Psychosocial aspects of functional gastrointestinal disorders

Gastroenterol Clin N Am 32 (2003) 477–506

Psychosocial aspects of functional gastrointestinal disorders Adriane I. Budavari, MDa, Kevin W. Olden, MDa,b,* a

Department of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Scottsdale, AZ 85054, USA b Department of Psychiatry, Mayo Clinic Scottsdale, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA

The functional gastrointestinal disorders (FGID) are the most common conditions seen in gastroenterology clinics [1], and constitute a significant number of primary care visits [2]. Estimations of prevalence vary depending on the diagnostic criteria used [3,4], but are believed to be similar among different races and in different nations [5–7]. Irritable bowel syndrome (IBS), the most common and most extensively studied FGID, is seen both in older and younger patients, with the latter being more common [8,9]. A telephone survey of US householders estimated the national prevalence of one or more FGID to be 70% [10]. Similarly, a recent population-based study conducted in Canada using the Rome II criteria identified at least one FGID in 61.7% of 1149 respondents (65.6% female, 57.6% male, P \ 0.05) [11]. The most prevalent FGID in this Canadian study were functional colonic disorders (41.6%) and functional esophageal disorders (28.9%). Even though FGID symptoms are common in the community, only a small portion seeks medical attention [12]. Nonetheless, even for most individuals who do not seek medical care, these disorders are associated with significant work absenteeism [10], impaired health-related quality of life (HRQOL) [10], and increased medical costs [13,14]. Despite their frequency, the pathophysiology of the FGID is incompletely understood. To date, these disorders have not consistently been associated with any pathognomonic biochemical, anatomic, or physiologic marker, and there are no data to support the idea that FGID are caused by, or are themselves, a psychologic disturbance. Psychosocial factors, however, such as acute and chronic stress, personality structure, coping skills,

* Corresponding author. E-mail address: [email protected] (K.W. Olden). 0889-8553/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0889-8553(03)00030-X

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psychiatric diagnosis, and abuse history, play a crucial role in FGID with respect to their effects on (1) gut physiology, (2) symptom severity, (3) health care seeking, (4) illness behavior, (5) quality of life, and (6) therapeutic approach. The theoretical model used to describe the bidirectional neural pathways that link the cognitive and emotional centers in the brain with the enteric nervous system (ENS) in the gut has been termed the ‘‘brain–gut axis’’ [15], and represents a unifying hypothesis to explain the FGID. For example, in IBS, the variable influences of life stress, personality and coping, emotions, and psychologic state on gut function as mediated through neurotransmitter release may explain the varied presentations of IBS between patients [4,16]. This concept also helps to explain how psychosocial trauma in the forms of physical or sexual abuse [17] or poor coping style [18] (eg, catastrophizing) can profoundly impact symptom severity, daily function, and health outcomes. For most patients with milder symptoms, who tend to be seen in primary care (if they seek a physician at all), psychologic stressors may not play a significant role, and psychologic interventions are rarely needed. A smaller but well-recognized group of patients with more refractory symptoms, however, suffer considerable impairment in their activities of daily living and HRQOL [17,19,20]. This latter group is much more likely to have comorbid psychologic difficulties or high levels of disability that limit the effectiveness of standard medical management [19,20]. Identification of psychologic disturbance or an abuse history and understanding their impact on the patient’s clinical state and distress are crucial [4]. This recognition in turn can lead to more effective treatment using a multidimensional approach as opposed to merely treating the pattern of the patient’s bowel symptoms [21]. The key to diagnosing and treating FGID is to adopt a biopsychosocial model, a perspective that includes medical, psychologic, and social dimensions [4]. The role of stress Research has shown that severe life stress frequently occurs immediately before the onset of FGID [22,23]. Life stressors can also play a role in symptom exacerbation, health care behavior, and outcomes [24]. In the FGID literature, the term ‘‘stress’’ is used to signify environmental events (stressors) and any incongruity between the stressors and one’s adaptation, such as coping and calling on social support. One useful measure of stressful life events is an interview-based instrument called the Life Events and Difficulties Schedule. At least five studies of GI disorders have used the Life Events and Difficulties Schedule [22,23,25–27] to show an association between stress and GI disorders. Creed et al [23] used the Life Events and Difficulties Schedule to demonstrate that stressful life events were more common in individuals with FGID than healthy controls (60% to 66% of

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FGID patients had experienced severe life events compared with 25% of healthy controls). Interestingly, although the frequency of life events was similar in patients with FGID and organic GI diseases, severe negative life events (bereavement, marital separation, court appearance with threat of imprisonment) were more common in the FGID group, and these events almost always preceded the onset of symptoms. In this study, level of stress in FGID was similar to that occurring in patients who had taken a deliberate overdose of psychiatric medications. Similarly, Craig and Brown [22] found that certain types of stress, or life events, are more often associated with onset of functional GI symptoms. In this study, dissolution of intimate relationships was closely associated with the onset of FGID. Evidence suggests that the presence of life stressors is also an important predictor of symptom exacerbation, treatment-seeking behavior [28], and outcome [29]. The precise mechanisms by which stressful life events ultimately translate into disturbed gut function or symptoms in FGID remain unclear. Several investigators have studied the physiologic effects of experimentally induced stress in an effort to determine the mechanisms behind the relationship between stress and FGID. Bradley et al [30] investigated the effects of experimental stressors on reflux events and showed that although patients reported increased symptoms of reflux when exposed to stressors, the actual number of reflux events was unchanged. Experimentally induced stress seems to delay gastric emptying of solids [31], probably secondary to inhibition of antral motility [32], which could be relevant to some patients with functional dyspepsia. In IBS, postprandial symptoms are common [33] and several studies show a prolonged and exaggerated gastrocolic reflex in terms of myoelectric and motor activity [34,35]. In the studies, however, colonic tone is not altered [36,37]. Finally, Cann et al [38] reported that stress significantly sped mouth-to-cecum transit time in diarrhea-predominant IBS and slowed transit time in constipationpredominant IBS. In general, compared with healthy controls, patients with FGID have increased motor reactivity to various stressors including balloon distention [39], food [34,35], various peptides [40,41], and physical and psychologic stressors [42,43]. Physiologic responses, however, are different between individuals and even different in the same individual over time. There is indeed evidence for motor hyperreactivity, possibly triggered by both psychologic and biologic factors, but motor abnormalities alone cannot fully explain the influence of stress on FGID.

The role of personality and coping style Although there is no consensus on what emotional variables are specifically related to FGID, certain personality factors have been regarded to be of importance. These include emotional hypersensitivity, maladaptive coping, high neuroticism, covert aggression, and hostility [29,44,45].

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A number of studies have used psychometric instruments to compare patients with IBS with controls (either healthy or medical patient groups). The results suggest that patients with IBS tend to be more neurotic and anxious than both people without health problems or people with similar GI complaints who do not seek medical attention [46,47]. Some authors have suggested that perhaps the clinical manifestations of these psychosocial factors, namely the increased levels of stress and anxiety, can result in altered autonomic activity and motility, thereby creating the link between personality and FGID [47–49]. These personality traits, however, are not unique to IBS or the other FGID. Clinic patients with other medical disorders show similar levels of neuroticism [50]. It is not known whether psychosocial variables associated with FGID are related to the FGID themselves, or to concomitant psychiatric disorders or psychosocial distress. For example, is the association between psychometric scores and IBS a result of selection bias? Do people with IBS who seek medical attention represent a subgroup more likely to have concomitant psychopathology? Whitehead et al [51] examined this issue by giving the NEO Personality Inventory and the Symptom Checklist-90-Revised (SCL90-R) to three groups of college students: (1) IBS consulters, (2) IBS nonconsulters, and (3) healthy controls with no bowel symptoms. The NEO Personality Inventory is a self-administered questionnaire containing 181 statements designed to measure five basic dimensions of personality: (1) neuroticism, (2) openness, (3) extraversion, (4) agreeableness, and (5) conscientiousness. The SCL-90-R is a measure of psychiatric symptoms, which is normed against medical outpatients, controlling for the effects of patient status. In addition, a quality of life measure, the SF-36, was administered. In this study, IBS consulters had significantly elevated levels of neuroticism as measured by the NEO Personality Inventory, and on the global symptom index of the SCL-90-R. This latter measure represents the overall level of psychologic distress as reported by the subject. Similar to the findings on the NEO Personality Inventory and the SCL-90-R, the SF-36 also discriminated between IBS care-seekers, IBS nonpatients, and healthy controls after statistically adjusting for the mediating effects of neuroticism. These findings suggest that personality factors, particularly levels of neuroticism (which are most commonly manifested clinically as symptoms of depression, anxiety, or somatization) lead patients to perceive their illness in a more alarming and distressing way. This in turn leads them to seek health care. These data suggest that the presence of psychopathology is certainly not etiologic for the universe of patients with IBS, but rather reflects an important intervening variable, which tends them to seek health care and experience greater distress from their IBS symptoms. Although the association between personality and FGID requires further definition, it is clear that personality features and coping skills should be taken into account when evaluating and treating patients with FGID.

