patients with Rome‐positive IBS were identified. Premenopausal women were <45 years of age with regular menses. Postmenopausal women were ≥45 years without menses for at least 1 year. Younger men were <45 years, and older men were ≥45 years. Questionnaires measured severity of IBS symptoms, somatic symptoms, health‐related quality of life (HRQOL), and psychological symptoms. Multivariable linear or logistic regressions evaluating relationships between age and sex were performed.
Key Results
190 premenopausal women (mean age 30.25 years), 52 postmenopausal women (mean age 54.38 years), 190 men <45 years (mean age 30.45 years), and 52 men ≥45 years (mean age 53.37 years) were included. Postmenopausal IBS women had greater severity of IBS symptoms (P = .003) and worse physical HRQOL (P = .048) compared to premenopausal women. No differences were observed between age‐matched older and younger IBS men. Constipation increased with age for both sexes but was the principal IBS subtype in women only.
Conclusions and Inferences
Postmenopausal women with IBS have more severe IBS symptoms than premenopausal women, while no comparable age‐related changes were seen in IBS men. The modulatory effect of female sex hormones on brain‐gut interactions which affect visceral perception and GI function likely contributes to these findings.
... Women with and without IBS tend to report more intense or more frequent symptoms around menses as compared with other cycle phases (7)(8)(9). Indeed, women with IBS frequently report other menstrual cycle-related conditions, such as dysmenorrhea (10). Despite these observations, the relationships between ovarian hormone levels and bowel function or pain sensitivity are unclear. ...
... In addition, these symptoms were significantly affected by menstrual cycle phase. In earlier studies, we had reported the effects of menstrual cycle phase on GI symptom reports in a mixed sample of women with IBS-diarrhea, -constipation, and -alternating (7,24). Other studies have also addressed the issue of GI symptom amplification at menses (8,10,25); however, those studies relied on retrospective recall of symptoms, did not consider predominant bowel pattern, did not validate menstrual cycle phase with measurements of luteinizing hormone and progesterone during the luteal phase, or assess the use of OC medications. ...
The purpose of this study was to describe the patterns of GI, somatic, and psychological symptoms across the menstrual cycle in women with irritable bowel syndrome, and to determine whether symptoms differed by oral contraceptive use or predominant bowel pattern.
A daily diary was used to assess symptoms across one menstrual cycle. Repeated-measures analysis of covariance, controlling for age and body mass index, was used to compare patterns of symptoms across the menstrual cycle by oral contraceptive use and predominant bowel pattern (diarrhea, constipation, alternating). Data from control women are presented for comparison.
For somatic and psychological as well as GI symptoms, women with irritable bowel syndrome had higher symptom severity than did controls. Women with irritable bowel syndrome using oral contraceptives had lower cognitive, anxiety, and depression symptoms (p < 0.05, but not significant after multiple comparison adjustment), but no differences were seen for most symptoms of irritable bowel syndrome. All symptoms except diarrhea were highest in the alternating group and lowest in the diarrhea group, with the constipation group either intermediate or close to the alternating group. This pattern was significant after multiple comparisons adjustment for GI symptoms, and trending toward significance (p < 0.05, but not significant after multiple comparison adjustment) for menstrual, sleep, and cognitive symptoms. The strongest menstrual cycle effect was seen in somatic and menstrual symptoms. The pattern of symptoms over the menstrual cycle did not differ by predominant bowel pattern or by oral contraceptive use.
Many of the symptoms examined differed by predominant bowel pattern and menstrual cycle phase, not just the GI symptoms. The menstrual cycle variation was similar regardless of oral contraceptive use or predominant bowel pattern.
... As regards hormonal profile, bloating is the most frequently reported symptom among patients with a common endocrine disorder, polycystic ovary syndrome (PCOS), and appears to be its primary predictor [38]. Bloating can be experienced perimenstrually by healthy women [39], although the mechanisms underlying the symptom might be different from those in other pathological situations. An association between IBS and sex hormonal status (menstrual cycle phase, pregnancy, menopause, and hormonal replacement therapy) has been recognized [40,41]. ...
Most female patients with irritable bowel syndrome (IBS) complain of abdominal bloating rather than abdominal pain and diarrhea. The higher incidence in women could be due to the so-called dysfunctional gas handling. Since diet seems the most effective and durable strategy for managing IBS symptoms, we aimed to evaluate the effects of a 12 week diet based on a relatively new cereal, Tritordeum (TBD), on gastrointestinal (GI) symptoms, anthropometric and bioelectrical impedance parameters, and psychological profiles in 18 diarrhea-predominant IBS (IBS-D) female patients with abdominal bloating as the dominant symptom. The IBS Severity Scoring System (IBS-SSS), the Symptom Checklist-90 Revised, the Italian version of the 36-Item Short-Form Health Survey, and the IBS-Quality of Life questionnaire were administered. The TBD reduces the IBS-SSS “Intensity of abdominal bloating” with a concomitant improvement in the anthropometric profile. No correlation was found between “Intensity of abdominal bloating” and “Abdominal circumference”. Anxiety, depression, somatization, interpersonal sensitivity, and phobic and avoidance manifestations were significantly reduced after TBD. Lastly, anxiety was correlated with “Intensity of abdominal bloating”. Overall, these results suggest the possibility of lowering abdominal bloating and improving the psychological profile of female IBS-D patients using a diet based on an alternative grain such as Tritordeum.
... Sex differences in pain thresholds between male and female animals have been well characterized, including variations in female pain responses throughout the estrus cycle [26]. Cyclical fluctuations in female animal pain responses parallel patient studies indicating that women experience worsening of symptoms during menses that correlate to increases in female hormones [27][28][29]. In support, the current series of experiments demonstrated variation in pain responses of female animals across the estrus cycle where females in the proestrus/estrus were more sensitive to painful stimuli than those in the metestrus/diestrus phases. ...
Background:
Early life stress (ELS) serves as a risk factor for the development of functional pain disorders such as irritable bowel syndrome (IBS) in adults. Although rodent models have been developed to mimic different forms of ELS experience, the use of predominantly male animals across various rodent strains has led to a paucity of information regarding sex-related differences in the persistent effects of ELS on pain behaviors in adulthood. We hypothesized that the context or nature of ELS experience may interact with sex differences to influence the development of chronic pain.
Methods:
We employed three rodent models mimicking different facets of early life adversity to investigate the effects of ELS on pain perception in adulthood. To eliminate strain differences, all experiments were carried out using Long Evans rats. As neonates, male and female rat pups were exposed to maternal separation (MS), limited nesting (LN), or odor attachment learning (OAL). In adulthood, visceral sensitivity and somatic sensitivity were assessed at ~postnatal day 90 via quantification of visceromotor responses to colorectal distension and von Frey probing, respectively.
Results:
Following exposure to MS or LN, male rats developed visceral and somatic hypersensitivity compared to controls, whereas females subjected to the same paradigms were normosensitive. In the OAL model, females exposed to unpredictable ELS exhibited visceral but not somatic hypersensitivity. There were no observed differences in visceral or somatic sensitivity in male animals following OAL exposure.
Conclusions:
In summary, our data confirms that early adverse experiences in the form of MS, LN, and OAL contribute to the long-term development of heightened pain responsiveness in adulthood. Furthermore, this study indicates that sex-related vulnerability or resilience for the development of heightened pain perception is directly associated with the context or nature of the ELS experienced.
... [29] Of the most common causes of poor sleep is psychological distress, [30,31] and the level of psychological distress has been shown to be noticeably higher in IBS patients. [32,33] On the other hand, several studies have found an association between BMI with gastrointestinal symptoms [34][35][36] and obesity is associated with disturbed sleep and shorter sleep duration. [37,38] In the present study, BMI was considered as a confounder variable and all analysis adjusted for BMI and some other demographic factors. ...
Recent studies have demonstrated that a high proportion of irritable bowel syndrome (IBS) patients shows an association with psychological factors. A few studies were conducted on the investigation of psychological features of IBS patients in Iran.
We aimed to evaluate the relationship of psychological distress with IBS in outpatient subjects.
A total of 153 consecutive outpatients met Rome III criteria, and 163 controls were interred to study and invited to complete the Symptom Checklist-90-Revised (SCL-90-R) instrument in order to assessment of psychological distress.
Univariate (t-test and Chi-square) and multivariate (logistic regression) methods were used for data analysis.
A significant association of IBS with all nine subscale and three global indices including global severity index (GSI), positive symptom distress index (PSDI), and positive symptom total (PST) of the SCL-90-R were detected. Patients with IBS reported significantly higher levels of poor appetite, trouble falling asleep, thoughts of death or dying, early morning awakening, disturbed sleep, and feelings of guilt compared to the controls. Multivariate analysis indicated that interpersonal sensitivity, somatization, paranoid ideation, depression and phobic anxiety subscales, and PST, PSDI, and GSI global indices were significantly associated with IBS (age, gender, educational level, marital status, employment status, smoking, alcohol use, and body mass index).
Psychological features are strongly associated with IBS; notably, interpersonal sensitivity, somatization, paranoid ideation, depression, phobic anxiety, and all global indices including PST, PSDI, and GSI is significantly associated with. Hence, the appropriate psychological assessment in these patients is critically important.
