Personal view: victim blaming as management strategy for the gastroenterologist--a game theoretical approach

BACKGROUND

A multitude of digestive diseases elude simple management strategies. Rather than admit failure of disease management, a gastroenterologist could resort to blaming patients for their own medical conditions. Blaming the patient constitutes an easy exit strategy for otherwise unsolvable disease conditions.

AIM

To shed light on the problem of patient blaming in gastroenterology and provide means for its resolution.

METHODS

The interaction between physician and patient can be formulated in terms of a non-zero-sum game between two adversaries. The outcomes associated with two behavioural strategies available to both adversaries are arranged in a two-by-two game matrix.

RESULTS

Blaming the patient is characterized by the general game pattern of the 'prisoner's dilemma'. If the physician-patient interaction is restricted to one single event, patient blaming represents the management strategy of choice with the highest expected payoff under all foreseeable circumstances. If there is a high probability for repeated physician-patient interactions, however, a physician admitting and a patient accepting the limits of medical performance yield a dominant strategy.

CONCLUSION

Only for single physician-patient encounters does a non-cooperative strategy of blaming one's adversary for a poor medical outcome yield the highest expected outcome. In the long run, the strategy of shifting blame becomes unproductive for both sides alike.

Health problems of victims before and after disaster: a longitudinal study in general practice

BACKGROUND

We aimed to quantify the health problems and to assess the possible risk factors for developing health problems in persons affected by the explosion of a firework depot at Enschede, The Netherlands, on May 13, 2000. The explosion considerably damaged buildings in the local neighbourhood and caused 22 immediate deaths and injuries in over 1000 people.

METHODS

A longitudinal study of (89% of all) victims (n = 9329) and controls (n = 7392) with pre-disaster baseline morbidity for 16 months and post-disaster data for 2.5 years was conducted using the electronic medical records of general practitioners. Symptoms and diagnoses were recorded using the International Classification of Primary Care (ICPC). Prevalence rates for clusters of symptoms were compared between victim and control groups pre- and post-disaster. Risk factors for developing health problems were examined in hierarchical linear models.

RESULTS

Two and a half years post-disaster, the prevalence of psychological problems in victims who had to relocate was about double and in the non-relocated victims one-third more than controls. Victims with pre-disaster psychological problems were at a greater risk for post-disaster psychological problems. Relocated victims showed an excess of medically unexplained physical symptoms (MUPS) especially in a period of increased media attention. Both groups of victims showed some increase of gastrointestinal (GI) morbidity 2.5 years post-disaster compared with their pre-disaster rate, and compared with the control group.

CONCLUSIONS

Two and a half years post-disaster an excess of psychological problems, MUPS, and gastrointestinal morbidity was observed. Pre-disaster psychological problems and inevitable relocation were predictors of more post-disaster psychological problems.

Anxiety, depression and psychotropic medication use in patients with persistent upper and lower gastrointestinal symptoms

BACKGROUND

Limited information is available about anxiety, depression and psychotropic medication use in patients referred for gastrointestinal endoscopy.

AIM

To determine anxiety and depression and its association with endoscopic findings in a representative sample of patients with persistent gastrointestinal symptoms prior to endoscopy.

METHODS

Patients referred to the hospital for endoscopy between February 2002 and February 2004 were asked to score anxiety and depression on the Hospital Anxiety and Depression Scale 2 weeks prior to endoscopy. Information about endoscopic diagnoses was obtained from medical files.

RESULTS

A total of 1298 subjects was studied (600 upper gastrointestinal endoscopies and 698 lower gastrointestinal endoscopies). Patients referred for upper gastrointestinal endoscopy used most psychotropic agents (24%; odds ratio = 3.1; 95% confidence interval = 2.3-4.2), especially patients with an organic abnormality when compared with patients without an organic abnormality (42% versus 8%; odds ratio = 8.6; 95% confidence interval = 5.4-14.0). Patients with colonic polyps were more anxious (odds ratio = 1.7; 95% confidence interval = 1.0-2.9) and depressed (odds ratio = 1.8; 95% confidence interval = 1.1-3.1) than other patients referred for lower gastrointestinal endoscopy.

CONCLUSIONS

There is no difference in anxiety nor depression between patients with and without organic abnormalities at endoscopy. Patients with colonic polyps are more anxious and depressed than other patients referred for lower gastrointestinal endoscopy. Psychotropic medication use is highest among patients with an organic abnormality in the proximal gastrointestinal tract.

