Subjective theories of illness and clinical and psychological outcomes in patients with irritable bowel syndrome

Characteristics of Walk-In Patients and Related Factors in a Dental University Hospital

This study aimed to identify the characteristics of walk-in patients who visited a dental university hospital more than once (returning patient). The factors affecting walk-in visits were analyzed in relation to demographic, appointment, and treatment characteristics among 146,567 cases treated between 1 March 2019 and 29 February 2020. Multiple logistic regression was used to assess factors influencing walk-in visits. The walk-in rate was 14.1%. The likelihood of walk-in visits was higher in men, patients aged 20–39 years, patients residing in Seoul, and hospital employees or their family members. Walk-in visits were more likely to take place from 8:00 to 9:59 and on Saturdays and Mondays. The walk-in odds ratios differed depending on the treatment department and diagnosis. Return patients had higher odds of walk-in visits for treatments not covered by insurance. The probability of being a walk-in patient was lower among patients who also received treatment in other departments on the same day than among those who did not. These results indicate that each examined factor has a predictable pattern. The findings also suggest a relatively high percentage of walk-in cases in dental university hospitals and that walk-in patients differ in their characteristics from patients with appointments.

A Qualitative Study on the Experiences of Women With Breast Implant Illness

BACKGROUND

Breast implant illness (BII) is a term used to describe physical and psychological symptoms experienced by some women following breast implant surgery. Few studies have examined the experiences of women with BII-a poorly understood condition with no clear cause or treatment.

OBJECTIVES

The aim of this study was to explore women's experiences of BII, including symptoms, healthcare encounters, social media, and explant surgery.

METHODS

Employing an exploratory qualitative methodology, researchers undertook semistructured interviews with 29 women who self-identified as having BII. Interviews were audio-recorded and transcribed verbatim. Data were analyzed by inductive thematic analysis.

RESULTS

Thematic analysis of the interviews identified 6 themes: (1) symptoms without explanation; (2) invalidation and invisibility; (3) making the BII connection; (4) implant toxicity; (5) explant surgery: solution to suffering?; and (6) concealed information. BII was described as distressing and debilitating across multiple domains including relationships, work, identity, and physical and mental health, and symptoms were attributed to implant toxicity and immune system rejection of foreign objects. When their experience was not validated by healthcare professionals, many looked to social media for information, support, and understanding, and saw explant as their only chance of recovery.

CONCLUSIONS

BII is disabling mentally and physically. Women with BII require support, understanding, and validation, and proactive treatment to prevent disability. With unclear pathophysiology, future research should examine how biopsychosocial approaches can be used to guide treatment, and how to best support women with BII, focusing on early detection and evidence-based education and intervention.

LEVEL OF EVIDENCE: 4

Subjective theories of illness in fibroid and endometriosis patients: Similarities, differences, and influencing factors

Introduction:

The aim of this study was to compare the subjective theories of illness in patients with fibroids and patients with endometriosis, and to identify potential factors influencing them.

Methodology:

Participating patients were recruited via three specialized centers for fibroids and endometriosis. To assess their subjective theories concerning the cause of their illness, we used a questionnaire based on the revised Illness Perceptions Questionnaire (IPQ-R). We also gathered and evaluated data relating to sociodemographic factors and psychological distress or possible anxieties using the Kessler Psychological Distress Scale (K10) and the Generalised Anxiety Disorder Assessment (GAD-7).

Results:

We were able to analyze data from 201 patients with fibroids and 212 patients with endometriosis. About 94.4% of the patients had one or more subjective theories concerning the cause of their illness. Both groups perceived “stress or worry” to be the most probable cause of their illness. Compared to endometriosis patients, patients with fibroids were more likely to assume “aging” and “heredity” as the cause of their illness. Endometriosis patients, on the other hand, were more likely to choose theories pertaining to the “environmental influences and immune system” category. The patients’ age, formal education, and conspicuous score values in the K10 or GAD-7 questionnaire proved to be important factors influencing their beliefs about the cause of illness.

Conclusion:

Patients perceive stress and psychological strain as possible causes for their illness. It might be beneficial to take this information into account in conversations between doctors and patients and when drawing up psychosomatic-gynecological treatment plans.

