Non-organic gastrointestinal illness: a medical and psychiatric study

The Irritable Bowel Syndrome: A Disease or a Response? Discussion Paper

The irritable bowel syndrome is a problem commonly found in the population as a whole, in general practice and in general hospital and specialist gastroenterological clinical practice. A population survey found that 14% of those interviewed exhibited symptoms of the irritable bowel syndrome but did not present to their general practitioner. In the gastroenterology clinic it is said to represent approximately one-third to one-half of referrals1.

Heart rate variability in anorexia nervosa and the irritable bowel syndrome

BACKGROUND

Many studies have reported disturbances of heart rate variability (HRV) in patients with psychosomatic disorders such as anorexia nervosa (AN) and the irritable bowel syndrome (IBS). However, both have never been directly compared.

METHODS

We compared HRV in AN (n = 21) and in IBS (n = 21) (all females) with 42 healthy female control subjects who were matched for age and in IBS to body mass index (BMI). Recovery periods between different cardiac load tests were compared with baseline recordings and tilt test to estimate time [mean successive difference (MSD)] and frequency domain (Goldberger dimension, frequency of HF peak location and HF power, log HF power) values and to assess general reactivity of the autonomic nervous system (ANS).

KEY RESULTS

Significantly longer inter-beat intervals (IBIs) in AN patients and lower values of MSD in IBS patients were found in comparison with respective controls; both were independent from experimental conditions and are found in baseline recordings only. Both effects were independent of age and BMI. We also demonstrate a significant relationship between age, BMI and some HRV parameters.

CONCLUSIONS & INFERENCES

Opposite autonomic patterns were found in AN and IBS: stronger vagal withdrawal in IBS and weaker vagal inhibition in AN patients. Records made at rest and without any autonomic load may be representative for assessment of ANS function. Age and BMI should be taken into consideration during assessment of HRV data.

[Brain-gut axis dysfunction]

There is a bidirectional relation between the central nervous system and the digestive tract, i.e., the brain-gut axis. Numerous data argue for a dysfunction of the brain-gut axis in the pathophysiology of irritable bowel syndrome (IBS). Visceral hypersensitivity is a marker of IBS as well as of an abnormality of the brain-gut axis. This visceral hypersensitivity is peripheral and/or central in origin and may be the consequence of digestive inflammation or an anomaly of the nociceptive message treatment at the spinal and/or supraspinal level. Stress is involved in the genesis and maintenance of IBS. Disturbances of the autonomic nervous system are observed in IBS as a consequence of brain-gut axis dysfunction. The contribution of the neurosciences, in particular brain imaging techniques, has contributed to the better understanding of IBS physiopathology. The better knowledge of brain-gut axis dysfunction has therapeutic implications, either through drugs and/or cognitive and behavioral therapies.

Significant psychological morbidity occurs in irritable bowel syndrome: a case-control study using a pharmacy reimbursement database

BACKGROUND

Psychological problems are associated with IBS but the strength of this association is unclear.

AIM

To assess co-prescribing of antispasmodic and CNS-acting drugs through a nested case-control study.

METHODS

A national dispensing database identified patients who were first dispensed antispasmodic medicines for a continuous 3-month period or more during 2006, using 2005 as a run-in period. Each patient was matched with four control patients and excluded if they received drugs indicated for IBD.

RESULTS

Four hundred and seven patients commenced antispasmodic drugs during 2006. These patients were matched with 1628 controls. In 2005, patients subsequently prescribed antispasmodics were 2-3 times more likely to receive CNS-acting drugs than controls. In the year following commencement of IBS therapy, patients were 2-4 times more likely than controls to be prescribed CNS-acting drugs including antidepressants (35.4% vs. 9.3%), anxiolytics (27.8% vs. 8.8%), antipsychotics (9.8% vs. 3.3%) and hypno-sedatives (32.7% vs. 11.3%; P < 0.0001). The adjusted OR (95% CI) for antidepressant, anxiolytic, hypnosedative and antipsychotic prescribing in IBS patients were 3.81 (2.79-5.20), 2.84 (2.12-3.81), 2.62 (1.91-3.60) and 2.58 (1.80-3.66), respectively.

CONCLUSIONS

Patients prescribed ongoing therapy for presumed IBS are 2-4 times more likely to be prescribed CNS-acting drugs than controls, providing evidence of psychological comorbidity in IBS.

Tryptophan catabolism in females with irritable bowel syndrome: relationship to interferon-gamma, severity of symptoms and psychiatric co-morbidity

Irritable bowel syndrome (IBS) has been linked with abnormal serotonin functioning and immune activation. Tryptophan forms the substrate for serotonin biosynthesis, but it can alternatively be catabolized to kynurenine (Kyn) by the enzyme indoleamine 2,3-dioxygenase (IDO), the main inducer of which is interferon-gamma. The primary aim of this study was to test the hypothesis that IBS is associated with increased tryptophan (Trp) catabolism along the Kyn pathway due to increased IFN-gamma levels. Plasma Kyn, Trp and IFN-gamma levels were measured in 41 female IBS subjects and 33 controls. Indoleamine 2,3-dioxygenase activity was assessed using the Kyn to Trp ratio. Psychiatric co-morbidity was assessed using the Patient Health Questionnaire, and severity of IBS assessed using self-report ordinal scales. Irritable bowel syndrome subjects had increased Kyn concentrations compared with controls (P = 0.039) and there was a trend for Kyn:Trp to be increased in the IBS group (P = 0.09). There was a positive correlation between IBS severity and Kyn:Trp (r = 0.57, P < 0.001). Those with severe IBS symptoms had increased Kyn:Trp (P < 0.005) compared to those with less severe symptoms and controls, and were over twice as likely to have depression or anxiety compared to those with less severe IBS (RR = 2.2, 95% CI 1.2-3.9). No difference in IFN-gamma levels was observed between groups; however, IFN-gamma was positively correlated with Kyn:Trp in IBS (r = 0.58, P = 0.005) but not controls (r = 0.12, P = 0.5). Females with IBS have abnormal Trp catabolism. The Kyn:Trp is related to symptom severity, and those with severe IBS symptoms have increased shunting of Trp along the Kyn pathway which contributes to the abnormal serotonergic functioning in this syndrome.

