A psychiatric study of patients with diseases of the small intestine

Editorial: Peering through the fog-New tools to assess neurocognitive symptoms in coeliac disease

This article is linked to Knowles et al paper. To view this article, visit https://doi.org/10.1111/apt.17942

Anxiety after coeliac disease diagnosis predicts mucosal healing: a population-based study

BACKGROUND

Coeliac disease has been linked to anxiety and depression. However, their association with mucosal healing is unknown.

AIM

To examine the relationship between anxiety, depression and mucosal healing in coeliac disease.

METHODS

Between 1969 and 2008, we collected data on all small intestinal biopsies with villous atrophy from Sweden's 28 pathology departments. We restricted our cohort to individuals with data on follow-up biopsy (either persistent villous atrophy [n = 3317] or mucosal healing [n = 4331]). Through Cox regression, we estimated hazard ratios (HRs) for anxiety or depression.

RESULTS

During follow-up, 123 (2.8/1000 person-years) individuals with mucosal healing had developed anxiety, compared to 94 (2.1/1000 person-years) with persistent villous atrophy. Mucosal healing was hence associated with a higher risk of future anxiety (HR = 1.49; 95% CI = 1.12-1.96). Similarly, 167 (3.8/1000 person-years) individuals with mucosal healing developed depression, compared to 148 (3.3/1000 person-years) with persistent villous atrophy, corresponding to a HR of 1.25 (95% CI = 0.99-1.59). Mucosal healing was more common in individuals with prior diagnoses of anxiety or depression before follow-up biopsy. Anxiety diagnosed between diagnostic and follow-up biopsy for coeliac disease was associated with an almost nine-fold increased chance of mucosal healing (odds ratio = 8.94; 95%CI = 2.03-39.27).

CONCLUSION

Anxiety and depression are more common in coeliac disease patients with mucosal healing, both before and after follow-up biopsy, an association potentially mediated through more vigilant compliance with a gluten-free diet. This finding raises concern that achieving the goal of mucosal healing may come at a cost of an increased risk of mood disorders.

Gluten related illnesses and severe mental disorders: a comprehensive review

The putative role of gluten in the pathophysiology of severe mental illnesses remains uncertain and there is doubt about the possible benefit of gluten-free diets for individuals affected by psychosis and mood disorders. The objective of this review was to summarize the findings linking gluten related conditions to pathophysiological substrates implicated in schizophrenia and mood disorders and review the evidences of potential benefits of glute-free diets in these populations. A literature search was conducted within PubMed and Scielo databases including references from inception until March 1st 2017. The strategy search was to use the key words "gluten", "celiac disease", "wheat", "bipolar disorder", "mood disorders", "psychosis", "schizophrenia", "depression". In the review about the potential efficacy of gluten-free diets in severe mental illnesses, we included only studies with original data, including cross sectional and longitudinal studies and clinical trials. Book chapters, review articles and meta-analysis and republished data were excluded. Although the current available evidences suggest that people with celiac disease or gluten allergy could have a slightly higher risk of schizophrenia and mood disorders compared to the general population, the literature review reveals significant inaccuracies in the data. There is insufficient evidence to recommend gluten-free diets for populations with psychosis and mood disorders.

Extraintestinal manifestations of celiac disease

Case finding for celiac disease (CD) is becoming increasingly common practice and is conducted in a wide range of clinical situations ranging from the presence of gastrointestinal symptoms to failure to thrive in children, prolonged fatigue, unexpected weight loss and anemia. Case finding is also performed in associated conditions, such as autoimmune thyroid disease, dermatitis herpetiformis and type 1 diabetes, as well as in patients with irritable bowel syndrome, unexplained neuropsychiatric disorders and first-degree relatives of patients with diagnosed CD. This aggressive active case finding has dramatically changed the clinical characteristics of newly diagnosed patients. For instance, higher numbers of patients who present with extraintestinal symptoms are now being diagnosed with CD. Current recommendations state that due to a high risk for complications if the disease remains undiagnosed, patients with extraintestinal symptoms due to CD require appropriate diagnosis and treatment. Despite criticism regarding the cost-effectiveness of case finding in CD, such an aggressive approach has been considered cost-effective for high-risk patients. The diagnosis of CD among patients with extraintestinal symptoms requires a high degree of awareness of the clinical conditions that carry a high risk for underlying CD. Also, understanding the correct use of specific serology and duodenal histology is key for an appropriate diagnostic approach. Both procedures combined are able to confirm diagnosis in the vast majority of cases. However, in certain circumstances, serology and even duodenal histology cannot confirm or rule out CD. A common cause of negative IgA serology is IgA deficiency. For such eventuality, IgG-based serological tests can help confirm the diagnosis. Importantly, some histologically diagnosed cases still remain seronegative despite exclusion of IgA deficiency. On the other hand, duodenal histology may be normal despite the presence of CD-specific antibodies and active CD. This has been clearly demonstrated in some cases of untreated dermatitis herpetiformis, but may also be due to the patchy condition of CD or lesions that are not adequately recognized by nonexpert endoscopists and/or pathologists. The effectiveness of agluten-free diet depends on the clinical end point addressed. A good example is the outcome of bone loss. While risk for fracture normalizes after the first year of dietary treatment, bone parameters measured by densitometry may not be normalized in the long-term follow-up. Moreover, it is still unclear how far an early gluten-free diet will positively affect associated autoimmune diseases like type 1 diabetes and autoimmune thyroiditis.