Illness perception and health care use in individuals with irritable bowel syndrome: results from an online survey

BACKGROUND

Individual illness perception is known to influence a range of outcome variables. However, little is known regarding illness perception in irritable bowel syndrome (IBS) and its relation to the use of the health care system. This study hypothesised a relationship between illness perception and inappropriate health care use (under-, over- and misuse).

METHODS

An internet-based, cross-sectional study in participants affected by IBS symptoms was carried out (April - October 2019) using open questions as well as validated standardized instruments, e.g. the illness perception questionnaire revised (IPQ-R) and its subscales. Sub-group comparisons were done non-parametrically and effect sizes were reported. Potential predictors of (1) conventional health care utilisation and (2) utilisation of treatment approaches with lacking or weak evidence regarding effectiveness in IBS were examined with logistic regression analyses and reported as odds ratio (OR) and 95% confidence interval.

RESULTS

Data from 513 individuals were available. More than one-third (35.7%) of participants were classified as high utilisers (> 5 doctor visits during the last year). Several indicators of inappropriate health care use were detected, such as a low proportion of state-of-the-art gynaecological evaluation of symptoms (35.0% of women) and a high proportion of individuals taking ineffective and not recommended non-steroidal antirheumatic drugs for IBS (29.4%). A majority (57.7%) used treatment approaches with lacking or weak evidence regarding the effectiveness in IBS (e.g. homeopathy). Being a high utiliser as defined above was predicted by the perceived daily life consequences of IBS (IPQ-R subscale "consequences", OR = 1.189 [1.100-1.284], p ≤ 0.001) and age (OR = 0.980 [0.962-0.998], p = 0.027). The use of treatment approaches with lacking or weak evidence was forecasted by the perceived daily life consequences (OR = 1.155 [1.091-1.223], p ≤ 0.001) and gender (reference category male: OR = 0.537 [0.327-0.881], p = 0.014), however effect sizes were small.

CONCLUSIONS

Daily life consequences, perceived cure and personal control as aspects of individual disease perception seem to be related to individuals' health care use. These aspects should be a standard part of the medical interview and actively explored. To face inappropriate health care use patients and professionals need to be trained. Interdisciplinary collaborative care may contribute to enhanced quality of medical supply in IBS.

Illness and disease: an empirical-ethical viewpoint

Background

The concepts of disease, illness and sickness capture fundamentally different aspects of phenomena related to human ailments and healthcare. The philosophy and theory of medicine are making manifold efforts to capture the essence and normative implications of these concepts. In parallel, socio-empirical studies on patients’ understanding of their situation have yielded a comprehensive body of knowledge regarding subjective perspectives on health-related statuses. Although both scientific fields provide varied valuable insights, they have not been strongly linked to each other. Therefore, the article aims to scrutinise the normative-ethical implications of patient perspectives in building a bridge to the empirical ethics debates.

Main text

Three potential fields of tension between the illness and the disease perspective are presented. Consequently, findings from empirical research examining patient perspectives on illness are displayed and the practical implications and associated ethical issues which arise are discussed. This leads to the conclusion that an explicit and elaborate empirical-ethical methodology is needed to deal appropriately with the complex interaction between patients’ views and the medico-professional view of disease. Kon’s four-stage model of normative-empirical collaboration is then applied against the background of empirical data on patient perceptions. Starting from this exemplary approach, the article suggests employing empirical-ethical frameworks for further research on the conceptual and normative issues, as they help to integrate perspectives from the philosophy of medicine with socio-empirical research.

Conclusion

The combination of theoretical and empirical perspectives suggested contributes to a more nuanced discussion of the normative impact of patients’ actual understanding of illness. Further empirical research in this area would profit from explicitly considering potential ethical issues to avoid naturalistic fallacies or crypto-normative conclusions that may compromise healthcare practice. Vice versa, medico-theoretical debates could be enriched by integrating subjective views of those people who are immediately affected.

