The relationship of psychiatric illness with gastrointestinal disease

When you are living and dying at the same time: A qualitative exploration of living with gastrointestinal motility disorders

BACKGROUND

An expanding base of evidence indicates that chronic gastrointestinal disorders not only impact physical wellbeing, but also affect many psychosocial aspects of life. However, less is known about gastrointestinal motility disorders. The present study aimed to explore how individuals experience gastrointestinal motility disorders and their impact on daily living.

METHODS

Eleven people with a gastrointestinal motility disorder participated in semi-structured interviews face-to-face or via telephone. The interviews explored how participants came to be diagnosed, their experiences with health professionals, as well as the impact of dysmotility on enjoyment of food, socialising, eating out and quality of life (QoL). Interviews were tape-recorded, transcribed and analysed using an inductive thematic analysis approach.

RESULTS

Analysis revealed an overarching theme of frustration that stemmed from three subthemes: (1) feeling misunderstood, judged and dismissed by health professionals leading to delayed diagnosis, misdiagnosis and multiple diagnoses; (2) severity and unpredictability of undesirable gastrointestinal symptoms; and (3) reduced QoL because of physical and social limitations, impairing their ability to have normal life experiences, including education, work and social activities.

CONCLUSIONS

Dysmotility is a complex illness that impacts almost all aspects of a person's life. In addition to managing reported physical symptoms, the social and psychological burden associated with dysmotility needs to be addressed to improve outcomes and QoL.

The Epidemiology of Irritable Bowel Syndrome in the US Military: Findings from the Millennium Cohort Study

OBJECTIVES

Functional gastrointestinal disorders occur more frequently among deployed veterans, although studies evaluating the relative impact of risk factors, including stress and antecedent infectious gastroenteritis (IGE), are limited. We examined risk factors for new-onset irritable bowel syndrome (IBS) among active duty participants in the military's Millennium Cohort Study.

METHODS

Medical encounter data from 2001 to 2009, limited to Cohort members on active duty, were used to identify incident IBS cases (any and highly probable). IGE was identified using medical encounter or self-report. Covariate data were obtained from the Millennium Cohort Study surveys and analyzed using Cox proportional hazards methods.

RESULTS

Overall, 41,175 Cohort members met the eligibility criteria for inclusion and 314 new-onset cases of IBS were identified among these. Significant risk factors (adjusted hazard ratio, 95% confidence interval) included antecedent IGE (2.05, 1.53-2.75), female gender (1.96, 1.53-2.52), number of life stressors (1: 1.82, 1.37-2.41; 2: 2.86, 2.01-4.06; 3+: 6.69, 4.59-9.77), and anxiety syndrome (1.74, 1.17-2.58). Limited to highly probable IBS, a stronger association with antecedent IGE was observed, particularly when based on medical encounter records (any IGE: 2.20, 1.10-4.43; medical encounter IGE only: 2.84, 1.33-6.09). Precedent anxiety or depression and IGE interacted with increased IBS risk compared with IGE alone.

CONCLUSIONS

These results confirm previous studies on the association between sociodemographic or life stressors and IBS. IGE was significantly associated with IBS risk. Whether deployed or not, US service members often encounter repeated exposure to high levels of stress, which, combined with other environmental factors such as IGE, may result in long-term debilitating functional gastrointestinal disorders.

Evaluation of psychological aspects among subtypes of irritable bowel syndrome

CONTEXT

While some studies have found disparities between subtypes of irritable bowel syndrome (IBS), others did not found such differences.

AIM

This study aimed to investigate whether there are differences in psychological features between the subtypes of IBS.

SETTINGS AND DESIGN

A cross-sectional study was performed on all consecutive outpatients IBS diagnosed (from Oct. 2010 to Oct. 2011) in Taleghani Hospital gastroenterology clinic, Tehran, Iran.

MATERIALS AND METHODS

A total of 153 consecutively diagnosed IBS patients (using Rome III criteria); including 80 constipation-predominant (IBS-C), 22 diarrhea-predominant (IBS-D), and 51 mixed IBS (IBS-M) were asked to complete the Symptom Checklist 90 Revised (SCL-90-R).

STATISTICAL ANALYSIS

Pearson's chi-square test was used to compare nominal variables. One-way ANOVA was used to compare continuous variables.

RESULTS

Although IBS-C patients were more suffered from psychiatric disorders, there were no statistical differences between mean score of IBS-C, IBS-D, and IBS-M patients regarding to all of SCL-90-R subscales and three global indices including Global Severity Index (GSI), Positive Symptom Distress Index (PSDI) and Positive Symptom Total (PST) (P<0.05).

CONCLUSION

Our finding showed that there are no different symptomatic profiles between IBS subtypes.