Radionuclear transit to assess sites of delay in large bowel transit in children with chronic idiopathic constipation

PURPOSE

Chronic idiopathic constipation (CIC) with soiling in children may result from slow colonic transit (SCT) or anorectal dysfunction and/or psychological problems known as functional fecal retention (FFR). Evidence is accumulating that SCT and FFR need different treatments, but they are poorly distinguished by solid marker studies. The authors used radionuclear transit scintigraphy to categorize children with CIC as having either FFR or SCT.

METHODS

Children (N = 101) with CIC (and soiling) who were referred for further investigation after failure of standard treatments (diet, laxatives) received radiolabeled colloid orally, and scintillation images were collected at 0 to 2, 6, 24, 30 and 48 hours (total radiation dosage = 2 standard x-rays). Radioactivity in 6 regions (precolonic, ascending, transverse, descending, rectosigmoid, and evacuated feces) was measured, and the median position (geometric center) of radioactivity at each time was determined.

RESULTS

In children, meals normally reach the cecum at 6 hours and are evacuated in 30 to 58 hours. Fifty patients had retention of radioactivity in the proximal colon at 48 hours, indicating SCT. Analysis of the images and the geometric center showed that passage through the ascending colon and transverse colon was delayed in SCT. In 24 patients, radioactivity was passed by 30 hours, indicating normal transit or possible FFR. Twenty-two patients had retention in the rectum, indicating definite FFR. Five studies were borderline.

CONCLUSIONS

Radionuclear transit scintigraphy is useful for categorizing patients with CIC as having either FFR or SCT, allowing for different treatments. Radionuclear transit scintigraphy provides more detail and greater sensitivity than solid marker studies in diagnosing CIC. Radionuclear transit scintigraphy showed that half of our patients had SCT.

Fatigue is not a specific symptom in patients with primary biliary cirrhosis

BACKGROUND

Fatigue has been reported to be common in patients with primary biliary cirrhosis (PBC). Limited data exist on comparison with fatigue in the general population and comparison with patients with other chronic gastrointestinal disorders are lacking.

METHOD

We enrolled 96 patients with PBC (87 females); mean age 63 (range 34-65) who completed the Fatigue Impact Scale (FIS). In comparison we included matched controls from the general population, patients with organic (OGD) and functional GI disorders (FGD). Liver function test and the latest liver biopsy were analysed and correlated with fatigue scores.

RESULTS

The mean duration of PBC was 7.4 years, the mean bilirubin 13 micromol/l. Twelve per cent of patients had cirrhosis, 29% were in stage I on Ludwig's histology score and 30% and 29% were in stages II and III, respectively. The PBC patients had a median FIS total score of 29 in comparison with 38 in GP controls (P<0.05). Patients with OGD and FGD had more severe fatigue (FIS total score 67 and 59 (P<0.01 compared with PBC)). Fatigue in the PBC patients did not correlate with liver tests and histology stage.

CONCLUSION

PBC patients had less severe fatigue measured with the FIS than controls from the GP and patients with OGD and FGD. This study also confirms results of other studies showing no correlation with fatigue in PBC and liver disease parameters. These results argues strongly against fatigue as a specific symptom in PBC.

Vulnerability and presenting symptoms in burning mouth syndrome

OBJECTIVES

To investigate if burning mouth syndrome (BMS) patients have differing health perceptions, medication, and life experiences compared with controls and to examine the role of vulnerability factors and differentiate them from the presenting symptomology in patients with BMS.

STUDY DESIGN

A nonprobability convenience sample of patients presenting with BMS and age- and sex-matched controls were recruited from Queen's University, Belfast, King's College London, and Baylor College of Dentistry, Dallas. Participants completed a questionnaire to assess 9 aspects of their medical and social history, including early and past life experiences. The subjects completed the Hospital Anxiety and Depression Scale to assess current distress.

RESULTS

Participants with BMS had significantly higher experiences of adverse early life experiences compared with controls. They had statistically significantly higher mean scores for anxiety and depression compared with controls. A hierarchical multiple logistic regression analysis showed that the characteristics of BMS included cancer phobia, gastro-intestinal problems, and chronic fatigue.

CONCLUSION

BMS is a complex disorder. People who experience adverse life experiences may become vulnerable to developing BMS in later life.