... Also "primary care IBS patients" and "non-patient" IBS in our study (paper IV) had higher HADS score than subjects with low IBS-like symptoms which also is supportive of a "true relationship" between anxiety/depression and IBS. Some studies claim that psychological disturbances are more prevalent in patients with IBS attending a gastroenterologic clinic compared to non-patients or IBS patients attending primary care (238)(239)(240)(241) but other studies suggest no differences in neuroticism and psychiatric comorbidity (242)(243)(244)(245). It has also been argued that non-patient IBS show less psychological denial and better ability to accept a link between psychological stress and the gut, whereas IBS patients at a gastroenterologic clinic attributed their complaints to somatic causes (238,246). ...
... Moreover, a role for hormones has been hypothesized based on female predominance in IBS. Although healthy women may report changes in bowel function at the time of menstruation, this effect is far more pronounced in women with IBS with approximately 40%-75% claiming that bowel habit and bloating are exacerbated perimenstrually [11,72,103] . This suggests that bloating may be strongly influenced by hormonal status to modify visceral sensitivity. ...
Bloating is one of the most common and bothersome symptoms complained by a large proportion of patients. This symptom has been described with various definitions, such as sensation of a distended abdomen or an abdominal tension or even excessive gas in the abdomen, although bloating should probably be defined as the feeling (e.g. a subjective sensation) of increased pressure within the abdomen. It is usually associated with functional gastrointestinal disorders, like irritable bowel syndrome, but when bloating is not part of another functional bowel or gastrointestinal disorder it is included as an independent entity in Rome III criteria named functional bloating. In terms of diagnosis, major difficulties are due to the lack of measurable parameters to assess and grade this symptom. In addition, it is still unclear to what extent the individual patient complaint of subjective bloating correlates with the objective evidence of abdominal distension. In fact, despite its clinical, social and economic relevance, bloating lacks a clear pathophysiology explanation, and an effective management endorsement, turning this common symptom into a true challenge for both patients and clinicians. Different theories on bloating etiology call into questions an increased luminal contents (gas, stools, liquid or fat) and/or an impaired abdominal empting and/or an altered intra-abdominal volume displacement (abdomino-phrenic theory) and/or an increased perception of intestinal stimuli with a subsequent use of empirical treatments (diet modifications, antibiotics and/or probiotics, prokinetic drugs, antispasmodics, gas reducing agents and tricyclic antidepressants). In this review, our aim was to review the latest knowledge on bloating physiopathology and therapeutic options trying to shed lights on those processes where a clinician could intervene to modify disease course.
... Indeed, previous evidence illustrates that sex differences in pain sensitivity are influenced by cyclical changes in ovarian hormones (Hellstrom and Anderberg, 2003). Specifically, symptom exacerbation and increased rectal sensitivity are observed in female IBS patients during menses, and pain sensitivity and perceived stress are also increased during high cyclical levels of estrogen and progesterone in fibromyalgia patients (Heitkemper et al., 1995;Kane et al., 1998;Korszun et al., 2000;Houghton et al., 2002). These studies strongly support that circulating ovarian hormones modulate pain behavior; however the precise mechanisms have yet to be elucidated. ...
A history of early life adversity (ELA) has health-related consequences that persist beyond the initial maltreatment and into adulthood. Childhood adversity is associated with abnormal glucocorticoid signaling within the hypothalamic-pituitary-adrenal (HPA) axis and the development of functional pain disorders such as the irritable bowel syndrome (IBS). IBS and many adult psychopathologies are more frequently diagnosed in women, and ovarian hormones have been shown to modulate pain sensitivity. Therefore, the sexually dimorphic effects of ELA and the role of ovarian hormones in visceral pain perception represent critical research concepts to enhance our understanding of the etiology of IBS. In this review, we discuss current animal models of ELA and the potential mechanisms through which ovarian hormones modulate the HPA axis to alter nociceptive signaling pathways and induce functionally relevant changes in pain behaviors following ELA.
... Another factor involved in the female predominance of IBS relates to the observation that IBS symptomatology fluctuates with changes in the female reproductive cycle suggesting a role for ovarian hormones in mediating symptom severity (Heitkemper et al., 2003). Specifically, IBS symptomatology worsens following the peak of estradiol and progesterone in the luteal phase and this exacerbation continues into early menses (Crowell et al., 1994;Heitkemper et al., 1995). Additionally, concentrations of cortisol, epinephrine, and norepinephrine in the urine of female IBS patients are significantly elevated throughout the luteal phase compared to healthy controls (Heitkemper et al., 1996). ...
A common characteristic of irritable bowel syndrome (IBS) is that symptoms, including abdominal pain and abnormal bowel habits, are often triggered or exacerbated during periods of stress and anxiety. However, the impact of anxiety and affective disorders on the gastrointestinal (GI) tract is poorly understood and may in part explain the lack of effective therapeutic approaches to treat IBS. The amygdala is an important structure for regulating anxiety with the central nucleus of the amygdala facilitating the activation of the hypothalamic-pituitary-adrenal axis and the autonomic nervous system in response to stress. Moreover, chronic stress enhances function of the amygdala and promotes neural plasticity throughout the amygdaloid complex. This review outlines the latest findings obtained from human studies and animal models related to the role of the emotional brain in the regulation of enteric function, specifically how increasing the gain of the amygdala to induce anxiety-like behavior using corticosterone or chronic stress increases responsiveness to both visceral and somatic stimuli in rodents. A focus of the review is the relative importance of mineralocorticoid receptor and glucocorticoid receptor-mediated mechanisms within the amygdala in the regulation of anxiety and nociceptive behaviors that are characteristic features of IBS. This review also discusses several outstanding questions important for future research on the role of the amygdala in the generation of abnormal GI function that may lead to potential targets for new therapies to treat functional bowel disorders such as IBS.
In the current article, conceptual approaches in psychiatry (considered as backgrounds in revising of psychosomatic conception) are discussed. The increasing development of neuroscience demonstrated the limitation of psychopathological methods. Significant differences and discrepancies in assessing the type, degree, course of psychopathological disorders at the nozological level are revealed. The widespread use of the new classification systems led to dissolving boundaries between mental and behavioral norms and pathology led to rejection of the classical approaches. It made transition from monothetic to polythetic categorization. Nozological psychiatry transformed into syndromological one. The phenomenological approach in psychiatry is considered as an alternative to the nozological principle. However, despite some advantages, they are not without disadvantages, which cover diagnostic, terminological, theoretical, pedagogical and other aspects. The phenomenological approach still leads to a disagreement among psychiatrists regarding the terminological definitions, the theoretical basis. The current classifications of mental and behavioral disorders lead to a blurring of the boundaries between the mental and behavioral norm and pathology and enormously expand the boundaries of mental abnormality, narrowing the boundaries of norm and health. Analysis of pathogenetic mechanisms of mental disorders demonstrated the failure of all the concepts, and approaches (primarily neurobiological) due to the lack of specificity for certain pathology. It is indicated that both endogenous disorders and psychosomatic ones are based on neurotransmitter processes. In this case the discrepancy in the diagnosis of mental disorders by different specialists is observed. There is no specific etiology, pathogenetic mechanisms, and environmental factors for a particular mental disorder.
In the current article, conceptual approaches in psychiatry (considered as backgrounds in revising of psychosomatic conception) are discussed. The increasing development of neuroscience demonstrated the limitation of psychopathological methods. Significant differences and discrepancies in assessing the type, degree, course of psychopathological disorders at the nozological level are revealed. The widespread use of the new classification systems led to dissolving boundaries between mental and behavioral norms and pathology led to rejection of the classical approaches. It made transition from monothetic to polythetic categorization. Nozological psychiatry transformed into syndromological one. The phenomenological approach in psychiatry is considered as an alternative to the nozological principle. However, despite some advantages, they are not without disadvantages, which cover diagnostic, terminological, theoretical, pedagogical and other aspects. The phenomenological approach still leads to a disagreement among psychiatrists regarding the terminological definitions, the theoretical basis. The current classifications of mental and behavioral disorders lead to a blurring of the boundaries between the mental and behavioral norm and pathology and enormously expand the boundaries of mental abnormality, narrowing the boundaries of norm and health. Analysis of pathogenetic mechanisms of mental disorders demonstrated the failure of all the concepts, and approaches (primarily neurobiological) due to the lack of specificity for certain pathology. It is indicated that both endogenous disorders and psychosomatic ones are based on neurotransmitter processes. In this case the discrepancy in the diagnosis of mental disorders by different specialists is observed. There is no specific etiology, pathogenetic mechanisms, and environmental factors for a particular mental disorder.
The process of forensic psychological examination, to assess various issues, requires the use of psychological tests that have passed and meet the requirements for foreign language tests for adaptation and reliability. The Miller Forensic Assessment of Symptoms Test(M-FAST) is a validated screening test for identifying malingered mental illness. The objective of this study was to translate, adapt, and validate the M-FAST into Armenian language. 54 psychiatric patients and 54 simulator participants drawn from the Republic of Armenia were tested with an Armenian version of M-FAST. The Armenian M-Fast Total and Subscale scores were comparable to the original version with adequate-to-high internal consistency. M-FAST total scores were significantly higher in the simulator group (M = 12.83) than psychiatric patients (M = 6.83) [d = 1.46]. Results provide evidence that the Armenian translation of the M-FAST is comprehensible to both test-taker and test-administrator and represents promising screening measure.
