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The brief Visual Analogue Scale for Irritable Bowel Syndrome questionnaire can be used to evaluate psychological well-being in patients with irritable bowel syndrome
European Journal of Internal Medicine 24 (2013) e82–e83
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor The brief Visual Analogue Scale for Irritable Bowel Syndrome questionnaire can be used to evaluate psychological well-being in patients with irritable bowel syndrome Keywords: Anxiety in close relationship Coping Irritable bowel syndrome Psychological well-being Self-esteem VAS-IBS
A Visual Analogue Scale for Irritable Bowel Syndrome (VAS-IBS) was developed to evaluate symptoms in patients with IBS [1]. We have shown that patients with IBS have higher anxiety and lower self-esteem than patients with inflammatory bowel disease (IBD) [2]. The aim of this study was to further evaluate the VAS-IBS, and to examine correlations between the item measuring psychological well-being and attachment in close relationships, self-esteem and coping. A search for adult participants having IBS according to the Rome criteria was made among patients who had visited the University Hospital in Malmö between 2005 and 2010. Totally, 417 patients were identified and all medical records were scrutinised. The participants should comprehend the Swedish language, and should not have other severe chronic diseases. After studying the records, 265 patients remained and were invited to participate in the study. The Ethics Committee at Lund University (2010/386) approved the study. The questionnaires VAS-IBS, Experiences in Close Relationships (ECR-36), Rosenberg Self-Esteem Scale (RSES), and the Sense of Coherence (SOC-13) together with written information, an inform consent formula, and a pre-paid return envelope, were sent to the invited patients. The VAS-IBS includes nine concerns; abdominal pain, diarrhoea, constipation, bloating and flatulence, vomiting and nausea, perception of psychological well-being and the intestinal symptoms' influence on daily life scored on a VAS (0 = very severe problems and 100 = absences of problems). The dichotomous scale YES/NO was chosen for: urgency and feeling of incomplete evacuation of the bowel passage. This questionnaire has been used and psychometrically tested [1,3,4]. The ECR has 36 statements describing the individual's feelings in close relationships and consists of the anxiety and the avoidance subscales (18 items each). Each item is scored on a 7-point Likert scale and secure persons score low on both dimensions. Data on reliability and validity for the ECR are considerable, and the validated Norwegian version [5] was translated into Swedish. The RSES is a reliable and valid questionnaire [6], and consists of 10 assertions (five negative and five positive) related to feelings of self-worth or self-acceptance. Patients rate the level of agreement on a 4-point Likert scale, and a high score indicates a high level of self-esteem. Each item in the SOC-13 is scored on a Likert scale ranging from 1
to 7 points. The higher the score, the more successful the coping and the better the health outcomes. The SOC-13 scale is reliable, valid, and cross-culturally applicable [7]. The data did not follow the Gaussian distribution norm, which is why the Spearman's rank correlation test, Kruskal–Wallis test, Mann–Whitney U-test, and Fisher's exact test were used. A difference was considered statistically significant if p ≤ 0.05. Cronbach's alpha was used to assess the degree of consistency or homogeneity of the items in the VAS-IBS. A coefficient of 0.70–0.90 was required. The results are based on 70 women and 11 men with IBS, median age 35 years (21–66 years) who returned the questionnaires. Of the 81 patients, 47 had mixed IBS (M-IBS), 21 diarrhoea-predominated (D-IBS), and 13 constipation-predominated (C-IBS). There were statistically significant differences between subgroups in the VAS-IBS questionnaire. Compared to patients with C-IBS and M-IBS, patients with D-IBS perceived more abdominal pain (p = 0.005 and p = 0.000, respectively), diarrhoea (p = 0.006 and p = 0.000, respectively), and bloating and flatulence (p = 0.003 and p = 0.029, respectively). Patients with D-IBS also had worse psychological well-being (p = 0.019 and p = 0.019, respectively), and perceived that symptoms affected their life to a higher extent (p = 0.011 