Correlates of depression, including overall and gastrointestinal functional status, among patients with systemic sclerosis

OBJECTIVE

Patients with systemic sclerosis (SSc) may develop psychological problems in addition to physiologic symptoms. We investigated whether demographic and clinical factors are associated with comorbid depression.

METHODS

From a university hospital's rheumatology clinic, 72 SSc patients who completed 3 questionnaires [Center for Epidemiologic Studies Depression (CES-D) scale, an abbreviated version of a functional status instrument, the Scleroderma Health Assessment Questionnaire (SHAQ), and the Gastrointestinal Quality of Life Index (GIQLI)] during an examination were recruited into the study. Correlations among scores on the 3 questionnaires [including upper and lower gastrointestinal (GI) tract subscales of the GIQLI] were calculated, and associations between CES-D scores and a variety of demographic and clinical characteristics were examined using stepwise linear regression.

RESULTS

Higher CES-D scores (i.e., more depression symptoms) were significantly correlated with upper (r = -0.48, p < 0.0001) and lower (r = -0.41, p < 0.001) GI tract dysfunction and worse overall functional status (r = 0.51, p < 0.0001). Stepwise regression indicated that higher levels of depression were independently associated with lower levels of education (p < 0.01), worse upper GI tract functioning (p = 0.019), worse functional status (p = 0.34), current corticosteroid use (p = 0.061), and cardiac involvement (p = 0.086).

CONCLUSION

Decreased functional status and abnormal GI functioning are significantly correlated with depression among patients with SSc. Other demographic and clinical indicators are also associated with depression.

Validation of the translation and cross-cultural adaptation into Finnish of the Abdominal Symptom Questionnaire, the Hospital Anxiety and Depression Scale and the Complaint Score Questionnaire

BACKGROUND

Epidemiological surveys require questionnaires to be validated in the native language of the participants. The aim of this study was to validate the Finnish translations of the Abdominal Symptom Questionnaire (ASQ), the Hospital Anxiety and Depression Scale (HAD) and the Complaint Score Questionnaire (CSQ).

METHODS

A random sample of adults (n = 3000) in a northern Swedish bilingual district was surveyed using a mailed ASQ offered in both SwedIsh and Finnish, and 2122 responded (239 in Finnish). A random subsample of the responders (n = 1001, 123 preferring Finish) was then surveyed once more using the ASQ, the HAD and the CSQ. The first 50 responders of the latter survey were then given the three questionnaires again within two weeks. The Finnish versions had been put through a comprehensive translation procedure

RESULTS

A factor analysis comparison between the responders using either language in the mailed survey gave a comparable factor construction, and this was also comparable with an earlier analysis of the Swedish version. The Finnish responses to the second survey were further evaluated by testing internal consistency reliability, convergent validity towards previously validated relevant instruments (ShortForm-36 and the Gastrointestinal Symptom Rating Scale) and the test/re-test accuracy of the three questionnaires. These were found to be reliable, as was the correlation between the ASQ and the CSQ, for relevant domains.

CONCLUSION

The Finnish translations of the ASQ, HAD and CSQ questionnaires all seem to be robust and usable for population-based surveys among Finnish adults.

Food habits in 10-11-year-old children with functional gastrointestinal disorders

OBJECTIVE

To evaluate the role of food habits and nutrient intake in children with functional gastrointestinal disorders (FGIDs) considering their association with psychosocial factors.

DESIGN

Cross-sectional.

SETTING

A rural town in Mid-Western Finland.

SUBJECTS

After excluding organic gastrointestinal (GI) disorders, a total of 49 children with FGID and 78 control children without GI symptoms from a cohort of 422 children were studied.

METHODS

Food frequency questionnaire, GI-symptoms questionnaire and the Child Behaviour Check List (CBCL) filled in by parents together with their child, and 24-h dietary recall and anthropometric and haematological measurements.

RESULTS

Compared to control children, fewer children with FGID had daily family dinner (77 vs 91%, P = 0.030) and they used less often vegetables (P = 0.023), fruits (P = 0.027) and berries (P = 0.011), but more often ice cream (P = 0.018) and soft drinks (P = 0.027) and had a higher sucrose intake (9 vs 7E%, P = 0.032) and lower lactose intake (27 vs 36 g, P = 0.001). Reported food-related symptoms were more common among FGID group (69 vs 11%), as well as restricted milk use (31 vs 0%). Children with FGID had higher total problem scores in CBCL (P=0.002), and the behavioural/emotional problems associated with occurrence of FGID (OR 1.04, 95% CI 1.07-1.076) as did the sugar intake (OR 1.1, 95% CI 1.004-1.215).