Psychophysiology of visceral pain in IBS and health

The psychophysiology of visceral pain as it relates to gastrointestinal motility, visceral sensitivity, and putative mechanisms of the processing of visceral stimuli by the central and peripheral nervous systems are discussed. Peripheral mechanisms may include low-grade mucosal inflammation, and it is likely that central nervous mechanisms such as neuronal plasticity at the level of the spinal cord and attentional bias at the cortical level are relevant for the chronification of visceral pain. From a psychophysiological perspective, visceral pain therefore remains a complex symptom because behavioral variables, such as the way an individual deals with stress, may be as important for the etiology of visceral pain as, for example, a history of inflammation.

The frequency of the psychiatric symptoms in the patients with dyspepsia at a university hospital

OBJECTIVE

According to the psychiatric hypothesis, the symptoms of dyspepsia may be due to depression, anxiety or a somatization disorder. We investigated the frequency of psychiatric symptoms in patients undergoing endoscopic procedures with dyspepsia, either with or without pathological findings, and compared this with control subjects without dyspeptic symptoms.

METHODS

Ninety patients with dyspeptic symptoms and 90 control subjects participated in the study. Both the patients and the controls were asked to complete a questionnaire about socio-demographic characteristics, the Turkish version of the Spielberger State-Trait Anxiety Inventory (STAI) and the Symptom Check List-90 (SCL-90). In order for us to determine whether the criteria for any of the conditions listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) were met, the patients were asked to take part in the Structured Clinical Interview for DSM-IV disorders.

RESULTS

Of the participants, 47.8% had a psychiatric disorder according to DSM-IV criteria, somatoform disorder (44.2%) being the most common. While 42.2% patients were determined to have a pathological finding using endoscopic evaluation, 57.8% had no findings. Together with the somatization and obsessive-compulsive disorder subscale scores, the total SCL-90 score and the mean trait anxiety score were statistically significantly higher in participants with no pathological findings. There were trends for anxiety (13.2% vs. 7.7%) and mood (2.6% vs. 0.0%) disorders to be more frequent in patients with pathological findings, while somatoform disorder+depressive disorder (17.3% vs. 5.2%) was more frequent in patients with no findings, although the differences were not statistically significant (Z=0.7, P>.05). The scores of state-trait anxiety, somatization, obsession-compulsion, depression, anxiety, phobic anxiety and psychotism subscales, and the total SCL-90 score were statistically significantly higher in those participants without a pathological finding than in the controls.

CONCLUSIONS

Regarding the high frequency of psychiatric disorders in patients with dyspeptic symptoms, we think that such patients should be evaluated by two separate departments, gastroenterology and psychiatry.

No difference in symptoms of irritable bowel syndrome between healthy subjects and patients with recurrent depression in remission

There is bidirectional comorbidity between anxiety/depression and irritable bowel syndrome (IBS). To investigate the prevalence of IBS symptoms, and factors associated with gastrointestinal symptoms in patients with recurrent depressive disorder. Patients (n = 95) with recurrent type of major depression according to DSM-IV criteria and sex- and age-matched controls (n = 190) were sent questionnaires investigating symptoms of IBS [Gastrointestinal Symptom Rating Scale (GSRS)-IBS] and symptoms of anxiety and depression [Hospital Anxiety and Depression Scale (HADS)]. Medical records were checked over a 10-year period for chronic somatic symptoms or diseases. Seventy-three patients with unipolar disorder (mean age 63.6 years SD 13.8; range 23-86 years) and 156 controls (mean age 59.2 years SD 11.6, range 21-85 years) responded. Patients with recurrent depression had higher GSRS-IBS scores and showed a strong correlation between symptoms of IBS and anxiety-depression (r(s) = 0.54; P < 0.001). IBS symptoms were also associated with multiple pain symptoms, higher health-seeking behaviour and selective-serotonin-reuptake inhibitor intake. However, patients with recurrent depression (n = 46) in remission (HADS-Depression score <8) did not have more symptoms of IBS than controls (GSRS-IBS median score 6.0 vs 6.5; P = 0.46). There is a strong association between symptoms of IBS and symptoms of anxiety and depression, whereas depressive patients in remission do not have more IBS symptoms than controls.

Risk of irritable bowel syndrome after an episode of bacterial gastroenteritis in general practice: influence of comorbidities

BACKGROUND & AIMS

Given the discrepant estimates of incidence rates of irritable bowel syndrome (IBS) after gastroenteritis (GE), we performed a cohort study to quantify this risk in community subjects and to identify factors acting as modifiers of this effect.

METHODS

In a previous study, we identified patients aged 20-74 years with a first ever episode of bacterial GE during 1992-2001. We excluded patients with a history of bowel disease and cancer, resulting in a cohort of 5894 individuals with GE. From the same source population, a control group free of GE was sampled. We followed up the 2 cohorts to identify incident cases of IBS. A nested case-control analysis was performed to quantify the role of potential risk factors.