Solution focused therapy: a promising new tool in the management of fatigue in Crohn's disease patients psychological interventions for the management of fatigue in Crohn's disease

BACKGROUND

Crohn's disease patients have a decreased Quality of Life (QoL) which is in part due to extreme fatigue. In a pilot study we prospectively assessed the feasibility and effect of psychological interventions in the management of fatigue.

METHODS

Patients with quiescent Crohn's disease and a high fatigue score according to the Checklist Individual Strength were randomized to Problem Solving Therapy (PST), Solution Focused Therapy (SFT) or to a control group (treatment as usual, TAU). Patients completed the Inflammatory Bowel Disease Questionnaire, the EuroQol-5D, and the Trimbos questionnaire for Costs.

RESULTS

Twenty-nine patients were included (12 TAU, 9 PST, 8 SFT), of these 72% were female, mean age was 31 years (range 20-50). The SFT group improved on the fatigue scale in 85.7% of the patients, in the PST group 60% showed improved fatigue scores and in the TAU group 45.5%. Although not significant, in both intervention groups the QoL increased. Medical costs lowered in 57.1% of the patients in the SFT group, in the TAU 45.5% and the in PST group 20%. The drop out rate was highest in the PST group (44%; SFT 12.5%; TAU 8.3%).

CONCLUSIONS

PST and SFT both positively affect the fatigue and QoL scores in patients with Crohn's disease. SFT seems most feasible with fewer dropouts and is therefore a promising new tool in the management of fatigue in Crohn's disease patients.

Impaired carbohydrate digestion and transport and mucosal dysbiosis in the intestines of children with autism and gastrointestinal disturbances

Gastrointestinal disturbances are commonly reported in children with autism, complicate clinical management, and may contribute to behavioral impairment. Reports of deficiencies in disaccharidase enzymatic activity and of beneficial responses to probiotic and dietary therapies led us to survey gene expression and the mucoepithelial microbiota in intestinal biopsies from children with autism and gastrointestinal disease and children with gastrointestinal disease alone. Ileal transcripts encoding disaccharidases and hexose transporters were deficient in children with autism, indicating impairment of the primary pathway for carbohydrate digestion and transport in enterocytes. Deficient expression of these enzymes and transporters was associated with expression of the intestinal transcription factor, CDX2. Metagenomic analysis of intestinal bacteria revealed compositional dysbiosis manifest as decreases in Bacteroidetes, increases in the ratio of Firmicutes to Bacteroidetes, and increases in Betaproteobacteria. Expression levels of disaccharidases and transporters were associated with the abundance of affected bacterial phylotypes. These results indicate a relationship between human intestinal gene expression and bacterial community structure and may provide insights into the pathophysiology of gastrointestinal disturbances in children with autism.

The impact of physical illnesses on non-psychotic psychiatric morbidity: Data from the household survey of psychiatric morbidity in Great Britain

OBJECTIVES

Psychiatric morbidity among the physically ill is an important issue, particularly in the light of research documenting the difficulties in accurately diagnosing and effectively treating psychiatric disorders in this group. The objectives of this study were: (1) To compare psychiatric morbidity in 11 physical conditions and a healthy comparison group. (2) To compare psychiatric morbidity between respondents with one of the 11 illnesses to those with more than one physical illness.

DESIGN

The sample was derived from the cross-sectional Household Survey of Psychiatric Morbidity.

METHODS

Psychiatric morbidity (excluding psychosis) was assessed by interview using the revised Clinical Interview Schedule (CIS-R) and physical illness through self-report in 10,108 adults.

RESULTS

Eight of the 11 illness groups were more likely to be classified as having psychiatric morbidity on the CIS-R than the physically healthy group. There were no differences in psychiatric morbidity between the different illness groups. The presence of more than one physical illness significantly increased the likelihood of psychiatric morbidity in 10 of the 11 groups.

CONCLUSIONS

This study further supports the association between physical and psychiatric illness. Importantly, it suggests an increased likelihood of psychiatric morbidity in the presence of more than one physical condition.

Increased feelings with increased body signals

Since the beginning of psychology as a scientific endeavour, the question of whether the body plays a role in how a person experiences emotion has been the centre of emotion research. Patients with structural gastrointestinal disorders, such as Crohn's disease, provide an intriguing opportunity to study the influence of body signals on emotions and feelings. In the present study, emotionally salient films were presented to participants with Crohn's disease in either the active state (Crohn's-active, CA) or silent state (Crohn's-silent, CS), and to normal comparison (NC) participants. We hypothesized that CA participants would have increased feelings, compared with CS and NC participants, when viewing emotional films designed to elicit happiness, disgust, sadness and fear. Gastric myoelectrical activity (electrogastrogram, or EGG) was measured during the films, and after each film was presented, participants rated emotion intensity (arousal) and pleasantness (valence). All groups labelled the emotions similarly. In support of the hypothesis, CA participants showed an increase in subjective arousal for negative emotions compared with CS and NC participants. The CA participants also showed increased EGG during emotional film viewing, as well as a strong positive correlation of EGG with arousal ratings. Together, these findings can be taken as evidence that aberrant feedback from the gastrointestinal system up-regulates the intensity of feelings of negative emotions.