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The role of psychiatric disorders The relationship between FGID and psychiatric disorders has been written about for many years [52]. These early reports relied on clinical perceptions and were not scientifically rigorous. Since the advent of formal diagnostic criteria for both psychiatric and functional GI disorders (the American Psychiatric Diagnostic and Statistical Manual of Mental Disorders and the ROME II criteria, respectively) investigators have been able systematically to study this relationship. Among patients with IBS studied at tertiary centers, the most frequent diagnostic categories are (1) anxiety disorders (panic and generalized anxiety disorder); (2) mood disorders (major depression and dysthymic disorder); and (3) somatoform disorders (pain disorder and somatization disorder) [53–55]. These psychiatric diagnoses often antedate the onset of the bowel disorder [55,56]. Although there are no data to support an etiologic role for psychiatric disturbance, it is generally accepted that psychiatric disturbances have a significant impact on (1) gut physiology, (2) symptom severity, (3) health care seeking and other illness behavior, (4) outcome, and (5) therapeutic approach. The question of whether psychologic factors are truly associated with FGID was first addressed by a number of investigators. These investigators compared samples of IBS-consulters with nonconsulters and found that although there were no psychologic disorders specific for IBS, psychologic disturbance seemed to predict a subset of individuals with IBS who sought medical care [46,57]. In a later population-based study, Walker et al [58] showed that the prevalence of psychiatric disorders among individuals with symptoms typical of FGID was higher than in people without GI symptoms. In addition, the former group had a higher lifetime risk of major depression (7.5% versus 2.9%); panic disorder (2.5% versus 0.7%); or agoraphobia (10% versus 3.6%). Higher rates of major depression (13.4%), panic (5.2%), and agoraphobia (17.8%) occurred in those subjects who complained of increased numbers of GI symptoms. Psychiatric disorder is greater among patients with IBS seen in referral centers than those seen in community clinics or those who do not seek medical evaluation. When evaluating for current psychiatric diagnoses in FGID patients attending referral centers, most investigators have found that between 42% and 61% of these patients meet the criteria for a psychiatric diagnosis, usually for anxiety or depression. This is significantly greater than that seen in the control groups (\ 25%) [59]. Generally, when patients from tertiary care centers have been studied, and lifetime psychiatric diagnoses considered, even higher rates (up to 94%) were reported [54,55]. There are at least two exceptions to this trend, however, noted in the literature [60,61]. Psychiatric comorbidity in IBS patients has been shown to influence disease severity. Recent data suggest that aberrant perception of visceral stimuli in the central nervous system (CNS) may be at least partially

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responsible. Blomhoff et al [62] compared IBS patients with and without phobic anxiety to see if this comorbid psychiatric disorder influenced brain information processing of auditory stimuli, and tried to detect possible consequences with respect to visceral sensitivity thresholds and disease severity. Their study used event-related potentials, auditory-presented words with emotional content, barostat-assessed visceral sensitivity thresholds, and symptom levels in 11 female IBS patients with comorbid phobic anxiety disorder and 22 age-matched female IBS patients without comorbidity. They found that the IBS patients with comorbid anxiety disorders showed differences in central processing of emotional stimuli. Phobic anxiety comorbidity seemed to interfere with the processing of visceral information in the frontal cerebral region and affected visceral sensitivity and IBS symptomatology. This link may also more generally describe the contribution of psychiatric comorbidity to the severity and duration of intestinal motility disorders [63]. The presence of a concomitant psychiatric diagnosis with an FGID is associated with poorer outcomes and, conversely, treatment of the psychiatric disturbance can result in improvement in the FGID [64]. For instance, panic disorder has been frequently linked to both IBS [54,65,66] and functional chest pain [66], and these GI symptoms improve when the concomitant panic disorder is successfully treated [67]. It is extremely important to recognize and treat psychiatric disorders in FGID patients.

The role of abuse Research suggests a strong epidemiologic relationship between selfreported sexual and physical abuse and FGID [68,69]. In a landmark study, Drossman et al [70] interviewed 206 women attending a university-based GI clinic and found that patients with FGID reported a significantly higher rate of early sexual and physical abuse compared with female patients with organic GI diseases (53% versus 37%). Most researchers have replicated these findings [68,71–75]. These studies consistently reported rates of abuse in the 30% to 56% range from referral centers in the United States and Europe. The high frequencies of abuse are not unique to FGID. High prevalences of abuse have been reported by patients with chronic or recurrent painful non-GI functional conditions, such as chronic pelvic pain, headaches, and fibromyalgia [50,76], and patients with certain behavioral disorders like bulimia, morbid obesity, and substance abuse [77]. Furthermore, there is some evidence to suggest that the association of abuse with FGID or any other chronic painful condition also depends on the clinical setting in which the patient is seen [1,17,69]. In fact, it could be argued that the high prevalence of abuse histories among patients with FGID seen at referral centers is a product of selection bias (ie, it is more closely associated with the clinical

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setting than with FGID per se). It has been noted that the frequency of abuse in patients with FGID in primary care settings is lower. In one study, the rate was one half that seen in tertiary care centers [1]. Leroi et al [78] attempted to address this issue by investigating a cohort 144 patients seen in both a tertiary care, university-based GI clinic and a community GI practice. They found that 40% of the patients ultimately diagnosed with a lower GI tract FGID had been sexually abused compared with only 10% of patients who ultimately received an organic diagnosis (P\0.0003). These findings held true in both the referral center and community settings. Abuse history has important implications for the evaluation and management of patients. It increases the odds for seeing a physician [73], for having more severe GI symptoms [79] and more non-GI symptoms [1,77], and for having an associated psychiatric disturbance [80–83], all of which leads to greater disability and overall poorer outcome [17,84]. For instance, Drossman et al [17] found that GI patients with abuse histories reported 70% more severe pain (P\0.0001); 40% greater psychologic distress (P\0.0001); spent over 2.5 times more days in bed in the previous 3 months (11.9 versus 4.5 days, P\0.0007); had almost twice as poor daily function (P\0.0001); saw physicians more often (8.7 versus 6.7 visits over 6 months, P\0.03); and even underwent more surgical procedures (4.9 versus 3.8, P\0.04). The definition of physical and sexual abuse in these studies can vary, and it becomes important to determine which types of abuse tend to be associated with poorer outcomes. Leserman et al [84] found that among GI patients, rape (penetration), multiple abuse experiences, and abuse perceived as life-threatening were associated with poorer health status. This has led to the development of an abuse severity score to try to quantitate abuse severity with the hope that this in turn can predict adverse health outcome [79]. Leserman et al [84] interviewed 239 women presenting for treatment of a FGID at a university-based gastroenterology clinic and found that 55.2% experienced some type of sexual abuse and 48.5% had some history of physical abuse. When severity of abuse was measured by structured interview, patients with sexual abuse were more likely to have increased levels of pain, non-GI somatic complaints, in-bed disability days, lifetime surgeries, psychologic distress, and poor overall functional status. The reason why abuse, particularly in childhood, leads to increased levels of functional bowel complaints and psychiatric disturbance remains incompletely understood. Some authors [69] have suggested that abuse history is not etiologic for any FGID, but is associated with a tendency to communicate psychologic distress through physical symptoms. The presence of an abuse history and associated difficulties may produce a chronic state of symptom amplification originating either at the CNS level (hypervigilance to body sensations) or gut level (visceral hypersensitivity and conditioned hypermotility). It may influence the individual’s appraisal of those symptoms (causing increased health care seeking and health anxiety), and

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perhaps even lead to unwarranted feelings of guilt and responsibility, making spontaneous disclosure unlikely [85]. Eventually, a vicious cycle of health care seeking, refractoriness, and repeated referral develops if the health care system provides only symptomatic treatments and does not address the abuse issues [84]. In conclusion, patients with FGID attending referral centers commonly suffer from high frequencies of sexual and physical abuse [69]. Alarmingly, physicians are often unaware of this abuse history. In the study by Drossman et al [70], the physicians knew about the abuse history in only 17% of cases, and 30% of the victims had never previously disclosed this history to anyone. Abusive experiences negatively impact health status [84]. Taking an abuse history should be included with other aspects of history taking in patients who present to gastroenterology practices. The role of health beliefs and illness behaviors As discussed previously, FGID are very common in the community, but symptoms are not always perceived as illness, and most individuals do not seek medical evaluation or treatment. Much research, particularly in the area of IBS, has focused on trying to identify the factors that lead certain individuals to seek health care (IBS-consulters versus nonconsulters or nonpatients). This subgroup of IBS patients accounts for an estimated $8 billion in health care expenses annually [14]. Numerous investigators have found that the main factors differentiating IBS-consulters from nonconsulters are greater pain severity and greater duration of pain [46,86,87]. Once pain severity is accounted for, however, increased psychologic distress determines which individuals with IBS seek treatment [46,87,88]. Furthermore, compared with IBS nonpatients, IBSconsulters are more likely to minimize or not even acknowledge the role of psychologic or stress-related factors in their symptoms [89,90]. Although some patients may be wary of the stigma associated with a psychologic component of their symptoms, another important reason for their reluctance to accept a role for psychosocial factors in their illness is health anxiety [86]. IBS-consulters often believe that their bowel symptoms indicate serious gut disease, such as cancer, and attend selectively to abdominal sensations, dismissing other information (eg, reassurance from a doctor) that contradicts their explanatory model of illness [91]. Ironically, this increase in health concerns and anxiety may lead to behavioral changes [92] or a physiologic response, such as diarrhea, which can then be interpreted as further evidence of underlying serious pathology. Excessive health anxiety represents but one of the maladaptive illness behaviors that IBS patients who are high health care users may exhibit. The term ‘‘illness behavior’’ refers to the ways individuals perceive and react to somatic sensations that may be interpreted as symptoms of disease. Although there is a wide range of normal, the abnormal illness behaviors

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lie at the extremes of denial and hypochondriasis. Some patients with FGID lie at the latter end of the spectrum, interpreting normal bodily sensations as evidence of disease, leading them to seek medical treatment and report symptoms and disability inconsistent with their physician’s assessment. This type of illness behavior may even elicit negative feelings in the physician [93]. From the patient’s perspective, even after consultation, some still feel something has been overlooked [91] and may seek out other gastroenterologists or alternative therapy [94]. What accounts for these illness behaviors? First, psychosocial disturbance is common in FGID, and there is a tendency for people who are distressed or depressed to have increased anxiety about bowel symptoms and related health concerns. Colgan et al [95] found that FGID patients with psychiatric disorders were more convinced that their symptoms represented physical disease than patients who actually had an organic GI disorder. Psychiatric disturbance alone, however, does not seem to explain the illness behavior. Gomborone et al [96] found that patients with IBS, compared with depressed patients seeing a psychiatrist, showed higher scores on hypochondriacal beliefs, disease phobia, and bodily preoccupation scales of the Illness Attitude Scale. Furthermore, bodily preoccupation is often not limited to the GI system. Somatization seems to be an important feature in many IBS-consulters. IBS patients score higher than healthy controls on the somatization scale of SCL-90-R [57] and report many non-GI disorders [97]. The types of symptoms and comorbid disorders vary greatly, but well-documented associations include fibromyalgia, dysmenorrhea, and asthma [98]. IBS patients make two to three times as many visits to physicians for non-GI complaints [10,13] and report missing an average of 13.4 days from work or usual activities because of illness compared with 4.9 days for controls [10]. They may also undergo unnecessary diagnostic procedures, increasing the risk for procedure-related morbidity. There is a growing body of evidence to suggest that these patterns of somatization and abnormal illness behavior, including using illness to avoid unpleasant interpersonal situations [99], may be learned during childhood [100]. Adults with IBS are more likely to report that their parents gave gifts or special privileges when they were ill as children, and to report their parents displayed illness behavior [100]. Furthermore, children of parents with IBS are more likely to present to their pediatrician for abdominal pain and diarrhea [99]. But is this learned illness behavior, or heredity, especially because it has been noted [101] that IBS tends to run in families?