Celiac and non-celiac gluten sensitivity: a review on the association with schizophrenia and mood disorders

An association between many psychiatric and gluten-related disorders has been known for some time. In the case of schizophrenia and mood disorders, the major psychiatric disorders, there is much evidence, not without contradictions, of a possible association between schizophrenia and celiac disease. The association between mood disorders and gluten-related disorders, especially celiac disease, has only been studied for depression, often coupled with anxiety, and very recently for bipolar disorder. Since non-celiac gluten sensitivity is now known to be different from celiac disease, many studies have shown that gluten sensitivity is also associated with major psychiatric disorders. Here we review the literature on the association between schizophrenia/mood disorders and celiac disease/gluten sensitivity, pointing out the differences between these associations.

Psychological factors and stress in inflammatory bowel disease

The role of psychological distress and personality as predisposing factors for the development of inflammatory bowel disease (IBD) remains controversial. Attempts to investigate the role of psychological factors in IBD exhibited rather conflicting results. Among the studies concerning the effects of stress or depression on the course of IBD, the majority suggest that stress worsened IBD, the rest giving either negative or inconclusive results. However, application of strategies, including avoidance of coping and training patients in problem solving or emotion-oriented, could influence the course of IBD. Large controlled clinical trials are needed in order to clarify the impact of psychological interventions on the quality of life and the course of disease.

Coeliac disease, diet adherence and depressive symptoms

OBJECTIVES

We aimed to investigate whether long-term adherence to a gluten-free diet is related to depressive symptoms in coeliac disease (CD) patients.

METHODS

A cross-sectional survey was performed in 2265 adult CD patients recruited through the Dutch Coeliac Association. Self-reported diet adherence was compared among groups based on self-reported depressive symptoms (categorized into current [1-month], remitted, and never).

RESULTS

The life-time prevalence rate of self-reported depressive symptoms was 39.0% (n=883), of whom 270 (11.9%) suffered from current depressive symptoms. Adherence to gluten-free diet was strict in 50.2% of patients, sufficient in 46.3%, and insufficient in 3.6%. Insufficient adherence was not associated with current depressive symptoms (odds ratio [OR] 0.95; 95% confidence interval [CI]: 0.48-1.92). Keeping a gluten-free diet for longer than five years was associated with lower OR of current depressive symptoms compared to being on a diet for less than two years (OR 0.69; 95% CI: 0.50-0.95).

CONCLUSIONS

Lifetime depressive symptoms may be present in one third of the CD patients who adhere to gluten-free diet. Long-term adherence to the gluten-free diet may reduce the risk of current depressive symptoms.

Meta-analysis on anxiety and depression in adult celiac disease

OBJECTIVE

We used meta-analysis to test hypotheses concerning whether adult celiac disease is reliably linked with anxiety and/or depression.

METHOD

We examined published reports on anxiety and depression in adult celiac disease.

RESULTS

Eighteen studies on depression and eleven studies on anxiety in adult celiac disease met selection criteria. They show that depression is reliably more common and/or more severe in adults with celiac disease than in healthy adults (overall meta-analysis effect size: 0.97). The fail-safe margin of unpublished reports that would be required to negate the finding exceeds 8000. Adults with celiac disease do not, however, differ reliably in terms of depression from adults with other physical illnesses, nor do they differ reliably from healthy adults or adults with other physical illnesses in terms of anxiety.

CONCLUSION

Depression is common in adult celiac disease and resembles the condition in other physical illnesses. We view the findings as support for the notion that non-specific mechanisms mediate emotional disorders in adult celiac disease.

[Psychological support and treatment in inflammatory bowel disease: the physician-patient relationship]

Inflammatory bowel disease (IBD) interferes with the daily activities of affected individuals and impairs their quality of life. The psychological factors related to IBD play an important role since they negatively affect the course of the disease and the patients' general wellbeing. Thus, stress, anxiety and depressed mood are highly frequent in patients with IBD and are associated with an increase in recurrences and symptom severity. Psychological treatments have been shown to improve the course of the disease by decreasing emotional distress. In addition, a good physician-patient relationship favors communication, trust and joint decision making. IBD requires a multidimensional approach in which psychological treatment forms part of the effective management of the disease.