The impact of biologics on health-related quality of life in patients with inflammatory bowel disease

Background:

Inflammatory bowel disease (IBD) is characterized by a chronic relapsing inflammation of the gastrointestinal tract. Adult IBD patients suffer from a disabling disease which greatly affects health-related quality of life (HRQoL). A worse HRQoL in these patients may result in a defensive and ineffective use of medical attention and thus higher medical costs. Because of its chronic nature, IBD may also cause psychological problems in many patients which may also influence HRQoL and care-seeking behavior. An important factor reducing HRQoL is disease activity. Induction of remission and long-term remission are important goals for improving HRQoL. Furthermore, remission is associated with a decreased need for hospitalization and surgery and increased employment, which in turn improve HRQoL. Treatment strategies available for many years are corticosteroids, 5-aminosalicylates and immunnosuppressants, but these treatments did not show significant long-term improvement on HRQoL. The biologics, which induce rapid and sustained remission, may improve HRQoL.

Objective:

To review and evaluate the current literature on the effect of biologics on HRQoL of IBD patients.

Methods:

We performed a MEDLINE search and reviewed the effect of different biologics on HRQoL. The following subjects and synonyms of these terms were used: inflammatory bowel disease, Crohn’s disease, ulcerative colitis, quality of life, health-related quality of life, fatigue, different anti-TNF medication, and biologicals/biologics (MESH). Studies included were limited to English-language, adult population, full-text, randomized, double-blind, placebo-controlled in which HRQoL was measured.

Results:

Out of 202 identified articles, 8 randomized controlled trials (RCT) met the inclusion criteria. Two RCTs on infliximab showed significant improvement of HRQoL compared to placebo which was sustained over the long term. One RCT on adalimumab showed a significant and sustained improvement of HRQoL compared to placebo. This study showed also significant decrease of fatigue in the adalimumab-treated patients. Three RCTs on certolizumab showed a significant improvement of HRQoL in the intervention group compared to placebo. Two RCTs of natalizumab treatment were found. One study showed significant and sustained improvement compared to placebo, and also scores of HRQoL comparable to that in the general population, but in the other no significant results were found.

Conclusion:

The biologics infliximab, adalimumab, certolizumab, and natalizumab demonstrated significant improvement of HRQoL of IBD patients compared with placebo. However, we found differences in improvement of HRQoL between the different biologics.

Depression and anxiety in inflammatory bowel disease: a review of comorbidity and management

While there has been a great deal of speculation over the years on the importance of emotional factors in inflammatory bowel disease (IBD), it is only in the last decade or so that studies with stronger designs have been available to clarify the nature of this relationship. This review considers recent evidence on the prevalence of anxiety and depressive disorders in IBD, the role of these disorders as a risk factor for IBD onset, the degree to which they affect the course of the IBD, and the contribution of corticosteroid treatment to psychiatric symptom onset. There is evidence that anxiety and depression are more common in patients with IBD and that the symptoms of these conditions are more severe during periods of active disease. The few studies that address the issue of anxiety and depression as risk factors for IBD do not yet provide enough information to support definite conclusions. There is evidence, however, that the course of the disease is worse in depressed patients. Treatment with corticosteroids can induce mood disorders or other psychiatric symptoms. The second part of the review focuses on patient management issues for those with comorbid anxiety or depression. Practical approaches to screening are discussed, and are recommended for routine use in the IBD clinic, especially during periods of active disease. We review evidence-based pharmacological and psychological treatments for anxiety and depression and discuss practical considerations in treating these conditions in the context of IBD to facilitate overall management of the IBD patient.

High-utilizing Crohn's disease patients under psychosomatic therapy

OBJECTIVE

Few studies have been published on health care utilization in Crohn's disease and the influence of psychological treatment on high utilizers.

METHODS

The present sub study of a prospective multi center investigation conducted in 87 of 488 consecutive Crohn's disease (CD) patients was designed to investigate the influence of the course of Crohn's disease on health care utilization (hospital days (HD) and sick leave days (SLD) collected by German insurance companies) and to examine the conditions of high-utilizing patients. Predictors of health care utilization should be selected. Based on a standardized somatic treatment, high health care utilizing patients of the psychotherapy and control groups should be compared before and after a one-year treatment.

RESULTS

Multivariate regression analysis identified disease activity at randomization as an important predictor of the clinical course (r2 = 0.28, p < 0.01). Health care utilization correlated with duration of disease (p < 0.04), but the model was not significant (r2 = 0.15, p = 0.09). The patients' level of anxiety, depression and lack of control at randomization predicted their health-related quality of life at the end of the study (r2 = 0.51, p < 0.00001). Interestingly, steroid intake and depression (t1) predicted the combined outcome measure (clinical course, HRQL, health care utilization) of Crohn's disease at the end of the study (r2 = 0.22, p < 0.001).Among high utilizers, a significantly greater drop in HD (p < 0.03) and in mean in SLD were found in the treatment compared to the control group.