RESULTS

During a mean follow-up period of 4.1 years, 1105 patients developed IBS. The incidence rate of IBS after an episode of bacterial GE was 98.2 per 10,000 person-years, and 45.3 per 10,000 person-years in the comparison cohort. The adjusted relative risk of IBS associated with bacterial GE was 2.2 (1.5-2.9) compared with the control cohort. The nested case-control analysis adjusting for additional risk factors produced similar results (odds ratio, 1.8; 95% confidence interval, 1.5-2.1). The risk of IBS after GE was increased significantly in patients with depression, anxiety, stress or sleep disorders, prior gastrointestinal morbidity, or prolonged use of antibiotics.

CONCLUSIONS

The risk of IBS in community individuals after having bacterial GE was two fold greater in the general population. Pre-existing psychologic and gastrointestinal comorbidities independently increase this risk of developing IBS.

Depression in patients with irritable bowel syndrome in Jos, Nigeria

AIM: To study the brain-gut interaction and the effect of behavioral or psychiatric conditions on irritable bowel syndrome (IBS) in an African population.

METHODS: IBS was diagnosed using the Rome II diagnostic criteria. The entry of each patient was confirmed following detailed explanations of the questions. Four hundred and eighteen patients were studied. Subjects satisfying the Rome II criteria for IBS were physically examined and stool microscopy was done to identify the presence of “alarm factors”. Depression was diagnosed using the symptom-check list adapted from the Research Diagnostic Criteria (DSM-IV) of the American Psychiatric Association.

RESULTS: Seventy-five (56.8%) of the 132 IBS patients were depressed whereas only 54 (20.1%) of the 268 non-IBS patients were depressed. There was a significant relationship between IBS and depression (χ² = 54.29, Odds ratio = 5.21, 56.8 ± 8.4 vs 20.1 ± 5.2, P = 0.001). Even though constipation predominant IBS patients were more likely to be depressed, no significant relationship was found between the subtype of IBS and depression (χ² = 0.02, OR = 0.95, P = 0.68).

CONCLUSION: IBS is significantly associated with major depression but not gender and bowel subtypes of the patients. Patients with IBS need to be evaluated for depression due to the highly significant relationship between the two conditions.

Factors associated with the development of post-infectious functional gastrointestinal diseases: does smoking play a role?

OBJECTIVES

Irritable bowel syndrome (IBS) is associated with psychological stress, alterations in gut motor function and/or visceral perception. Previous studies suggest 7-32% of people develop IBS after bacterial gastroenteritis but the exact mechanisms underlying post-infectious IBS are not clear. The present study's aim was to examine the role of possible causative factors in the development of post-infectious functional gastro-intestinal disorders (FGIDs), including IBS.

METHODS

A prospective cohort study where 122 people without a prior FGID under study and with stool-positive bacterial gastroenteritis consented to participate. The presence or not of IBS, functional dyspepsia or functional diarrhoea was diagnosed at the start and on 6-month follow-up using self-complete Rome II modular questionnaires. Demographic data, smoking, alcohol use, anxiety and depression (using the Hospital Anxiety and Depression Scale), and life events and impact (using the Life Events Survey) were collected at the start of the study.

RESULTS

One hundred and seven questionnaires were returned with 25 participants (23.4%) developing a FGID and 16 participants presenting symptoms consistent with IBS (15%). Smoking was significantly associated with the development of a post-infectious FGID (odds ratio = 4.8, 95% confidence interval = 1.5-15.2) on regression analysis.

CONCLUSIONS

Post-infectious FGIDs appear to be associated with smoking. Smoking is known to moderate gut immunity in other disorders such as ulcerative colitis and Crohn's disease. This study adds to increasing evidence for an organic basis to post-infectious FGIDs, perhaps moderated via inflammatory pathways.

The presentation of irritable bowel syndrome in the context of somatization disorder

BACKGROUND AND AIMS

Somatization disorder, a female predominant disorder, has been found with higher than expected prevalence in previous studies of irritable bowel syndrome (IBS) and might be responsible for some of the comorbidity and excessive health care resource use associated with IBS. The study's aim was to determine within a female IBS population the degree of segregation of psychiatric illness, functional disorders, and health care utilization with somatization disorder.

METHODS

In a prospective, 6-month follow-up study, psychiatric disorders were assessed with the Diagnostic Interview Schedule, gastrointestinal and other symptoms with self-report questionnaires, and medically unexplained complaints by thorough chart review. The setting was a university gastroenterology clinic. The participants were a convenience sample of female clinic attendees with IBS (N = 56).

RESULTS

Somatization disorder was diagnosed in 25% of patients and highly probable in another 5%. Somatization disorder was associated with significantly greater numbers of gastrointestinal and other symptoms, psychiatric disorders, physicians consulted, telephone calls to physicians, urgent care visits, medication changes, and missed work days and with benzodiazepine use. On follow-up, somatization disorder was associated with psychiatric and IBS symptoms, medication changes, and treatment dissatisfaction. Both somatization disorder and other psychiatric illnesses were associated with other functional gastrointestinal disorders; only somatization disorder remained predictive in a regression model that controlled for the presence of other psychiatric illness.

CONCLUSIONS

Among female IBS patients attending a university gastroenterology clinic, many aspects of comorbidity and health care behaviors previously associated with IBS segregated with the diagnosis of somatization disorder. Recognition and appreciation of somatization disorder in IBS have important ramifications for the conduct of research and clinical practice.