Neurological symptoms in patients with biopsy proven celiac disease

In celiac disease (CD), the gut is the typical manifestation site but atypical neurological presentations are thought to occur in 6 to 10% with cerebellar ataxia being the most frequent symptom. Most studies in this field are focused on patients under primary neurological care. To exclude such an observation bias, patients with biopsy proven celiac disease were screened for neurological disease. A total of 72 patients with biopsy proven celiac disease (CD) (mean age 51 +/- 15 years, mean disease duration 8 +/- 11 years) were recruited through advertisements. All participants adhered to a gluten-free diet. Patients were interviewed following a standard questionnaire and examined clinically for neurological symptoms. Medical history revealed neurological disorders such as migraine (28%), carpal tunnel syndrome (20%), vestibular dysfunction (8%), seizures (6%), and myelitis (3%). Interestingly, 35% of patients with CD reported of a history of psychiatric disease including depression, personality changes, or even psychosis. Physical examination yielded stance and gait problems in about one third of patients that could be attributed to afferent ataxia in 26%, vestibular dysfunction in 6%, and cerebellar ataxia in 6%. Other motor features such as basal ganglia symptoms, pyramidal tract signs, tics, and myoclonus were infrequent. 35% of patients with CD showed deep sensory loss and reduced ankle reflexes in 14%. Gait disturbances in CD do not only result from cerebellar ataxia but also from proprioceptive or vestibular impairment. Neurological problems may even develop despite strict adherence to a gluten-free diet.

Psychoneurotic symptoms and alexithymia in coeliac disease

OBJECTIVE

Depression, psychological problems and the impairment of quality of life are reported to occur in untreated coeliac disease. Alexithymia ("no words for feelings") is associated with various gastrointestinal disorders. The aim of this study was to evaluate whether patients with coeliac disease suffer from psychoneurotic symptoms or alexithymia, and whether a gluten-free diet has an impact on the symptoms.

MATERIAL AND METHODS

The Crown-Crisp Experiential Index (CCEI) and its six subscales were applied to measure neurotic psychopathology, and the 20-item version of the Toronto Alexithymia Scale (TAS-20) and its 3-factor scales to measure alexithymia. The testing was carried out in 20 consecutive adult patients with biopsy-proven coeliac disease before and after one year of treatment on a gluten-free diet. The data were compared with those obtained earlier in non-coeliac Finnish subjects.

RESULTS

Somatic anxiety was higher in coeliac disease patients before the introduction of the gluten-free diet than after adhering to the diet. Otherwise, the diet had no significant impact on the CCEI scores. The patients were not suffering from alexithymia, but the TAS-20 score improved significantly during the follow-up. The scores did not differ from those published in the Finnish population.

CONCLUSIONS

Psychological problems were not common in adult coeliac disease patients. Gluten-free diet had only a minor influence on the symptoms. Common knowledge about coeliac disease and the readily available gluten-free products may have had an impact on these results.

Coeliac disease and risk of mood disorders--a general population-based cohort study

BACKGROUND

Earlier research has indicated a positive association between coeliac disease (CD) and some mental disorders. Studies on CD and depression have inconsistent findings and we know of no study of CD and the risk of bipolar disorder (BD).

METHODS

We used Cox regression to investigate the risk of subsequent mood disorders (MD); depression and BD in 13,776 individuals with CD and 66,815 age- and sex-matched reference individuals in a general population-based cohort study in Sweden. We also studied the association between prior MD and CD through conditional logistic regression.

RESULTS

CD was associated with an increased risk of subsequent depression (Hazard ratio (HR)=1.8; 95% CI=1.6-2.2; p<0.001, based on 181 positive events in individuals with CD and 529 positive events in reference individuals). CD was not associated with subsequent BD (HR=1.1; 95% CI=0.7-1.7; p=0.779, based on 22 and 99 positive events). Individuals with prior depression (OR=2.3; 95% CI=2.0-2.8; p<0.001) or prior BD (OR=1.7; 95% CI=1.2-2.3; p=0.001) were at increased risk of a subsequent diagnosis of CD.

LIMITATIONS

Study participants with CD and MD may have more severe disease than the average patient with these disorders since they were identified through a hospital-based register.

CONCLUSIONS

CD is positively associated with subsequent depression. The risk increase for CD in individuals with prior depression and BD may be due to screening for CD among those with MD.

The gluten connection: the association between schizophrenia and celiac disease

OBJECTIVE

Schizophrenia affects roughly 1% of the population and is considered one of the top 10 causes of disability worldwide. Given the immense cost to society, successful treatment options are imperative. Based on initial findings, gluten withdrawal may serve as a safe and economical alternative for the reduction of symptoms in a subset of patients.

METHOD

A review of the literature relevant to the association between schizophrenia and celiac disease (gluten intolerance) was conducted.

RESULTS

A drastic reduction, if not full remission, of schizophrenic symptoms after initiation of gluten withdrawal has been noted in a variety of studies. However, this occurs only in a subset of schizophrenic patients.

CONCLUSION

Large-scale epidemiological studies and clinical trials are needed to confirm the association between gluten and schizophrenia, and address the underlying mechanisms by which this association occurs.