В настоящей работе сделана попытка представить собственное видение психосоматической проблемы. В книге представлен краткий исторической анализ психологических и психиатрических подходов и концепций, а также анализ современных достижений наук о мозге и человеке, которые подводят нас к новому видению проблемы, которая определена как непсихиатрическая психиатрия. Одной из предпосылок к данному подходу явилось широкое внедрение психиатрии в общемедицинскую практику и наоборот. Работа является обобщением исследуемой автором с 90-х годов прошлого века проблемы соматизированных психических расстройств.
Книга предназначена для психиатров, психологов, интернистов.
The review of etiopathogenetic mechanisms and clinical manifestations of mental disorders highlights their diagnostic significance (as opposed to neurobiological approaches) in the field of psychosomatic pathology. Clinical, personal, psychological and other patterns common for the psychosomatic pathology are identified. It is emphasized, that those patterns are specific not only for psychosomatic pathology but for somatic, mental, psychosomatic, and affective disorders as well. It is indicated that similar neurotransmitter processes are involved in the pathodynamics of many diseases. The lack of specificity of these processes led to dissolving boundaries between mental pathology and diagnostic problems. There is no specific etiology, pathogenetic mechanisms, and environmental factors for a particular mental disorder. The only thing that combines these disorders is the presence of somatic symptoms in their structure. Analyzes of the works on the study of somatovegetative manifestations in mental disorders demonstrated that most of researchers inclined to classify such dysfunctions as somatic equivalents of mental pathology along with the current psychopathological disorders. This phenomenon allows us to assume that both the psyche and the body represent a unity that develops according to uniform laws. So, any pathology that affects one of the components of this unity involves another component in the pathological process. The obligatory pathogenetic factors as the basis of development and dynamic of internals dysfunction are examined. In other words, the subject of psychiatry is not limited to the pathology of the psyche, but also includes the pathology of the brain. This approach allows us to talk not about psychosomatic disorders, but about “non-psychiatric psychiatry,” widely represented in the general medical network in the form of “minor” (in the terminology of old authors) mental disorders in the form of psycho-vegetative, functional, somatoform and similar disorders.
Irritable bowel syndrome (IBS) is a very common gastrointestinal condition seen by both specialists and primary care physicians. There is increasing evidence for important gender differences in this syndrome, not only in prevalence, but also clinical presentation, pathophysiology and treatment response. While rates of abdominal pain are similar in men and women with IBS, women with IBS report more constipation, bloating, and extracolonic symptoms. These symptoms also appear to be influenced by the menstrual cycle. Recently, there has been evidence which suggested that women with IBS may preferentially respond to serotonergic agents, a finding that has intensified research interest in gender differences in IBS. Thus far, the reasons for sex-related differences in this disorder are not well understood, however, recent epidemiological and experimental studies suggest that sex differences exist in symptoms, visceral sensitivity, gastrointestinal motility, autonomic nervous system responses and response to treatment in IBS. Further studies are needed to elucidate the significance of these sex and gender-based differences and if they play a role in the female prevalence of IBS and the difference in symptom presentation.
Functional bowel disorders (FBDs) are among the most common medical conditions seen in primary care as well as gastroenterology specialty clinics. Gender appears to play an important role in FBDs, particularly irritable bowel syndrome (IBS) and chronic constipation, but a lesser role in functional dyspepsia. Increasing evidences support gender-related differences in the prevalence, clinical symptoms, physiologic responses, health-care seeking, and response to treatment in FBDs, particularly irritable bowel syndrome (IBS). There appears to be increasing evidence supporting greater female predominance in constipation, bloating, and extraintestinal manifestations in the population with IBS. Clinical symptoms of IBS and GI physiology appear to be influenced by menstrual cycle with increased visceral symptoms and sensation just prior to and at onset of menses. Ovarian hormones may modulate visceral pain and motility/transit in health and disease through several mechanisms including central and peripheral effects that are not completely understood. Physiologic gastroesophageal reflux disease and functional dyspepsia appear to be more common in men, while functional constipation is more prevalent in women. Gender differences have not been well studied in individuals with chest pain, which is of presumed esophageal origin.
The purpose of this phenomenological analysis was to describe perceptions of women with irritable bowel syndrome regarding the relationship of diet to their symptoms. Thirty-five women ages 18–45 with a medical diagnosis of irritable bowel syndrome or symptoms compatible with a diagnosis of irritable bowel syndrome were interviewed and completed questionnaires as part of a larger study. During the interview, the women were asked what they thought caused their symptoms. Overall, women tried to adjust their diet to achieve a “Range of Comfort” so their symptoms were tolerable or manageable. To do this, women used a process of “Trial and Error.” If a link could be made to diet, then women developed “Self-care Strategies” to maintain a “Healthy Diet.” Women who failed to find a relationship during the “Trial and Error” process either felt the frustration of “Uncertainty” or, for a few women, decided that adjusting their diet was not worth the bother. This study suggests diet and eating behaviors are an important starting point for many women as they try to manage their irritable bowel syndrome symptoms.
OBJECTIVE:Gender-related differences have been demonstrated with regard to GI motility: gallbladder contraction, colonic transit, and gastric emptying are delayed in women. It is not known whether gender influences proximal gastric motility and perception.METHODS:We have studied the influence of gender on proximal gastric motility and perception under fasting and postprandial conditions by retrospective analysis of data obtained in 99 healthy volunteers (42 men, 57 women) who participated in barostat studies performed according to standardized protocols at the Leiden University Medical Center (Leiden, The Netherlands) between 1996 and 2000.RESULTS:Minimal distending pressure (MDP) was significantly higher in women than in men (respectively, 6.8 ± 0.2 vs 5.5 ± 0.2 mm Hg; p < 0.001). During stepwise pressure distensions pressure-volume curves were similar in both sexes after correction for MDP, whereas perception of fullness and abdominal pressure increased significantly (p < 0.05) more rapidly in women. Before the meal intragastric volumes (at MDP + 2 mm Hg) did not differ between sexes. After the meal gastric relaxation in the first 30 min did not differ in women and men (respectively, 186 ± 23 ml and 140 ± 32 ml). However, from 30 until 90 min after the meal a significantly (p < 0.05) delayed return of intragastric volume to basal was seen in women. Perception of postprandial nausea was significantly (p < 0.01) increased in women. Perception of postprandial fullness remained increased for a longer period of time in women.CONCLUSIONS:Proximal gastric motility and perception are influenced by gender. Gender-related differences in postprandial proximal gastric motility and perception should be taken into account in barostat studies comparing patients with controls.
This article presents an overview of the role of complaint-related cognitions, emotions and behaviours, as well as environmental factors in patients with irritable bowel syndrome during each phase of the medical health care process. Literature findings support the authors' opinion about the importance of attending to patients' complaint-related cognitions as these factors appear to trigger a person to consult a doctor. Although doctors subsequently appear to attend to these factors by means of patient-centred interviewing, it is the opinion of the authors that a more thorough and individually tailored complaint analysis by the doctor is required to systematically and explicitly explore and discuss the different complaint dimensions. Such an interactive complaint analysis is considered to be a prerequisite for the effective reassurance of the patients that is reflected in positive changes in dysfunctional complaint-related cognitions, emotions and behaviours. A structured course in interactive consulting may help doctors to acquire this interactive patient-centred complaint analysis.
Unlabelled:
Visceral pain is the hallmark feature of irritable bowel syndrome (IBS), a gastrointestinal disorder, which is more commonly diagnosed in women. Female IBS patients frequently report a history of early life adversity (ELA); however, sex differences in ELA-induced visceral pain and the role of ovarian hormones have yet to be investigated. Therefore, we tested the hypothesis that ELA induces visceral hypersensitivity through a sexually dimorphic mechanism mediated via estradiol. As a model of ELA, neonatal rats were exposed to different pairings of an odor and shock to control for trauma predictability. In adulthood, visceral sensitivity was assessed via a visceromotor response to colorectal distension. Following ovariectomy and estradiol replacement in a separate group of rats, the visceral sensitivity was quantified. We found that females that received unpredictable odor-shock developed visceral hypersensitivity in adulthood. In contrast, visceral sensitivity was not significantly different following ELA in adult males. Ovariectomy reversed visceral hypersensitivity following unpredictable ELA, whereas estradiol replacement reestablished visceral hypersensitivity in the unpredictable group. This study is the first to show sex-related differences in visceral sensitivity following unpredictable ELA. Our data highlight the activational effect of estradiol as a pivotal mechanism in maintaining visceral hypersensitivity.
Perspective:
This article directly implicates a critical role for ovarian hormones in maintaining visceral hypersensitivity following ELA, specifically identifying the activational effect of estradiol as a key modulator of visceral sensitivity. These data suggest that ELA induces persistent functional abdominal pain in female IBS patients through an estrogen-dependent mechanism.
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.
Research on irritable bowel syndrome (IBS), a functional disorder of the gastrointestinal (GI) system, has linked GI symptoms to stress. This study examined the relationship between daily stress and GI symptoms across women and within woman in IBS patients (n = 26), IBS nonpatients (IBS-NP; n = 23), and controls (n = 26), controlling for menstrual cycle phase. Women (ages 20–45) completed daily health diaries for two cycles in which they monitored daily GI symptoms and stress levels. The Life Event Survey (LES) was used as a retrospective measure of self-reported stress. The across-women analyses showed higher mean GI symptoms and stress in the IBS and IBS-NP groups relative to controls but no group differences in LES scores. The within-woman analyses found a significant and positive relationship between daily stress and daily symptoms in both the IBS-NP and the IBS groups. Controlling for menstrual cycle had no substantial impact on the results.