CONCLUSION

The course of Crohn's disease is influenced by psychological as well as somatic factors; especially depression seems important here. A significant drop of health care utilization demonstrates the benefit of psychological treatment in the subgroup of high-utilizing CD patients. Further studies are needed to replicate the findings of the clinical outcome in this CD subgroup.

Psychological comorbidity and complexity of gastrointestinal symptoms in clinically diagnosed irritable bowel syndrome patients

BACKGROUND AND AIM

The prevalence of psychological disorders is high in patients with irritable bowel syndrome (IBS) but their role in symptom reporting is uncertain. It is thus interesting whether the number of functional gastrointestinal disorders (FGID) determines the load of psychological comorbidity. The Rome III criteria have not been used to evaluate such a relationship as yet. Moreover, not many studies have examined the sensitivity of the Rome III criteria in detecting IBS. Our aims were therefore: (i) to determine whether those IBS participants with more FGID had a tendency to greater psychological comorbidity than those with fewer FGID; and (ii) to assess the performance of the Rome III criteria in detecting IBS versus the diagnosis of the gastroenterologist.

METHODS

A cross-sectional survey of 32 consecutive outpatients with clinically diagnosed IBS was performed. The Hospital Anxiety and Depression Scale (HADS), the Short Form 12 Health Survey (SF-12), and the Rome III criteria questionnaire (BDQ-6) were administered. Multiple linear regression was conducted to detect associations among FGID, anxiety, depression and quality of life.

RESULTS

Overall, 50% of participants were anxious and 12% were depressed. Forty-four percent of participants had >two FGID; however, the number of FGID did not correlate with scores for anxiety, depression or quality of life. Amazingly, only 50% (CI: 33-67) of participants clinically diagnosed with IBS met Rome III criteria for IBS.

CONCLUSION

Contrary to our expectations, a greater load of FGID did not correlate with a greater load of psychological comorbidity. Surprisingly, the Rome III criteria detected only 50% of clinical cases of IBS.

Psychological problems in gastroenterology outpatients: A South Australian experience. Psychological co-morbidity in IBD, IBS and hepatitis C

BACKGROUND

In independent studies, IBD, IBS and HCV have each been associated with a substantially increased risk of psychological problems such as depression and anxiety and impairment of quality of life compared to the general healthy population. However, the relative psychological burden for each of these diagnoses is unknown as it has never been compared contemporaneously at one institution. Current local data are therefore needed to enable an evidence-based allocation of limited clinical psychological resources.

METHODS

Overall, 139 outpatients (64 IBD, 41 HCV, and 34 IBS) were enrolled in this cross-sectional study. The HADS, SCL90, SF-12 and appropriate disease-specific activity measures were administered. Differences between groups were assesed with ANOVA, the Chi-Square test and the independent samples t-test (two-tailed).

RESULTS

Each of the three groups had significantly lower quality of life than the general population (p < 0.05). Overall, a total of 58 (42%) participants met HADS screening criteria for anxiety and 26 (19%) participants for depression. The HCV group had a significantly higher prevalence of depression than either of the other groups (HCV = 34%, IBS = 15% and IBD = 11%, p = 0.009). In the SCL90, the three disease groups differed on 7 out of 12 subscales. On each of these subscales, the HCV group were most severely affected and differed most from the general population.

CONCLUSION

Patients with these common chronic gastrointestinal diseases have significant impairment of quality of life. Anxiety is a greater problem than depression, although patients with HCV in particular, should be regularly monitored and treated for co-morbid depression. Evaluation of specific psychological interventions targeting anxiety is warranted.

Depressive and anxiety symptoms, dysfunctional attitudes and social aspects in irritable bowel syndrome and inflammatory bowel disease

OBJECTIVE

Biopsychosocial models for both organic and functional gastrointestinal (GI) disorders have been described in the recent literature. The objective of this study was to give further data to this model by assessing stressful life events, social support, psychopathological symptoms, and dysfunctional attitudes in irritable bowel syndrome (IBS), inflammatory bowel disease (IBD) and healthy subjects.

METHOD

Age- and gender-matched IBS and IBD patients presenting at a tertiary care gastroenterological center completed self-reported questionnaires on stressful life events, social support, depressive and anxiety symptoms and dysfunctional attitudes. For comparative purposes, data from an age- and gender-matched healthy control group were obtained.

RESULTS

No significant differences were found between the groups regarding stressful life events and social support. Both patient groups had higher depressive and anxiety symptoms compared to healthy subjects, and IBS patients had higher depressive scores compared to IBD patients. IBS patients had more dysfunctional attitudes compared to both IBD and healthy subjects, while IBD and healthy subjects did not differ on dysfunctional attitudes.