Predictors of etiological beliefs about panic disorder and impact of beliefs on treatment outcomes

Little is known about the beliefs people with panic disorder (PD) have about their illness and how these beliefs might influence treatment outcome. This study explored demographic and clinical predictors of etiological beliefs about PD and the impact these beliefs have on treatment response. The sample included 251 outpatients with PD who participated in a randomized placebo-controlled trial of treatments for PD. Regression analyses revealed that sex, duration of PD and family history of psychiatric illnesses predicted biological etiological beliefs, previous history of psychotherapy predicted environmental etiological beliefs, and age, impaired functioning, and measures of "fear of fear" predicted multiple etiological beliefs about PD. Etiological beliefs predicted more severe symptoms at 12 weeks post-treatment, irrespective of the type of treatment received, but had no effect on attrition, treatment adherence or treatment-related adverse effects This study contributes to the sparse literature on etiological beliefs about PD. Results are preliminary and further research is needed to understand more fully the factors that shape etiological beliefs about PD, whether these beliefs change over the course of illness, and the impact etiological beliefs have on treatment outcome.

Desperately seeking a cure: Treatment seeking and appraisal in irritable bowel syndrome

Objectives

Irritable bowel syndrome (IBS) is common and adversely affects patients' quality of life. Multiple potential treatment options exist for patients (and clinicians) to choose from, with limited evidence to inform treatment selection. The aim was to explore how patients with IBS go about seeking and appraising different treatment modalities, with a view to elucidating the psychological processes involved and identifying opportunities to improve clinical practice.

Design

Qualitative study nested within a randomized controlled trial of therapist‐delivered and web‐based cognitive behavioural therapy versus treatment‐as‐usual for IBS.

Methods

A total of 52 people participated in semi‐structured interviews about their prior experiences of treatments for IBS. Transcripts were analysed using inductive thematic analysis.

Results

Key themes (desperation for a cure, disappointment at lack of cure, appraising the effects of diverse treatments, and hope for positive effects) clustered around an overarching theme of being trapped within a vicious cycle of hope and despair on treatment seeking. A desperation and willingness drove interviewees to try any treatment modality available that might potentially offer relief. Coming to accept there is no cure for IBS helped interviewees escape the vicious cycle. Treatments were appraised for their effects on symptoms and quality of life while also considering, but rarely prioritizing, other aspects including convenience of the regimen itself, whether it addressed the perceived root causes of IBS, perceived side‐effects, and cost.

Conclusion

Treatment seeking in IBS can be challenging for patients. Supportive discussions with health care professionals about illness perceptions, treatment beliefs, and goals could improve patients' experiences.

Irritable Bowel Syndrome: Patient-Provider Interaction and Patient Education

The Patient-Provider (P-P) relationship is the foundation of medical practice. The quality of this relationship is essential, particularly for the management of chronic illness such as Irritable Bowel Syndrome (IBS), since it correlates with disease improvement. A significant aspect of fostering the P-P relationship is providing effective patient-centered education about IBS. An effective education empowers the patients to achieve the main therapeutic goals: to reduce symptoms and improve quality of life. Method: A literature search of PubMed was conducted using the terms “Irritable Bowel syndrome”, “Patient Physician Relationship”, “Patient Provider Relationship”, and “Patient Physician interaction”. Preference was given to articles with a clearly defined methodology and those with control groups if applicable/appropriate. This article provides a review of the literature on Patient-Provider interaction and patient education as it relates to IBS and provides practical recommendations on how to optimize this important relationship.

Patients' beliefs about the causes of myomas: a pilot study from a large European city

INTRODUCTION

Patients usually develop subjective concepts about their illness, which then influences their further health behaviors and treatment decisions. This study aimed to evaluate several possible patient beliefs about the causal factors of illness, in a large sample of women seeking treatment for myomas.

METHODS

From November 2011 to October 2013, all patients at a specialized myoma clinic in a large European city were surveyed about their beliefs about the causes of myomas. We used a modified version of the Patient Theory Questionnaire from Zenz et al., which presented 16 of the most common possible beliefs about the causes of myomas, and asked patients to rate them on a five-point scale of likelihood. Retrospectively, statistical analysis was performed on their answers and sociodemographic data.

RESULTS

Data from 482 patients was included (return rate of 91.5%). The most frequent answers for possible causes were "inherited susceptibility for myomas" (67.3%), "reorganization in the body during a particular phase of life" (63.5%), "stress at work or home" (49.3%) and "an in-born tendency to react to emotional agitation with physical disorders" (41.8%). Significant differences were found for the factors of age, immigration background and self-rated knowledge about myomas.

CONCLUSIONS

It is curious that two of the four most common explanations for myomas were stress and somatization, and were endorsed by nearly half of all patients. Physicians seeing women for myomas should consider that many such patients may have further hidden reasons for seeking medical care.