The role of heredity To investigate the potential role of heredity in IBS, Levy et al [102] performed a large health survey of monozygotic and dizygotic twins. After

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analyzing questionnaires completed by 6060 monozygotic and dizygotic twin pairs, they found that the concordance for IBS was 17.2% in monozygotic and only 8.4% in dizygotic twins (P = 0.030), supporting some possible degree of genetic contribution. They also noted, however, that the proportion of dizygotic twins with IBS who have mothers with IBS (15.2%) was greater than the proportion of dizygotic twins with IBS who have a co-twin with IBS (6.7%, P\0.001). The probability that a monozygotic twin with IBS has a mother with IBS is similar to the probability of having the monozygotic co-twin have IBS, and is significantly greater than the probability of having IBS in a dizygotic co-twin. Having a mother with IBS accounts for as much variance as having an identical set of genes with a co-twin who has IBS. This suggests that the contribution of social learning (what an individual learns from those in his or her environment through such mechanisms as modeling and positive reinforcement) to IBS is at least as great as the contribution of heredity. These findings are consistent with other studies [99,103] suggesting that parental modeling and reinforcement of illness behavior contributes to the cause of IBS.

HRQOL Some individuals may experience the symptoms of a FGID as mild nuisances, whereas others can be completely debilitated by them. HRQOL is a relatively recent measure that tries to gauge the impact that illness has on an individual’s life, incorporating the patient’s perception of the illness experience and of his or her functional status as related to the illness. HRQOL is influenced by social, cultural, physiologic, and disease-related factors [104]. HRQOL can be distinguished from other health outcome measures because the impact of illness is assessed in relation to (1) patient’s role and function (eg, ability to carry out activities of daily living, such as work, social, family interactions, and self-care); (2) patient’s perception of what his or her needs are and whether they are being met (eg, independence, attractiveness); (3) perceptions of the illness; and (4) concerns about consequences of the illness. There are two approaches to measuring HRQOL. The first is the generic instrument, like the SF-36 [105], which is applicable to all medical disorders and provides a way of comparing the relative impact of, say, IBS to the impact of other diseases like congestive heart failure or renal failure. Then there are disease-specific instruments, like the Irritable Bowel SyndromeQuality of Life [106], which are thought to be more responsive than generic instruments to the changes resulting from treatment of a specific disorder. They do not, however, permit one to compare the impact of the specific disease of interest with the impact of other common health concerns. Generic quality-of-life instruments have demonstrated that patients with IBS [51] and functional dyspepsia [107] have impaired quality of life. For

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example, Drossman et al [17] found that among patients attending an academic GI clinic, those with FGID had greater impairment than individuals with structural abnormalities like peptic ulcer disease and liver disease. In a paper [108] reporting on a series of interviews with IBS patients, three overriding themes emerged: (1) a sense of frustration, (2) a sense of isolation, and (3) a search for a niche in the health-sick role continuum. The patients interviewed were frustrated by their perceived inability to control symptoms, prevent episodes, identify episode triggers, and obtain medical validation of the condition. Their constant anticipation of the next IBS episode, the need for immediate access to toilet facilities, and the nature of the bowel symptoms often required withdrawal from social activities and resultant isolation. Finally, interaction with the medical community seldom clarified their understanding of the condition or improved its management. Health-related quality of life has traditionally been assessed in a treatment setting. Olden et al [109], however, recently evaluated HRQOL and health care use in a community-based sample of women with IBS (1014 women with IBS and 1010 controls). The women with IBS in this community sample had significantly poorer general health, lower HRQOL, and greater health care use. They also missed more days of work and reported greater limitations in their activities. Intriguingly, even in the absence of symptoms, up to two thirds of IBS patients experience difficulties in carrying out their daily activities [110], improvement in symptoms over time may occur independently of any change in the severity of the disability [111]. IBS has been shown to impact significantly on personal relationships. Silk [112] sent a questionnaire about personal relationships, working practices, and treatment to subscribers of IBS Bulletin and found that 57% reported daily symptoms, 25% weekly symptoms, and 14% monthly symptoms. A substantial portion also reported sexual dysfunction, with 45% stating that IBS interfered with their sex life. Twelve percent said IBS caused them to give up work completely, and 47% lost time off work (although only 35% gave IBS as the reason). Approximately 53% suffered embarrassment using toilets at work and 32% said IBS stopped them from applying for promotion or new job. A recent study suggested that IBS patients have poorer quality of life than chronic dialysis patients [113]. A great deal of research is now focusing on determinants of HRQOL in patients with FGID. The brain–gut axis: a unifying model Research has shown that factors like stress, psychiatric diagnoses, personality, coping style, abuse experiences, and learned illness behaviors all can play pivotal roles in the expression and outcomes of functional GI disorders, but none seem to be unique to or etiologic for the FGID. Conversely, these factors are not simply a result of the chronic illness and disability caused by FGID. Research on potential etiologic factors in FGID

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evolved through phases ranging from a psychosocial emphasis, to a focus on motility changes in the gut, and onto the more recent visceral hypersensitivity hypothesis. Although some abnormalities in motility and visceral sensation have been noted in subgroups of FGID patients (abnormalities modulated by some psychosocial factors no less) none are consistent or specific to FGID. FGID are not simply motility, sensory, or psychogenic disorders. How can all of these factors be combined into one etiologic model? The answer proposed by some is the brain–gut axis, the bidirectional link between the CNS and ENS [15]. It has been shown that patients with FGID, such as functional chest pain, dyspepsia, and IBS, frequently display abnormalities in motility, especially in response to stressors. Motor abnormalities are not seen in all patients, however, and no specific pattern of motility has been identified that is unique to patients with FGID. Investigators then began to hypothesize that altered pain thresholds [15,114] rather than motor abnormalities contributed to FGID symptoms, and represented the pathophysiologic mechanism common to all FGID. In a landmark study, Ritchie [115] was the first to demonstrate that patients with IBS report pain at lower volumes of balloon distention in the sigmoid colon. This result has been replicated in numerous studies, not only for sigmoid-rectal distention in IBS, but also esophageal distention in functional chest pain [30,116–118] and gastric distention in functional dyspepsia [3,119–122]. Some investigators have found that IBS patients demonstrate increased sensitivity not only to painful stimuli, but also to nonpainful sensations, such as low-volume balloon distention [123] and even to normal physiologic events [123,124], although these findings are controversial. This hypersensitivity seems to be confined to the GI tract (visceral hypersensitivity), because IBS patients studied displayed normal cutaneous (somatic) pain thresholds [39,125–127]. The visceral hypersensitivity, however, was not specific to the anatomic area of their FGID [127–129]. Clinically, changes in pain thresholds seem to correlate with changes in symptoms of abdominal pain [130,131]. There is a good deal of controversy in the literature as to whether the altered threshold to report pain in IBS represents a biologic marker for IBS [130] or, instead, perceptual response bias [131]. Signal detection methodology used to separate perceptual sensitivity from perceptual response bias suggests that this increased sensitivity is, in fact, caused by response bias, a tendency to report pain at lower thresholds for psychologic reasons unrelated to end-organ receptor sensitivity [30,132]. Studies investigating the ability of stress or a warning signal to lower pain thresholds, and conversely distraction or relaxation to raise pain thresholds, illustrate the modulatory role of psychologic factors in perception thresholds [133,134]. The CNS has been shown to have a modulatory role in both motility and visceral perception. Research has shown that motility disturbances in IBS disappear during sleep, and that the migrating motor complex frequency

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decreases and propagating velocity increases progressively with alertness and arousal [135]. The role of the CNS in modulating visceral perception is supported by recent studies using cortical evoked potentials [136,137], positron emission tomography [138], and functional MRI [139] to demonstrate differential brain activation in IBS patients compared with healthy controls. Positron emission tomography studies have shown that in response to rectal distention, or even the anticipation of rectal distention, patients with IBS, compared with controls, fail to activate the anterior cingulate cortex, an area of the limbic system associated with active opiate binding. Instead, they activate the prefrontal cortex, an area associated with hypervigilance and anxiety [138]. That is, patients with IBS may fail to use CNS downregulating mechanisms in response to incoming or anticipated visceral pain and instead they may activate an area of the brain that amplifies pain perception. The relationships between psychosocial factors, GI symptoms and function, susceptibility to disease, and clinical outcome can now be understood as the result of interacting subsystems in the CNS and ENS. The brain–gut axis concept also helps to explain how psychosocial trauma in the forms of physical or sexual abuse [17] or poor coping style [18] can influence susceptibility to developing an FGID, and profoundly impact symptom severity, daily function, and health outcome. This FGID is in turn influenced by one’s psychosocial milieu, leading to unique and varying effects on symptom expression and clinical outcome, as mediated through CNS–ENS pathways. Based on these data, it is futile to try to discriminate whether physiologic or psychologic factors cause pain or other bowel symptoms because both contribute. The key is to determine what the factors are, how much each is contributing, and what can be done in terms of multicomponent therapy. Approach to the patient The FGID are multifaceted conditions, with both physiologic and psychologic parameters. Entering a patient encounter using either a purely biomedical or, alternatively, purely psychologic approach is likely to result in suboptimal patient outcomes. If the physician focuses on symptoms at the exclusion of working toward psychosocial adaptation, illness behaviors may be reinforced. A challenge for the physician is to reinforce positive coping behaviors and move the patient gently away from focusing on physical symptoms, as a means to reduce diagnostic studies and symptomatic treatments. Once an FGID has been diagnosed, adopting a biopsychosocial approach to the patient is essential, and is especially helpful for patients who have been refractory to standard medical therapy [140–142]. Some key points in the approach to the patient with a FGID are as follows: Establish a strong doctor–patient relationship Seek out and acknowledge the patient’s concerns and expectations