CONCLUSIONS

GI patient status is associated with depressive and anxiety symptoms, in addition IBS patients have more severe depressive symptoms and depressogenic dysfunctional attitudes. The fact that functional GI patients are characterized by more severe psychological, but not social parameters, supports the hypothesis that IBS might be related to the range of depressive disorders.

Psychological factors, quality of life, and gastrointestinal symptoms in patients with erosive and non-erosive reflux disorder

OBJECTIVE

Inconsistent findings are published regarding the psychosocial characteristics of erosive reflux disorder (ERD) and non-erosive reflux disorder (NERD) patients. The objective of this study was to determine the possible similarities and differences concerning psychosocial and somatic characteristics of these patients.

METHOD

Patients at a tertiary care center completed questionnaires on demographic characteristics, frequency of reflux symptoms, psychological distress, quality of life, and gastrointestinal symptoms. For comparative purposes, data from an age-matched healthy control group were obtained.

RESULTS

Higher proportion of female patients and a younger mean age was observed in NERD patients. No significant differences were detected regarding levels of psychological distress, gastrointestinal symptom severity, quality of life, and frequency of reflux symptoms. Both patient groups exhibited more severe psychological distress compared to healthy subjects. Only ERD patients demonstrated significant correlations between frequency of reflux symptoms and quality of life and severity of gastrointestinal symptoms. Compared to ERD patients, NERD patients showed stronger correlation between psychological distress and severity of reflux symptoms.

CONCLUSIONS

Reflux-like symptoms have a strong impact on patients' wellbeing, irrespective of endoscopical findings. The different patterns of associations between psychological, somatic and quality of life parameters in NERD and ERD patients can have theoretical and clinical implications.

Psychological treatment may reduce the need for healthcare in patients with Crohn's disease

BACKGROUND

Few published studies examine the influence of psychological treatment on health care utilization in Crohn's disease.

METHODS

The present substudy of a prospective, randomized, multicenter trial conducted in 69 of 488 consecutive Crohn's disease (CD) patients was designed to investigate the way in which healthcare utilization is influenced by psychotherapy and relaxation in addition to standardized glucocorticoid therapy. Before and after a 1-year period of standardized somatic treatment the psychotherapy and control groups were compared with regard to hospital and sick-leave days. Predictors of healthcare utilization were analyzed.

RESULTS

The comparison between groups before and after psychological treatment showed a significantly higher decrease of mean hospital days (P < 0.03) and sick-leave days in the treatment group compared with the controls. When a covariate analysis was applied to compare the data at randomization, the difference in hospital days remained statistically a trend (P < 0.1). Multivariate regression analysis detected a significant gender and depression effect for hospital days (cor r(2) = 0.114) and a significant gender and age effect for sick-leave days (cor r(2) = 0.112).

CONCLUSION

A significant drop in healthcare utilization after psychological treatment demonstrates a clear benefit of this additional therapy. This is important, since the study failed to demonstrate significant changes in the psychosocial status or somatic course of study patients. Clinical and psychological factors influencing these outcomes are discussed.

Psychological distress and impaired quality of life common among community-dwelling adults with lower gastrointestinal disorders

This study examines the comparison of psychological well-being and health-related quality of life (HRQOL) between adults with and without lower gastrointestinal (GI) disorders and between adults with lower GI disorders and those with other common chronic illnesses. Data of adults aged 18 years or older from the 2002 National Health Interview Survey (n=29,828) were analyzed. Approximately 5.4% of survey participants reported they had been told by a physician that they had lower GI disorders. Those reporting lower GI disorders were 1.8 times more likely to meet the criteria for serious mental illness (SMI) and were significantly more likely to report impaired HRQOL than those without GI disorders. In addition, those with lower GI disorders were significantly more likely than those with heart disease and diabetes and equally as likely as those with arthritis and asthma to meet the criteria for SMI. Because psychological comorbidity is common among adults with lower GI disorders and may complicate their course and treatment, clinicians should consider screening patients presenting with lower GI disorders for these comorbid conditions.

Depression and inflammatory bowel disease: findings from two nationally representative Canadian surveys