People's beliefs about the meaning of crepitus in patellofemoral pain and the impact of these beliefs on their behaviour: A qualitative study

BACKGROUND

A feature of patellofemoral pain is joint crepitus. Several causes of crepitus have been described, but previous research has focused on the pathological meaning of crepitus. No research has demonstrated a definitive link between noise and pathology and its importance and meaning to patients is unresearched.

OBJECTIVE

To explore the beliefs of patients with non-osteoarthritic patellofemoral pain regarding their crepitus, and how this impacts on their behaviour.

DESIGN

Qualitative design using semi-structured interviews.

METHOD

A general inductive approach was used as this is a previously unresearched topic. Underpinned by the health beliefs model, an interview schedule was used to reflect different elements. Inductive thematic analysis was used to generate themes to represent the dataset. Participants were 11 patients diagnosed with non-osteoarthritic patellofemoral pain, crepitus as one of their symptoms, referred to an outpatient clinic.

RESULTS/FINDINGS

Three key themes emerged all with sub-themes within them. Firstly, belief about the noise had a sub-theme of search for and perceived meaning of noise. Symbolising ageing was another sub-theme whereby participants described feelings of premature ageing. The final sub-theme was emotional response with participants feeling a range of negative emotions. The second theme of the influence of others reveals participants describing two distinctly different relationships, one with friends and family and one with professionals. The final theme was avoiding the noise. A sub-theme of altering movement shows participants describing fear-avoidant behaviour.

CONCLUSION

Crepitus is a poorly understood symptom that creates negative emotions, inaccurate etiological beliefs and ultimately leads to altered behaviour.

Systematic review: knowledge and educational needs of patients with irritable bowel syndrome

Educational programs have been used as a control condition in trials on psychological therapies for irritable bowel syndrome (IBS). An optimal control condition should have all logistic features of the experimental intervention, except the active component, but also have basic therapeutic benefit for the patient. The aim of the present study is to systematically determine patients' educational needs on the basis of the (mis)conceptions that they have of their disease and their reported desire for information to optimize the control intervention in IBS research. A systematic review of studies on the knowledge and educational needs of IBS patients in terms of their condition was performed. Studies published as full text in the English language in peer-reviewed journals and that included adult IBS patients diagnosed according to the Manning or Rome I, II, or III criteria were selected. Eight studies involving 2132 patients were included. When focusing on misconceptions of patients, the most prevalent are that IBS is caused by dietary factors, food allergies and intolerance (37-90%), heredity (52%), or a lack of digestive enzymes (52%); IBS is a form of colitis (43%); and will last a lifetime (31-54%), develop into cancer (15-49%), or worsens with age (48%). Patients are 'unhappy' with their level of knowledge or feel poorly informed (65%). They want information about the diagnostic process, which foods to avoid (63%), causes (62%), coping strategies (59%), new medications (55%), course (52%), and the role of psychological factors (51%). IBS patients do have a large variety of educational needs. Educational programs optimally addressing these needs can be used adequately as a placebo control condition in research on psychological interventions.

Illness perceptions mediate the relationship between bowel symptom severity and health-related quality of life in IBS patients

PURPOSE

Irritable bowel syndrome (IBS) is a functional bowel disorder with a large negative impact on HRQOL. The present study examines whether severity of bowel symptoms is directly related to HRQOL, and/or indirectly, mediated by the patients' illness perceptions.

METHODS

Patients were recruited from an IBS support group (N = 123), and data were collected online. HRQOL was measured with the Quality of Life Measure for Persons with IBS and illness perceptions with the brief Illness Perception Questionnaire. Mediation models were tested using the bootstrapping procedure developed by Hayes.

RESULTS

Irritable bowel syndrome symptom severity is directly related to total HRQOL and its subscales; after entering the mediator variables (i.e. the patients' illness perceptions) into the model, this direct association remained only significant for total HRQOL. The relationship between bowel symptom severity and total HRQOL was partially mediated by illness perceptions, and its relationship with each of the HRQOL subscales was fully mediated by the patients' illness perceptions. Perceived consequences were a mediator of the relationship between bowel symptom severity, total HRQOL as well as its subscales, with the exception of Sexuality.