The female menstrual cycle is associated with multiple hormonal, physiological and psychological changes. Over the centuries
menarche has been referred to as both a rite of passage into womanhood and a curse to be endured. Indeed, there is now a debate
over the use of oral contraceptives for the express purpose of reducing the frequency or even discontinuing menstruation.
Epidemiological and survey data indicate that over one-third of women in the general population experience significant physical
and psychological symptoms across the menstrual cycle, with pain being among the most common symptoms (Huerta-Franco & Malacara, 1993; Kessel & Coppen, 1963). The purpose of this chapter is to present information related to alterations in pain perception associated with menstrual
cycle-related clinical conditions. First, an overview of research examining changes in pain sensitivity across the menstrual
cycle will be presented. Then, research investigating pain perception in women with dysmenorrhea and premenstrual dysphoric
disorders will be reviewed. Finally, menstrual cycle influences on clinical symptoms in several pain disorders will be considered,
and practical implications will be discussed.
Sex-related differences in the experience of both clinical and experimentally induced pain have been widely reported. Specifically,
females are at greater risk for developing several chronic pain disorders, and women exhibit greater sensitivity to noxious
stimuli in the laboratory compared with men. Several mechanisms have been proposed to account for these sex differences. Psychosocial
factors such as sex role beliefs, pain coping strategies, mood, and pain-related expectancies may underlie these effects.
In addition, there is evidence that familial factors can alter pain responses, and these intergenerational influences may
differ as a function of sex. Sex hormones are also known to affect pain responses, which may mediate the sex differences.
Although the magnitude of these effects has not been well characterized, there are potentially important practical implications
of sex differences in pain responses. These implications are discussed, and directions for future research are delineated.
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.
Sleep dysfunction is associated with altered gastrointestinal functioning and the presence of irritable bowel syndrome (IBS). We aimed to investigate whether sleep dysfunction would influence anorectal motility in IBS patients.
A total of 16 healthy volunteers and 15 IBS patients underwent anorectal manometry. The anorectal parameters included resting and squeeze sphincter pressure, sensory thresholds in response to balloon distension, and rectoanal inhibitory reflex. Sleep dysfunction was assessed by using the Pittsburgh Sleep Quality Index (PSQI).
IBS patients had a lower threshold volume for urge (p = 0.04) and pain (p = 0.002) as compared with the controls. IBS patients with sleep dysfunction had a significantly lower threshold volume for urge (p = 0.04) and anal sphincter pressure for maximal squeeze (p = 0.048) as compared with those without sleep dysfunction. In IBS patients, the PSQI score significantly correlated with threshold volume for first sensation (r = -0.55; p = 0.03), urge (r = -0.56; p = 0.03) and pain (r = -0.58; p = 0.03).
IBS patients with sleep dysfunction are characterized by lower thresholds for rectal perception. Sleep disturbance might be associated with anorectal dysfunction and appears to create some degree of rectal hyperalgesia in patients with IBS.
Functional disorders of the gastrointestinal tract comprise a common but ill-defined group of diseases; they primarily afflict women. Although predominantly involving nerve and muscle, the cellular and molecular bases of the pathogenesis of these functional disorders are unknown. Clinical studies indicate that some result from neural dysfunction within the enteric nervous system, others may be due to muscular problems, and the causes of still others remain unknown. Laboratory studies have shown that ovarian products such as progesterone, luteinizing hormone, human chorionic gonadotropin, and relaxin (but not estrogen), are neural antagonists of gastrointestinal motility. The production and secretion of these ovarian substances are controlled by gonadotropin-releasing hormone (GnRH) released from the hypothalamus; they probably act on gamma-aminobutyric acid receptors and alter chloride influx into the cell. GnRH analogs are effective drugs that downmodulate the hypothalamic-pituitary-gonadal axis and inhibit the secretion of gonadal products involved in such hormone-dependent diseases as endometriosis and prostate cancer. Acting on the GnRH receptors (seven transmembrane domain receptors) on myenteric neurons, GnRH analogs are also effective neural modulators in such disorders as functional bowel disease. These analogs are a promising new group of compounds that may be used to treat difficult gastrointestinal problems.
Unlabelled:
Females are disproportionately affected by irritable bowel syndrome (IBS) with menstrual cycle-dependent fluctuations in abdominal pain suggesting a role for ovarian hormones. IBS patients also exhibit greater activation of brain areas involved in pain affect such as the amygdala, yet the role of supraspinal processes in the effects of ovarian hormones on visceral pain is largely unexplored. The goal of the current study was to determine whether sex steroids act at the level of the amygdala to alter colonic pain sensitivity. Ovariectomized rats received implants on the amygdala of progesterone, estradiol, progesterone combined with estradiol, or cholesterol as a control to examine the involvement of the amygdala in ovarian hormone-mediated changes in visceral sensitivity. Visceral sensitivity was quantified as the number of abdominal contractions, a visceromotor response (VMR), in response to graded pressures of colorectal distension (CRD). Somatic sensitivity was also assessed by measuring the mechanical force required to elicit hindpaw withdrawal. Elevated levels of progesterone and/or estradiol on the amygdala heightened the responsiveness to CRD; in contrast, neither estradiol nor progesterone altered somatic sensation. Furthermore, administration of progesterone or estradiol to areas adjacent to the amygdala did not affect visceral sensitivity. Future studies will address the specific steroid receptors mediating the effects of progesterone and estradiol.
Perspective:
To our knowledge, this study represents the first description of a specific brain site mediating the effects of ovarian steroids on visceral sensitivity. These data also suggest that an amygdala-dependent mechanism may be responsible, at least in part, for the exacerbation of visceral symptomatology in females.
Studies suggest that sex and gender-related differences exist in irritable bowel syndrome (IBS), but data is often conflicting.
To evaluate gender differences and the effect of menstrual cycle and menopausal status on IBS symptoms.
We performed a systematic review of MEDLINE to search for studies comparing IBS symptoms between gender, menstrual cycle phases and menopausal states in IBS and/or healthy individuals. We performed meta-analyses to compare the relative risk (RR) of individual IBS symptoms between men and women.
Twenty-two studies measured gender differences in IBS symptoms. Women were more likely to report abdominal pain (RR = 1.12, 95% CI: 1.02, 1.22) and constipation-related symptoms (RR = 1.12, 95% CI: 1.02, 1.23) than men (all P < 0.05). However, men with IBS were more likely to report diarrhoea-related symptoms than women with IBS (RR = 0.84, 95% CI: 0.75, 0.94, P < 0.05). A systematic review of 13 studies demonstrated that both IBS and healthy women reported increased IBS symptoms during menses vs. other phases. There were insufficient data to determine the effect of menopause and hormone supplementation on IBS symptoms.
In the general and IBS populations, gender differences in IBS symptoms exist, although these differences are modest. Studies suggest that female sex hormones influence the severity of IBS symptoms, but more studies are needed.
Irritable bowel syndrome (IBS) supports the concept of a dysregulated hypothalamic-pituitary-adrenal (HPA) axis. This study investigates the neuroendocrine and psychological responses to the acute physical stress of a lumbar puncture (LP) in women with diarrhea-predominant IBS by assessing central and peripheral HPA activity and affective measures. Blood samples have been collected at baseline and immediately post- and 1 hr following LP from 13 women with IBS and 13 controls. Plasma adrenocorticotropic hormone (ACTH), cortisol, epinephrine, and norepinephrine levels are analyzed. A single measure of cerebrospinal fluid (CSF) concentrations of corticotropin-releasing factor (CRF(CSF)) and norepinephrine(CSF) is noted. Affective assessments are used to rate anxiety and depression with the Hospital Anxiety and Depression Scale (HADS) and acute mood state is rated using the Stress Symptom Rating questionnaire (stress, anxiety, anger, arousal). The women with IBS display blunted ACTH and cortisol responses to the LP along with a profile of affective responsiveness suggestive of chronic psychosocial stress, although no CRF(CSF) differences between groups are observed.
In the United States, more women than men seek health-care services for symptoms of irritable bowel syndrome (IBS). A number of explanations are given for this gender difference including the higher rates of somatic non-gastrointestinal symptoms and increased psychological distress reported by women with IBS. However, these gender differences are found in studies that rely on retrospective recall with little attention to age or reproductive status. The purpose of the current analysis was to prospectively compare the frequency (days/month of moderate to severe based on a daily diary) of somatic, gastrointestinal (GI), and psychological distress symptoms, in menstruating women (N = 89) and postmenopausal women (N = 66) to men (N = 32) with IBS. In addition, the correlation between daily symptoms and daily report of overall health was evaluated. Postmenopausal women reported significantly more GI pain/discomfort symptoms, especially bloating and abdominal distension, than men, however these differences are greatly attenuated when age is controlled for. Both postmenopausal and menstruating women reported significantly more somatic symptoms (especially joint pain and muscle pain) than men with IBS. The effect was stronger in postmenopausal women, whose somatic symptoms were also higher than menstruating women (P = 0.014). Fatigue and stress were higher in women than men but anxiety and depression were not. All three types of symptoms were strongly correlated with self-rating of health, both across and within-person. Gender-related differences in GI and somatic symptoms are apparent in persons with IBS, more strongly in postmenopausal women. The presence of somatic symptoms in postmenopausal women with IBS may challenge clinicians to find suitable therapeutic options.
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.