Most studies of depression and inflammatory bowel disease (IBD) have been drawn from clinical populations or from samples selected from the membership of Crohn's and ulcerative colitis community organizations. This study determined the prevalence and correlates of depression in people with IBD or a similar bowel disorder from 2 nationally representative Canadian surveys. In the Canadian Community Health Survey, conducted in 2000 through 2001, there were 3076 respondents who reported that they had "a bowel disorder such as Crohn's disease or colitis" that had lasted >or=6 months and had been diagnosed by a health professional. The National Population Health Survey, conducted from 1996 through 1997, had 1438 respondents who reported that they had such a condition. Within each subsample, bivariate analyses were conducted to compare the depressed and nondepressed individuals. Logistic regression analyses also were conducted using the Canadian Community Health Survey 1.1 data set. The 12-month period prevalence of depression among individuals with IBD and similar bowel disorders was comparable in the 2 data sets (16.3% and 14.7%). Depression rates were higher among female respondents, those without partners, younger respondents, those who reported greater pain, and those who had functional limitations. Seventeen percent of depressed respondents had considered suicide in the past 12 months; an additional 30% had considered suicide at an earlier time. Only 40% of depressed individuals were using antidepressants. Individuals with IBD and similar bowel disorders experience rates of depression that are triple those of the general population. It is important for clinicians to assess depression and suicidal ideation among their patients with active IBD symptoms, particularly among those reporting moderate to severe pain.

Adolescent chronic pelvic pain

The presentation of chronic pelvic pain in the adolescent can at times be quite daunting. A careful and insightful approach to obtaining the history and physical examination must be implemented while maintaining an appreciation of the various stages of adolescent development. The etiologies can range from gynecologic to nongynecologic causes. The ability to render an early diagnosis and appropriate treatment in this population of patients can significantly improve future reproductive health outcomes. The following minireview will outline a systematic approach to the adolescent with chronic pelvic pain.

The biopsychosocial model and hypothyroidism

This paper comments on the role and emergence of the biopsychosocial model in modern medical literature and health care settings. The evolution of the biopsychosocial model and its close association with modern pain theory is also examined. This paper seeks to discuss the place of this model with respect to the management of hypothyroidism. This discussion represents a forerunner to a randomised control trial that will seek to investigate the effect of a biopsychosocial-based treatment regime on hypothyroidism.

Predictors of quality of life in ulcerative colitis: the importance of symptoms and illness representations

BACKGROUND

Establishing predictors of quality of life (QoL) in individuals with inflammatory bowel disease could help to identify those patients who are most likely to experience poor QoL and to target therapeutic interventions appropriately. We aimed to investigate how disease-specific QoL depends on demographic, diseaserelated, and physiological markers of disease activity, cognitive representations of illness, and perceived general health status.

METHODS

A total of 111 individuals completed the Inflammatory Bowel Disease Questionnaire (IBDQ), the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and the Illness Perception Questionnaire (IPQ). The extent of disease was determined from records, and disease activity was determined by a symptom index. Bivariate analyses and multivariate regression models were used to identify predictors of disease-specific QoL.

RESULTS

Bivariate analyses showed that symptom-related disease activity, elements of illness representation measured by the IPQ, and elements of physical and mental health measured by the SF-36 were the only variables that were strongly or moderately correlated with disease-specific QoL. Multivariate regression modeling showed that disease activity was the major explanatory variable for each of the 4 domains and for the total score on the IBDQ.

CONCLUSION

This study highlights the strong relationship between individuals' symptoms and all domains of their health-related QoL, but shows little association with age, gender, physiological markers of disease activity, or anatomic disease extent. Perceptions of the condition were relatively weak predictors of self-reported QoL. The best strategy for improving QoL among individuals with ulcerative colitis may be to find ways to reduce their symptoms.

Effect of psychotherapy and relaxation on the psychosocial and somatic course of Crohn's disease: main results of the German Prospective Multicenter Psychotherapy Treatment study on Crohn's Disease

OBJECTIVE

Few studies have been published on the influence of psychotherapy on the physical and psychosocial course of Crohn's disease (CD).

METHODS

The present study, a prospective, randomized multicenter investigation conducted with 108 of 488 consecutive CD patients, was designed to investigate the influence of short-term psychodynamic therapy and relaxation in addition to a standardized glucocorticoid therapy on the somatic course of the disease as well as on patient psychosocial status. Based on the same standardized somatic treatment, the psychotherapy and control groups were compared after a 1-year treatment period and a follow-up of another year with regard to somatic course and psychosocial situation.

RESULTS

A total of 81 (75%) of 108 randomized patients completed the psychosocial follow-up. The comparison between the therapy groups after 1 year showed no significant differences in the four main target criteria of psychosocial status (depression, anxiety, psychosocial-communicative status and health-related quality of life). The mean Beck's Depression Inventory (BDI) score at admission was 12.3 in the psychotherapy group and 8.7 in the control group. At the 1-year follow-up, the scores for depression have been 7.8 (psychotherapy group) and 7.8 (control group). In the 2-year follow-up, 84 patients were classified into four groups on the basis of somatic course; 23% of the control group and 30% of the psychotherapy group showed episode-free courses, 29% and 17% respectively underwent surgery due to failure of immunosuppressive or medical therapy, and a further subranking showed no significant differences between the two groups (P=.125). At the 1-year follow-up, the scores for depression of patients with an active episode respective remission were 14.6 vs. 5.8. From the patient's point of view, at the end of the 2-year follow-up, the overall subjective evaluation of the effectiveness of psychotherapy was positive.