Review article: The rationale for antidepressant therapy in functional gastrointestinal disorders

The rationale for antidepressants in the treatment of functional gastrointestinal disorders (FGDs) has been the subject of much interest. However, because of our incomplete understanding of FGDs, this rationale remains unclear. A key point is whether the high degree of psychiatric co-morbidity associated with FGDs (40-90%) represents a shared pathophysiology or the ascertainment bias of tertiary referral patients. Our aims were four-fold: (i) to review the current rationale for antidepressant therapy in FGDs; (ii) to review the studies comparing the characteristics of FGDs with both organic gastrointestinal disease and psychiatric disorders; (iii) to propose a model of FGDs which explains the high psychiatric co-morbidity; (iv) to compare the treatment regimes and effectiveness of antidepressants in FGDs and psychiatric illnesses. The review highlights two important observations. Firstly, the characteristics of FGDs are similar to those of affective disorders and dissimilar to those of organic disease. Secondly, although antidepressants benefit FGD sufferers, their benefits in psychiatric illnesses are greater. We conclude that, in view of the degree of similarity between FGDs and affective disorders, FGDs could be considered as affective disorders in their own right and, if the prescription of antidepressants conformed to their use in affective disorders, FGD morbidity would be reduced.

Inflammatory bowel disease versus irritable bowel syndrome: a hospital-based, case-control study of disease impact on quality of life

BACKGROUND

Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) are intestinal diseases perceived differently by patients and doctors: the former is considered essentially as an 'organic' disease (i.e. an illness in which the role of stress or psychological factors is at best secondary to the disease itself), whereas the latter is acknowledged as a 'functional' disorder (i.e. illness thought to be more in the 'mind' than in the body of the patient). Accordingly, the respective impact of the two diseases on patients' health-related quality of life (HRQOL) is perceived to be very different. We aimed to compare the relative impact of the disease on HRQOL, psychological profile and perceived burden of stressful life events in two groups of outpatients suffering from IBS and IBD and attending our outpatient department at an Italian university hospital. Eighty patients with IBD (26 with ulcerative colitis and 54 with Crohn disease) and 85 controls with IBS formed the patient samples of the study.

METHODS

Three questionnaires were given to the patients while they were attending the outpatient department because of their previously diagnosed disease, namely the SF-36 (a generic well-validated tool for measuring HRQOL), the SCL-90 (for assessing the psychological profile of patients), and the Holmes & Rahe schedule (for the assessment of stressful life experiences). The results were then compared by means of analysis of variance (ANOVA) and Bonferroni-adjusted t test, when appropriate.

RESULTS

HRQOL appeared to be similarly reduced in both disease groups (SF-36 overall mean value: 58.2 +/- 16.1 in IBS patients versus 56.4 +/- 22.3 in IBD patients: P > 0.05) in comparison with normative Italian data. Furthermore, the overall severity of psychological symptoms was not statistically different between patients suffering from IBD versus IBS, as shown by SCL-90 mean scores of 0.89 + 0.45 versus 0.83 +/- 0.48, respectively (P > 0.05). On the contrary, the severity of recent stressful life experiences was perceived to be higher by IBS than by IBD patients (mean SRE score: 110.8 = 110.2 versus 61.6 +/- 78.8; P < 0.05).

CONCLUSION

Our study supports the notion that, at least in referral centres, patients with IBS show health-related quality of life, psychological distress and recent occurrence of stressful life events of severity at least comparable with age-matched IBD patients.

The irritable bowel syndrome and psychiatric disorders in the community: is there a link?

OBJECTIVE

Psychiatric morbidity is high among patients who present to referral centers with irritable bowel syndrome (IBS). However, few studies have investigated the relationship between psychiatric disturbance and IBS in community samples. We hypothesized that psychiatric disorders are linked to IBS in the general community, but this is influenced by the criteria used to establish a diagnosis of IBS.

METHODS

The data were collected from a birth cohort born in Dunedin (New Zealand) between April 1972 and March 1973. This cohort consisted of 1037 members (52% male), who were assessed at ages 3, 5, 7, 9, 11, 13, 15, 18, 21, and 26 yr. GI symptoms were recorded at age 26 yr, using an abbreviated version of the Bowel Symptom Questionnaire; psychiatric history was obtained at ages 18 and 21 yr, using a modified version of the Diagnostic Interview Schedule.

RESULTS

The prevalence of IBS was 12.7% according to the Manning criteria and 4.3% according to the Rome II criteria. The IBS was not significantly related to a diagnostic history for psychiatric illness overall, nor to a history of anxiety disorders, depressive disorders, and substance dependence. These results were independent of the IBS criteria used; there was no association between psychiatric history and IBS when IBS was defined according to the Manning criteria (p = 0.11 to 0.98) or the Rome criteria (p = 0.18 to 0.92): Rome and Manning criteria subjects did not significantly differ from each other in terms of psychiatric history (p = 0.16 to 0.89).

CONCLUSION

In a cohort of young adults with IBS from New Zealand, IBS appears to not be related to psychiatric disorders.

Core mental state in irritable bowel syndrome

OBJECTIVE

Psychiatric illness is higher among patients with irritable bowel syndrome (IBS) who seek medical care; however, a specific psychopathology that differentiates patients with IBS from patients with other organic gastrointestinal disorders has not been found. In the study described here, we investigated the predominant psychiatric symptoms in women with IBS.