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Adopt a low-control style of interviewing Connect psychosocial factors with GI symptoms Encouraging the patient the keep a ‘‘bowel chart’’ may help the patient recognize connections between GI symptoms and psychosocial precipitants Inquire about recent stressful life events Screen for a history of abuse Screen for concomitant psychiatric diagnoses Screen for maladaptive coping styles or personality traits Assess the patient’s health beliefs Be sensitive to culture-specific health beliefs Reassure the patient Stress a ‘‘care’’ rather than ‘‘cure’’ approach Stress improving patient’s function in the presence of illness rather than attempting to cure Discuss the treatment plan Any recommended psychotherapeutic intervention should be presented as part of the overall ongoing care provided by the primary care physician Assess for outstanding concerns Ask the patient if there are any unresolved concerns Ensure continuity of care Establish a strong doctor–patient relationship Central to the biopsychosocial model is the establishment of a strong, therapeutic, doctor–patient relationship. In general, a physician best establishes a therapeutic relationship by (1) seeking out and acknowledging the patient’s concerns, expectations, and health beliefs; (2) educating; (3) clarifying misunderstandings; (4) offering empathy when required; and (5) negotiating a plan of treatment with the patient [143]. Medical history can be obtained by encouraging the patient to tell his or her story in his or her own way, so that any psychosocial events contributing to the illness naturally unfold [140,141,144]. Adopting a care versus cure approach has been shown to be more effective in achieving a positive outcome [140,145]. The care model focuses on the patient’s overall concerns about illness and on improving the patient’s function in the presence of illness rather than attempting to cure. The physician should reassure the patient of his or her willingness to help in ongoing care rather than guarantee success. Take a psychosocial history There is some evidence that taking a psychosocial history can play a role in improving outcome as marked by, for example, a reduction in the frequency of visits [146]. It is important that the treating physician expresses

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his or her willingness to address both biologic and psychologic aspects of the illness, and not focus exclusively on either symptoms or, conversely, only on psychologic aspects. Table 1 illustrates some questions that may help the physician understand the role of psychosocial factors in the patient’s illness. Assess the patient’s illness beliefs It is important to be sensitive to the patient’s cultural background, because most cultures have unique beliefs about the significance of physical symptoms [141]. In some cases, for cultural reasons, some patients may be unwilling to accept a role for psychosocial factors in the illness, even when it is clear to others. In such cases, it is usually counterproductive to discuss psychosocial and biologic factors in terms of causation, or as being separate [143]. Instead the physician needs to help the patient express his or her distress in a way that is consistent with his or her illness beliefs. It may help for the physician to illustrate the psychosocial impact of the patient’s illness in terms of its emotional effects, impaired quality of life, and consequences on family and social dynamics. If the patient initially does not make a connection between his or her GI symptoms and psychosocial precipitants, having them keep a bowel chart may not only help to elucidate the connection, but also help find ways to modify stress-related responses. The patient can keep a daily record of predominant symptoms, symptom severity, time of bowel movements, dietary changes, lifestyle changes, stressors, and time of menses. This record may reveal connections between some of these factors and symptom exacerbations, and can demonstrate whether mood state and thoughts vary with symptoms. Screen for a psychiatric diagnosis Evaluating for mood disorder or other psychiatric diagnosis is an important part of the patient encounter, but one for which most gastroenterologists and primary care physicians have not received extensive training. Although many patients with FGID have comorbid psychiatric diagnoses, the differential is actually quite limited, and primarily involves anxiety disorders, mood disorders, and somatization disorder. Table 2 reviews symptoms that should alert the physician about the possibility of an underlying psychiatric diagnosis. If any of these are positive, the physician can delve further to establish the psychiatric diagnosis, and refer to a mental health specialist if indicated. The identification of an anxiety disorder or depression that can respond to multicomponent treatment can lead to a more optimal outcome in patients with FGID symptoms [147]. Discuss the proposed treatment plan The patient must first acknowledge the relevance of the psychosocial aspects as they relate to their presenting problem. He or she may be

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Table 1 Questions that can help the physician understand the role of psychosocial factors in a patient’s illness 1. Is the patient’s illness acute or chronic? Chronic illness has a greater potential for having psychosocial concomitants. 2. What is the patient’s illness history? A history of multiple vague complaints, multiple procedures, and poor response to treatment should raise suspicion that psychosocial factors are contributing. 3. Why is the patient presenting to the office now? Psychosocial factors often influence health care seeking. 4. Is there a psychiatric diagnosis? Identifying a psychiatric diagnosis that could improve with psychologic or psychopharmacologic therapy can improve outcomes. 5. Is there a history of abuse? Refer to section on ‘‘taking an abuse history’’ 6. Is there evidence of unhelpful illness behavior or coping style? Examples of unhelpful illness behaviors include overly demanding requests for health care, and unrealistic expectations to find organic disease or a cure. 7. What are the family dynamics around the illness? There may be evidence of counterproductive family interactions like marital power struggles that manifest through illness, over-protectiveness, and so forth. 8. What are the patient’s supports? Strong social support is important for clinical improvement. Adapted from Drossman DA. Irritable bowel syndrome and sexual/physical abuse history. Eur J Gastroenterol Hepatol 1997;9:327–30.

reluctant to see a psychologist or psychiatrist, either because the patient may view the problem as physical, and prefers to visit a medical physician, or because the patient may feel stigmatized by such a referral, and lack the knowledge of benefits of psychologic evaluation and treatment. A major goal in preparing the patient for a referral to a mental health professional is to define the patient’s complaints in terms of a biopsychosocial disorder rather than just a medical illness, and to get the patient interested in and motivated to explore further the psychologic factors involved. It should be noted that if the referral is made at end of a medical evaluation, the patient will possibly view it as a rejection. It is very important for the physician to Table 2 Symptoms that should alert the physician to the possibility of a psychiatric diagnosis Panic or anxiety

Depression

Somatization

Palpitations

Change in appetite

Multiple vague symptoms referable to more than five organ systems

Diaphoresis Early insomnia Constant worries Ruminative thinking Agoraphobia

Anhedonia Late insomnia Fatigue Decreased libido Excessive guilt or feelings of worthlessness

Data from Olden KW. Diagnosis of irritable bowel syndrome. Gastroenterology 2002; 122:1701–14.

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explain that the mental health professional is a member of the team involved in the patient’s overall care. Any recommended psychotherapeutic care should be presented in addition to the other ongoing care provided by the patient’s primary care physician. This avoids creating a mind–body dualism and gives the patient the clear message that they are not being dismissed [140]. At the end of a visit, the physician should ask in a supportive manner what specific concerns the patient believes are still not resolved. A satisfactory consultation with the gastroenterologist leads to a reduction of overall anxiety, less fear that the symptoms represent cancer, and a reduction in the patient’s preoccupation and helplessness in relation to the pain [148]. In conclusion, successful strategies for managing especially those patients with refractory symptoms include scheduling frequent, brief visits with the same physician; recognizing the value of the patient as a human being rather than having an illness-based relationship (the sick role); screening for treatable mood and anxiety disorders [149]; and adopting a collaborative approach to care involving behavioral interventions, collaborative definition of problems, use of self-care, and support services (particularly support groups) with sustained follow-up by the primary care physician [21].

Taking an abuse history Someone who has been physically or sexually abused may feel ashamed, or even afraid to tell anyone about it. Most patients who have been sexually abused have not discussed this information with their doctor [70]. Many are willing to report this information when asked [150], however, especially if the physician explains the reason for this intimate line of questioning. The interviewer must take care to be supportive, understanding, empathetic, and reassuring. It should be noted that if the patient senses that the physician is uncomfortable, anxious, or is rushing to get through this line of questioning, the patient may ultimately feel more anxious and uncomfortable [4]. Nonverbal communication, such as maintaining eye contact with the patient, leaning toward (but not touching) the patient, and shaking one’s head in an affirmative and supportive manner are subtle, but very helpful in eliciting an abuse history [141]. Table 3 reviews some signs that may indicate an underlying abuse history.

Implications for treatment Nonpharmacologic therapy can play an important role in the management of some patients with FGID, especially those with more severe or refractory symptoms and concomitant psychologic disturbance [142,151]. Research suggests that no particular form of treatment is superior. Instead,

Somatoform disorders Depression Anxiety disorders Post-traumatic stress disorder Eating disorders Substance abuse

Unexplained vomiting Sexual dysfunction Severe constipation (especially caused by pelvic floor dyssynergia)

Doctor–patient relationship Problems establishing trust Dependent behavior Difficulty with certain procedures (endoscopy, rectal or pelvic examinations) Borderline behaviors (‘‘splitting,’’ intense attachments, demanding behaviors)

Illness behaviors Excessive health care utilization Multiple diagnostic procedures, surgeries, and treatments Denial of a role for psychologic factors Reluctance to engage in health-promoting behavior Disability disproportionate to clinical data Litigation-seeking behavior

Data from Drossman DA, Li Z, Leserman J, et al. Health status by gastrointestinal diagnosis and abuse history. Gastroenterology 1996;110:999–1007; and McCauley J, Kern DE, Kolodner K, et al. Clinical characteristics of women with a history of childhood abuse. JAMA 1997;277:1362–8.