CONCLUSIONS

This population-based study suggests that school-aged children with FGIDs have less-organized food habits and higher milk avoidance, and they display internalizing psychological characteristics.

SPONSORSHIP

Juho Vainio Foundation, Finland; the Alma and K.A. Snellman Foundation, Oulu, and the Pediatric Research Foundation, Finland.

Infant colic and feeding difficulties

AIMS

To examine the relation between colic and feeding difficulties and their impact on parental functioning for a primarily clinic referred sample.

METHODS

Forty three infants (and their mothers) were enrolled between 6 and 8 weeks of age. Infants were divided into two groups, colic (n = 19) and comparison (n = 24), based on a modified Wessel rule of three criteria for colic. Families were assessed at two visits; one occurred in the laboratory and one occurred in a paediatric radiology office. Outcome measures included the clinical assessment of infant oral motor skills, behavioural observation of mother-infant feeding interactions, maternal questionnaires on infant crying, sleeping and feeding behaviours, and the occurrence of gastro-oesophageal reflux (GOR) in the infants using abdominal ultrasound.

RESULTS

Infants in the colic group displayed more difficulties with feeding; including disorganised feeding behaviours, less rhythmic nutritive and non-nutritive sucking, more discomfort following feedings, and lower responsiveness during feeding interactions. Infants in the colic group also had more evidence of GOR based on the number of reflux episodes on abdominal ultrasound as well as maternal report of reflux. Mothers in the colic group reported higher levels of parenting stress.

CONCLUSIONS

Results provide the first systematic evidence of feeding problems in a subgroup of infants with colic. Data also illustrate the impact of these difficulties on parental and infant functioning. The association between feeding difficulties and colic suggests the potential for ongoing regulatory problems in infants presenting with clinically significant colic symptoms.

Personal view: 'don't ask, don't tell'--the undesirable consequences of incidental test results in gastroenterology

A gastroenterologist is frequently approached to perform an endoscopic procedure after an incidental test has resulted in an unexpected positive finding. Should the incidental test result be ignored or automatically followed by an endoscopic procedure? The present analysis strives to characterize the common pattern of such scenarios and resolve their underlying dilemma. A model of game theory is used as a mathematical tool to develop general management strategies. Three clinical scenarios are used as examples to demonstrate this approach. The model is based on how doctors rank the various outcomes with which they are confronted by the incidental test results. The ranks of different outcomes are listed in a decision matrix that is converted into a two-by-two, non-zero, ordinal game. All scenarios of incidental test results emerge as a similar type of game that is best played by both parties adhering to the same set of strategies: 'Don't do the test' and 'don't respond to whatever test result it yields'. These two strategies lead to a Nash equilibrium for a non-zero game, where neither party can improve its payoff any further by choosing a different strategy. Although the equilibrium does not provide the individual players with their best possible payoff, it yields the best overall outcome available to both parties given the economic and medical constraints of the situation.

The symptom experience of hospitalised Chinese children and adolescents and relationship to pre-hospital factors and behaviour problems

PURPOSE

To describe the symptom experience of hospitalised Chinese children and adolescents and examine the relationship of symptoms to pre-hospital factors and child behaviour.

METHODS

Data were collected at two hospital sites in Hong Kong (HK) and at five hospitals in the Chinese Mainland (CM). A total of 307 hospitalised children and adolescents (ages 2-18) and their primary caregiver (e.g., mother, father or grandparent) participated in the study. Children and adolescents completed an age-appropriate symptom diary on one evening and subsequent morning early in their hospital stay. Parents completed the diary for the children less than 6 years of age. Parents also completed an age-appropriate Chinese version of the Child Behaviour Checklist.

RESULTS

Over 50% of the children and adolescents reported some degree of pain, 75% of them reported evening tiredness, and 21% reported gastrointestinal symptoms. The intensity of symptoms varied by age and region and symptoms often co-occurred. Greater symptom burden was predicted by previous surgery, higher level of worst pain prior to hospitalisation, parent report of child behaviour problems, and co-occurrence of other symptoms.

CONCLUSIONS

Hospitalised Chinese children manifest symptoms of pain, tiredness, and gastrointestinal distress that vary based on pre-hospital factors and are associated with child behaviour problems. Further research is needed to identify causes and treatments for children's symptoms.

