Psychosocial factors in gastrointestinal illness

Gastrointestinal (GI) illnesses represent a paradigm of psychosomatic medicine. Nearly half of patients seen in GI practice present with functional illnesses, and patients commonly complain of symptoms that have coexisting organic and functional etiologies. This chapter addresses the connected nature of psychosocial factors and GI function, disease and outcome in the context of the biopsychosocial model, which allows illness to be examined from the encompassing perspective of interacting system, from the cellular to the environmental. This perspective also helps explain why biologic events such as oncogene alteration can produce heterogeneous clinical and biological responses. Links between gut and brain, involving neuroendocrine associations of the enteric nervous system and its connections with the spinal, autonomic and central nervous systems, are well documented. Neural connections allow information to affect GI secretion and motility. Disturbances in one component of the system can lead to brain-gut effects, such as dysmotility and mood disturbance. Appropriate diagnosis and treatment require clear understanding of biologic, psychologic, and social contributory events. In chronic unexplained GI illnesses, the appropriate clinical approach may be to suspend the search for structural disease, and work instead to assess and treat the physical symptoms and psychosocial problems at hand.

The outcome of unexplained dyspepsia. A questionnaire follow-up study of patients after endoscopy

Ninety-three consecutive patients referred to a gastroenterology unit with unexplained dyspeptic symptoms were sent a postal questionnaire 6-12 months after endoscopy. It inquired into their current physical symptoms and subjective improvement since investigation, satisfaction with treatment, past history and current psychological well-being. A comparison group of 47 patients with peptic disease were similarly surveyed. Those with unexplained dyspepsia reported more current physical symptoms, more dissatisfaction with their treatment and less subjective improvement than those with peptic disease. The two groups were similar in terms of psychological distress but previous consultation for abdominal and other somatic complaints were more common in those with unexplained dyspepsia. The implications for management of dyspeptic patients are discussed.

[Functional stomach and intestinal complaints in young adults: incidence, follow-up, personality and psychosocial factors]

The prevalence rates and the course of functional gastrointestinal disorders in addition to psychopathology and psychosocial factors which are assumed to be associated with functional disorders were longitudinally investigated in an epidemiological cohort study of young adults aged 21-30 from the Canton of Zurich (Switzerland), by means of four interviews. Case definition was based on operational criteria concerning frequency and duration of symptoms reported by the subjects. One-year prevalence rates of (functional) stomach complaints and intestinal complaints were found to vary between 8.7 and 12.7 percent, and 9.1 and 11.1 percent, respectively, depending an the year of the interview. Subjects with stomach complaints scored higher on depression, anxiety and hostility (Hopkins Symptom Check List, Freiburger Persönlichkeitsinventar) then the controls. These associations were less strong among subjects with intestinal complaints. In addition, both complaints were found to be associated with scores on a life events measure, with distress from the social network, and with lack of social support.

A study of psychosocial factors in the psychosomatic symptoms of adolescents in Okinawa

High school students (N = 902) in Okinawa were asked to participate in a questionnaire survey which was designed to investigate the psychosocial factors in the psychosomatic symptoms of adolescents. The questionnaire focused on mental distress, perception of school and home environment and psychosomatic symptoms. The Japanese Edition Cornell Medical Index-Health Questionnaire (JCMI) for evaluating emotional instability and the New TK Diagnostic Test for Parent-Child Relationship were also utilized. Distress in relationships with family or friends, finding little pleasure in school and/or home, showing emotional instability as diagnosed according to regions III and IV of JCMI, or showing strained parent-child relationships according to the TK Test items were found to be closely associated with psychosomatic symptoms. In addition, students with human relations problems, especially family problems, tended to have a strained relationship with parents and tended to show autonomic hyperactivity represented by orthostatic dysregulation. Students with peer problems tended to have emotional instability and to find little pleasure in school; they had mental as well as urinary and bowel symptoms. The findings of this study suggest that distresses in family or peer relationships, emotional instability and a strained parent-child relationship are important factors in the onset of psychosomatic symptoms in adolescents.