Neurologic presentation of celiac disease

Celiac disease (CD) long has been associated with neurologic and psychiatric disorders including cerebellar ataxia, peripheral neuropathy, epilepsy, dementia, and depression. Earlier reports mainly have documented the involvement of the nervous system as a complication of prediagnosed CD. However, more recent studies have emphasized that a wider spectrum of neurologic syndromes may be the presenting extraintestinal manifestation of gluten sensitivity with or without intestinal pathology. These include migraine, encephalopathy, chorea, brain stem dysfunction, myelopathy, mononeuritis multiplex, Guillain-Barre-like syndrome, and neuropathy with positive antiganglioside antibodies. The association between most neurologic syndromes described and gluten sensitivity remains to be confirmed by larger epidemiologic studies. It further has been suggested that gluten sensitivity (as evidenced by high antigliadin antibodies) is a common cause of neurologic syndromes (notably cerebellar ataxia) of otherwise unknown cause. Additional studies showed high prevalence of gluten sensitivity in genetic neurodegenerative disorders such as hereditary spinocerebellar ataxia and Huntington's disease. It remains unclear whether gluten sensitivity contributes to the pathogenesis of these disorders or whether it represents an epiphenomenon. Studies of gluten-free diet in patients with gluten sensitivity and neurologic syndromes have shown variable results. Diet trials also have been inconclusive in autism and schizophrenia, 2 diseases in which sensitivity to dietary gluten has been implicated. Further studies clearly are needed to assess the efficacy of gluten-free diet and to address the underlying mechanisms of nervous system pathology in gluten sensitivity.

Depressive symptoms and inflammatory bowel disease in children and adolescents: a cross-sectional study

OBJECTIVES

This study assessed the rates of depressive symptoms in older children and adolescents with inflammatory bowel disease (IBD) and the associations between depressive symptoms and IBD disease characteristics.

METHODS

One hundred and two youths (aged 11-17 years) with IBD seen consecutively in a gastroenterology clinic were screened for depressive symptoms using the Children's Depression Inventory (CDI). Subjects with CDI scores > or = 12 were evaluated for current psychiatric diagnoses using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Disease characteristics examined included IBD type, duration, current severity, course, age at diagnosis and steroid treatment.

RESULTS

Of the total sample, 25 (24.5%) had a CDI score > or = 12, consistent with clinically significant depressive symptoms. Nineteen of 25 qualified subjects participated in the K-SADS-PL semi-structured interview and 16 of 19 met criteria for major or minor depressive disorder. Mean CDI scores positively correlated with age at IBD diagnosis but not with IBD type, duration or course. Youths with moderate/severe current IBD-related symptoms had significantly higher mean CDI scores than those with inactive disease activity. Anhedonia, fatigue and decreased appetite were selectively correlated with IBD disease severity. Subjects on steroids were more likely to have CDI scores > or = 12, and those with such scores were on higher doses of steroids than subjects without clinically significant depressive symptoms (both P values < 0.05).

CONCLUSIONS

These findings support the recommendation that adolescents with IBD in outpatient medical care settings, particularly older adolescents and those on steroids, should be screened for depression.

Mental Disorders in Adolescents With Celiac Disease

A high prevalence of depressive symptoms, hypothetically related to serotonergic dysfunction, has been reported among adults with celiac disease. The authors used semistructured psychiatric interviews and symptom measurement scales to study mental disorders in 29 adolescents with celiac disease and 29 matched comparison subjects. Relative to the comparison subjects, the celiac disease patients had significantly higher lifetime prevalences of major depressive disorder (31% versus 7%) and disruptive behavior disorders (28% versus 3%). In most cases these disorders preceded the diagnosis of celiac disease and its treatment with a gluten-free diet. The prevalence of current mental disorders was similar in both groups. Celiac disease in adolescents is associated with an increased prevalence of depressive and disruptive behavioral disorders, particularly in the phase before diet treatment.

Affective disorders and quality of life in adult coeliac disease patients on a gluten-free diet

BACKGROUND

Psychiatric symptoms, common in untreated coeliac disease patients, may improve after gluten withdrawal.

AIMS

To estimate the incidence of psychiatric disorders in coeliac disease patients on gluten withdrawal and to evaluate: (1) the psychological weight of a chronic disease that involves a restrictive diet and a limited life style; (2) the acceptance of the disease; (3) the effects of both disease and diet on behaviour and quality of life.

PATIENTS AND METHODS

Three groups of 100 patients (coeliac disease patients, diabetic patients and healthy controls, respectively) were assessed by means of a professional semi-structured diagnostic interview based on DSM-IV criteria. This interview, together with specific psychiatric questionnaires, ruled out axis I or II psychopathological disturbances.

RESULTS

The modified Self-rating Depression Scale and State and Trait Anxiety Inventory Y2 scores were significantly higher in both coeliac and diabetic patients than in healthy controls. The duration of gluten restriction was related to significantly higher modified Self-rating Depression Scale scores in patients with a more recent diagnosis. Quality of life was poorer in both coeliac and diabetic patients than in healthy controls and significantly correlated with anxiety. The Illness Behaviour Questionnaire showed a high psychological and somatic perception of illness in both coeliac and diabetic patients. Its subscale scores correlated significantly with anxiety and depression symptoms.

CONCLUSIONS

In coeliac disease, affective disorders should be ascribed to difficulties in adjusting to the chronic nature of the disease rather than directly to the disease itself, thus giving an indication for preventive liaison psychiatric interventions.