METHODS

The criteria of Manning et al., as modified by Thompson et al., were used to make the diagnoses of IBS. Psychiatric assessment was performed by using a structured interview in 64 women, aged 20 to 70 years, 36 with IBS and 28 with chronic cholelithiasis. Diagnosis of chronic cholelithiasis was made by histopathological examination. The final diagnoses were confirmed by interview after 1 year. The diagnostic system based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was used to make the current diagnoses. The Present State Examination (PSE)-Index of Definition (ID) computer program (CATEGO) was used to define total psychopathology (total PSE score), current clinical severity (ID), and clusters of psychiatric symptoms.

RESULTS

No difference in the specific DSM-IV diagnostic categories was found, but there were more total depressive disorders in the IBS group. The ID and total PSE score were high among patients with IBS. Multiple logistic regression analysis showed that duration of gastrointestinal pain, and the symptoms of general anxiety, and hypochondriasis significantly predicted a diagnosis of IBS.

CONCLUSIONS

Female patients with IBS are categorized into the general DSM-IV category of depressive disorder, their current psychiatric severity is high compared with that of women with chronic cholelithiasis, and patients with IBS are characterized by the psychiatric syndromes of general anxiety and hypochondriasis. The implications of these findings and areas for future research are discussed.

Efeito do tratamento da depressão sobre o esvaziamento gástrico

O esvaziamento gástrico foi medido por meio de refeição sólida marcada com 99mTc em 11 pacientes que atendiam os critérios de "depressão maior" do DSM-III-R antes e após o tratamento com fluoxetina (20 a 40mg por dia) durante nove semanas. Após o tratamento não se observou redução no tempo para o esvaziamento gástrico de metade da refeição de prova (T1/2) em relação a antes do tratamento. Pode-se, no entanto, separar os pacientes em dois subgrupos: 1) Os que exibiram resposta ao antidepressivo (redução do escore da Escala de Depressão de Hamilton >50%) e apresentaram redução significativa do T1/2 (p<0,001) e 2) Os pacientes que, sem resposta ao tratamento (redução do escore da Escala de Depressão de Hamilton £50%), não apresentaram redução do T1/2 (p>0,10). Concluímos que a alteração da velocidade do esvaziamento gástrico pode estar correlacionada à resposta ao tratamento antidepressivo e que sua redução ou aumento não pode ser atribuída à ação farmacológica da fluoxetina sobre o estômago, mas antes ao efeito da melhoria da depressão sobre a motilidade gástrica.

Features of eating disorders in patients with irritable bowel syndrome

The relationship between characteristics of irritable bowel syndrome (IBS) and eating disorders (ED) was investigated in a clinical sample of 43 female and 17 male IBS patients who completed the Eating Disorder Inventory (EDI). A diagnosis of IBS was generally unrelated to the Body Dissatisfaction, Perfectionism, and Ineffectiveness subscales of the EDI, but symptom severity was correlated with Perfectionism and Ineffectiveness. Severe bouts of vomiting were significantly associated with desires for lower body weight and reported binge-purge behaviors and cognitions measured by the Bulimia subscale of the EDI. Results suggest the need for a more comprehensive understanding of both types of illness as well as a possible framework for future empirical work.

The value of screening for psychiatric disorders prior to upper endoscopy

Gastrointestinal (GI) complaints are among the most common symptoms in primary care yet are frequently unexplained and often lead to costly diagnostic testing. We sought to determine the prevalence of psychiatric disorders in patients with unexplained GI complaints undergoing upper endoscopy, and the likelihood of endoscopic abnormalities in patients with and without psychiatric diagnoses. We prospectively evaluated 116 adult patients who were undergoing upper endoscopy to evaluate GI complaints. All subjects received a structured psychiatric interview prior to endoscopy using PRIME-MD, and endoscopists were blinded to the PRIME-MD results. Psychiatric disorders were detected in 70 (60%) patients. Overall, there were 113 diagnoses (some patients had multiple disorders) with the most common being somatoform (44%), depressive (29%), and anxiety (19%) disorders. Only 29 patients had major endoscopic abnormalities, including esophageal disease (14), peptic ulcer (9), severe gastritis (4), gastric cancer (1), and esophageal cancer (1). There was a much higher prevalence of psychiatric disorders in patients without major endoscopic abnormalities (74% vs. 21%, p < 0.0001). Psychiatric disease was strongly predictive of endoscopic findings (OR for major abnormality = 0.11 in women, and 0.40 in men), especially if somatoform disorder was present (OR = 0.15). We conclude that, with a simple questionnaire, psychiatric disorders can be diagnosed in a large proportion of patients with unexplained GI complaints who are referred for upper endoscopy. The presence of a psychiatric disorder, particularly if somatoform, makes it unlikely that endoscopy will reveal significant GI disease.

Review article: irritable bowel syndrome

Irritable bowel syndrome is a disease that can be diagnosed positively on the basis of an established series of criteria and limited exclusion of organic disease. It is the most common disease diagnosed by gastroenterologists and affects about 20% of all people at any one time. Symptoms fluctuate, and the overall prevalence rate is relatively constant in Western communities. Ten per cent of patients present to their physicians; the illness has a large economic impact on health-care utilization and absenteeism. Irritable bowel syndrome is a biopsychosocial disorder in which three major mechanisms interact: psychosocial factors; altered motility; and/or sensory function of the intestine. Management of patients is based on positive diagnosis of the symptom complex, limited exclusion of underlying organic disease and institution of a therapeutic trial. If patient symptoms are intractable, further investigations are needed to exclude significant motility or other disorders. Symptomatic treatment includes fibre for constipation, loperamide for diarrhoea and low-dose antidepressants or infrequent use of antispasmodics for pain; novel pharmacological agents, psychotherapy and hypnotherapy are being evaluated.