Basal and stimulated gastric emptying and gastrointestinal (GI) transit in rats of varying ovarian hormone status were compared to define direct ovarian hormone effects on GI function. Thyrotropin-releasing hormone (TRH) was used to evoke vagal GI motility stimulation. Adult female Sprague-Dawley rats were anesthetized (equithesin), ovariectomized, and implanted with 28-day estrogen (E), progesterone, (P), E+P, or vehicle (V) pellets; males were also studied. On Day 26, fasted rats were anesthetized (urethane). Nonabsorbable 14C polyethylene glycol-4000 in saline was gavaged at t = 0. At t = 5 minutes, TRH or saline was administered intracisternally. At t = 30 or 60 minutes, the GI tract was removed, ligated, sectioned, and counted. Gastric emptying was expressed as 100% minus the ratio of gastric to total counts; GI transit was expressed as geometric center of radioactivity. In saline-treated rats, gastric emptying and GI transit at 60 minutes varied significantly among ovarian hormone-treated groups, with E lower and males elevated. TRH-significantly increased both variables at both times in all groups. Results are consistent with acceleration of upper GI function in the absence of E, possibly contributing to GI symptoms during menopause and late luteal phase.
Symptoms associated with gastric motility alteration vary with stress and ovarian hormone status, most notably in women with irritable bowel syndrome. This study examines combined effects, comparing gastric motility during administration of a stress-related neuropeptide thyrotropin-releasing hormone (TRH) and restraint stress in conscious rats of varied ovarian hormone status. Adult rats were ovariectomized and implanted with estrogen, progesterone, or vehicle-releasing pellets. After 21 days, intracerebroventricular (i.c.) cannula and gastric tension transducer were implanted. After 25-27 days, motility was recorded during neuropeptide injection (TRH/saline i.c.) or restraint stress. TRH induced increased motility in all groups; the response varied with hormone group, and was least and briefest in estrogen-treated rats. Motility during restraint varied with hormone group; it was diminished in estrogen-treated but not other groups. Ovarian hormone status (estrogen) modifies gut response to TRH and restraint stress.
Women who report chronic gastrointestinal symptoms compatible with a diagnosis of irritable bowel syndrome (IBS) frequently report sleep disturbances.
The purposes of this study were to (a) compare self-reported and polysomnographic indicators of sleep quality in women with IBS symptoms (IBS-SX, n= 16) and controls (n= 16); (b) examine the relationship between the indicators of sleep quality; and (c) determine the relationship between sleep indicators and psychological distress.
The women slept in a laboratory for 2 consecutive nights. Polysomnographic measurements were recorded during sleep, and a sleep questionnaire was completed upon awakening each morning. Psychological distress was measured with the Symptom Checklist-90-R during the initial interview.
Women in the IBS-SX group reported significantly greater numbers of awakenings during sleep (p = .008) and had a longer latency to REM sleep (p = .04) than did the controls. Self-reported and polysomnographic indicators were more highly correlated in the control group than in the IBS-SX group. In the IBS-SX group, the greater the psychological distress, the less alert (rs = .419) and rested (rs = .564) the women felt in the morning and the more time the women spent in stages 3 and 4 sleep (rs = .479) and less in stage 2 (rs = -.447) and REM (rs = -.414) sleep. In the control group, psychological distress was not significantly associated with self-reported measures but was significantly associated with the number of awakenings (rs = .506) and time in stages 3 and 4 sleep (rs = -.677).
Although the women in the IBS-SX group reported significantly more awakenings, the weak relationship between self-reported and polysomnographic indicators suggests that clinicians must keep in mind that further assessments may be necessary.
Although there is a wide variability in symptoms, disorders of colonic motility are the most prominent features in irritable bowel syndrome (IBS). Stool weight is within the normal range but many patients appear to have abnormal rectal sensations. Straining even with soft stool is common. Dietary fibre stimulates ileocolonic flow and may induce more symptoms in IBS than normal. There is evidence of increased responsiveness of the IBS colon, both to the effect of eating and to stress. Defaecatory disorders are common and may reflect both increased or decreased rectal sensitivity. The normal colon is quiescent during sleep, but in IBS coma sleep is often abnormal, with more periods of arousal and the colon consequently more active. There is evidence of increased responsiveness to corticotrophin releasing factor, which mediates much of the effect of stress on the gut. Many patients show a sympathetic/vagal imbalance with relative excess of sympathetic influence in keeping with increased levels of psychological stress and anxiety. There is undoubtedly more than one cause of IBS and around 25% appear to develop symptoms after an infectious enteritis. This has effects on the entero-endocrine system which may take many years to subside.
This article addresses a series of points that should be considered in the design of future clinical trials in irritable bowel syndrome (IBS). A precise, uncontroversial definition of the disorder and the affected patient is required that accurately describes the condition that practitioners recognize intuitively exists. Regarding patient source and selection, the principle should be applied that patients be recruited to trials from all sources to which an indication is intended. Because abdominal pain is the most central symptom of IBS, it should be used as the primary trial endpoint. Because there are currently no effective treatments, placebo-controlled trials pose no ethical problems. High placebo responses may equally well be the temporary spontaneous improvements that are characteristic of the condition. Clinical trials should be designed to meet specific aims of treatments: when taken as single doses to terminate an attack of pain; when taken over a brief period of time to speed resolution of a period of exacerbation of IBS; when taken after termination of a period of activity to prevent relapse; when taken regularly on a long-term basis to reduce the days on which a number of symptoms are experienced; when taken in form of discrete courses of treatment designed to achieve a pivotal change in the natural history of the condition.
This analysis evaluated the association between sleep disturbance and gastrointestinal symptoms in women with and without irritable bowel syndrome (IBS), and examined the role of psychological distress in this relationship. Women with lBS (N = 82) reported considerably higher levels of sleep disturbance compared to controls (N = 35), using both retrospective seven-day recall and daily diary recall for two menstrual cycles (P < 0.05 on 8 of 10 measures). We used daily diary data to estimate the association between sleep disturbance and gastrointestinal symptoms, both across women (ie, whether women with high average sleep disturbance have higher average gastrointestinal symptoms) and within woman (ie, whether poorer than average sleep on one night is associated with higher than average gastrointestinal symptoms the following day). The regression coefficients for the acrosswomen effect are large and highly significant in both groups (IBS, β ± SE = 0.46 ± 0.08, P < 0.001; controls, 0.57 ± 0.13, P < 0.001). The regression coefficients for the within-woman effect are considerably smaller and statistically significant only in the lBS group (IBS, 0.06 ± 0.02, P = 0.006; control, 0.01 ± 0.03, P = 0.691). These regression coefficients showed little change when daily psychological distress or stress was controlled for, the one exception being the coefficient for the across-women effect in the IBS group, which decreased substantially but still remained highly significant. Because it is possible that gastrointestinal symptoms could, in fact, cause poor sleep, we also fitted the temporally reversed model to evaluate the association between gastrointestinal symptoms on one day and sleep disturbance that night. The within-woman regression coefficients were nonsignificant in both the IBS and control groups. In conclusion, these results are consistent with the hypothesis that poor sleep leads to higher gastrointestinal symptoms on the following day among women with IBS.
Considerable evidence indicates sex-related differences in pain responses and in the effectiveness of various analgesic agents. Specifically, females are at greater risk for experiencing many forms of clinical pain and are more sensitive to experimentally induced pain relative to males. Regarding analgesic responses, nonhuman animal studies indicate greater opioid analgesia for males, while a limited human literature suggests the opposite. Though the mechanisms underlying these effects remain unclear, the influence of gonadal hormones on nociceptive processing represents one plausible pathway whereby such sex differences could emerge. The present article reviews the complex literature concerning sex steroid effects on pain responses and analgesia. First, nonhuman animal research related to hormonal effects on nociceptive sensitivity and analgesic responses is presented. Next, human studies regarding gonadal hormonal influences on experimental pain responses are reviewed. Several potential mechanisms underlying hormonal effects on nociceptive processing are discussed, including hormonal effects to both peripheral and central nervous system pathways involved in pain transmission. Finally, based on these findings we draw several conclusions and make specific recommendations that will guide future research as it attempts to elucidate the magnitude and importance of sex-related hormonal effects on the experience of pain.
It's now believed that IBS has a basis in visceral hypersensitivity and abnormal gut motor function, possibly caused by anomalies in the gut-brain axis. New therapies are in development.
Considerable experimental research suggests that ovarian hormones can influence pain perception, and recent epidemiologic and clinical research suggests that exogenous hormone use may influence the prevalence and severity of clinical pain among women. However, to date no studies have examined the influence of hormone replacement therapy (HRT) on experimental pain responses and recent pain complaints among postmenopausal women. In this study, self-reported recent pain and general health were obtained, and thermal pain responses were assessed in three groups of healthy older adults: (1) women on HRT, (2) women not on HRT (No-HRT), and (3) men. Results indicated no group differences in recent pain complaints or self-reported health, but differences emerged for measures of thermal pain perception. Specifically, HRT women showed lower pain thresholds and tolerances than No-HRT women and men, and the latter two groups did not differ from each other. The potential explanations and limitations of the observed findings are discussed.
Gender-related differences have been demonstrated with regard to GI motility: gallbladder contraction, colonic transit, and gastric emptying are delayed in women. It is not known whether gender influences proximal gastric motility and perception.
We have studied the influence of gender on proximal gastric motility and perception under fasting and postprandial conditions by retrospective analysis of data obtained in 99 healthy volunteers (42 men, 57 women) who participated in barostat studies performed according to standardized protocols at the Leiden University Medical Center (Leiden, The Netherlands) between 1996 and 2000.