Psychiatric disorders

Medical disorders

Table 3 Potential signs of an underlying abuse history

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the most crucial aspect of treatment is that the patient accepts the need for treatment, and is motivated to engage in it. This can be enhanced if a gastroenterologist and mental health professional help the patient to accept the treatment as a necessary part of his or her overall plan of care. Most of the research done thus far has been in IBS, and has involved multicomponent treatment plans with various combinations of the major types of therapy (cognitive-behavioral therapy [CBT], dynamic psychotherapy, hypnotherapy, and relaxation therapy) so that it is difficult to assess the effectiveness of each individual approach. Psychologic therapies for IBS have been recently reviewed [152]. Briefly, CBT consists of a variety of strategies and procedures aimed at helping patients recognize the role played by their illness beliefs and behavior, and then learn new ways of thinking and behaving to change their perception of their situation, and their ability to control their GI symptoms [90]. CBT may be especially useful for IBS because studies have found a high prevalence of anxiety and depression, high frequency of difficulties with appropriate assertiveness, high need for social approval, and perfectionist attitudes [55,59], all of which are amenable to CBT. Trials using CBT compared with a symptom-monitoring control group [153] or a self-help support group as controls [154] in IBS patients reported greater reduction in GI symptoms [153,154] and in depression and anxiety [154]. The results held up at 3-month follow-up. Dynamic psychotherapy, like brief interpersonal psychotherapy, is based on the idea that a significant degree of psychologic and physical distress is either caused or made worse by problems in interpersonal relationships. These difficulties are mirrored during therapy sessions. Ideally, the patient begins to recognize the problems in his or her relationships, and acts on these insights so that both psychologic and GI symptoms may improve. Svedlund et al [155] compared psychotherapy with routine medical care in a group of IBS patients and found that the psychotherapy group had significantly less abdominal pain and bowel disturbance than the control group. At the 1-year follow-up, this difference in GI symptoms between groups was even more pronounced, and was accompanied by further improvement in anxiety and depression. The work of Guthrie et al [156] has been particularly impressive in this area. To test the efficacy of psychotherapy for severe refractory patients with IBS, they studied 101 patients referred for refractory IBS symptoms to consulting gastroenterologists in the National Health Service in the United Kingdom. Patients were randomized either to 12 hours of interpersonal psychotherapy or supportive listening. Interpersonal psychotherapy is based on dynamic psychotherapeutic principles, but focuses on a higher degree of interaction between the treating therapist and the patient and gives the patient more opportunities to express their emotions, concerns, and ask questions in traditional psychotherapy. To control for the presence of the therapist, the control group consisted of patients who spent 1 hour per week

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with the same therapist (the principal investigator) who was also the person administering the psychotherapy in the act of treatment arm. In the control group, however, the psychotherapist engaged in general conversation and made no psychotherapeutic comments, suggestions, or gave any guidance of any sort. In this study, patients were rated both on entry and on exit from the study in terms of the severity of their IBS symptoms, their level of pain, their psychologic well-being and in addition, were rated on how much their GI symptoms improved by their treating gastroenterologist who were blinded as to the arm in which the patients were participating. The results were impressive. Patients in the psychotherapy group had statistically significant improvements in their self-reported GI symptoms, their emotional well-being as measured by standardized psychologic instruments, and improvements in their ability to perform their activities of daily living, and overall quality of life. In addition, blinded gastroenterologists also perceived the patients in the psychotherapy group more improved compared with patients who had not been in the psychotherapy group. Again, it is important to remember that these gastroenterologists were blinded as to the treatment status of their patients. Finally, Guthrie followed these patients over 1 year after the end of the trial. In addition to finding that the therapeutic effect of the psychotherapy continued at the 1-year follow-up, she also noted a 75% reduction in all health care use in the psychotherapy group. Both of these findings were not seen in the supportive listening group. Guthrie et al [156] makes a powerful case for the usefulness of psychotherapy in the treatment of IBS particularly in patients with severe symptoms. The fact that the subjects in the Guthrie et al [156] study had been refractory to a wide spectrum of medical interventions and responded so dramatically to psychotherapy strongly supports the case for a multidimensional approach to IBS. One other lesson from Guthrie et al [156] and from other studies in this area is that psychotherapy does not need to be long term. Guthrie et al [156] used 12 hours of psychotherapy. The studies of Blanchard [153], Toner [90], Guthrie [156], Svedlund et al [155] and others have all shown that 8 to 12 contact hours of psychotherapy seems to be more than adequate to have a therapeutic effect that persists over time. A new psychotherapeutic intervention, group counseling psychotherapy, was recently reported to be effective by Poitras et al [157]. Hypnotherapy for FGID has been well-studied in England [158]. The rationale behind using hypnosis in FGID is that while the patient is in the highly suggestible hypnotic state, the hypnotherapist can use progressive muscle relaxation techniques and guided imagery to relax GI smooth muscle. In fact, there is evidence to suggest that hypnosis can reduce colonic contractile activity [43,159] and normalize thresholds for pain during balloon distention in the rectum [160–162]. Patients are also instructed on autohypnosis and are asked to practice at home. Whorwell et al [43,159] have had much success with the use of hypnosis in IBS patients, but many clinics

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do not have this expertise, and it remains to be seen whether these results will be reproduced by other investigators. Relaxation therapy involves a variety of techniques designed to teach patients how to counteract the physiologic effects of stress and anxiety. Again, most trials have used relaxation techniques in combination with other therapies, but a few investigators have compared relaxation directly with various control groups for the treatment of IBS and found that relaxation therapy improved GI symptoms [163–165] and reduced visits to medical clinics. Improvements persisted up to 40 months after treatment [163]. Relaxation therapy is often combined with CBT because of its effect in reducing autonomic arousal and anxiety in IBS [154]. Several studies examined the combination of CBT with relaxation therapy and generally reported that this combination was superior to the control groups (which ranged from waiting list, to conventional medical therapy, to two studies using an active placebo group in the form of educational treatment) [90,152,166]. In conclusion, numerous studies have used a controlled design to compare psychologic therapy with conventional medical treatment, although many have methodologic flaws. On the whole, most show that psychologic treatment is superior for reduction in bowel symptoms, and that this reduction is maintained over time. More importantly, there seem to be no differences in outcome based on particular type of therapy, so that the mental health professional should use whatever technique in which he or she is most experienced. The literature on the psychotherapeutic approach to IBS has demonstrated a number of important points. First is that in all the studies that have measured it, psychotherapy irrespective of modality tends to be effective for treatment of IBS [167]. Patients with IBS have improvements in their GI symptoms, their emotional well-being, and overall ability to function in response to psychotherapeutic intervention. The effects of psychotherapy tend to persist over time and do seem to reflect a genuine change in the patient’s ability to perceive, cope, and deal with their illness. Finally, the economic burden of introducing a psychotherapeutic modality into the treatment of an IBS patient seems to be minimal. All the studies to date have demonstrated 6 to 12 contact hours of therapy can produce a positive therapeutic effect and that long-term therapy is not needed in most cases. Finally, the literature has demonstrated that patients who benefit from psychotherapeutic intervention do so whether they have a psychiatric diagnosis or not. Certainly patients who have a concomitant diagnosis of depression, anxiety disorder, or somatization disorder should be considered for psychotherapeutic intervention for their psychiatric disorder. It is important to understand, however, that the treatment trials using psychotherapy in IBS, and other functional bowel disorders, have demonstrated that patients who do not have a diagnosable psychiatric disorder can also receive tremendous benefit. This has implications for the doctor–patient relationship.

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One of the challenges for the treating physician is to make a patient feel comfortable about accepting behavioral intervention for their IBS symptoms. The authors’ approach has been to use the medical literature to educate the patient and to make the patient’s perceptions of a psychotherapeutic intervention and the goals for the psychotherapeutic intervention the same as the treating physicians’. It is the authors’ practice to listen to the patient’s concerns about their illness and to obtain by the history a good understanding of the negative impact that their illness is having on their ability to function in their daily life. In presenting a psychotherapeutic treatment recommendation, the authors reiterate to the patient that they understand and agree with their concerns about disability, pain, and discomfort, and the general burden their IBS has placed on their life. The authors then tell patients that the purpose of psychotherapy is not to treat an emotional disorder, but rather to help them build better coping skills, to learn behavioral techniques (such as relaxation) to help them deal with their ongoing symptoms. When presented in this manner (ie, psychotherapy being recommended for the treatment of the IBS and not for an emotional disturbance) patients are much more likely to accept this recommendation. Likewise, it is important for the referring physician to make the receiving therapist clear that the goal of psychotherapy is to help patients deal with physical symptoms, burden of illness, and develop overall better coping styles as opposed to treating emotional symptoms alone. The authors find it helpful to work with a small number of therapists who work closely with their group regarding these patients to allow a commonality of goals between referring physician, patient, and receiving therapist. Summary Psychosocial factors, such as stress, abuse history, psychiatric disturbance, coping style, and learned illness behaviors, play an important role in functional GI disorders in terms of symptom experience and clinical outcome. These psychosocial factors are influenced by and influence GI symptoms in a bidirectional manner as mediated through the brain–gut axis (CNS and ENS pathways). Entering the patient encounter using a biopsychosocial approach and a care (versus cure) style can help avoid excessive diagnostic testing, and elicit crucial information about potential abuse history or psychiatric symptoms that can help guide therapy. Finally, for patients with severe, refractory symptoms, multicomponent treatment involving psychologic therapy, such as CBT, relaxation, or hypnotherapy, can be beneficial. References [1] Longstreth GF, Wolde-Tsadik G. Irritable bowel-type symptoms in HMO examinees: prevalence, demographics, and clinical correlates. Dig Dis Sci 1993;38:1581–9.