Comorbidity of gastrointestinal complaints, depression, and anxiety in the Epidemiologic Catchment Area (ECA) Study

The purpose of this investigation is to determine if the high prevalence rates of major depression, panic disorder, and agoraphobia found in tertiary-care studies of irritable bowel syndrome and medically unexplained gastrointestinal symptoms are also found in the general population. Structured psychiatric interviews on 18,571 subjects from the NIMH Epidemiologic Catchment Area (ECA) Study were reviewed for prevalence of gastrointestinal distress symptoms and selected psychiatric disorders. Medically unexplained gastrointestinal symptoms had a high prevalence in the general population (6-25%). When compared with those reporting no gastrointestinal symptoms, subjects who report at least one of these symptoms were significantly more likely to have also experienced lifetime episodes of major depression (7.5% vs 2.9%), panic disorder (2.5% vs 0.7%), or agoraphobia (10.0% vs 3.6%). Subjects with two gastrointestinal symptoms had even higher lifetime rates of depression (13.4%), panic (5.2%), or agoraphobia (17.8%). Lifetime rates of affective and anxiety disorders in the general population are higher in subjects with gastrointestinal symptoms compared with subjects without gastrointestinal symptoms. An even higher prevalence of affective and anxiety disorders is found in patients with medically unexplained gastrointestinal symptoms in tertiary-care clinics. Future studies are needed in primary-care populations where prevalence rates of psychiatric illness are probably intermediate between those of the general population and tertiary care.

Behavioral medicine approaches to gastrointestinal disorders

Behavioral research in gastroenterology has grown exponentially over the last decade. Controlled studies demonstrate that psychotherapy, stress management, and hypnosis are effective for irritable bowel syndrome; and behavioral treatments are preferred over medical management for some types of fecal incontinence and vomiting. For peptic ulcer disease, interest in behavioral treatments has declined. However, a new syndrome, functional dyspepsia, is now recognized, in which ulcerlike symptoms occur without ulcer and frequently in association with psychological symptoms. For inflammatory bowel disease, stress management training has produced inconsistent outcomes. Newly recognized disorders for which behavioral treatments are needed include constipation associated with inability to relax the pelvic floor muscles during defecation, functional rectal pain (proctalgia), noncardiac chest pain, and aerophagia (excessive air swallowing).

[Behavior therapy in gastrointestinal functional disorders]

Almost all functions of the gastrointestinal tract have been shown to be under central nervous control and to respond to environmental factors such as stress. It is, therefore, not surprising that disturbed gastrointestinal functions may be altered through psychological therapy approaches. For motor dysfunctions of the esophagus and functional dyspepsia, there is a lack of behavioral therapy studies, while controlled studies utilizing relaxation techniques, stress management strategies and anxiety treatment have been shown to improve symptoms and prevent recurrence in reflux esophagitis and peptic ulcer disease despite the wide use of effective medication. Most studies have treated patients with symptoms of the irritable bowel syndrome: This approach usually combined conventional medical treatment with psychotherapy. Psychological management usually consisted of relaxation training, stress management and patient information. Additional behavioral modification, e.g. of eating and defecation behavior, is superior to pharmacological and dietary management alone. The role of biofeedback therapy in these patients remains to be clarified in the future. It is, however, therapy of choice in some patients with constipation due to spastic pelvic floor syndrome and in fecal incontinence, if the external anal sphincter is insufficient to maintain continence. There ist a systematic lack of treatment opportunities as compared to the number of patients seeking health care for functional bowel disorders.

Office management of the infant with colic

Coping with a colicky infant can be stressful for parents. Proper office management can reduce parental stress and help parents handle the prolonged crying periods. This article assists the practitioner to better define colic and the current "cures" for excessive crying. Office management is reviewed, focusing on calming techniques and psychosocial support for parents and family. A case study is reviewed, and the use of appropriate referrals is discussed.

[Psyche and gastrointestinal diseases: hypotheses and facts]

The notion that the development of certain gastrointestinal disorders and diseases can, at least in part, be ascribed to specific psychological characteristics of the patient, to an antecedent psychologically important event or to an unconscious conflict, is very popular both in the public and the medical profession. One of its earliest formulations was the conversion theory forwarded by Sigmund Freud, who assumed that the accumulation of a traumatic and unabreacted quota of affect induced defense or repression and caused a somatic conversion of emotion, i.e., a transformation into bodily symptoms. Subsequently, disorders such as globus sensation, diffuse oesophageal spasms and achalasia, the latter misconceived as "cardiospasm", were viewed as conversion symptoms. However, it has become clear that these disorders are the consequence of organic lesions and not of conversion. Similarly, concepts of an aetiological role of a specific psychological factor, a specific conflict, of certain affective states or live events and of "inappropriate perpetuations of organ reactions adaptive to, or protective against, some stress in human life" could not be verified. Although psychological characteristics and states have been shown to affect normal gastrointestinal function, there is no evidence to suggest that such influences can lead to gastrointestinal disorders or diseases. The fact that the validity of the concepts claiming such aetiological relationships remained to be tested has been repressed to such an extent in some quarters that these concepts still are advocated so as if they had been proven since long.