Psychological dimensions of celiac disease: toward an integrated approach

Psychic alterations have been reported in celiac disease. Our aim was to evaluate the emotional impact of celiac disease diagnosis in adulthood, the patient/doctor relationship, and the patients' cooperation with disease treatment and diet. The patients were 114 adult celiac patients on a gluten-free diet, there were 25 untreated celiac patients. Self-administered questionnaires aimed to evaluate the patients' level of knowledge of disease, the emotional impact at diagnosis, and feelings during follow-up. Celiac patients showed good knowledge of the disease, directly correlated to their socioeconomic level (P = 0.011). At diagnosis, relief was most intense feeling (Mean +/- SD, 10.82 +/- 7.63), demographics, time latency of diagnosis, and the duration of the disease had no effect on the intensity of all feelings. The scores of the self-rated emotions were entered into a principal component analysis that generated three factors: 1 (fear, anger, anxiety and sadness), 2 (reassurance and resignation), and 3 (relief); patients judged the clinicians presenting the disease "in the right way" (F = 33.279; P < 0.0001). The right way correlated with relief and reassurance (P = 0.0009; P = 0.0008 respectively). At follow-up, anger was the predominant emotion that induced patients to transgress. A positive correlation was observed between feeling different and the sadness, anger, fear (P < 0.0001 for all). Anger was inversely correlated with actual compliance to diet (P = 0.0005). In conclusion, in adult patients, adaptive and psychological aspects must be taken into account to understand the celiac patient and for better clinical management.

Case control study on health-related quality of life in adult coeliac disease

AIMS

To evaluate whether health-related quality of life in adult coeliac disease is related to: 1) adhesion to gluten-free diet; 2) manifestation of clinical features; and 3) associated diseases.

PATIENTS AND METHODS

A total of 68 coeliac patients (54 female and 14 male) aged between 18 and 74 years, on gluten-free diet for at least two years were studied. The subjective health status was measured by means of the Short Form 36 Health Survey. A series of 136 subjects, matched according to sex, age and ethnic group, were evaluated as control group.

RESULTS

Patients obtained worse scores with respect to healthy controls at all domains of Short Form 36 Health Survey (p<0.05); compliers showed better results than non-compliers. The lowest scores were obtained in patients with more than six symptoms, mostly in non-compliers, the highest in compliers with less than six symptoms. Patients with two or more associated diseases presented significantly worse scores than patients with only one associated disease.

CONCLUSIONS

The importance of gluten-free diet in clinical management of coeliac disease is confirmed by results of the present study; moreover, the results seem to indicate that a complex interplay of factors should be taken into account in evaluating health-related quality of life in adult coeliac disease. Accordingly, our data show that health-related quality of life of coeliac patients is impaired not only by poor compliance but also by different negative factors such as severity of illness (in terms of number of symptoms) at diagnosis and comorbidity.

Neurological complications of coeliac disease

A variety of neurological disorders have been reported in association with coeliac disease including epilepsy, ataxia, neuropathy, and myelopathy. The nature of this association is unclear and whether a specific neurological complication occurs in coeliac disease remains unproved. Malabsorption may lead to vitamin and trace element deficiencies. Therefore, patients who develop neurological dysfunction should be carefully screened for these. However, malabsorption does not satisfactorily explain the pathophysiology and clinical course of many of the associated neurological disorders. Other mechanisms proposed include altered autoimmunity, heredity, and gluten toxicity. This review attempts to summarise the literature and suggests directions for future research.

Quality of life of adult coeliac patients treated for 10 years

BACKGROUND

For patients with coeliac disease, adherence to a gluten-free diet (GFD) is essential to restore the intestinal mucosa. It is less clear whether this ensures well-being of the patient. We have therefore assessed aspects of the quality of life of adult coeliac patients who had been on a GFD for 10 years.

METHODS

By means of the Short Form 36 Health Survey (SF-36), the subjective health status was measured in 89 adult coeliac patients (61% women) aged 35-74 years. Patients shown to be in histologic remission (n=60) were evaluated by means of the Gastrointestinal Symptom Rating Scale (GSRS).

RESULTS

The coeliac patients scored significantly lower in the SF-36 than general population, notably within the General Health and Vitality domains. The low scoring was confined to the female patients, who also reported significantly more gastrointestinal symptoms in the GSRS than the male coeliacs. The functional status and perceived health of the coeliac patients appeared unrelated to their biopsy findings.

CONCLUSIONS

After 10 years on a GFD adult coeliac patients fail to attain the same degree of subjective health as the general population. This is particularly true for female patients and suggests that factors beyond normalization of the intestinal mucosa are of importance for the perceived health status of coeliacs diagnosed in adult life.

Epidemiology of inflammatory bowel disease: an update

What have epidemiologic studies on IBD taught so far? Consistent findings are as follows: A high incidence of both CD and UC in industrialized countries and an increase in these areas of the incidence of CD during the years 1960-80 followed by a plateau phase, and a more stable pattern in UC during the same period have been found. A greater number of mild cases have probably been diagnosed recently. This also helps to explain the differences in severity and survival between community and referral centre groups. The male to female ratio is greater than 1 in UC, and this is the opposite in CD. Mortality of IBD has decreased during the past decades. As young people are especially prone to develop IBD, most of those affected will have their disease for many years. In developing IBD, genetic influences are of importance. However, epidemiologic studies strongly point to possible interactions between genetically determined features and environmental or other factors. Of these exogenic factors smoking is the most consistent, being of negative influence in CD and protective in UC. Diet and oral contraceptives may influence disease expression, and perinatal events such as viral infections may alter adult susceptibility. The question remains open whether UC and CD are one diseases entity. Similarities in the epidemiologic features of UC and CD support the idea of IBD being one disease. Other findings suggest dividing UC and CD into further subgroups: in CD it has been suggested that fibrostenotic, penetrating, and inflammatory behaviour should be considered different disease entities; in UC some groups consider ulcerative proctitis a disease entity on its own, separating it from the proximally extending colitis. In therapeutic trials this approach has proved to be of importance, and it is not inconceivable that in subgroups, with regard to aetiopathogenetic mechanisms, different factors have to be looked for.