and p = 0.000, respectively) than patients with C-IBS and M-IBS. There was no difference between M-IBS and C-IBS, or between subgroups in the ECR-36, RSES, and SOC-13. The item psychological well-being in the VAS-IBS corresponded with the scores based on the subscale anxiety in the ECR-36, the RSES, and the SOC-13. Poor psychological well-being correlated with higher anxiety, lower self-esteem, and more impaired coping mechanisms. A poor psychological well-being correlated with increased influence of the intestinal symptoms on the patients' daily life. Neither the ECR-36, RSES, nor SOC-13 corresponded to the intestinal symptoms' influence on the patients' daily life. The subscale avoidance in the ECR-36 did not correlate to any of the other questionnaires (Table 1). The overall VAS-IBS showed a high degree of internal consistency reliability as indicated by a Cronbach's alpha coefficient of 0.793. Each of the items had a high alpha value (0.721–0.806) if the item was deleted. This study shows that the item psychological well-being in the VAS-IBS strongly correlates to anxiety in close relations, self-esteem, and coping skills. Psychological well-being in general correlated to how the intestinal symptoms influenced the daily life. This may explain the discrepancy between how the health care professionals and the patients perceive the degree of physical symptoms [4]. Mild symptoms may be troublesome for the patient, but ignored by the health care professionals, though they do not take into account psychological aspects. The present study underlines how important it is to recognise and treat not only physical symptoms, but also psychological illness, which all influence the clinical outcome [8]. The benefits of anti-depressant drugs and psychotherapeutic methods in IBS are probably due to the treatment of both gastrointestinal symptoms and psychological well-being [9]. Taken into account that the VAS-IBS
0953-6205/$ – see front matter © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ejim.2013.05.013
Letter to the Editor
e83
Table 1 Correlation between psychological aspects evaluated with the Experiences in Close Relation-ships (ECR-36), the Rosenberg Self-Esteem Scale (RSES), the Sense of Coherence (SOC-13), and the item psychological well-being in the Visual Analogue Scale for Irritable Bowel Syndrome (VAS-IBS).
VAS-IBS item Psychological well-being Influence on daily life
VAS-IBS item
ECR-36
Influence on daily life
Anxiety subscale
Avoidance subscale
RSES
Rs
p-Value
Rs
p-Value
Rs
p-Value
0.515
0.000
−0.293 −0.022
0.008 0.843
0.002 −0.043
0.985 0.702
0.487 0.133
0.000 0.238
0.579 0.209
0.000 0.061
0.135
0.228
−0.498 −0.203
0.000 0.069
−0.470 −0.210
0.000 0.060
0.669
0.000
ECR-36 Anxiety subscale Avoidance subscale
Rs
SOC-13
p-Value
Rs
p-Value
RSES Spearman's correlation test has been used and values are given as correlation coefficients (Rs) and p-value. p ≤ 0.05 was considered statistically significant.
has high internal consistency reliability, the questionnaire should be regarded as a one-dimensional questionnaire. By this easy-to-use and brief VAS-IBS questionnaire, the health care professionals get a lot of information not only about physical symptoms, but also about the patient's psychological well-being. A majority of the patients with IBS who seek treatment have a history of affective disturbances, and the prevalence of these disorders is higher in IBS than in the general population [8]. Patients with D-IBS have higher rates of doctor consultations, compared with patients with C-IBS [10]. They search help for their symptoms, and the symptoms often trigger a fear of serious disease. These factors, together with anxiety and low self-esteem, could explain why health care professionals perceive that patients with IBS have a “support-seeking” behaviour and cling to the health care system more than what is reasonable from a pure medical point of view. Contributions MB and BO together designed the study, collected, analysed the data and wrote the manuscript. Conflict of interests The authors declare that they have no competing interests. Acknowledgements This study was supported by grants from Ruth and Richard Julin Foundation and Foundation of Skåne University Hospital. References [1] Bengtsson M, Ohlsson B, Ulander K. Development and psychometric testing of the Visual Analogue Scale for Irritable Bowel Syndrome (VAS-IBS). BMC Gastroenterol 2007;3:16.