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[2] Thompson WG, Heaton KW, Smyth T, et al. Irritable bowel syndrome in general practice: prevalence, characteristics, and referral. Gut 2000;46:78–82. [3] Mearin F, Cucala M, Azpiroz F, et al. The origin of symptoms on the brain-gut axis in functional dyspepsia. Gastroenterology 1991;101:999–1006. [4] Olden KW. Diagnosis of irritable bowel syndrome. Gastroenterology 2002;122: 1701–14. [5] Jones R, Lydeard S. Irritable bowel syndrome in the general population. BMJ 1992; 304:87–90. [6] Talley NJ, Holtmann G, Agreus L, et al. Gastrointestinal symptoms and subjects cluster into distinct upper and lower groupings in the community: a four nations study. Am J Gastroenterol 2000;95:1439–47. [7] Taub B, Cuevas JL, Cook III EW, et al. Irritable bowel syndrome defined by factor analysis: gender and race comparisons. Dig Dis Sci 1995;40:2647–55. [8] Hyams JS, Burke G, Davis PM, et al. Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. J Pediatr 1996;129:220–6. [9] Kay L. Prevalence, incidence and prognosis of gastrointestinal symptoms in a random sample of an elderly population. Age Ageing 1994;23:146–9. [10] Drossman DA, Li Z, Andruzzi E, et al. US householder survey of functional gastrointestinal disorders: prevalence, sociodemography and health impact. Dig Dis Sci 1993;38:1569–80. [11] Thompson WG, Irvine EJ, Pare P, et al. Functional gastrointestinal disorders in Canada: first population-based survey using Rome II criteria with suggestions for improving the questionnaire. Dig Dis Sci 2002;47:225–35. [12] Sandler RS, Drossman DA, Nathan HP, et al. Symptom complaints and health care seeking behavior in subjects with bowel dysfunction. Gastroenterology 1984;87:314–8. [13] Levy RL, Von Korff M, Whitehead WE, et al. Costs of care for irritable bowel syndrome patients in a health maintenance organization. Am J Gastroenterol 2001;96:3122–9. [14] Talley NJ, Gabriel SE, Harmsen MC, et al. Medical costs in community subjects with irritable bowel syndrome. Gastroenterology 1995;109:1736–41. [15] Mayer EA, Gebhart GF. Basic and clinical aspects of visceral hyperalgesia. Gastroenterology 1994;107:271–93. [16] Mayer EA, Naliboff BD, Chang L, et al. Stress and the gastrointestinal tract: V. Stress and irritable bowel syndrome. Am J Physiol 2001;280:G519–24. [17] Drossman DA, Li Z, Leserman J, et al. Health status by gastrointestinal diagnosis and abuse history. Gastroenterology 1996;110:999–1007. [18] Drossman DA, Leserman J, Li Z, et al. Effects of coping on health outcome among women with gastrointestinal disorders. Psychosom Med 2000;62:309–17. [19] Creed F, Ratcliffe J, Fernandez L, et al. Health-related quality of life and health care costs in severe, refractory irritable bowel syndrome. Ann Intern Med 2001;134:860–8. [20] Drossman DA, Whitehead WE, Toner BB, et al. What determines severity among patients with painful functional bowel disorders? Am J Gastroenterol 2000;95:974–80. [21] Von Korff M, Gruman J, Schaefer J. Collaborative management of chronic illness. Ann Intern Med 1997;127:1097–102. [22] Craig TKJ, Brown GW. Goal frustration and life events in the aetiology of painful gastrointestinal disorder. J Psychosom Res 1984;28:411–21. [23] Creed FH, Craig T, Farmer RG. Functional abdominal pain, psychiatric illness and life events. Gut 1988;29:235–42. [24] Olden KW, Drossman DA. Psychologic and psychiatric aspects of gastrointestinal disease. Med Clin North Am 2000;84:1313–27. [25] Ellard K, Beaurepaire J, Jones M, et al. Acute and chronic stress in duodenal ulcer disease. Gastroenterology 1990;99:1628–32. [26] Ford MJ, Miller PM, Eastwood J, et al. Life events, psychiatric illness and the irritable bowel syndrome. Gut 1987;28:160–5.

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[27] Gilligan I, Fung L, Piper DW, et al. Life event stress and chronic difficulties in duodenal ulcer: a case control study. J Psychosom Res 1987;31:117–23. [28] Whitehead WE, Crowell MD, Robinson JC, et al. Effects of stressful life events on bowel symptoms: subjects with irritable bowel syndrome compared to subjects without bowel dysfunction. Gut 1992;33:825–30. [29] Bennett EJ, Tennant CC, Piesse C, et al. Level of chronic life stress predicts clinical outcome in irritable bowel syndrome. Gut 1998;43:256–62. [30] Bradley LA, Richter JE, Pulliam TJ, et al. The relationship between stress and symptoms of gastroesophageal reflux: the influence of psychological factors. Am J Gastroenterol 1993;88:11–9. [31] Thompson DG, Richelson E, Malagelada JR. Perturbation of upper gastrointestinal function by cold stress. Gut 1983;24:277–83. [32] Stranghellini V, Malagelada JR, Zinsmeister AR, et al. Stress-induced gastroduodenal motor disturbances in man: possible humoral mechanisms. Gastroenterology 1983;85: 83–91. [33] Ragnarsson G, Bodemar G. Pain is temporally related to eating but not to defaecation in the irritable bowel syndrome (IBS): patients’ description of diarrhea, constipation and symptom variation during a prospective 6-week study. Eur J Gastroenterol Hepatol 1998;10:415–21. [34] Narducci F, Bassotti G, Granata MT, et al. Colonic motility and gastric emptying in patients with irritable bowel syndrome: effect of pretreatment with octylonium bromide. Dig Dis Sci 1986;31:241–6. [35] Rogers J, Henry MM, Misiewicz JJ. Increased segmental activity and intraluminal pressures in the sigmoid colon of patients with the irritable bowel syndrome. Gut 1989;30:634–41. [36] Bjo¨rnsson ES, Chey WD, Hooper F, et al. Selectively enhanced phasic but not tonic gastro-colonic contractions in diarrhea-predominant irritable bowel syndrome: role of 5–HT3 neural pathways. Gastroenterology 1998;114:A722. [37] Vassallo MJ, Camilleri M, Phillips SF, et al. Colonic tone and motility in patients with irritable bowel syndrome. Mayo Clin Proc 1992;67:725–31. [38] Cann PA, Read NW, Brown C, et al. Irritable bowel syndrome: relationship of disorders in the transit of a single solid meal to symptom patterns. Gut 1983;24:405–11. [39] Whitehead WE, Holtkotter B, Enck P, et al. Tolerance for rectosigmoid distension in irritable bowel syndrome. Gastroenterology 1990;98:1187–92. [40] Preston DM, Adrian TE, Christofides ND, et al. Positive correlation between symptoms and circulating motilin, pancreatic polypeptide and gastrin concentrations in functional bowel disorders. Gut 1986;26:1059–64. [41] Sjo¨lund K, Ekman R, Lindgren S, et al. Disturbed motilin and cholecystokinin release in the irritable bowel syndrome. Scand J Gastroenterol 1996;31:1110–4. [42] Welgan P, Meshkinpour H, Beeler M, et al. Effect of anger on colon motor and myoelectric activity in irritable bowel syndrome. Gastroenterology 1988;94:1150–6. [43] Whorwell PJ, Houghton LA, Taylor EE, et al. Physiological effects of emotion: assessment via hypnosis. Lancet 1992;340:69–72. [44] Talley NJ, Boyce PM, Jones M. Is the association between irritable bowel syndrome and abuse explained by neuroticism? Gut 1998;42:47–53. [45] Tanum L, Malt UF. Personality and physical symptoms in nonpsychiatric patients with functional gastrointestinal disorder. J Psychosom Res 2001;50:139–46. [46] Drossman DA, McKee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome: a multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology 1988;95:701–8. [47] Talley NJ, Phillips SF, Bruce B, et al. Relation among personality and symptoms in nonulcer dyspepsia and the irritable bowel syndrome. Gastroenterology 1990;99:327–33.

A.I. Budavari, K.W. Olden / Gastroenterol Clin N Am 32 (2003) 477–506

501

[48] Haug TT, Svebak S, Wilhelmsen I, et al. Psychological factors and somatic symptoms in functional dyspepsia: a comparison with duodenal ulcer and healthy controls. J Psychosom Res 1994;38:281–91. [49] Platz T, Junkert B, Tress W, et al. Is there typical conflict in gastric complaints? An epidemiologic-psychoanalytic contribution to the question of conflict specificity in psychosomatic medicine. Psychother Psychosom 1993;59:165–72. [50] Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med 2001;134:917–25. [51] Whitehead WE, Burnett CK, Cook III E, et al. Health related quality of life in IBS patients compared to IBS non-consulters and asymptomatic individuals [abstract]. Am J Gastroenterol 1994;89:1700. [52] Bockus HL, Bank J, Wilkinson SA. Neurogenic mucous colitis. Am J Med Sci 1928; 176:813–29. [53] Drossman DA, Creed FH, Olden KW, et al. Psychosocial aspects of the functional gastrointestinal disorders. In: Drossman DA, Corazziari E, Talley NJ, et al, editors. Rome II: the functional gastrointestinal disorders: diagnosis, pathophysiology and treatment: a multinational consensus. McLean, VA: Degnon and Associates; 2000. p. 157–245. [54] Lydiard RB, Fossey MD, Marsh W, et al. Prevalence of psychiatric disorders in patients with irritable bowel syndrome. Psychosomatics 1993;34:229–34. [55] Walker EA, Roy-Byrne PP, Katon WJ. Irritable bowel syndrome and psychiatric illness. Am J Psychiatry 1990;147:565–72. [56] Walker EA, Roy-Byrne PP, Katon WJ, et al. Psychiatric illness and irritable bowel syndrome: a comparison with inflammatory bowel disease. Am J Psychiatry 1990;147: 656–61. [57] Whitehead WE, Bosmajian L, Zonderman AB, et al. Symptoms of psychologic distress associated with irritable bowel syndrome: comparison of community and medical clinic samples. Gastroenterology 1988;95:709–14. [58] Walker EA, Katon WJ, Jemelka PP, et al. Comorbidity of gastrointestinal complaints, depression, and anxiety in the Epidemiologic Catchment Area (ECA) Study. Am J Med 1992;92:26S–30S. [59] Toner BB, Garfinkel PE, Jeejeebhoy KN. Psychological factors in irritable bowel syndrome. Can J Psychiatry 1990;35:158–61. [60] Blewett A, Allison M, Calcraft B, et al. Psychiatric disorder and outcome in irritable bowel syndrome. Psychosomatics 1996;37:155–60. [61] Sullivan G, Jenkins PL, Blewett AE. Irritable bowel syndrome and family history of psychiatric disorders: a preliminary study. Gen Hosp Psychiatry 1995;17:43–6. [62] Blomhoff S, Spetalen S, Jacobsen MB, et al. Phobic anxiety changes the function of braingut axis in irritable bowel syndrome. Psychosom Med 2001;63:959–65. [63] Read NW. Harnessing the patient’s powers of recovery: the role of the psychotherapies in the irritable bowel syndrome. Baillieres Best Pract Res Clin Gastroenterol 1999;13:473–87. [64] Noyes RJ, Cook C, Garvey M, et al. Reduction of gastrointestinal symptoms following treatment for panic disorder. Psychosomatics 1990;31:75–9. [65] Lydiard RB, Greenwald S, Weissman MM, et al. Panic disorder and gastrointestinal symptoms: findings from the NIMH Epidemiologic Catchment Area project. Am J Psychiatry 1994;151:64–70. [66] Zaubler TS, Katon W. Panic disorder and medical comorbidity: a review of the medical and psychiatric literature. Bull Menninger Clin 1996;60(suppl A):A12–38. [67] Olden KW, Brotman AW. Irritable bowel/irritable mood: the mind/gut connection. Harv Rev Psychiatry 1998;6:149–54. [68] Delvaux M, Denis P, Allemand H. French Club of Digestive Motility: sexual and physical abuses are more frequently reported by IBS patients than by patients with organic