The prevalence of symptoms of irritable bowel syndrome among acute psychiatric inpatients with an affective diagnosis

An interview study of 87 inpatients with affective diagnoses, according to the International Classification of Diseases (9th Edition), yielded a prevalence of irritable bowel syndrome (IBS) of 39.7%, approximately twice that found in the general population. The IBS symptoms almost invariably preceded the onset of the affective disorder, but were exacerbated by it. The consultation rate for bowel symptoms (41.9%) was greater than that in the general population. In this study, 69.2% of consulters and 55.5% of nonconsulters had experienced an exacerbation of their IBS symptoms since the onset of their emotional disorder. These findings suggest that such disorders may influence the subjective severity of IBS and also consultation behavior, but do not play a major part in the etiology of the gastrointestinal symptoms.

Psychiatric disorder and outcome in irritable bowel syndrome

A link between irritable bowel syndrome (IBS) and psychiatric illness is well recognized. The authors set out to establish whether a group with a risk of poor outcome IBS could be identified at presentation to a general hospital clinic in a prospective series of 70 subjects. Potential risk factors showed no correlation with IBS outcome at 6-9 months. There was a high rate of persistent mental illness. Clinicians offering specialist care for IBS should consult with psychiatric services to provide assessment irrespective of IBS outcome if major psychopathology is not to be neglected.

Psychometric scores and persistence of irritable bowel after infectious diarrhoea

BACKGROUND

Although previous studies have shown that psychological disturbances are frequently associated with the irritable bowel syndrome (IBS), the relation was not necessarily cause and effect. The development of chronic bowel symptoms resembling IBS after an episode of acute gastroenteritis has allowed us to examine prospectively the role of psychological factors.

METHODS

75 patients with acute gastroenteritis completed a series of psychometric tests soon after admission to hospital. Of these, 22 had persistent symptoms compatible with IBS after the acute illness, and in 20 of these the symptoms were still present at six months.

FINDINGS

At the time of their initial illness, patients who subsequently developed IBS symptoms had higher scores for anxiety, depression, somatisation, and neurotic trait than those who returned to normal bowel function. The psychometric scores had not changed when remeasured three months after the acute illness. Lactose malabsorption was not an important factor.

INTERPRETATION

These results support the hypothesis that psychological factors are important in IBS.

The Zurich Study: XXII. Epidemiology of gastrointestinal complaints and comorbidity with anxiety and depression

A representative cohort of Swiss adults recruited at age 20 years and interviewed at ages 23, 28 and 30 years was studied regarding the symptomatology, prevalence and longitudinal course of functional gastrointestinal symptoms and their association with psychiatric syndromes. A functional gastrointestinal complaint was identified if a proband reported symptoms at least eight times in the past year or for a duration of at least 2 weeks without medical explanation and with a moderate degree of distress. Of the population, 9.4-17.7% was found to suffer from functional stomach complaints and 4.9-16% from functional intestinal complaints. Women reported functional gastrointestinal complaints two to three times more often than men, and increasingly so with age. The overlap of stomach and intestinal complaints was modest with 2.0-6.7%. Cross sectionally, functional stomach complaints were significantly associated with major depression (DSM-III-R), recurrent brief depression (RBD), subthreshold RBD and dysthymia, and with subthreshold panic disorder, agoraphobia, social phobia and recurrent brief anxiety. Functional intestinal complaints showed a consistently significant association with RBD, dysthymia, major depression, subthreshold RBD, panic disorder, subthreshold panic disorder, agoraphobia, simple and social phobia and generalized anxiety disorder. Individuals who at younger ages suffered from functional gastrointestinal complaints did not show an increased risk for a subsequent development of an anxiety or depressive disorder. Functional gastrointestinal complaints reflect an unspecific concomitant vegetative disturbance common to depression and anxiety; they do not reflect a risk factor for the development of a specific anxiety or depressive disorder.

Detecting psychological distress among patients attending secondary health care clinics. Self-report and physician rating

A study was conducted to determine the prevalence of psychological distress, as reported by patients and their physicians, in orthopedic, neurology, dermatology, and ophthalmology clinics; to study their accuracy in detecting psychological distress; and to determine if there is any connection among psychological distress, accuracy of detecting distress, and use of mental health and primary health care physicians' prognosis for the somatic complaints. Five hundred and fifty-six patients, ages 18-21, responded to the Psychiatric Epidemiology Research Interview Demoralization Scale (PERI-D), a measure of psychological distress, and to questions about their mental health and use of mental health and primary health services. Physicians, who were blind to patients' responses, were asked to what extent they thought the cause of patients' complaints was physical and to what extent they thought it was psychological in nature, and to prognosticate. Based on the PERI-D, about 25% of patients were distressed, this was less for females than males and varied between clinics. Based on self-reporting, about 14% of patients (males and females) were distressed. Based on physician reporting, about 17% (males less) were distressed. Physicians identified 35% of the PERI-D-distressed cases and 79% of nondistressed cases. About 66% of patients identified their distress and 83% their lack of distress. Increased use of primary health care and mental health care was related to distress. The prognosis was negatively related to distress. Based on this study, there is a need for more attention to psychological distress among secondary health care patients. Patients' ability to identify their distress suggests the importance of involving the patient in the diagnostic process. Correct detection of distress alone does not appear to decrease the use of primary medical and mental health services.