[2] Bengtsson M, Sjöberg K, Candamio M, Lerman A, Ohlsson B. Anxiety in close relationships is higher and self-esteem lower in patients with irritable bowel syndrome compared to patients with inflammatory bowel disease. Eur J Intern Med 2013;24:266–72. [3] Bengtsson M, Sjölund K, Persson J, Ohlsson B. Further validation of the Visual Analogue Scale for Irritable Bowel Syndrome (VAS-IBS) after use in clinical practice.Gastroenterol Nurs 2013 [in press]. [4] Bengtsson M, Hammar O, Mandl T, Ohlsson B. Evaluation of gastrointestinal symptoms in different patient groups using the visual analogue scale for irritable bowel syndrome (VAS-IBS). BMC Gastroenterol 2011;11:122. [5] Olssøn I, Sørebø Ø, Dahl AA. The Norwegian version of the experiences in close relationships measure of adult attachment: psychometric properties and normative data. Nord J Psychiatry 2010;64:340–9. [6] Schmitt DP, Allik J. Simultaneous administration of the Rosenberg Self-Esteem Scale in 53 nations: exploring the universal and culture-specific features of global self-esteem. J Pers Soc Psychol 2005;89:623–42. [7] Eriksson M, Lindström B. Validity of Antonovsky's sense of coherence scale: a systematic review. J Epidemiol Community Health 2005;59:460–6. [8] Tanaka Y, Kanazawa M, Fukudo S, Drossman DA. Biopsychosocial model of irritable bowel syndrome. J Neurogastroenterol Motil 2011;17:131–9. [9] Surdea-Blaga T, Băban A, Dumitrascu DL. Psychosocial determinants of irritable bowel syndrome. World J Gastroenterol 2012;21:616–26. [10] Guthrie E, Creed F, Fernandes L, Ratcliffe J, Van Der Jagt J, Martin J, et al. Cluster analysis of symptoms and health seeking behaviour differentiates subgroups of patients with severe irritable bowel syndrome. Gut 2003;52:1616–22.
Mariette Bengtsson Faculty of Health and Society, Institution of Care Science, Malmö University, Sweden Corresponding author at: Faculty of Health and Society, Institution of Care Science, Malmö University, SE 20506 Malmö, Sweden. Tel.: + 46 705 66 73 77. E-mail address: [email protected]. Bodil Ohlsson Department of Clinical Sciences, Division of Internal Medicine, Skåne University Hospital, Malmö, Lund University, Sweden 12 May 2013
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor The brief Visual Analogue Scale for Irritable Bowel Syndrome questionnaire can be used to evaluate psychological well-being in patients with irritable bowel syndrome Keywords: Anxiety in close relationship Coping Irritable bowel syndrome Psychological well-being Self-esteem VAS-IBS
A Visual Analogue Scale for Irritable Bowel Syndrome (VAS-IBS) was developed to evaluate symptoms in patients with IBS [1]. We have shown that patients with IBS have higher anxiety and lower self-esteem than patients with inflammatory bowel disease (IBD) [2]. The aim of this study was to further evaluate the VAS-IBS, and to examine correlations between the item measuring psychological well-being and attachment in close relationships, self-esteem and coping. A search for adult participants having IBS according to the Rome criteria was made among patients who had visited the University Hospital in Malmö between 2005 and 2010. Totally, 417 patients were identified and all medical records were scrutinised. The participants should comprehend the Swedish language, and should not have other severe chronic diseases. After studying the records, 265 patients remained and were invited to participate in the study. The Ethics Committee at Lund University (2010/386) approved the study. The questionnaires VAS-IBS, Experiences in Close Relationships (ECR-36), Rosenberg Self-Esteem Scale (RSES), and the Sense of Coherence (SOC-13) together with written information, an inform consent formula, and a pre-paid return envelope, were sent to the invited patients. The VAS-IBS includes nine concerns; abdominal pain, diarrhoea, constipation, bloating and flatulence, vomiting and nausea, perception of psychological well-being and the intestinal symptoms' influence on daily life scored on a VAS (0 = very severe problems and 100 = absences of problems). The dichotomous scale YES/NO was chosen for: urgency and feeling of incomplete evacuation of the bowel passage. This questionnaire has been used and psychometrically tested [1,3,4]. The ECR has 36 statements describing the individual's feelings in close relationships and consists of the anxiety and the avoidance subscales (18 items each). Each item is scored on a 7-point Likert scale and secure persons score low on both dimensions. Data on reliability and validity for the ECR are considerable, and the validated Norwegian version [5] was translated into Swedish. The RSES is a reliable and valid questionnaire [6], and consists of 10 assertions (five negative and five positive) related to feelings of self-worth or self-acceptance. Patients rate the level of agreement on a 4-point Likert scale, and a high score indicates a high level of self-esteem. Each item in the SOC-13 is scored on a Likert scale ranging from 1