An epidemiological description of a folk illness: a study of empacho in Guatemala

Although anthropologists have provided descriptions of many folk illnesses, few have systematically evaluated their prevalence and determined who is at greatest risk for acquiring them. This report attempts to provide a systematic description of the folk illness empacho including the symptoms that define it. Illness prevalence was estimated and subpopulations at greatest risk were identified from illness histories collected from a random sample of households in rural Guatemala. Empacho was found to constitute a distinct cluster of symptoms: diarrhea, vomiting, headache, and lack of appetite. It differed from other gastrointestinal illnesses in that headaches were more likely and stomachaches were less likely to be reported. Empacho was highly prevalent and occurred in adults and children. Further, results showed that although empacho was frequently diagnosed by residents, folk healers were rarely consulted for any illness. Nevertheless, a strong association exists between a household diagnosis of empacho and the use of folk healers by those households (p less than .001).

Gastrin, somatostatin and oxytocin levels in patients with functional disorders of the gastrointestinal tract and their response to feeding and interaction

Twenty-four individuals with functional disorders of the gastrointestinal tract participated in the study. Symptoms from the upper and lower gastrointestinal tract were recorded by means of a self-administered questionnaire before, 3 months and 3 yr after participation in group therapy. Blood was sampled from the patients while they were subjected to three different provocations (a friendly greeting, a food stimulus and a stress stimulus). Ten subjects without gastrointestinal symptoms participated in an identical experiment. Gastrin, somatostatin and oxytocin levels were measured with radioimmunoassay. Both gastrin and somatostatin levels were influenced by the provocations and by the greeting and the stress stimulus in particular. In principle, the controls tended to react with a parasympathetic response pattern following the interactive stimuli, whereas the individuals with functional disorders of the gastrointestinal tract reacted with an activation of the sympathetic nervous system. Somatostatin levels were significantly higher and oxytocin levels lower in patients than in controls and gastrin levels tended to be higher in patients than in controls. Most individuals reported both gastric as well as intestinal symptoms. Gastrin levels correlated positively with total symptom level and somatostatin levels with intestinal symptoms scores reported by the patients.

Personality traits in a group of individuals with functional disorders of the gastrointestinal tract and their correlation with gastrin, somatostatin and oxytocin levels

The Karolinska Scales of Personality (KSP) and some dimensions of the Bergman scale reflecting social dependency and self-confidence were used in 24 individuals with functional disorders of the gastrointestinal tract. Patients showed higher scores of somatic anxiety, indirect aggression and irritability and lower scores in socialization when compared with a reference group. The levels of gastrointestinal symptoms as well as the levels of some hormones related to vagal nerve activity in this patient group have been reported in a previous publication. When the scores obtained in personality inventories were related to symptom levels, we found significant correlations with intestinal but not abdominal symptoms. Gastrin levels correlated inversely with socialization. Somatostatin levels on the other hand, correlated negatively with social dependency and positively with self-confidence in the Bergman scale. Interestingly, oxytocin levels correlated positively with social dependency and in addition with indirect aggression and verbal aggression. The correlation between hormone levels and scores of personality dimensions will be interpreted and discussed within a physiological context.