Irritable bowel syndrome and family history of psychiatric disorder: a preliminary study

A series of 70 consecutive patients with irritable bowel syndrome (IBS) were interviewed concerning their family history of psychiatric disorders. A series of 60 consecutive patients with major depression (MDE) were also interviewed, as were a control group of 46 relatives of patients with organic brain disease. The results showed that both IBS and MDE groups had a similar, higher prevalence of relatives with psychiatric illness than controls, and that this was due to a higher prevalence of anxiety and depressive disorder in the relatives. The implications of these findings are discussed.

Anxiety and depression in patients with abdominal bloating

Eighteen patients with a syndrome of abdominal bloating and discomfort were examined to explore the relationship between their symptoms and their emotional problems. They were compared with 33 patients with Crohn's disease and 38 normal, healthy volunteers. Using the Hospital Anxiety and Depression Scale, patients with bloating were found to resemble patients with Crohn's disease. Both groups showed increased anxiety and depression. After controlling for age, sex, education, occupation, personality variables and childhood experience, there was a trend towards more anxiety in the bloating group compared with normal subjects and a significant difference for depression. These characteristics appear to be related to the effects of the illness or to selection, but not to personality or childhood experience. Although psychiatric problems are common among patients with abdominal bloating and pain who stay in touch with a clinic, they are not the primary cause of the disorder.

Selective affective biasing in recognition memory in the irritable bowel syndrome

The cognitive model of depression assigns a central role to negatively biased information processing in the pathogenesis of the emotional disorder. The relationship between depression and irritable bowel syndrome (IBS) was explored from a cognitive perspective. A word recognition memory task was constructed: subjects had to memorize and subsequently recognise a set of emotionally loaded stimulus words with either positive, neutral, or negative connotations. Four age matched groups participated--30 IBS patients, 28 depressed patients, 28 patients with organic gastrointestinal disease, and 30 healthy volunteers. The depressed patients, as would be expected, showed a significant bias in favour of emotionally negative words (p < 0.05): the IBS patients showed the same negative bias. In addition the IBS patients made significantly more false-positive type errors in recognising emotionally negative words than either the depressed patients (p < 0.05) or the healthy volunteers (p < 0.01). This suggests that the IBS patients have a peculiar confirmatory bias for negative material. This may have clinical relevance in terms of the IBS patients' evaluation of their own abdominal sensory experience.

Narcissism, interpersonal adjustment, and coping in children of Holocaust survivors

We tested the theory of intergenerational transmission, which suggests that the Holocaust trauma, combined with circumstances in the survivors' lives (early loss of a parent, was a child survivor, had a hiding experience) and circumstances in their children's lives (having a father who survived, being the first-born or only child, and not participating in a children of survivors group) would result in poorer interpersonal adjustment and coping and greater narcissism than in children of survivors without these circumstances and children of parents who imigrated from Europe before World War II. Three hundred fifty children (241 children of Holocaust survivors and 109 children o escaped European-born partners) completed four scales of the California Psychological Inventory (Gough, 1988), the O'Brien Multiphasic Narcissism Inventory (O'Brien, 1987), and the Hardiness scale (Kobasa & Puccetti, 1983). The results failed to support the attribution of adjustment and personality differences in children of survivors to survivor status.

Psychiatric disorders in relation to medical illness among patients of a general medical out-patient clinic

In many patients clinical care in general medical settings is complicated by the presence of psychiatric disorders in addition to the presenting physical symptoms. In the present study the prevalence and type of psychiatric disorders was assessed in relation to the medical diagnostic findings in a general internal medicine out-patient clinic. The Present State Examination, a standardized psychiatric interview, was used to detect psychiatric disorders in 191 newly referred patients. Psychiatric disorders were found to be particularly prevalent among patients with medically ill-explained or unexplained symptoms. The prevalence of psychiatric disorders was 15% for patients with a medical explanation for their presenting symptom, 45% for patients with ill-explained and 38% for those with unexplained symptoms. Approximately 40% of the patients with psychiatric disorders met DSM-III-R criteria for somatization disorder or hypochondriasis, suggesting that these disorders contributed in particular to general medical out-patient referrals.

Irritable bowel syndrome: the influence of psychological factors on the symptom complex

A 5 yr follow up of Irritable Bowel Syndrome (IBS) is described. With the notable exception of abdominal pain, gastrointestinal symptoms changed little over this period, and were unrelated to the overall improvement in wellbeing reported by 65% of patients. The anxiety ratings of the improved and unimproved groups at initial assessment and 5 yr later are considered. There was a persisting trend towards higher ratings in those who did not improve, and an exaggeration of this trend after 5 yr, which owed more to a reduction in anxiety in those who improved than to an increase in the anxiety ratings of those who did not. There was no evidence that depression ratings behaved similarly. We suggest that anxiety may be more important in the maintenance of the IBS symptom complex, and depression more important in determining intercurrent fluctuations in perceived distress and illness behaviour in response to adverse life events.

Irritable bowel syndrome: assessment of psychological disturbance and its influence on the response to fibre supplementation

This study describes the effect of fibre supplementation on the gastrointestinal symptoms and general wellbeing of patients with constipated irritable bowel syndrome. In a single centre, double blind, placebo controlled trial of 3 months duration, a daily supplement of 4.1 g fibre produced no greater change in gastrointestinal symptoms than placebo. Pretreatment constipation was related to baseline fibre intake. Overall outcome was the same in treated and control groups; a considerable placebo response was evident. This level of fibre supplementation is not a useful treatment; improving neither constipation nor other symptoms. At the outset pain severity correlated with depression score on psychometric testing. Those who felt better at the end of the study scored significantly lower for depression at outset than those who felt no better. In irritable bowel syndrome a depressive emotional state profile is a powerful determinant of outcome, shaping the response to treatment, which includes a considerable placebo element.