Minimal distending pressure (MDP) was significantly higher in women than in men (respectively, 6.8+/-0.2 vs 5.5+/-0.2 mm Hg; p < 0.001). During stepwise pressure distensions pressure-volume curves were similar in both sexes after correction for MDP, whereas perception of fullness and abdominal pressure increased significantly (p < 0.05) more rapidly in women. Before the meal intragastric volumes (at MDP + 2 mm Hg) did not differ between sexes. After the meal gastric relaxation in the first 30 min did not differ in women and men (respectively, 186+/-23 ml and 140+/-32 ml). However, from 30 until 90 min after the meal a significantly (p < 0.05) delayed return of intragastric volume to basal was seen in women. Perception of postprandial nausea was significantly (p < 0.01) increased in women. Perception of postprandial fullness remained increased for a longer period of time in women.
Proximal gastric motility and perception are influenced by gender. Gender-related differences in postprandial proximal gastric motility and perception should be taken into account in barostat studies comparing patients with controls.
Irritable bowel syndrome (IBS) is a common health care problem worldwide. In the United States and Northern European countries, more women than men seek health care services for IBS. Nurses are often called on to help women with IBS manage their symptoms. This article reviews the literature related to gender differences in diagnosis, symptoms (gastrointestinal, somatic, and disturbed sleep), and physiologic and psychological factors as well as current pharmacologic therapies used in the management of IBS.
In the United States and other Western cultures, a greater number of women seek health care services for symptoms of functional pain disorders, including irritable bowel syndrome, than men. Recent clinical trials indicate that gender differences in responsiveness to drug therapy also occur. Several lines of inquiry have focused on explaining this gender-related difference due to the higher prevalence of these disorders in women. Evidence of a physiologic component is based on gender differences in gastrointestinal transit time, visceral sensitivity, central nervous system pain processing, and specific effects of estrogen and progesterone on gut function. Additional factors may play a role, including gender-related differences in neuroendocrine, autonomic nervous system, and stress reactivity, which are related to bowel function and pain. However, the link between these measures and gut motility or sensitivity remains to be clarified. Psychological characteristics, including somatization, depression, and anxiety as well as a history of sexual abuse, may also contribute to gender-related differences in the prevalence of irritable bowel syndrome. Although gender differences in the therapeutic benefit of serotonergic agents have been observed, less is known about potential differences in responsiveness to nondrug therapies for irritable bowel syndrome.
Irritable bowel syndrome (IBS) is a common functional bowel disorder characterized by abdominal pain and change in defecation pattern. This review addresses the topic of possible sex (genetic, biological) and gender (experiential, perceptual) differences in individuals with and without IBS. Several observations make the topic important. First, there is a predominance of women as compared to men who seek health care services for IBS in the United States and other industrialized societies. Second, menstrual cycle-linked differences are observed in IBS symptom reports. Third, women with IBS tend to report greater problems with constipation and nongastrointestinal complaints associated with IBS. Fourth, serotonin (5-HT3) receptor antagonist and 5-HT4 partial agonist drugs appear to more effectively diminish reports of bowel pattern disruption in women with IBS as compared to men. This review examines sex and gender modulation of gastrointestinal motility and transit, visceral pain sensitivity, autonomic nervous system function, serotonin biochemistry, and differences in health care-seeking behavior for IBS.
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.
Appropriate guidelines for clinical trials in irritable bowel syndrome are needed because of the inadequacy of previously performed trials, the use of new and more adequate patient definition, new emerging pathophysiological models and the unique requirements related to the assessment of treatment outcome that, in the absence of a biological marker, can rely only on the evaluation of clinical manifestations.
This consensus report highlights the following points.
(a) A 4-week period is considered to be adequate to assess drug efficacy for the control of symptoms.
(b) For the cyclic and non-life-threatening nature of the disease, a long-term study of 4–6 months or more of active treatment to establish efficacy is considered to be inappropriate in the large majority of patients.
(c) In the initial assessment phase of drug efficacy, the withdrawal effect of treatment can be ascertained during a follow-up period prolonged for a sufficient time (4–8 weeks) after stopping treatment. Subsequent trials with proper withdrawal phase design and duration can then ascertain the drug post-treatment benefit.
(d) Considering the intermittent clinical manifestations of irritable bowel syndrome, designing trials with on-demand or repeated cycles of treatment could be envisaged. However, the lack of a definition of what constitutes an exacerbation is a major obstacle to the design of such trials. In the absence of an established gold standard, appropriately justified novel trial designs are welcome.
(e) Patients eligible for inclusion should comply with the Rome II diagnostic criteria for irritable bowel syndrome.
(f) The main efficacy outcome of the treatment should be based on one primary end-point.
(g) The primary efficacy end-point could combine, in a global assessment, the key symptoms (abdominal pain, abdominal discomfort, bowel alterations) of irritable bowel syndrome or rate any single symptom for drugs considered to target specific symptoms.
(h) A 50% improvement in the primary efficacy end-point seems to be a reasonable definition of a responder.
Our objective was to obtain national data of the estimated prevalence, sociodemographic relationships, and health impact of persons with functional gastrointestinal disorders. We surveyed a stratified probability random sample of U.S householders selected from a data base of a national market firm (National Family Opinion, Inc.). Questions were asked about bowel symptoms, sociodemographic associations, work absenteeism, and physician visits. The sampling frame was constructed to be demographically similar to the U.S. householder population based on geographic region, age of householder, population density, household income and household size. Of 8250 mailings, 5430 were returned suitable for analysis (66% response). The survey assessed the prevalence of 20 functional gastrointestinal syndromes based on fulfillment of multinational diagnostic (Rome) criteria. Additional variables studied included: demographic status, work absenteeism, health care use, employment status, family income, geographic area of residence, population density, and number of persons in household. For this sample, 69% reported having at least one of 20 functional gastrointestinal syndromes in the previous three months. The symptoms were attributed to four major anatomic regions: esophageal (42%), gastroduodenal (26%), bowel (44%), and anorectal (26%), with considerable overlap. Females reported greater frequencies of globus, functional dysphagia, irritable bowel syndrome, functional constipation, functional abdominal pain, functional biliary pain and dyschezia; males reported greater frequencies of aerophagia and functional bloating. Symptom reporting, except for incontinence, declines with age, and low income is associated with greater symptom reporting. The rate of work/school absenteeism and physician visits is increased for those having a functional gastrointestinal disorder. Furthermore, the greatest rates are associated with those having gross fecal incontinence and certain more painful functional gastrointestinal disorders such as chronic abdominal pain, biliary pain, functional dyspepsia and IBS. Preliminary information on the prevalence, socio-demographic features and health impact is provided for persons who fulfill diagnostic criteria for functional gastrointestinal disorders.
Since it is not known whether the symptoms and bowel function of patients with the irritable bowel syndrome are truly abnormal we used diaries and frequent telephone interviews over a 31 day period to assess symptoms, defecation, and stool types in 26 unselected female hospital patients with the irritable bowel syndrome, 27 women who admitted to recurrent colonic pain but had not consulted a doctor (non-complainers), and 27 healthy control subjects. Unexpectedly, abdominal pain and bloating occurred in most of the control subjects. Pain, however, was six times more frequent in the patients and was more often considered severe. Bloating occurred three times more often. Defecation was more frequent, more erratic in timing and stool form, and more likely to produce stools of extreme forms, indicating rapid fluctuations in intestinal transit time. Urgency was four times more prevalent in patients than control subjects. Straining to finish defecating was nine times more prevalent and was often accompanied by feelings of incomplete evacuation--a combination which could lead to the misdiagnosis of constipation. The normal relation between stool form and the above symptoms was distorted, possibly due to rectal irritability. Non-complainers were intermediate between patients and control subjects in almost every parameter but were closer to control subjects than to patients. Patients with the irritable bowel syndrome have real cause for complaint and their bowel function is truly abnormal.
To determine the prevalence of a history of sexual and physical abuse in women seen in a referral-based gastroenterology practice, to determine whether patients with functional gastrointestinal disorders report greater frequencies of abuse than do patients with organic gastrointestinal diseases, and to determine whether a history of abuse is associated with more symptom reporting and health care utilization.
A consecutive sample of women seen in a university-based gastroenterology practice over a 2-month period was asked to complete a brief questionnaire.
The self-administered questionnaire requested information about demographics, symptoms, health care utilization, and history of abuse. Physicians indicated the primary diagnosis for each patient and whether she had ever discussed having been sexually or physically abused.
Of 206 patients, 89 (44%) reported a history of sexual or physical abuse in childhood or later in life; all but 1 of the physically abused patients had been sexually abused. Almost one third of the abused patients had never discussed their experiences with anyone; only 17% had informed their doctors. Patients with functional disorders were more likely than those with organic disease diagnoses to report a history of forced intercourse (odds ratio, 2.08; 95% CI, 1.03 to 4.21) and frequent physical abuse (odds ratio, 11.39; CI, 2.22 to 58.48), chronic or recurrent abdominal pain (odds ratio, 2.06; CI, 1.03 to 4.12), and more lifetime surgeries (2.7 compared with 2.0 surgeries; P less than 0.03). Abused patients were more likely than nonabused patients to report pelvic pain (odds ratio, 4.05; CI, 1.41 to 11.69), multiple somatic symptoms (7.1 compared with 5.8 symptoms; P less than 0.001), and more lifetime surgeries (2.8 compared with 2.0 surgeries; P less than 0.01).