Functional disorders of the stomach

Gastroenterologists frequently encounter patients who report vague epigastric discomforts or sensations of fullness, bloating, and distention in the upper abdomen. The discomfort is neither burning in character nor severe in intensity; there is no nocturnal pain. The epigastric location of discomfort and lack of radiation may help to exclude biliary tract and pancreatic diseases. Nausea may be present, but there is little or no vomiting. After these patients ingest liquids or solid foods, the symptoms of easy filling or early satiety and increasing discomfort and nausea are almost always present. The patient may only report "indigestion," but a specific chief complaint, such as pain, discomfort, nausea, or bloating may be elicited with further inquiries. Solid foods usually provoke more symptoms than do liquids. Symptoms of early satiety, nausea, bloating, and abdominal discomfort may culminate in the vomiting of undigested food. These vague upper gastrointestinal (GI) symptoms have been termed "dyspepsia." When peptic diseases of the stomach are excluded, the symptom complex has been called "nonulcer" dyspepsia, a vague syndrome with symptoms attributed to stomach dysfunction. Nonulcer dyspepsia has been reviewed recently. Such symptoms, commonly attributed to a "functional" disorder, are very common in clinical practice, with an incidence of 30% of patients. In this review, we will discuss an approach to the evaluation and treatment of patients with symptoms of nausea, early satiety, bloating, and vague epigastric discomfort--dyspeptic symptoms associated with functional stomach disorders. We will review the anatomy and motility of the stomach and suggest potential neuromuscular malfunctions of the stomach that may result in epigastric symptoms. The potential role of stress and other brain-gut interactions, which may underlie these symptoms, will also be reviewed.

The case-control study in psychiatry

Case-control studies involve 'cases' being compared to 'controls' with respect to 'exposures', possible aetiological (or associated) factors. Associations between a disease and an exposure can be explained by chance, reverse causality, confounding and biases or, lastly, by causality. However, confounders as well as information and selection biases can be adjusted for at the design (or analysis) stage of the study. The strength of an association can be measured by means of relative risk, calculated indirectly using the odds ratio. Well conducted control studies should produce accurate estimates of relative risks in many psychiatric investigations.

Relation among personality and symptoms in nonulcer dyspepsia and the irritable bowel syndrome

The importance of personality traits in nonulcer dyspepsia and irritable bowel syndrome is a controversial issue. We wished to assess the distribution of abnormal personality traits in nonulcer dyspepsia and the irritable bowel syndrome, define any relation among personality and symptoms, and determine whether personality factors discriminate among patients with functional, psychiatric, or organic gastrointestinal diseases. Patients with nonulcer dyspepsia (n = 31), irritable bowel syndrome (n = 67), organic gastrointestinal disease (n = 64), somatoform disorder (n = 36) and healthy controls (n = 128) were studied. Before diagnostic evaluation by an independent physician, all patients completed the Minnesota Multiphasic Personality Inventory and a symptom questionnaire. Symptom scores for abdominal pain and the Manning criteria, which is considered to be diagnostic for the irritable bowel syndrome, were evaluated. Personality scales in patients with nonulcer dyspepsia, irritable bowel syndrome, and organic disease were very similar. However, patients in the other groups differed from somatoform disorder on nearly all scales. In nonulcer dyspepsia, irritable bowel syndrome, and organic disease, hypochondriasis weakly correlated with pain. Subgroups of irritable bowel syndrome patients with predominant constipation and those with predominant diarrhea had similar personality traits, although hypomania was minimally increased in constipation. Patients who fulfilled the Manning criteria for irritable bowel syndrome had more psychological distress than those who did not. The Minnesota Multiphasic Personality Inventory correctly classified somatoform disorder and health 81% and 75% of the time, respectively, but it classified nonulcer dyspepsia and irritable bowel syndrome correctly in only 32% and 34% of cases. Our results suggest that psychopathology may not be the major explanation for functional gastrointestinal disorders.

Use of alternative medicine by patients attending a gastroenterology clinic

We carried out a study to determine the proportion of patients attending a university-based gastroenterology outpatient clinic who sought alternative medical care for the same health problem that had prompted them to see a gastroenterologist. After the patients completed a self-administered questionnaire, the gastroenterologist gave a diagnosis and assigned a functional rating. Of the 395 patients 287 (73%) had not used alternative medicine, and 36 (9%) had sought alternative medical care for the problem that had prompted them to see a gastroenterologist. There were no significant differences between alternative medicine users and nonusers in sociodemographic characteristics, use of health care services or general health status. Patients with a functional disease were more likely to seek alternative medical care than those with organic disease (33% v. 7%) (p less than 0.0001). Fewer alternative medicine users (54%) than nonusers (85%) were satisfied with conventional medicine (p less than 0.001), and more alternative medicine users (49%) than nonusers (13%) were very sceptical of conventional medicine (p less than 0.0001).