Molecular basis of functional gastrointestinal disorders

There are a number of abnormalities of gastrointestinal function, including sensory and motor dysfunction, which are believed to play a role in the manifestation of symptoms in patients with functional gastrointestinal disorders (FGID). In addition, there is a remarkable psychiatric comorbidity. Family and twin studies have provided strong evidence for a clustering of FGID in families and an increased concordance in monozygotic compared to dizygotic twins. This points towards the role of one or more hereditary (genetic) factors. Considering these disorders of function and the psychiatric comorbidity, polymorphisms of adrenergic, opioidergic or serotonergic receptors as well as G-protein beta3 (GNB3) subunit gene polymorphisms (C825T) and polymorphisms of 5-HT transporter genes are suitable causes. In addition, mediators or regulators of mucosal inflammation may trigger events that ultimately result in the manifestation of FGID. Thus, relevant polymorphisms of genes with immunmodulating and/or neuromodulating features (OPRM1, IL-4, IL-4R, TNFalpha) may also play a role in the manifestation of FGIDs.

Health-related quality of life of patients with gastrointestinal symptoms

BACKGROUND

Little is known about the variation in health-related quality of life among patients with different presentations of gastrointestinal symptoms.

AIM

To study the association between health-related quality of life and presentations of gastrointestinal symptoms.

METHODS

Health-related quality of life and demographic information was obtained from 873 patients referred to the hospital for endoscopy, using a questionnaire.

RESULTS

A total of 436 patients (50%) reported predominantly upper gastrointestinal symptoms, 344 (39%) predominantly lower symptoms, and 93 (11%) patients reported both upper and lower symptoms. Patients with mild, moderate and severe symptoms, reported mean scores on a 100-point visual analogue scale (95% CI) of 90 (79-100), 75 (64-86) and 64 (53-76), respectively (P < 0.001). Mean visual analogue scale scores (95% CI) almost linearly declined from 81 (77-85) to 49 (46-52) for those with one to those with more than eight symptoms. Patients who reported upper gastrointestinal symptoms and in particular epigastric pain, bloating and vomiting had significantly impaired health status in comparison to patients without these symptoms (P < 0.05).

CONCLUSIONS

Severity of gastrointestinal symptoms is the most important factor in affecting health status, followed by the numbers and type of gastrointestinal symptoms.

Exploring how to tell the truth and preserve hope: can a balance between communication and empathy be calculated?

BACKGROUND & AIMS

When told the harsh truth about severe disease, a patient might despair and lose all hope. Without knowing the truth, however, the patient cannot participate in decision making and adjust life according to his illness. The present study aims to analyze the relationships between hope and truth in the decision on how much information to disclose to a patient with severe gastrointestinal disease.

METHODS

The decision analysis is based on the economic concepts of indifference curves and utility function. An inverse linear relationship exists between hope and truth; as more truth becomes revealed, the amount of hope declines. The utility function and the corresponding indifference curve of hope plotted versus truth describe the patient's personal choices among different combinations of hope and truth. The optimal choice among various combinations of hope and truth corresponds with the point at which the inverse hope-truth line meets the indifference curve.

RESULTS

In situations in which hope drops steeply as more medical facts are being revealed, the utility to the patient is maximized with less truth being told. With a less pronounced truth-related decline in hope, utility is maximized at higher levels of truth, and, occasionally, utility is maximized only after all medical facts have been disclosed. The lesser the impact of truth on hope, the more truth is being tolerated.

CONCLUSIONS

A caring gastroenterologist trying to optimize his/her patient's well-being should try to assess the potential influence of truth on the patient's psyche and dispense it accordingly.

[Chronic abdominal pain--internistic-psychosomatic aspects]

Abdominal pain is considered to be chronic when it persists for at least three months or when a patient experiences such pain for a total of three months during the course of a year. Pathophysiologically, nociceptive/neuropathic functional pain syndrome, mental disorders with the cardinal symptom of chronic pain, and mixed forms can be distinguished. In 50% of the patients, the cause of chronic abdominal pain is a functional gastrointestinal disorder e.g. functional dyspepsia irritable bowel syndrome. On the basis of a structured pain history, a physical examination and a basic "technical" diagnostic program (laboratory investigations, abdominal ultrasonography, Esophagogastroduodenoscopy, colonoscopy), correct assignment to one of the above-mentioned can be achieved in most of the cases.

Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research

BACKGROUND

The literature on patient adherence to treatment includes hundreds of empirical studies. A comprehensive examination of the findings requires the organization and quantification that is possible with meta-analysis.

OBJECTIVES

The goals of this research are retrieval, compilation, and averaging of adherence rates in all published empirical studies from 1948 to 1998; assessment of variation according to sample characteristics, time period of publication, measurement method, disease, and regimen; and examination of the effects on adherence of patient demographic characteristics.

METHODS

We calculated a meta-analysis of 569 studies reporting adherence to medical treatment prescribed by a nonpsychiatrist physician, and 164 studies providing correlations between adherence and patients' age, gender, education, and income/socioeconomic status; group comparison and multiple regression analysis of moderators.

RESULTS

The average nonadherence rate is 24.8%. Controlling for intercorrelations among moderator variables, adherence is significantly higher in more recent and smaller studies and in those involving medication regimens and adult samples. The use of physical tests and self-report have respectively significant and borderline negative effects on the level of adherence, and disease severity and use of the medical record have no significant effects. Adherence is highest in HIV disease, arthritis, gastrointestinal disorders, and cancer, and lowest in pulmonary disease, diabetes, and sleep. Demographic effects on adherence are small and moderated by sample, regimen, and measurement variables.

CONCLUSIONS

This review offers insights into the literature on patient adherence, providing direction for future research. A focus on reliability and validity of adherence measurement and systematic study of substantive and methodologic moderators are recommended for future research on patient adherence.

Illness-related parenting in mothers with functional gastrointestinal symptoms

OBJECTIVE

Social learning has been identified as a factor that increases vulnerability to the development of irritable bowel syndrome (IBS). This study aimed to distinguish between child-mediated and parent-mediated modes of transmission of illness behavior. The reporting of infants' symptoms and treatment seeking for these symptoms, by mothers, was examined over the period during which infants were aged 0 to 18 months. Thus childrens' imitation of excessive maternal illness behavior could be ruled out as a possible cause of differences in treatment seeking.

METHODS

Questionnaire data from the Avon Longitudinal Study of Parents and Children (ALSPAC) were analyzed, comparing illness-related parenting in 73 mothers who reported taking medication for functional bowel symptoms (mostly IBS) with parenting in 154 mothers who reported past or current stomach ulcers (SU).

RESULTS

There were no significant differences between the groups in the reported incidence of infants' symptoms. However, mothers with bowel symptoms had taken their infants to the doctor for a greater number of conditions than mothers reporting SU. This difference was not due to increased treatment seeking for gastrointestinal symptoms.

CONCLUSIONS

Mothers with functional bowel symptoms are more likely to seek treatment when their infants experience symptoms, providing evidence of early social reinforcement of illness behavior. Such reinforcement may increase the child's vulnerability to a range of functional disorders, including IBS.

Alexithymia and psychopathology in patients with psychiatric and functional gastrointestinal disorders

BACKGROUND

Alexithymia and psychopathology may influence the way individuals experience psychological distress and somatic symptoms. This study evaluated patients referred to psychiatric and gastroenterologic outpatient settings in order to investigate the levels of alexithymia and psychopathology, and the possible role of alexithymia in symptom perception and health care utilization. The association between psychiatric disorders and functional gastrointestinal disorders (FGIDs) was also assessed.

METHODS

Psychopathology (by the Revised 90-item Symptom Checklist), alexithymia (by the 20-item Toronto Alexithymia Scale), and gastrointestinal symptoms (by the Gastrointestinal Symptom Rating Scale) were evaluated in 52 psychiatric outpatients and 58 medical outpatients with FGIDs. Two comorbid subgroups of 25 psychiatric patients with FGIDs and 38 FGID patients with psychiatric disorders were formed and compared.

RESULTS

Forty-eight percent of the psychiatric patients had associated FGIDs, and 65.5% of the FGID patients had associated psychiatric disorders. The FGID patients had significantly less psychopathology, but significantly higher alexithymia and more severe gastrointestinal symptoms, than the psychiatric patients. In the comparison of the two subgroups with comorbidity, FGID patients with psychiatric disorders were still more alexithymic and had less psychopathology than psychiatric patients with FGIDs, but gastrointestinal symptoms were not significantly different.