502

[69] [70] [71] [72]

[73] [74]

[75]

[76] [77]

[78] [79]

[80] [81] [82] [83]

[84] [85] [86] [87] [88]

[89]

A.I. Budavari, K.W. Olden / Gastroenterol Clin N Am 32 (2003) 477–506 digestive diseases or controls: results of a multicenter inquiry. Eur J Gastroenterol Hepatol 1997;9:3345–52. Drossman DA, Talley NJ, Olden KW, et al. Sexual and physical abuse and gastrointestinal illness: review and recommendations. Ann Intern Med 1995;123:782–94. Drossman DA, Leserman J, Nachman G, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 1990;113:828–33. McCauley J, Kern DE, Kolodner K, et al. Clinical characteristics of women with a history of childhood abuse. JAMA 1997;277:1362–8. Scarinci IC, McDonald-Haile JM, Bradley LA, et al. Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: a preliminary model. Am J Med 1994;97:108–18. Talley NJ, Fett SL, Zinsmeister AR. Gastrointestinal tract symptoms and self-reported abuse: a population-based study. Gastroenterology 1994;107:1040–9. Talley NJ, Fett SL, Zinsmeister AR. Self-reported abuse and gastrointestinal disease in outpatients: association with irritable bowel-type symptoms. Am J Gastroenterol 1995;90:366–71. Walker EA, Katon WJ, Roy-Byrne PP, et al. Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease. Am J Psychiatry 1993; 150:1502–6. Laws A. Sexual abuse history and women’s medical problems. J Gen Intern Med 1993;8:441–3. Leserman J, Drossman DA. The reliability and validity of a sexual and physical abuse history questionnaire in female patients with gastrointestinal disorders. Behav Med 1995;21:141–50. Leroi AM, Bernier C, Watier A, et al. Prevalence of sexual abuse among patients with functional disorders of the lower gastrointestinal tract. Int J Colorectal Dis 1995;10:200–6. Leserman J, Li Z, Drossman DA, et al. Impact of sexual and physical abuse dimensions on health status: development of an abuse severity measure. Psychosom Med 1997; 59:152–60. Blanchard EB, Keefer L, Payne A, et al. Early abuse, psychiatric diagnoses and irritable bowel syndrome. Behav Res Ther 2002;40:289–98. Dinwiddie S, Heath AC, Dunne MP, et al. Early sexual abuse and lifetime psychopathology: a co-twin control study. Psychol Med 2000;30:41–52. Kendler KS, Bulik CM, Siberg J, et al. Childhood sexual abuse and adult psychiatric and substance use disorders in women. Arch Gen Psychiatry 2000;57:933–59. Walker EA, Gelfand AN, Gelfand MD, et al. Psychiatric diagnosis, sexual and physical victimization, and disability in patients with irritable bowel syndrome or inflammatory bowel disease. Psychol Med 1995;25:1259–67. Leserman J, Drossman DA, Li Z, et al. Sexual and physical abuse in gastroenterology practice: how types of abuse impact health status. Psychosom Med 1996;58:4–15. Drossman DA. Irritable bowel syndrome and sexual/physical abuse history. Eur J Gastroenterol Hepatol 1997;9:327–30. Kettell J, Jones R, Lydeard S. Reasons for consultation in irritable bowel syndrome and patient characteristics. Br J Gen Pract 1992;42:459–61. Talley NJ, Boyce PM, Jones M. Predictors of health care seeking for irritable bowel syndrome: a population based study. Gut 1997;41:394–8. Heaton KW, O’Donnell LJD, Braddon FEM, et al. Symptoms of irritable bowel syndrome in a British urban community: consulters and nonconsulters. Gastroenterology 1992;102:1962–7. Levy RL, Cain KC, Jarrett M, et al. The relationship between daily life stress and gastrointestinal symptoms in women with irritable bowel syndrome. J Behav Med 1997;20:177–93.

A.I. Budavari, K.W. Olden / Gastroenterol Clin N Am 32 (2003) 477–506

503

[90] Toner BB, Segal ZV, Emmott S, et al. Cognitive behavioral group therapy for patients with irritable bowel syndrome. Int J Group Psychother 1998;48:215–43. [91] Barsky AJ. Functional somatic syndromes. Ann Intern Med 1999;130:910–21. [92] Sharpe M, Peveler R, Mayou R. The psychological treatment of patients with functional somatic symptoms: a practical guide. J Psychosom Res 1992;36:515–29. [93] Groves JE. Taking care of the hateful patient. N Engl J Med 1978;298:883–7. [94] Verhoef MJ, Sutherland LR, Brkich L. Use of alternative medicine by patients attending a gastroenterology clinic. Can Med Assoc J 1990;142:121–5. [95] Colgan S, Creed F, Klass H. Symptom complaints, psychiatric disorder and abnormal illness behaviour in patients with upper abdominal pain. Psychol Med 1988;18:887–92. [96] Gomborone J, Dewsnap P, Libby G, et al. Abnormal illness attitudes in patients with irritable bowel syndrome. J Psychosom Res 1995;39:227–30. [97] Olden KW. Extragastrointestinal comorbidity in chronic functional gastrointestinal disorders. In: Corazziari E, editor. Approach to the patient with chronic gastrointestinal disorders. Milan, Italy: Messaggi; 2000. p. 43–54. [98] Whitehead WE, Palsson O, Jones KR. Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications? Gastroenterology 2002;122:1140–56. [99] Levy RL, Whitehead WE, Von Korff MR, et al. Intergenerational transmission of gastrointestinal illness behavior. Am J Gastroenterol 2000;95:451–6. [100] Whitehead WE, Crowell MD, Heller RR, et al. Modeling and reinforcement of the sick role during childhood predicts adult illness behavior. Psychosom Med 1994;6: 541–50. [101] Locke III GR, Zinsmeister AR, Talley NJ, et al. Familial association in adults with functional gastrointestinal disorders. Mayo Clin Proc 2000;75:907–12. [102] Levy RL, Jones KR, Whitehead WE, et al. Irritable bowel syndrome in twins: heredity and social learning both contribute to etiology. Gastroenterology 2001;121:799–804. [103] Walker LS, Garber J, Greene JW. Somatization symptoms in pediatric abdominal pain patients: relation to chronicity of abdominal pain and parent somatization. J Abnorm Child Psychol 1991;19:379–94. [104] Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life. Ann Intern Med 1993;118:622–9. [105] Ware JE, Sherbourne CD. The MOS 36-item short form Health Survey (SF-36): I, conceptual framework and item selection. Med Care 1992;30:473–83. [106] Patrick DL, Drossman DA, Frederick IO, et al. Quality of life in persons with irritable bowel syndrome: development and validation of a new measure. Dig Dis Sci 1998;43: 400–11. [107] Talley NJ, Weaver AL, Zinsmeister AR. Impact of functional dyspepsia on quality of life. Dig Dis Sci 1995;40:584–9. [108] Bertram S, Kurland M, Lydick E, et al. The patient’s perspective of irritable bowel syndrome. J Fam Pract 2001;50:521–5. [109] Olden KW, Chey WD, Boyle J, et al. Health related quality of life in irritable bowel syndrome: a community based study [abstract 3216]. Gastroenterology 2001;120(suppl 1): A-634. [110] Chassany O, Bergmann JF, Billardon M, et al. Quality of life in irritable bowel syndrome. Gastroenterology 1996;110:A646. [111] O’Sullivan M, Mahmud N, Lovett E, et al. Impaired quality of life in irritable bowel syndrome as compared to inflammatory bowel disease. Gut 1996;39:A33. [112] Silk D. Impact of irritable bowel syndrome on personal relationships and working practices. Eur J Gastroenterol Hepatol 2001;13:1327–32. [113] Gralnek IM, Hays RD, Kilbourne A, et al. The impact of irritable bowel syndrome on health-related quality of life. Gastroenterology 2000;119:654–60.