CONCLUSIONS

Bowel symptom severity not only has a direct relationship with HRQOL, but also an indirect relationship via the patients' cognitive and emotional representations of their illness. In order to better understand this relationship, future research should not only include illness perceptions but also assess cognitive and behavioural coping responses. Clinicians wanting to improve patients' HRQOL should not only focus on the patients' symptoms, but also on their illness beliefs and coping responses.

Cognitive behavioral approach to understanding irritable bowel syndrome

Irritable bowel syndrome (IBS) is considered a biopsychosocial disorder, whose onset and precipitation are a consequence of interaction among multiple factors which include motility disturbances, abnormalities of gastrointestinal sensation, gut inflammation and infection, altered processing of afferent sensory information, psychological distress, and affective disturbances. Several models have been proposed in order to describe and explain IBS, each of them focusing on specific aspects or mechanisms of the disorder. This review attempts to present and discuss different determinants of IBS and its symptoms, from a cognitive behavioral therapy framework, distinguishing between the developmental predispositions and precipitants of the disorder, and its perpetuating cognitive, behavioral, affective and physiological factors. The main focus in understanding IBS will be placed on the numerous psychosocial factors, such as personality traits, early experiences, affective disturbances, altered attention and cognitions, avoidance behavior, stress, coping and social support. In conclusion, a symptom perpetuation model is proposed.

Unclear abdominal discomfort: pivotal role of carbohydrate malabsorption

Background/Aims

Carbohydrate malabsorption is frequent in patients with functional gastrointestinal disorders and in healthy volunteers and can cause gastrointestinal symptoms mimicking irritable bowel syndrome (IBS). The aim of this study was to investigate the prevalence of symptomatic lactose and fructose malabsorption in a large population of patients with IBS-like symptoms based on Rome II criteria.

Methods

Patients with unclear abdominal discomfort (n = 2,390) underwent lactose (50 g) and fructose (50 g) hydrogen (H₂) breath tests and depending on the results further testing with 25 g fructose or 50 g glucose, or upper endoscopy with duodenal biopsies. Additionally, this population was investigated regarding the prevalence of small intestinal bacterial overgrowth (SIBO) based on glucose breath test and celiac disease.

Results

Of the 2,390 patients with IBS-like symptoms, 848 (35%) were symptomatic lactose malabsorbers and 1,531 (64%) symptomatic fructose malabsorbers. A combined symptomatic carbohydrate malabsorption was found in 587 (25%) patients. Severe fructose malabsorbers (pathologic 25 g fructose test) exhaled significantly higher H₂ concentrations in the 50 g test than patients with negative 25 g fructose test (P < 0.001). Out of 460/659 patients with early significant H₂ increase in the lactose and fructose test who underwent a glucose breath test, 88 patients had positive results indicative of SIBO and they were significantly older than patients with negative test result (P < 0.01). Celiac disease was found in 1/161 patients by upper endoscopy.

Conclusions

Carbohydrate malabsorption is a frequent but underestimated condition in patients with IBS-like symptoms although diagnosis can be easily confirmed by H₂ breath testing.

Participants' experiences of being debriefed to placebo allocation in a clinical trial

Participants in placebo-controlled clinical trials give informed consent to be randomized to verum or placebo. However, researchers rarely tell participants which treatment they actually received. We interviewed 4 participants in a trial of acupuncture for irritable bowel syndrome before, during, and after they received a course of placebo treatments over 6 weeks. During the final interview, we informed participants that they had received a course of placebo treatments. We used an idiographic phenomenological approach based on the Sheffield School to describe each participant's experiences of being blinded to and then debriefed to placebo allocation. The participants' experiences of blinding and debriefing were embodied, related to their goals in undertaking the study, and social (e.g., embedded in trusting and valued relationships with acupuncturists). We suggest ways in which debriefing to placebo allocation can be managed sensitively to facilitate positive outcomes for participants.

A comparison of a short nurse-based and a long multidisciplinary version of structured patient education in irritable bowel syndrome

OBJECTIVE

Structured multidisciplinary patient group education has positive effects on symptoms, health-related quality of life, and disease-related knowledge in patients with irritable bowel syndrome (IBS), but few studies comparing different forms of educational interventions are available. Our aim was to compare the effects of long multidisciplinary group education with a short nurse-based group education with regard to symptoms, knowledge, quality of life, and satisfaction with the intervention in IBS patients.