CONCLUSION

Patients with 'functional' gastrointestinal symptoms attending a medical care service are likely to be highly alexithymic, whereas those attending a psychiatric care service are likely to show severe psychopathology. Alexithymia seems to influence the presentation of 'functional' somatic symptoms and the type of health care utilization.

Psychosocial factors are linked to functional gastrointestinal disorders: a population based nested case-control study

BACKGROUND

It is widely accepted based on volunteer studies that levels of psychological distress are similar in those with functional gastrointestinal (GI) disorders and health in the community, while increased psychological distress in outpatients is largely explained by health-care seeking.

AIMS

To determine if psychological distress, life event stress, or social support is associated with functional GI disorders in a population-based study.

METHODS

A nested case-control study was performed by first mailing a self-report bowel disease questionnaire to a random sample of Olmsted County, Minnesota, aged 20-50 yr. All persons who reported symptoms of nonulcer dyspepsia (NUD) or irritable bowel syndrome (IBS) (cases), or an absence of GI symptoms (controls), were invited to complete a series of validated questionnaires designed to measure psychological distress, life event stress, social support, current symptoms, and physician visits.

RESULTS

103 subjects with functional GI disorders and 119 controls participated (85% of eligible). Functional GI disorders were more likely to be reported by those with higher scores on each of the nine SCL-90-R scales used to measure psychological distress (except phobic anxiety), and those with more negative and total life event stress. In a multiple logistic regression model (including age and gender), somatization, interpersonal sensitivity, and total life event stress were independently associated with functional GI disorders. Findings were similar when subjects with the IBS and NUD were analyzed separately compared to controls.

CONCLUSIONS

Contrary to current dogma, psychosocial factors were significantly associated with functional GI disorders in this community sample. This suggests that these factors may be involved in the etiopathogenesis rather than just driving health-care utilization.

Perceptions of physicians and patients with organic and functional gastrointestinal diagnoses

BACKGROUND AND AIMS

We studied patient after-hours telephone calls to gastrointestinal (GI) fellows at a university program to determine requests made, physicians' responses, and perceptions of patients and physicians to these requests.

METHODS

During a 4-month period, 4 GI fellows taking call were asked about reasons for patient-initiated after-hours telephone calls, actions taken, and their perceptions about the nature of the request, the illness impact, and their role in the care administered. Patients were telephoned within 1 week and asked the same questions about their perceptions of the call.

RESULTS

Patients (N = 102) made 103 telephone calls, averaging 8.7 minutes, for symptoms (56%), procedure-related concerns (19%), and medications (18%). Physicians usually referred the patient to the clinic or emergency room (40%) or provided discussion and reassurance (36%). Patients' perceptions differed from physicians' perceptions: patients believed their problems to be more severe and more disabling and requests were more reasonable than perceived by the physician. Furthermore, their interactions with physicians (physician helpfulness, satisfaction with the recommendation, and likeability of the physician) were more positive than believed by physicians. Physicians believed phone calls from patients with functional disorders were less serious and less reasonable, that these patients were less disabled, and also that these patients were less liked than patients with an organic diagnosis.

CONCLUSIONS

In this study, physicians carried a lower perception of the importance of telephone requests, the impact of the disorder, and their perceived helpfulness to patients than did patients making these requests. Physician perceptions were significantly lower for all these factors for patients with functional GI diagnoses. Additional studies are needed to understand the reasons for differing perceptions between physicians and patients.

Illness perceptions in people with acute bacterial gastro-enteritis

Functional gastro-intestinal disorders (FGID) like irritable bowel syndrome (IBS) are common and can develop after gastro-enteritis. Illness representations may be important influences on the development of post-infectious FGIDs. Here, we studied both the relationship between prior chronic symptoms (FGIDs) and illness perception during an acute illness (bacterial gastro-enteritis) as well as the relationship between illness perception during an acute illness (bacterial gastro-enteritis) and the subsequent development of chronic abdominal symptoms. Two hundred and seventeen people with recent gastro-enteritis completed a questionnaire asking about gut symptoms consistent with a diagnosis of IBS, functional dyspepsia or functional diarrhoea and the Illness Perception Questionnaire. Those without a prior FGID were followed up and completed a similar gut questionnaire at six months. People with a prior FGID had significantly more symptoms and scored significantly higher on the timeline and consequence scores than those without. People who developed a FGID had a non-significantly higher number of symptoms and higher consequence and timeline scores than those who did not. Neither comparative group differed in the control/cure scores or causation scores. The implications of the findings are discussed.