Long-term monitoring of psychosocial stress and symptomatology in inflammatory bowel disease

Eleven subjects with inflammatory bowel disease (IBD) participated in a longterm self-monitoring investigation of the relationship between psychosocial stress and IBD symptomatology. Two measurement instruments, the IBD Symptom Diary and the Psychosocial Stress Diary, were completed by each subject for 7 consecutive days each month for one year. Pooled time-series analysis of the influence of daily stress on IBD activity revealed a significant effect. A positive concurrent relationship was found between both daily and monthly psychosocial stress and IBD activity. Investigations of temporal relationship among variables revealed a negative effect of previous month stress on IBD. Results suggest a monthly rebound effect whereby IBD symptom severity is negatively responsive to the severity of the previous month stress. The effects of stress upon IBD were not found to be modified by behavioral coping strategies. These results support the prevailing impression that psychosocial stress contributes to the clinical course of IBD, and specifically suggest an influential role of daily and monthly stress. A pattern matching IBD's characteristic waxing and waning clinical course emerges when the association between stress and IBD is examined from a monthly viewpoint. Refinement of our knowledge of the IBD-stress model calls for replication and explanation of the monthly rebound effect as well as investigations into type of stressor and coping strategy that may influence IBD activity.

The prevalence of psychiatric morbidity on a coronary care ward

Numerous studies have documented the high prevalence of psychological and emotional disorders in patients seen in general medical settings. However, despite the emphasis placed on holistic approaches to nursing care in all professional models of nursing practice, much of this distress is still missed by nursing staff. The Hospital Anxiety and Depression (HAD) scale is an easy-to-use self-administered screening instrument purportedly designed to detect psychological distress amongst hospitalized patients with physical illnesses. On using the HAD scale on patients admitted to a coronary care ward of a district general hospital, 44% were found to be suffering high levels of anxiety or depression. This figure is consistent with the results of similar studies in other cardiac wards and out-patient clinics. In most cases, the levels of distress found were not sufficiently severe to warrant seeking specialist psychiatric support. Instead, there is much that the general nurse can do to alleviate the understandable fears and worries of patients being treated for cardiac disease. However, to respond appropriately, nursing staff must be able to identify psychological distress in patients. The HAD scale, if it can be validated in cardiac in-patient settings, provides an instrument which could easily become part of the routine assessment of patients' nursing needs.

The relation between daily stress and Crohn's disease

This study examined the effect of minor daily stressors on the primary indices of Crohn's disease in 10 adult volunteers from a support group for individuals with inflammatory bowel disease. All subjects monitored the occurrence of daily stress concurrently with the signs and symptoms of their disease for 28 days. The results of the regression and between-subject analyses indicate a relation between daily stress and self-rated disease severity in Crohn's disease. The effects of daily stress on signs and symptoms of Crohn's disease were significant even after controlling for the effects of major life events. Individual within-subject correlations, however, indicated that stress and indicators of disease were highly related for only three subjects. The results of the current study therefore suggest that at least for some individuals with Crohn's disease, daily stress is related to self-reported indicators of the illness.

Obsessive-compulsive symptoms in childhood inflammatory bowel disease and cystic fibrosis

The Leyton Obsessional Inventory-Child Version was administered to 33 children with Crohn's disease, 11 with ulcerative colitis, and 46 with cystic fibrosis. Subjects with ulcerative colitis scored significantly higher on total number of obsessional symptoms and degree of resistance to symptoms than subjects with Crohn's disease. Scores of subjects with cystic fibrosis were intermediate between those of the ulcerative colitis and Crohn's disease groups. However, neither the ulcerative colitis group nor the Crohn's disease group differed significantly from the cystic fibrosis group that were statistically significant. Duration of illness was negatively correlated with symptoms in Crohn's disease and ulcerative colitis. The results suggest that obsessive-compulsive symptoms are not specific to Crohn's disease or ulcerative colitis and that obsessive-compulsive symptoms in pediatric chronic illness may be secondary to the demands of the illness.

Psychiatric disorder in the general hospital

There have been many reports of psychiatric disorder in medical populations, but few have used standard methods on representative patient groups. Even so, there is consistent evidence for considerable psychiatric morbidity in in-patient, out-patient and casualty department populations, much of which is unrecognised by hospital doctors. We require a better classification of psychiatric disorder in the general hospital, improved research measures, and more evidence about the nature and course of the many different types of problem so that we can provide precise advice for their management of routine clinical practice.