Psychologic factors in diagnosis, prognosis, and treatment of functional abdominal complaints

Functional abdominal complaints are frequently a reason to refer a patient to an outpatients' clinic for internal medicine. According to general views, certain psychologic and anamnestic data can constitute an indication for the diagnosis 'functional'. However, in our experience patients with functional complaints cannot be distinguished from patients with organic disease on such data. These same anamnestic and psychologic data, however, do have value in predicting the outcome of the complaints. Apparently, psychologic factors play a role in the course of functional abdominal complaints. Therefore, we tested the hypothesis that prognosis of functional abdominal complaints can be improved by psychologic intervention, and we offered our patients such a psychologic intervention in the form of a cognitive-behavioural group treatment. The first, encouraging, results are presented.

Role of psychological factors in the irritable bowel syndrome

Our study was designed to test the hypothesis that psychoneurosis in irritable bowel syndrome (IBS) may be the secondary effects of the unsatisfactory nature of the medical transactions (diagnosis, explanation, prognosis, and therapy) in IBS rather than a primary cause of the syndrome. We carried out psychometric assessments on three groups of subjects: 10 healthy volunteers, 12 patients diagnosed as suffering from benign gastrointestinal disease, and 18 patients with IBS. We found a significantly raised incidence of psychoneurosis in IBS, but the components of this were predominantly anxiety and obsession; the incidence of depression in all 3 groups was similar. We argue that the data support our hypothesis that the psychoneurotic manifestations are secondary components of IBS; the data do not support the hypothesis that IBS is a manifestation of depression.

Searching for projection in the Rorschach

The issue of assumptions concerning projection and the Rorschach is discussed in relation to the Rorschach response process and the process of projection. Some data suggest that some minus answers may evolve because of projection, but the limited nature of the findings indicate that these types of projected answers will be difficult to identify in most cases. Findings concerning passive and aggressive movement responses, morbid content responses, and movement answers, coded using a new special score for positive cooperative interaction (COP) in human and animal movement responses, suggest that most projections will manifest in responses that depart from and/or embellish the stimulus field. Caution is recommended about attempting to interpret single answers tht appear to be projections, because most any might be the product of simple stimulus classification.

Colic--a pain syndrome of infancy?

A review of colic research supports the theory that colic may be caused by pain, particularly pain generated by gastrointestinal causes. At the same time, it also supports the view that disturbing crying in the first 3 months of life may be secondary to behavioral-interactive problems or simple parental misinterpretation of cry. In fact, a closer look at the methodology of colic studies along with our preliminary results suggest there may be at least two different patterns of disturbing infant crying. It is possible that one is associated with true pain and the other not. Dependence on retrospective parental reports alone to substantiate the presence of pain is only as reliable as parent interpretation of crying. Although specific cry patterns may represent specific infant conditions, parents may not be accurate interpreters of those patterns. In trying to determine the presence of gastrointestinal pain in colicky crying, close attention therefore should be given to the nature of the cry. Specific attention to qualitative and quantitative aspects of crying in colicky infants is identified as important by our pilot work. In the future this may help to explain the apparent discrepancies in the colic literature and to determine to what extent infant colic is a true pain syndrome.

Gastrointestinal symptoms in diabetic patients: lack of association with neuropathy

Symptoms suggesting gastrointestinal motor dysfunction were determined in 114 diabetic subjects (type 1 and type 2) to see if they were most significantly related to diabetic neuropathy or to psychiatric illness. Presence of neuropathy was established using peripheral nerve conduction studies and objective tests of autonomic function. Affective and anxiety disorders were determined with a structured interview and standard diagnostic criteria. Symptoms were reported by the subsets of subjects with and without neuropathy, ranging in prevalence from 8% to 35%. Log-linear analysis indicated that each group of symptoms (upper gastrointestinal symptoms, altered bowel habits, and abdominal discomforts) was more significantly associated with psychiatric illness (p less than 0.01 for each) than with peripheral neuropathy (p greater than 0.2 for each). In this study, where anxiety and depression were prevalent, no symptom group was significantly associated with autonomic neuropathy once the effects of psychiatric illness on the analysis were taken into account (p greater than 0.2 for each). These findings suggest that gastrointestinal symptoms occurring in diabetic patients are poorly related to neuropathic complications and may often represent gastrointestinal syndromes commonly associated with psychiatric illness.