CONCLUSION

The patients included showed no psychosocial disturbances of clinical relevance. Although a tendency toward fewer surgical interventions, fewer relapses and reduction of depression was noted, the analysis was unable to demonstrate any benefit from psychosocial intervention on hypothesized parameters of psychosocial status and somatic course. Further studies should be performed to identify patient subgroups that may benefit from psychosocial intervention.

Neural correlates of the prolonged salience of painful stimulation

Pain is a unique class of sensory experience from the perspective of salience. Nonpainful somatosensory stimuli usually require behavioral relevance or voluntary attention to maintain salience. In contrast, painful stimuli tend to have sustained salience even without explicit behavioral relevance or voluntary attention. We have previously identified a frontal-parietal-cingulate network of regions responding transiently to nonpainful sensory events. This network is sensitive to the task relevance and novelty of sensory events and likely represents the salience of events in the sensory environment. Since pain can remain salient for a prolonged period, we hypothesized that this network should show transient responses to the onset or offset of a nonpainful stimulus, but sustained responses throughout the duration of a painful stimulus. To test this hypothesis, we used functional MRI to examine the response of these regions to sustained (60-s) periods of painful and nonpainful transcutaneous electrical nerve stimulation. As predicted, the temporoparietal, inferior frontal, and anterior cingulate cortex showed only transient responses to the onset or offset of nonpainful stimulation, but a sustained response throughout the duration of painful stimulation. These regions therefore show tonic responses to stimuli with tonic salience, supporting a general role for these areas in representing stimulus salience. The thalamus and putamen also responded tonically throughout painful but not nonpainful stimulation. Previous studies have implicated the basal ganglia in supporting voluntary sustained attention. Our findings suggest that the basal ganglia may play a more general role in supporting sustained salience, whether through voluntary or involuntary mechanisms.

Pan-enteric dysmotility, impaired quality of life and alexithymia in a large group of patients meeting ROME II criteria for irritable bowel syndrome

AIM: Psychological factors, altered motility and sensation disorders of the intestine can be variably associated with irritable bowel syndrome (IBS). Such aspects have not been investigated simultaneously. The aim of this paper was to evaluate gastrointestinal motility and symptoms, psychological spectrum and quality of life in a large group of IBS patients in southern Italy.

METHODS: One hundred IBS patients (F:M = 73:27, age 48 ± 2 years, mean ± SE) fulfilling ROME II criteria matched with 100 healthy subjects (F:M = 70:30, 45 ± 2 years). Dyspepsia, bowel habit, alexithymia, psycho-affective profile and quality of life were assessed using specific questionnaires. Basally and postprandially, changes in gallbladder volumes and antral areas after liquid meal and orocaecal transit time (OCTT) were measured respectively by ultrasonography and H₂-breath test. Appetite, satiety, fullness, nausea, and epigastric pain/discomfort were monitored using visual-analogue scales.

RESULTS: Compared with controls, IBS patients had increased dyspepsia (score 12.6 ± 0.7 vs 5.1 ± 0.2, P < 0.0001), weekly bowel movements (12.3 ± 0.4 vs 5.5 ± 0.2, P < 0.00001, comparable stool shape), alexithymia (score 59.1 ± 1.1 vs 40.5 ± 1.0, P = 0.001), poor quality of life and psycho-affective profile. IBS patients had normal gallbladder emptying, but delayed gastric emptying (T₅₀: 35.5 ± 1.0 vs 26.1 ± 0.6 min, P = 0.00001) and OCTT (163.0 ± 5.4 vs 96.6 ± 1.8 min, P = 0.00001). Fullness, nausea, and epigastric pain/discomfort were greater in IBS than in controls.

CONCLUSION: ROME II IBS patients have a pan-enteric dysmotility with frequent dyspepsia, associated with psychological morbidity and greatly impaired quality of life. The presence of alexithymia, a stable trait, is a novel finding of potential interest to detect subgroups of IBS patients with different patterns recoveed after therapy.

[Sphincter of Oddi dysfunction--prolonged medical therapy or early endoscopic sphincter ablation]

INTRODUCTION

Sphincter of Oddi dysfunction is a real challenge from both diagnostic and therapeutic point of view.

PATIENTS AND METHODS

In the last two years the authors have performed ERCP and EST in 29 patients with positive evocative test results, who had important enzyme elevations and/or did not respond to prolonged medical treatment.

RESULTS

Endoscopic findings were positive in 25/29 patients (86.2%): 8 adenoma of p. Vateri, 17 papillitis were identified, and in 4 cases the papilla was intact. Histopathology obtained in 12 patients supported the diagnosis. In 6 patients, who underwent a postpapillotomy evocative test, after an average of 10 months follow up the results have been converted from positive to negative response in all but two cases. The two patients continued to have abdominal symptoms with persistent positive provocation tests because of restenosis, were treated with repapillotomy.