[Psychotherapy of Crohn disease]

Research and experience with 266 patients show that psychotherapy is an important element in the treatment of this disease, the etiology of which is still unknown. It widens the therapeutic possibilities of drugs, diet and operation. The different steps of psychotherapy combined with relaxation and removal of stress are described. The personality of the patient before the outbreak of the disease, his unknown conflicts may influence its course as well as the alteration caused by the disease itself, especially depression, mental lability and anorexia.

The recognition of psychiatric illness by non-psychiatrists

Psychiatric illness occurs commonly during the course of medical and surgical illnesses, and commonly presents to non-psychiatric physicians inextricably mixed with physical symptoms. Non-psychiatrists vary widely between themselves in their ability to detect such disorders, so that such disorders are often missed. Reasons for failure to detect such disorders include the diagnostic practices taught in medical schools, the inadequacy of psychiatric taxonomy of neurosis, and the fact that most doctors have not been taught how to interview their patients.

Chest pain with normal coronary arteries: a comparative study of psychiatric and social morbidity

Ninety-nine patients with chest pain and a presumptive diagnosis of coronary heart disease were assessed blindly within 24 hours of angiography, using standardized psychiatric and social interviews and a personality inventory. Thirty-one patients had normal coronary arteries (NCA), 15 had slight disease and 53 had significant coronary obstruction. Twenty-eight (61%) of the 46 patients with insignificant disease and 12 (23%) of the 53 with significant obstruction had psychiatric morbidity. Associations between the overall severity of psychiatric morbidity and measures of social maladjustment were strongest in the patients with normal coronary arteries. The 26 men with insignificant coronary artery disease had higher scores of neuroticism and extraversion than the 41 with important coronary occlusions. No differences were observed when the same comparisons were made for the women. The findings indicate that approximately two thirds of patients with normal and near-normal coronary arteries have predominantly psychiatric rather than cardiac disorders: the symptoms in these patients are more likely to represent the somatic manifestations of anxiety and overbreathing than the consequences of underlying cardiac disease. Physicians should be aware of the ways in which neurotic illness may present with symptoms mimicking cardiac disease, especially when cardiovascular symptoms are accompanied by phobic symptoms and unexplained shortness of breath.

The effectiveness of attached social workers in the management of depressed female patients in general practice

There is a pressing need to evaluate the different forms of treatment for depressive illness encountered in general practice. This study consists of a controlled, randomized, clinical trial designed to investigate the effectiveness of social work intervention with depressed women. Eighty women aged between 18 and 45 were included and assessed initially by means of a psychiatric and social interview. Those ascertained to be suffering from 'acute' or 'acute on chronic' depression were randomly allocated to an experimental group who were referred to a social worker attached to a general practice or to a control group for routine treatment by their doctor. They were re-assessed 6 months later. Over 60% of both groups were clinically improved at follow-up, with no statistically significant differences between the two groups in clinical, social or medical outcome. Further analyses suggested, however, that those women initially assessed as suffering from 'acute on chronic' depression with major marital difficulties were found to benefit from social work treatment. These patients could be distinguished from the others by their high degree of motivation, by the initial severity of their problems and by the amount of practical help provided by the social workers.

The effect of illness behaviour on the apparent relationship between physical and mental disorders

Evidence for associations between organic disease and psychopathology is reviewed and it is concluded that some of this is determined by complaint and consultation behaviours. The concept of illness behaviour is described. The Self Care Assessment Schedule (SCAS) is a new measure of illness behaviour and has been used to provide an independent assessment of psychiatric day patients, gynaecology and surgical outpatients. Only weak positive correlations were found between SCAS scores and mental illness, measured using the General Health Questionnaire (GHQ). Subjects with organic pathology differed little from those without organic pathology, with regard to SCAS and GHQ scores. However SCAS and GHQ scores were more highly correlated in those without organic pathology. It is concluded that claimed associations between physical disease and psychopathology should be based on objective evidence rather than subjective complaints and that this should be found across the entire spectrum of illness behaviour.

Food hypersensitivity in irritable bowel syndrome

Food hypersensitivity as a cause of abdominal symptoms was investigated by means of exclusion diets and double-blind food provocation in patients with irritable bowel syndrome. Twenty-seven patients entered the study; nineteen complied with dietary manipulation. Food hypersensitivity as a cause of their presenting symptoms was confirmed by double-blind food provocation in only three patients, who also had evidence of associated atopic disease and positive skin tests to common inhalant allergens. Evidence of minor psychiatric disorder was found in twelve of fourteen patients examined by an independent psychiatrist.

Improvement in central monoamine metabolism in adult coeliac patients starting a gluten-free diet

Adult coeliac patients taking a gluten-free diet for one year showed an increase of 33% in the concentrations in CSF of major monoamine metabolites (5-HIAA, HVA and MOPEG). Tryptophan in CSF rose by 10%. There was concomitant morphological improvement in the jejunal mucosa, and the results would seem to indicate that the reduced central monoamine metabolism in untreated adult coeliacs is not primarily genetically determined but is probably related to the poor intestinal absorption.