METHODS

Patients with IBS according to the Rome II criteria were randomized to either short nurse-based or a long multidisciplinary-based education. The effects were evaluated by self-administered questionnaires at 3, 6, and 12 months after baseline, and compared between the groups.

RESULTS

No differences in effects were detected in the between-group comparisons at any of the follow-up assessments. However, positive effects on symptoms, knowledge, quality of life, and satisfaction with the intervention were found in both the short and the long version.

CONCLUSION

A short, nurse-based educational intervention seems to be as efficacious as a longer multidisciplinary version. In both groups, positive effects on patients' well-being were found to a similar extent. This is an important finding that, from a cost-effective perspective, could contribute toward an optimized management of patients with IBS.

Chronic psychosocial stress induces reversible mitochondrial damage and corticotropin-releasing factor receptor type-1 upregulation in the rat intestine and IBS-like gut dysfunction

The association between psychological and environmental stress with functional gastrointestinal disorders, especially irritable bowel syndrome (IBS), is well established. However, the underlying pathogenic mechanisms remain unknown. We aimed to probe chronic psychosocial stress as a primary inducer of intestinal dysfunction and investigate corticotropin-releasing factor (CRF) signaling and mitochondrial damage as key contributors to the stress-mediated effects. Wistar-Kyoto rats were submitted to crowding stress (CS; 8 rats/cage) or sham-crowding stress (SC; 2 rats/cage) for up to 15 consecutive days. Hypothalamic-pituitary-adrenal (HPA) axis activity was evaluated. Intestinal tissues were obtained 1h, 1, 7, or 30 days after stress exposure, to assess neutrophil infiltration, epithelial ion transport, mitochondrial function, and CRF receptors expression. Colonic response to CRF (10 μg/kg i.p.) and hyperalgesia were evaluated after ending stress exposure. Chronic psychosocial stress activated HPA axis and induced reversible intestinal mucosal inflammation. Epithelial permeability and conductance were increased in CS rats, effect that lasted for up to 7 days after stress cessation. Visceral hypersensitivity persisted for up to 30 days post stress. Abnormal colonic response to exogenous CRF lasted for up to 7 days after stress. Mitochondrial activity was disturbed throughout the intestine, although mitochondrial response to CRF was preserved. Colonic expression of CRF receptor type-1 was increased in CS rats, and negatively correlated with body weight gain. In conclusion, chronic psychosocial stress triggers reversible inflammation, persistent epithelial dysfunction, and colonic hyperalgesia. These findings support crowding stress as a suitable animal model to unravel the complex pathophysiology underlying to common human intestinal stress-related disorders, such as IBS.

Characteristics of acute pain attacks in patients with irritable bowel syndrome meeting Rome III criteria

OBJECTIVES

An international multicenter, prospective, non-interventional, 2-month study characterized acute pain attacks in patients with irritable bowel syndrome (IBS).

METHODS

Adult patients meeting the Rome III IBS diagnostic criteria with a history of ≥ 3 pain attacks per month participated in a survey that captured daily and episodic information regarding IBS symptoms and pain attacks for 2 months. Acute pain attacks were defined as a sudden onset or increase in the intensity of IBS abdominal pain with a minimum intensity of 4 (0-10 scale).

RESULTS

The majority (84%) of the 158 patients taking the survey were women with a mean age of 41 years and time since IBS diagnosis of 5 years. The median pain attack frequency was 5.4 attacks per month and was significantly higher in the IBS with diarrhea (IBS-D, 6.4 per month) group vs. the IBS with constipation (4.4 per month) and the IBS with mixed pattern (5.5 per month) groups (P=0.019). The median pain attack duration was 2.8 h and the median intensity score was 7. The majority of pain attacks resulted in defecation (78%), and occurred more often in IBS-D patients than in other subgroups. The majority of pain attacks (63%) interfered with work and/or daily activities. Medication to manage pain attacks was used by 44% of patients during 29% of attacks. Although used by less than half of all patients, medication helped 66% of attacks treated.

CONCLUSIONS

The frequency of severe pain attacks was 1.4 per week and the majority affected daily activities. However, most of the pain attacks were untreated in IBS patients. Pain attack management is an unmet need of IBS treatment.