We found that a history of sexual and physical abuse is a frequent, yet hidden, experience in women seen in referral-based gastroenterology practice and is particularly common in those with functional gastrointestinal disorders. A history of abuse, regardless of diagnosis, is associated with greater risk for symptom reporting and lifetime surgeries.
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.
Our objective was to obtain national data of the estimated prevalence, sociodemographic relationships, and health impact of persons with functional gastrointestinal disorders. We surveyed a stratified probability random sample of U.S. householders selected from a data base of a national market firm (National Family Opinion, Inc.). Questions were asked about bowel symptoms, sociodemographic associations, work absenteeism, and physician visits. The sampling frame was constructed to be demographically similar to the U.S. householder population based on geographic region, age of householder, population density, household income, and household size. Of 8250 mailings, 5430 were returned suitable for analysis (66% response). The survey assessed the prevalence of 20 functional gastrointestinal syndromes based on fulfillment of multinational diagnostic (Rome) criteria. Additional variables studied included: demographic status, work absenteeism, health care use, employment status, family income, geographic area of residence, population density, and number of persons in household. For this sample, 69% reported having at least one of 20 functional gastrointestinal syndromes in the previous three months. The symptoms were attributed to four major anatomic regions: esophageal (42%), gastroduodenal (26%), bowel (44%), and anorectal (26%), with considerable overlap. Females reported greater frequencies of globus, functional dysphagia, irritable bowel syndrome, functional constipation, functional abdominal pain, functional biliary pain and dyschezia; males reported greater frequencies of aerophagia and functional bloating. Symptom reporting, except for incontinence, declines with age, and low income is associated with greater symptom reporting. The rate of work/school absenteeism and physician visits is increased for those having a functional gastrointestinal disorder. Furthermore, the greatest rates are associated with those having gross fecal incontinence and certain more painful functional gastrointestinal disorders such as chronic abdominal pain, biliary pain, functional dyspepsia and IBS. Preliminary information on the prevalence, socio-demographic features and health impact is provided for persons who fulfill diagnostic criteria for functional gastrointestinal disorders.
Women with symptoms indicative of irritable bowel syndrome who had not consulted a physician were compared with female patients at a gastroenterology clinic to investigate whether self-selection for treatment accounts for psychologic abnormalities in clinic patients with irritable bowel syndrome. Two sets of diagnostic criteria were compared; restrictive criteria based on the work of Manning and conventional criteria (abdominal pain plus altered bowel habits). Lactose malabsorbers were included as a control group because they have medically explained bowel symptoms similar to those that define irritable bowel syndrome. Thus they control for the causative effects of chronic bowel symptoms on psychologic distress. Women who met restrictive criteria for irritable bowel syndrome but had not consulted a physician had no more symptoms of psychologic distress on the Hopkins Symptom Checklist than asymptomatic controls. However, medical clinic patients with both irritable bowel syndrome and lactose malabsorption had significantly more psychologic symptoms than asymptomatic controls or nonconsulters with the same diagnoses. Individuals who met only the conventional criteria for irritable bowel syndrome reported more psychologic distress than controls, whether or not they consulted a physician. These results suggest that (a) symptoms of psychologic distress are unrelated to irritable bowel syndrome but influence which patients consult a doctor and (b) conventional diagnostic criteria identify more psychologically distressed individuals than do restrictive criteria.
The dimensional structure of the SCL-90, a multidimensional self-report symptom inventory, was subjected to a confirmatory empirical test with a sample of 1,002 psychiatric outpatients. A variation of factor analytic method termed a „Procrustes procedure” was utilized to compare the hypothesized nine-dimensional clinical-rational structure with the dimensional structure developed empirically. The hypothetical vs. empirical match was judged to be very good for eight of the nine dimensions, and moderate on the ninth and thereby makes a substantive contribution to the construct validity of the instrument.
Irritable bowel syndrome (IBS) is the most common gastrointestinal disorder encountered by primary care physicians and gastroenterologists with an estimated prevalence of 8% to 17% in the general population. This paper provides a review of available literature in the field of psychogastroenterology, that supports the biopsychosocial model as the basis for understanding and treatment of IBS, as well as epidemiological and clinical data associated with the influence of psychosocial factors on the gut physiology, symptom presentation, behavior related to health conditions and the final outcome of disorder. The psychological assessment of IBS patients, compared with normal subjects or other medical patients, shows a high prevalence of stress reports, abnormal personality features, psychiatric diagnoses and illness behavior. Psychosocial factors are important with regard to their effects on the gut physiology, their modulation of the symptom experience, their influence on illness behavior, their impact on the outcome and the choice of therapeutic approach. Psychological factors, such as the type of personality, health believes, the history of previous physical or sexual abuse may play an important role in determining health care-seeking behavior. The examination of psychosocial histories of the IBS patients suggested that many of the IBS features might be more characteristics of patient's coping and adoption patterns than of the very disease. The psychiatrist may be of assistance by treating IBS as a biological vulnerability that worsens with psychological distress, providing proper diagnosis and treatment of coexisting psychiatric disease and maladaptive illness behavior, and developing multimodal treatment plan including psychotherapeutic and pharmacological management.
The pattern of gastrointestinal symptoms and select mood and somatic symptoms was examined across two menstrual cycles in women with (n = 19) and without (n = 39) functional bowel distress (FBD). The women (a) rated their gastrointestinal, perimenstrual, mood, and other symptoms and stool frequency and consistency daily; (b) completed the Menstrual Distress Questionnaire-T; and (c) had serum levels of estrogen and progesterone measured during the menses, follicular, and luteal phases. Stomach pain, nausea, and diarrhea were rated higher at menses in the group with FBD than in the group without FBD. Stomach pain was higher during the remaining days as well. The group with FBD reported higher levels of perimenstrual symptoms also on six of the eight Menstrual Distress Questionnaire-T subscales (P less than 0.01). Other complaints, e.g., poor work/school performance, were higher in women with FBD, but somatic symptoms that were expected to vary over the cycle did not differ between groups, except cramping pain. There were no significant group differences in ovarian hormone levels or stool consistency/frequency scores.
Functional gastrointestinal disease is believed to be very common, but reports of its prevalence have not usually evaluated random community samples, and validated questionnaires have not been used to elicit symptoms. The prevalence of specific colonic symptoms and the irritable bowel syndrome among representative middle-aged whites was determined from a defined population, and the impact of these symptoms on presentation for medical care was measured. An age- and sex-stratified random sample of 1021 residents of Olmsted County, Minnesota, aged 30-64 years, was obtained. All subjects were mailed a valid self-report questionnaire that identified gastrointestinal symptoms and functional gastrointestinal disorders. The response rate was 82% (n = 835). The age- and sex-adjusted prevalence of abdominal pain (more than six times in the prior year) was 26.2 per 100 (95% confidence interval, 23.1-29.2). The prevalence of chronic constipation (hard stools and straining and/or less than 3 stools per week greater than 25% of the time) was 17.4 (95% confidence interval, 14.8-20.0), whereas the prevalence of chronic diarrhea (loose watery stools, and/or greater than 3 stools per day greater than 25% of the time) was 17.9 (95% confidence interval, 15.3-20.5). The prevalence of abdominal pain and disturbed defecation was similar in women and men, except that infrequent defecation and straining at stool were more common in women. Using the Manning symptom criteria to identify irritable bowel syndrome (greater than or equal to 2 of 6 symptoms in those with abdominal pain more than six times in the prior year), the prevalence of irritable bowel syndrome was 17.0 per 100 (95% confidence interval, 14.4-19.6). Overall, 71 persons (9%) reported visiting a physician for abdominal pain or disturbed defecation in the prior year; a subset of variables related to pain severity were the best predictors of health care seeking after adjustment for age and gender. However, these accounted for only 22% of the log likelihood. In conclusion, more than one third of an unselected middle-aged population reported chronic abdominal pain or disturbed defecation, and more than one in six had symptoms compatible with the irritable bowel syndrome. Only a minority had presented for medical evaluation; moreover, the characteristics of the abdominal complaints did not explain the seeking of health care in most cases.
United States estimates of the frequency of visits to physicians and patterns of medical care for the diagnosis of the irritable bowel syndrome were derived from the 1975, 1980-1981, and 1985 National Ambulatory Medical Care Surveys. These surveys of office-based physicians allow national estimates of various aspects of ambulatory care. The overall rate of visits with the diagnosis of irritable bowel syndrome in 1980-1981 and 1985 were 10.6 per thousand U.S. population. Women had 2.4 times the rate of visits by men and rates rose in both sexes until middle-age. Irritable bowel syndrome was the leading digestive disease diagnosis among gastroenterologists but only the seventh leading diagnosis among all physicians. Gastrointestinal symptoms, association with mental disorders, prescriptions, and disposition were also examined in patients with visits for irritable bowel syndrome. Among records with digestive tract symptoms and a first listed diagnosis of irritable bowel syndrome, stomach or abdominal pain was listed on only about one half of records and disorders of bowel function were listed on fewer than 40%. In 1975 and 1985, irritable bowel syndrome was noted approximately twice as often as other digestive diseases at visits with mental disorder symptoms and diagnosis, although mental disorder symptoms and diagnoses were noted at fewer than 15% of visits with irritable bowel syndrome. Medications were prescribed at approximately 75% of visits for irritable bowel syndrome; the most common were gastrointestinal medications followed by combination gastrointestinal-psychoactive medications. Subsequent appointments were scheduled following at least 50% of the visits of patients with irritable bowel syndrome.