Reversal of psychopathology in adult coeliac disease with the aid of pyridoxine (vitamin B6)

Signs of mental depression are typical in adults presenting with coeliac disease. The response to treatment was evaluated in 12 consecutive patients by means of the Minnesota Multiphasic Personality Inventory (MMPI), with surgical patients serving as controls. The coeliacs reported no change in depressive symptoms after 1 year's gluten withdrawal despite evidence of improvement in the small intestine. When retested after 3 years, however, after 6 months of 80 mg/day of oral pyridoxine (vitamin B6) therapy, they showed a fall in the score of scale 2 ('depression') from 70 to 56 (p less than 0.01), which became normalized like other pretreatment abnormalities in the MMPI. Cholecystectomy in the control subjects produced no alterations in the MMPI profile. The results indicate a causal relationship between adult coeliac disease and concomitant depressive symptoms which seems to implicate metabolic effects from pyridoxine deficiency influencing central mechanisms regulating mood.

Intellectual ability of adults after lifelong intestinal malabsorption due to coeliac disease

The intellectual impact of lifelong intestinal malabsorption was examined in a consecutive series of 19 adults (mean age, 48 ± 11 years) with untreated coeliac disease. Using a comprehensive test battery no consistent signs of cognitive impairment were found and in the light of recent observations on coeliacs, aspects of nutritional deficiency may prove more pertinent to other forms of cerebral dysfunction.

Influence of drug treatment on the irritable bowel syndrome and its interaction with psychoneurotic morbidity

Sixty per cent of the patients referred to two gastroenterological clinics and diagnosed as suffering from the irritable bowel syndrome (IBS), were found to have significant psychoneurotic morbidity on the basis of the General Health Questionnaire. A double-blind, completely randomised, placebo controlled comparison of treatment with a combined anxiolytic/antidepressant (Motipress) found a significantly better effect of Motipress than placebo on diarrhoea and abdominal pain. Detailed analysis of the results suggests that there is no direct relationship between psychoneurotic illness and IBS, but the presence of the former has an adverse effect on the short-term outcome of the bowel disorder.

Psychiatric disorders associated with Crohn's disease

This article is a report of the authors' experience with a series of forty-six patients with Crohn's disease seen in psychiatric consultation over a nine year period. We treated twenty-two of these patients in either long term or short term psychotherapy in addition to the initial psychiatric evaluation. A brief literature review of previous studies on the psychiatric aspects of Crohn's disease is also presented. The most common reason that psychiatric consultation was requested was depression, followed by pain and narcotic-related problems. Factors which appeared to contribute to psychiatric morbidity were the following: duration of Crohn's disease, frequent hospitalizations and surgical procedures, presence of an ostomy, history of proctocolectomy, current psychosocial stress unrelated to Crohn's disease and a history of traumatic childhood experiences. Four suggestions regarding psychiatric management of this group of patients are presented and discussed.

Psychic disturbances in adult coeliac disease. III. Reduced central monoamine metabolism and signs of depression

Untreated adult coeliac patients have previously been shown to have a high frequency of depressive symptoms as reported in a personality inventory (the MMPI). In the present study we determined the concentrations of three major monoamine metabolites in samples of lumbar cerebrospinal fluid of ten consecutive adults with newly detected coeliac disease. They showed significant reduction in levels of 5-HIAA (70.3 +/- 25.4 pmol/ml). HVA (128.2 +/- 58.3 pmol/ml), and MOPEG (27.7 +/- 7.4 pmol/ml), indicating reduced central metabolism in all three monoamine pathways. The concentrations, in particular that of MOPEG, were inversely correlated with depressive symptoms reported on the MMPI scale 2 ('depression'), which conforms with current concepts on the pathogenesis of depression.

Life events, psychiatric disturbance and physical illness

The relationship between life events and the onset of organic physical illness has been studied in a group of women in the general population. The link between severe events and the onset of organic illness, which held only for women of 50 years or younger, was not a direct causal association but mediated by an intervening psychiatric disturbance of an affective kind, all occurring within a six month period. The findings are discussed in the light of the high psychiatric morbidity found in physically ill patients.

Crohn's disease: a review of the psychological and social outcome

A review of the psychosocial literature relating to Crohn's disease reveals that most available studies have been aetiologically oriented and that there are important gaps in our knowledge about the psychological and social concomitants of the disease. Some future research possibilities are discussed.

The neurological manifestations of malabsorption

The clinical and pathological findings in patients with neurological disorders in association with disordered function of the small intestine, in particular coeliac disease, are outlined. The possible significance of the abnormalities of pyridoxine, tyrosine and tryptophan metabolism are considered in relation to biopterin derivatives and their relevance to neurological dysfunction.

Crohn's disease: a psychosomatic illness?

We investigated the psychological status of Crohn's disease patients because 10 such patients had been referred to our psychiatric out-patient department over a period of six years, whereas if there were no association between the disease and psychiatric morbidity, the expected referral rate would be one case in 20 to 100 years. We found an association between episodes of psychiatric and physical symptoms in the case histories. We administered the Eysenck Personality Inventory and the Manifest Anxiety Scale to 28 out-patients with Crohn's disease (8 psychiatrically and 20 non-psychiatrically referred), 17 with chronic non-psychosomatic medical diseases, 43 with psychosomatic diseases and 100 with neurosis. Crohn's disease patients were significantly more anxious, neurotic and introverted than both the test norms and the non-psychosomatic medical out-patients and did not differ appreciably from the psychosomatic patients in these respect.