CONCLUSIONS

The Debray and Nardi tests are useful screening tests for hypertonic biliary or pancreatic dyskinesia. Structural endoscopic and histological findings are frequent already in the functional cases. Early sphincter ablation should be considered in failure of medical therapy for preventing the transformation of this functional disorder into an organic, potentially precancerous state.

Psychological comorbidity and stress reactivity in children and adolescents with recurrent abdominal pain and anxiety disorders

OBJECTIVE

To compare clinical symptoms, diagnoses, and physiological measures in children and adolescents with recurrent abdominal pain (RAP) (n = 14), to a group with anxiety disorders (ANX) (n = 14) and a physically and psychiatrically healthy control group (HC) (n = 14).

METHOD

The cross-sectional study examined group differences in clinical symptoms of anxiety, somatic complaints, depression, and behavior problems. Physiological measures included heart rate, systolic and diastolic blood pressure, and salivary cortisol in response to the Trier Social Stress Test for Children (TSST-C). Subjects were between the ages of 8 and 16 years.

RESULTS

RAP and ANX subjects had comparable scores on most psychological measures, and their scores were higher (n < .05) than those of the HC. The ANX and RAP groups exhibited physiological findings that had more shared similarities than either group with the HC group. Few statistically significant group differences were noted in physiological measures, yet the pattern of findings in blood pressure and cortisol supported the use of the TSST-C and the direction of the findings was consistent with expectations.

CONCLUSIONS

Understanding more about comorbidity between RAP and anxiety could have important management implications, with observed congruities between the disorders suggesting treatments already demonstrated to be efficacious for pediatric anxiety and depression might be applied productively to RAP.

Irritable bowel syndrome

The irritable bowel syndrome (IBS) is a functional gastrointestinal disorder whose hallmark is abdominal pain or discomfort associated with a change in the consistency or frequency of stools. In the western world, 8% to 23% of adults have IBS and its socioeconomic cost is substantial. Research-generated insights have led to the understanding of IBS as a disorder of brain-gut regulation. The experience of symptoms derives from dysregulation of the bidirectional communication system between the gastrointestinal tract and the brain, mediated by neuroendocrine and immunological factors and modulated by psychosocial factors. The biopsychosocial model integrates the various physical and psychosocial factors that contribute to the patient's illness. This model and the recently revised symptom-based criteria (i.e. the "Rome II criteria") form the basis for establishing a comprehensive and effective approach for the diagnosis and management of the disorder.

Functional gut disorders: from motility to sensitivity disorders. A review of current and investigational drugs for their management

Functional gut disorders include several clinical entities defined on the basis of symptom patterns (e.g., functional dyspepsia, irritable bowel syndrome, functional abdominal pain, functional abdominal bloating), for which there is no established pathophysiological mechanism. Because there is no well-defined pathophysiological target, treatment should be aimed at symptom improvement. Prokinetics and antispasmodics have been widely used in the treatment of functional gut disorders on the assumption that disordered motility is the underlying cause of symptoms, and symptom improvement is indeed achievable with these compounds in some, but not all, patients with features of hypo- or hypermotility, respectively. In the first part of this review, we cover the basic pharmacology and discuss the rationale for the clinical use of prokinetics and antispasmodics. On the other hand, in the past few years, the explosive growth in the research focusing on visceral sensitivity and visceral reflexes has suggested that at least some patients with functional gut disorders have altered visceral perception. Thus, the second part of the review covers these developments and focuses on studies addressing the issue of drugs modulating visceral sensitivity.

A biopsychosocial understanding of the irritable bowel syndrome: a review

OBJECTIVES

To review and examine the clinical and research literature on irritable bowel syndrome (IBS) with a view to establishing the role that psychiatric factors play in the pathogenesis and treatment of this syndrome.

RESULTS

Comorbid psychiatric illness is common with IBS, yet only a small proportion of these patients seek medical attention. Many patients are either satisfied by reassurance or experience symptom relief from medical treatment directed at target symptoms. A small group of patients do not experience much relief, and it is largely this group who come to the psychiatrist's attention. Psychotropic medication is helpful when clinically indicated, and tricyclic antidepressants in small doses (for example, 50 mg) may be helpful for those patients with a pain-predominant pattern of IBS. Psychotherapy (including cognitive, behavioural, relaxation, thermal-biofeedback, insight-oriented therapy, and hypnosis) has been shown to provide relief, although it has often been difficult to differentiate this improvement from a placebo response.

CONCLUSIONS

The group of patients with "refractory IBS" used a large amount of health care resources in an attempt to find relief to their distress. Further study is needed to gain a better understanding of which component of psychotherapy is most cost-effective and which patients are most likely to benefit. The large group of those who admit to symptoms compatible with IBS but who do not seek medical attention has to a large extent been excluded from most studies. Exploring this group may provide further insight into this perplexing syndrome.