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.

A controlled trial of psychological treatment for the irritable bowel syndrome

One hundred two patients with irritable bowel syndrome were studied in a controlled trial of psychological treatment involving psychotherapy, relaxation, and standard medical treatment compared with standard medical treatment alone. Patients were only selected if their symptoms had not improved with standard medical treatment over the previous 6 months. At 3 months, the treatment group showed significantly greater improvement than the controls on both gastroenterologists' and patients' ratings of diarrhea and abdominal pain, but constipation changed little. Good prognostic factors included overt psychiatric symptoms and intermittent pain exacerbated by stress, whereas those with constant abdominal pain were helped little by this treatment. This study has demonstrated that psychological treatment is feasible and effective in two thirds of those patients with irritable bowel syndrome who do not respond to standard medical treatment.

Non-ulcer dyspepsia

This paper discusses the definition of non-ulcer dyspepsia and its relationship to other functional bowel disorders. The research on the prevalence, outcome, aetiology and management of this condition is reviewed with particular emphasis on its multifactorial nature. Future research will need to concentrate on the inter-relationship of physical and psychosocial factors including the health beliefs of the individual patient.

Psychogenic abdominal pain

A series of 25 patients referred for psychiatric consultation with nonspecific abdominal pain (NSAP) are compared with a prospectively admitted series who were not referred. The referred patients had a longer duration of pain and also had high levels of psychiatric illness. The referred patients had more life events associated with the onset of their pain than controls. Inquiry about previous psychiatric history, childhood abuse, and a symptom model would increase the detection of NSAP patients who require psychiatric evaluation. Outcome after recommended treatment is also addressed.

An investigation of 'functional' somatic symptoms among patients attending hospital medical clinics in Pakistan--I. Characteristics of 'non-organic' patients

Six hundred medical clinic attenders at the Mayo Hospital, Lahore, Pakistan, were screened using the Bradford Somatic Inventory (BSI) in Urdu. The physicians' clinical diagnosis was recorded. The characteristics of mood-disordered, functional and no-diagnosis groups were compared with patients receiving organic diagnoses. Of the non-organic patients, only the mood-disordered group reported significantly more BSI symptoms than the organic group. The functional group did not have especially high scores. All groups reported a greater mean number of BSI symptoms than a student comparison group. Among the non-organic patients, there was no relationship between the number of BSI symptoms reported and sex, age, education or occupational group.

Therapeutic trial in dyspepsia: its role in the primary care setting

Owing to the vast proportions of the dyspeptic patient population, it is not practicable to initiate diagnostic investigations immediately in every single patient who presents with dyspepsia. The risks associated with postponing definite diagnosis 4-8 weeks in dyspeptic patients aged less than 45 years are exceedingly small. Therefore, empiric therapeutic trial without a firm diagnosis is an acceptable alternative in those age groups. Those who recover during the course of the trial are spared the costs and inconvenience of invasive tests. Possible adverse consequences for the patients are minimized if the therapy covers those organic diseases that may cause complications (such as peptic ulcer and esophagitis). The concept of diagnosis-free therapeutic trials presupposes, however, that a sufficiently large number of patients are cured and that their need of investigation is permanently eliminated. If not, inevitable investigations are only postponed. In those patients the costs will thereby not only be the same as if early investigation had been carried out, but the total costs may in fact increase in a longer perspective owing to suboptimal management in the period before a firm diagnosis has been established. Thus, the ideal strategy would be to treat those who have a high probability of recovering during the ensuing 6-8 weeks and to investigate those in whom a prolonged course is anticipated. An empiric therapeutic trial must be followed by a thorough evaluation within 8 weeks.

Reduction of gastrointestinal symptoms following treatment for panic disorder

Symptoms of gastrointestinal distress, including those of irritable bowel syndrome, were reported more frequently by patients with panic disorder than by nonanxious controls. Five of 30 subjects with panic disorder met criteria for irritable bowel syndrome, the onset of which coincided with the onset of panic disorder. Effective treatment for the anxiety disorder was accompanied by a reduction in gastrointestinal symptoms in all subjects.

Assessment of central noradrenergic functioning in irritable bowel syndrome using a neuroendocrine challenge test

Desipramine, the monoamine reuptake inhibitor, acts predominantly on noradrenergic neurones, and via alpha-2 receptors brings about the release of growth hormone in normal healthy subjects. Thirteen patients with a diagnosis of irritable bowel syndrome, 10 normal controls and eight patients with peptic ulcer disease were each given a challenge test of desipramine 1 mg/kg body weight. Growth hormone release over a 3 h period was monitored. A blunted response was defined as a failure of growth hormone levels to rise at least 5 mU/l above baseline. Of the 13 patients with irritable bowel syndrome 11 showed such a blunting. The results suggest abnormal central alpha-2 receptor functioning in irritable bowel syndrome.

Physical symptom severity, psychological and social dysfunction in a series of outpatients with irritable bowel syndrome

Details of physical symptoms, psychological and social dysfunction of 42 outpatients diagnosed as having irritable bowel syndrome (IBS) were collected by interview and questionnaire. Social stresses and problems were also elicited as well as the impact of symptoms on their subjects' daily lives. High proportions of subjects were handicapped in their social, sexual and working lives by IBS symptoms and social stresses and problems were common. Forty-eight per cent were classified as having a 'minor psychiatric illness' using the Clinical Psychiatric Interview. Women were more severely affected by physical symptoms (with the exception of diarrhoea) and were more likely to be in pain longer and for more days in the month. They were also more likely than men to be diagnosed as having a psychiatric illness.