Psychiatric illnesses such as mood, anxiety, and somatization disorders share many common features with irritable bowel syndrome. The authors review recent developments in the definition of irritable bowel syndrome and its relationship to psychiatric illness, discuss the diagnostic validity of irritable bowel syndrome from several perspectives, and offer a pathophysiological model of irritable bowel syndrome that integrates many of the biological and psychosocial findings of earlier studies. Psychiatric evaluation appears to be an important factor in the diagnosis and treatment of patients with irritable bowel syndrome.
A need exists for a self-report questionnaire that reliably and accurately measures symptoms and that distinguishes patients with functional gastrointestinal disease from those with other conditions. We have developed such an instrument, the bowel disease questionnaire, and herein describe details of its discriminatory validity. Data from 399 subjects were analyzed. Patients with gastrointestinal symptoms were ultimately diagnosed as having functional gastrointestinal disease (82 with the irritable bowel syndrome and 33 with functional dyspepsia) or organic gastrointestinal disease (N = 101). There were 145 healthy control subjects and 38 patients with a psychiatric disease, somatoform disorder (which includes those with a diagnosis of hypochrondriasis, psychogenic pain, and somatization or conversion disorder). All subjects completed the questionnaire before undergoing an independent diagnostic assessment by experienced physicians. Functional gastrointestinal disease could be distinguished from organic disease, somatoform disorder, and health by using models derived from logistic discriminant analysis. With use of these models, the estimated probability of functional gastrointestinal disease was then calculated. Descriptive symptom scores were of less value than the scores derived from the data sets by logistic discriminant analysis. Age did not significantly affect the responses to the questionnaire items. We conclude that, in the population studied, the bowel disease questionnaire is a valid measure of symptoms of functional gastrointestinal disease, and this instrument may have clinical and research applications.
To determine whether bowel symptoms covary in a pattern consistent with the existence of irritable bowel as a distinct syndrome, bowel symptom questionnaires from 2 independent samples were factor analyzed. Samples consisted of 351 18-40-yr-old women who visited Planned Parenthood clinics for contraception and 149 18-89-yr-old women recruited through church women's societies. Factor analysis of 23 bowel symptoms identified 4 factors (clusters of symptoms that were correlated with each other) in both samples. The factor accounting for the most variance in both samples included relief of pain with defecation, looser stools with pain onset, more frequent stools with pain, and gastrointestinal reactions to eating. This irritable bowel factor was not correlated with an objective measure of lactose intolerance. An independent constipation factor was found in both samples to include self-reported constipation, straining with bowel movements, feeling of incomplete evacuation, and rectal bleeding. Thus factor analysis of bowel symptoms supports the existence of a specific irritable bowel syndrome and suggests symptoms that may be used to diagnose this syndrome.
Many women report that bowel symptoms are associated with menstruation, but neither the prevalence of these complaints nor their physiological basis is known. This study aimed to estimate prevalence, to determine whether patients with irritable bowel syndrome are more likely to make such complaints, and to determine whether bowel complaints during menstruation are attributable to psychological traits such as increased somatization. To estimate prevalence, 369 clients of Planned Parenthood of Maryland were asked whether gas, diarrhea, or constipation occurred during menstruation. These subjects were compared with women referred to a gastroenterology clinic and found to have irritable bowel syndrome or functional bowel disorder (abdominal pain plus altered bowel habits but not satisfying restrictive criteria for irritable bowel syndrome). Thirty-four percent of 233 Planned Parenthood clients who denied symptoms of irritable bowel syndrome or functional bowel disorder reported that menstruation was associated with one or more bowel symptoms. Gastroenterology clinic patients with irritable bowel syndrome were significantly more likely to experience exacerbations of each of these bowel symptoms, but especially increased bowel gas. Self-reports of bowel symptoms during menstruation were not associated with psychological traits or with menses-related changes in affect.
Although functional gastrointestinal symptoms are seen frequently by internists and are the commonest reason for patients to be referred to gastroenterologists, no validated self-report questionnaire is available for their diagnosis. To differentiate among non-ulcer dyspepsia, the irritable bowel syndrome, organic gastrointestinal disease, and health, we developed a self-report questionnaire. Our bowel disease questionnaire, which evaluated 46 symptom-related items was completed prospectively by 361 subjects before their clinical evaluation as outpatients. Of these subjects, 115 were categorized ultimately as having functional bowel disease (non-ulcer dyspepsia or the irritable bowel syndrome), 101 were categorized ultimately as having organic gastrointestinal disease, and 145 were healthy persons having routine periodic examinations for whom no additional diagnoses were made. All diagnoses were based on independent clinical evaluations, not on the patients' responses to the questionnaire. The bowel disease questionnaire was acceptable and easily completed; it elicited symptoms in a highly reliable manner and was shown to be a valid measure of functional bowel complaints. Our questionnaire discriminated non-ulcer dyspepsia from irritable bowel syndrome with a sensitivity of 75% and a specificity of 72%, and it discriminated functional bowel disease from organic disease and health with sensitivities of 85% and 83%, and specificities of 60% and 76%, respectively. We believe that this questionnaire is an additional and useful diagnostic tool for identifying patients with functional gastrointestinal symptoms.
Gastrointestinal (GI) functional indicators and symptoms across the menstrual cycle were examined in three groups of women: dysmenorrheic (n = 15), non-pill-taking nondysmenorrheic (n = 10), and nondysmenorrheic taking birth control pills (BCPs) (n = 9). Group assignment was based on the reported presence or absence of moderate to severe menstrual cramps in a GI Health Diary which subjects kept for two menstrual cycles. Stool consistencies and frequencies and GI symptoms were also recorded in this diary. Menstrual cycle phase significantly, p = .03, influenced stool consistencies for the sample as a whole with the loosest stools at menses. Reports of stomach pain were higher, p less than .001, at menses than at other cycle phases in all groups, and nausea, p less than .001, and decreased food intake, p less than .01, were more frequently reported by dysmenorrheic women at menses. More dysmenorrheic women had a history of menses-related GI symptoms. Both cycle phase and group differences were significant, p less than .05, for menstrual distress, with negative affect, pain, behavior changes, and autonomic reactions reported more frequently at menses by dysmenorrheic women.
Women with symptoms indicative of irritable bowel syndrome who had not consulted a physician were compared with female patients at a gastroenterology clinic to investigate whether self-selection for treatment accounts for psychologic abnormalities in clinic patients' with irritable bowel syndrome. Two sets of diagnostic criteria were compared: restrictive criteria based on the work of Manning and conventional criteria (abdominal pain plus altered bowel habits). Lactose malabsorbers were included as a control group because they have medically explained bowel symptoms similar to those that define irritable bowel syndrome. Thus they control for the causative effects of chronic bowel symptoms on psychologic distress. Women who met restrictive criteria for irritable bowel syndrome but had not consulted a physician had no more symptoms of psychologic distress on the Hopkins Symptom Checklist than asymptomatic controls. However, medical clinic patients with both irritable bowel syndrome and lactose malabsorption had significantly more psychologic symptoms than asymptomatic controls or nonconsulters with the same diagnoses. Individuals who met only the conventional criteria for irritable bowel syndrome reported more psychologic distress than controls, whether or not they consulted a physician. These results suggest that (a) symptoms of psychologic distress are unrelated to irritable bowel syndrome but influence which patients consult a doctor and (b) conventional diagnostic criteria identify more psychologically distressed individuals than do restrictive criteria.
A significant proportion of the population (14%-22%) appears to have symptoms compatible with the irritable bowel syndrome, yet only a small number seek medical aid. To explore why some people with bowel dysfunction go to the doctor and others do not, we surveyed 566 healthy subjects. Eighty-six (15%) had bowel dysfunction compatible with irritable bowel syndrome, but the majority of those affected (53 subjects or 62%) had never been to a doctor for these complaints. Although those who consulted physicians for bowel symptoms were more likely to report abdominal pain than those who did not, pain was not sufficient to explain doctor visits. Subjects with bowel dysfunction also reported more nongastrointestinal symptoms, and those with bowel dysfunction who visited physicians were more likely to see physicians for their nongastrointestinal symptoms. The reported higher prevalence of psychopathology among the patient population with irritable bowel syndrome may be due to behavioral influences that lead to health care seeking.
Thirty-five patients with irritable bowel syndrome were referred from the gastroenterology service and underwent structured psychiatric interviews to assess the prevalence of psychiatric illness. Thirty-three (94%) of 35 patients were found to have a lifetime prevalence of any Axis I disorder; the predominant diagnoses were mood and anxiety disorders. Theoretical and practical implications of these findings are discussed.
Symptoms of psychologic distress associated with irritable bowel syndrome A patient questionnaire to identify bowel disease
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Whitehead WE, Bosmajian L, Zonderman A, Costa PT Jr, Schuster MM: Symptoms of psychologic distress associated with irritable bowel syndrome. Gastroenterology 95:709-714, 1988 11. Talley NJ, Phillips SF, Melton J 3d, Wiltgen C, Zinsmeister AR: A patient questionnaire to identify bowel disease. Ann Intern Med 111:671-674, 1989
Stool consistency assessmentIn Reducing Diarrhea in Tube-fed Patients
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Diagnostic Interview Schedule
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Stool consistency assessment
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