to 7 points. The higher the score, the more successful the coping and the better the health outcomes. The SOC-13 scale is reliable, valid, and cross-culturally applicable [7]. The data did not follow the Gaussian distribution norm, which is why the Spearman's rank correlation test, Kruskal–Wallis test, Mann–Whitney U-test, and Fisher's exact test were used. A difference was considered statistically significant if p ≤ 0.05. Cronbach's alpha was used to assess the degree of consistency or homogeneity of the items in the VAS-IBS. A coefficient of 0.70–0.90 was required. The results are based on 70 women and 11 men with IBS, median age 35 years (21–66 years) who returned the questionnaires. Of the 81 patients, 47 had mixed IBS (M-IBS), 21 diarrhoea-predominated (D-IBS), and 13 constipation-predominated (C-IBS). There were statistically significant differences between subgroups in the VAS-IBS questionnaire. Compared to patients with C-IBS and M-IBS, patients with D-IBS perceived more abdominal pain (p = 0.005 and p = 0.000, respectively), diarrhoea (p = 0.006 and p = 0.000, respectively), and bloating and flatulence (p = 0.003 and p = 0.029, respectively). Patients with D-IBS also had worse psychological well-being (p = 0.019 and p = 0.019, respectively), and perceived that symptoms affected their life to a higher extent (p = 0.011 and p = 0.000, respectively) than patients with C-IBS and M-IBS. There was no difference between M-IBS and C-IBS, or between subgroups in the ECR-36, RSES, and SOC-13. The item psychological well-being in the VAS-IBS corresponded with the scores based on the subscale anxiety in the ECR-36, the RSES, and the SOC-13. Poor psychological well-being correlated with higher anxiety, lower self-esteem, and more impaired coping mechanisms. A poor psychological well-being correlated with increased influence of the intestinal symptoms on the patients' daily life. Neither the ECR-36, RSES, nor SOC-13 corresponded to the intestinal symptoms' influence on the patients' daily life. The subscale avoidance in the ECR-36 did not correlate to any of the other questionnaires (Table 1). The overall VAS-IBS showed a high degree of internal consistency reliability as indicated by a Cronbach's alpha coefficient of 0.793. Each of the items had a high alpha value (0.721–0.806) if the item was deleted. This study shows that the item psychological well-being in the VAS-IBS strongly correlates to anxiety in close relations, self-esteem, and coping skills. Psychological well-being in general correlated to how the intestinal symptoms influenced the daily life. This may explain the discrepancy between how the health care professionals and the patients perceive the degree of physical symptoms [4]. Mild symptoms may be troublesome for the patient, but ignored by the health care professionals, though they do not take into account psychological aspects. The present study underlines how important it is to recognise and treat not only physical symptoms, but also psychological illness, which all influence the clinical outcome [8]. The benefits of anti-depressant drugs and psychotherapeutic methods in IBS are probably due to the treatment of both gastrointestinal symptoms and psychological well-being [9]. Taken into account that the VAS-IBS
0953-6205/$ – see front matter © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ejim.2013.05.013
Letter to the Editor
e83
Table 1 Correlation between psychological aspects evaluated with the Experiences in Close Relation-ships (ECR-36), the Rosenberg Self-Esteem Scale (RSES), the Sense of Coherence (SOC-13), and the item psychological well-being in the Visual Analogue Scale for Irritable Bowel Syndrome (VAS-IBS).