504

A.I. Budavari, K.W. Olden / Gastroenterol Clin N Am 32 (2003) 477–506

[114] Mayer EA, Raybould HE. Role of visceral afferent mechanisms in functional bowel disorders. Gastroenterology 1990;99:1688–704. [115] Ritchie J. Pain from distension of pelvic colon by inflating a balloon in the irritable bowel syndrome. Gut 1973;6:105–12. [116] Clouse RE, Lustman PJ, McCord GS, et al. Clinical correlates of abnormal sensitivity to intraesophageal balloon distension. Dig Dis Sci 1991;36:1040–5. [117] Rao SSC, Gregersen H, Hayek B, et al. Unexplained chest pain: the hypersensitive, hyperactive, and poorly compliant esophagus. Ann Intern Med 1996;124:950–8. [118] Richter JE, Barish CF, Castell DO. Abnormal sensory perception in patients with esophageal chest pain. Gastroenterology 1986;91:845–52. [119] Bradette M, Pare P, Douville P, et al. Visceral perception in health and functional dyspepsia: crossover study of gastric distension with placebo and domperidone. Dig Dis Sci 1991;36:52–8. [120] Coffin B, Azpiroz F, Guarner F, et al. Selective gastric hypersensitivity and reflex hyporeactivity in functional dyspepsia. Gastroenterology 1994;107:1345–51. [121] Lemann M, Dederding JP, Flourie B, et al. Abnormal perception of visceral pain in response to gastric distension in chronic idiopathic dyspepsia: the irritable stomach syndrome. Dig Dis Sci 1991;36:1249–54. [122] Notivol R, Coffin B, Azpiroz F, et al. Gastric tone determines the sensitivity of the stomach to distension. Gastroenterology 1995;108:330–6. [123] Kellow JE, Eckersley GM, Jones M. Enhanced perception of physiological intestinal motility in the irritable bowel syndrome. Gastroenterology 1991;101:1621–7. [124] Simre´n M, Abrahamsson H, Bjo¨rnsson ES. An exaggerated sensory component of the gastrocolonic response in patients with irritable bowel syndrome. Gut 2001;48:20–7. [125] Accarino AM, Azpiroz F, Malagelada JR. Selective dysfunction of mechanosensitive intestinal afferents in irritable bowel syndrome. Gastroenterology 1995;108: 636–43. [126] Greenwood B, Rodriguez S, Decktor D, et al. Irritable bowel syndrome: a study to investigate the mechanism(s) of visceral hypersensitivity. Med J Aust 1996;89:47–50. [127] Stein MB, Koverola C, Hanna C, et al. Hippocampal volume in women victimized by childhood sexual abuse. Psychol Med 1997;27:951–9. [128] Constantini M, Sturniolo GC, Zaninotto G, et al. Altered esophageal pain threshold in irritable bowel syndrome. Dig Dis Sci 1993;38:206–12. [129] Trimble KC, Farouk R, Pryde A, et al. Heightened visceral sensation in functional gastrointestinal disease is not site-specific: evidence for a generalized disorder of gut sensitivity. Dig Dis Sci 1995;40:1607–13. [130] Mertz H, Naliboff B, Munakata J, et al. Altered rectal perception is a biological marker of patients with irritable bowel syndrome. Gastroenterology 1995;109:40–52. [131] Whitehead WE, Palsson OS. Is rectal pain sensitivity a biological marker for irritable bowel syndrome: psychological influences on pain perception. Gastroenterology 1998; 115:1263–71. [132] Whitehead WE, Crowell MD, Davidoff LE, et al. Pain from rectal distension in women with irritable bowel syndrome: relationship to sexual abuse. Dig Dis Sci 1997;42:796–804. [133] Accarino AM, Azpiroz F, Malagelada JR. Attention and distraction: effects on gut perception. Gastroenterology 1997;113:415–22. [134] Ford MJ, Camilleri M, Zinsmeister AR, et al. Psychosensory modulation of colonic sensation in the human transverse and sigmoid colon. Gastroenterology 1995;109: 1772–80. [135] Kellow JE, Gill RC, Wingate DL. Prolonged ambulant recordings of small bowel motility demonstrate abnormalities in the irritable bowel syndrome. Gastroenterology 1990; 98:1208–18. [136] Castell DO, Wood JD, Frieling T, et al. Cerebral electrical potentials evoked by balloon distension of the human esophagus. Gastroenterology 1994;98:662–6.

A.I. Budavari, K.W. Olden / Gastroenterol Clin N Am 32 (2003) 477–506

505

[137] Frieling T, Enck P, Wienbeck M. Cerebral responses evoked by electrical stimulation of rectosigmoid in normal subjects. Dig Dis Sci 1994;34:202–5. [138] Silverman DHS, Munakata JA, Ennes H, et al. Regional cerebral activity in normal and pathologic perception of visceral pain. Gastroenterology 1997;112:64–72. [139] Aziz Q, Thompson DG. Brain-gut axis in health and disease. Gastroenterology 1998;114:559–78. [140] Olden KW. Approach to the patient with irritable bowel syndrome. In: Stern TA, Herman JB, Slavin PL, editors. The MGH guide to psychiatry in primary care. New York: McGraw-Hill; 1998. p. 113–20. [141] Olden KW. Psychosocial aspects of gastroenterology: doctor-patient interactions. In: Brandt LJ, Friedman LS, editors. Clinical practice of gastroenterology, vol. 2. Philadelphia: Churchill Livingstone; 1998:1640–7. [142] Olden KW. Refractory gastrointestinal symptoms: a combined medical psychiatric approach. Semin Gastrointest Dis 1999;10:37–45. [143] Drossman DA. Psychosocial sound bites: exercises in the patient-doctor relationship. Am J Gastroenterol 1997;92:1418–23. [144] Drossman DA. Struggling with the ‘‘controlling’’ patient. Am J Gastroenterol 1994;89:1441–6. [145] Ong LM, de Haes JC, Hoos AM, et al. Doctor-patient communication: a review of the literature. Soc Sci Med 1995;40:903–18. [146] Owens DM, Nelson DK, Talley NJ. The irritable bowel syndrome: long term prognosis and the physician-patient interaction. Ann Intern Med 1995;122:107–12. [147] Heymann-Monnikes I, Arnold R, Florin I, et al. The combination of medical treatment plus multicomponent behavioral therapy is superior to medical treatment alone in therapy of irritable bowel syndrome. Am J Gastroenterol 2000;95:981–94. [148] Van Dulmen AM, Fennis JFM, Mokkink HGA, et al. Doctor-dependent changes in complaint-related cognitions and anxiety during medical consultations in functional abdominal complaints. Psychol Med 1995;25:1011–8. [149] Barsky A, Borus JF. Somatization and medicalization in the era of managed care. JAMA 1995;274:1931–4. [150] Friedman LS, Samet JH, Roberts MS, et al. Inquiry about victimization experiences: a survey of patient preferences and physician practices. Arch Intern Med 1992;152: 1186–90. [151] Drossman DA. Review article: an integrated approach to the irritable bowel syndrome. Aliment Pharmacol Ther 1999;13(suppl 2):3–14. [152] Boyce P. Psychologic therapies for irritable bowel syndrome. Curr Treat Options Gastroenterol 2001;4:323–31. [153] Greene B, Blanchard EB. Cognitive therapy for irritable bowel syndrome. J Consult Clin Psychol 1994;62:576–82. [154] Payne A, Blanchard EB. A controlled comparison of cognitive therapy and self-help support groups in the treatment of irritable bowel syndrome. J Consult Clin Psychol 1995;63:779–86. [155] Svedlund J, Sjodin I, Ohosson JO, et al. Controlled study of psychotherapy in irritable bowel syndrome. Lancet 1983;2:589–92. [156] Guthrie E, Creed F, Dawson D, et al. A randomized controlled trial of psychotherapy in patients with refractory irritable bowel syndrome. Br J Psychiatry 1993;163:315–21. [157] Poitras MR, Verrier P, So C, et al. Group counseling psychotherapy for patients with functional gastrointestinal disorders: development of new measures for symptoms severity and quality of life. Dig Dis Sci 2002;47:1297–307. [158] Gonsalkorale WM, Houghton LA, Whorwell PJ. Hypnotherapy in irritable bowel syndrome: a large-scale audit of a clinical service with examination of factors influencing responsiveness. Am J Gastroenterol 2002;97:954–61.

506

A.I. Budavari, K.W. Olden / Gastroenterol Clin N Am 32 (2003) 477–506

[159] Whorwell PJ. Use of hypnotherapy in gastrointestinal disease. Br J Hosp Med 1991;45:27–9. [160] Prior A, Colgan SM, Whorwell PJ. Changes in rectal sensitivity after hypnotherapy in patients with irritable bowel syndrome. Gut 1990;31:896–8. [161] Lembo T, Munakata J, Mertz H, et al. Evidence for the hypersensitivity of the lumbar splanchnic afferents in irritable bowel syndrome. Gastroenterology 1994;107:1686–96. [162] Mearin F, Badı´ a X, Balboa A, et al. Irritable bowel syndrome prevalence varies enormously depending on the employed diagnostic criteria: comparison of Rome II versus previous criteria in a general population. Scand J Gastroenterol 2001;36:1155–61. [163] Blanchard EB, Greene B, Scharff L, et al. Relaxation training as a treatment for irritable bowel syndrome. Biofeedback Self Regul 1993;18:125–32. [164] Keefer L, Blanchard EB. A one year follow-up of relaxation response meditation as a treatment for irritable bowel syndrome. Behav Res Ther 2002;40:541–6. [165] Keefer L, Blanchard EB. The effects of relaxation response meditation on the symptoms of irritable bowel syndrome: results of a controlled treatment study. Behav Res Ther 2001;39:801–11. [166] Van Dulmen AM, Fennis JF, Bleijenberg G. Cognitive-behavioral group therapy for irritable bowel syndrome: effects and long-term follow-up. Psychosom Med 1996;58: 508–14. [167] Palsson OS, Turner MJ, Johnson DA, et al. Hypnosis treatment for severe irritable bowel syndrome: investigation of mechanism and effect on symptoms. Dig Dis Sci 2002;47: 2605–14.