VAS-IBS item Psychological well-being Influence on daily life
VAS-IBS item
ECR-36
Influence on daily life
Anxiety subscale
Avoidance subscale
RSES
Rs
p-Value
Rs
p-Value
Rs
p-Value
0.515
0.000
−0.293 −0.022
0.008 0.843
0.002 −0.043
0.985 0.702
0.487 0.133
0.000 0.238
0.579 0.209
0.000 0.061
0.135
0.228
−0.498 −0.203
0.000 0.069
−0.470 −0.210
0.000 0.060
0.669
0.000
ECR-36 Anxiety subscale Avoidance subscale
Rs
SOC-13
p-Value
Rs
p-Value
RSES Spearman's correlation test has been used and values are given as correlation coefficients (Rs) and p-value. p ≤ 0.05 was considered statistically significant.
has high internal consistency reliability, the questionnaire should be regarded as a one-dimensional questionnaire. By this easy-to-use and brief VAS-IBS questionnaire, the health care professionals get a lot of information not only about physical symptoms, but also about the patient's psychological well-being. A majority of the patients with IBS who seek treatment have a history of affective disturbances, and the prevalence of these disorders is higher in IBS than in the general population [8]. Patients with D-IBS have higher rates of doctor consultations, compared with patients with C-IBS [10]. They search help for their symptoms, and the symptoms often trigger a fear of serious disease. These factors, together with anxiety and low self-esteem, could explain why health care professionals perceive that patients with IBS have a “support-seeking” behaviour and cling to the health care system more than what is reasonable from a pure medical point of view. Contributions MB and BO together designed the study, collected, analysed the data and wrote the manuscript. Conflict of interests The authors declare that they have no competing interests. Acknowledgements This study was supported by grants from Ruth and Richard Julin Foundation and Foundation of Skåne University Hospital. References [1] Bengtsson M, Ohlsson B, Ulander K. Development and psychometric testing of the Visual Analogue Scale for Irritable Bowel Syndrome (VAS-IBS). BMC Gastroenterol 2007;3:16.
[2] Bengtsson M, Sjöberg K, Candamio M, Lerman A, Ohlsson B. Anxiety in close relationships is higher and self-esteem lower in patients with irritable bowel syndrome compared to patients with inflammatory bowel disease. Eur J Intern Med 2013;24:266–72. [3] Bengtsson M, Sjölund K, Persson J, Ohlsson B. Further validation of the Visual Analogue Scale for Irritable Bowel Syndrome (VAS-IBS) after use in clinical practice.Gastroenterol Nurs 2013 [in press]. [4] Bengtsson M, Hammar O, Mandl T, Ohlsson B. Evaluation of gastrointestinal symptoms in different patient groups using the visual analogue scale for irritable bowel syndrome (VAS-IBS). BMC Gastroenterol 2011;11:122. [5] Olssøn I, Sørebø Ø, Dahl AA. The Norwegian version of the experiences in close relationships measure of adult attachment: psychometric properties and normative data. Nord J Psychiatry 2010;64:340–9. [6] Schmitt DP, Allik J. Simultaneous administration of the Rosenberg Self-Esteem Scale in 53 nations: exploring the universal and culture-specific features of global self-esteem. J Pers Soc Psychol 2005;89:623–42. [7] Eriksson M, Lindström B. Validity of Antonovsky's sense of coherence scale: a systematic review. J Epidemiol Community Health 2005;59:460–6. [8] Tanaka Y, Kanazawa M, Fukudo S, Drossman DA. Biopsychosocial model of irritable bowel syndrome. J Neurogastroenterol Motil 2011;17:131–9. [9] Surdea-Blaga T, Băban A, Dumitrascu DL. Psychosocial determinants of irritable bowel syndrome. World J Gastroenterol 2012;21:616–26. [10] Guthrie E, Creed F, Fernandes L, Ratcliffe J, Van Der Jagt J, Martin J, et al. Cluster analysis of symptoms and health seeking behaviour differentiates subgroups of patients with severe irritable bowel syndrome. Gut 2003;52:1616–22.
Mariette Bengtsson Faculty of Health and Society, Institution of Care Science, Malmö University, Sweden Corresponding author at: Faculty of Health and Society, Institution of Care Science, Malmö University, SE 20506 Malmö, Sweden. Tel.: + 46 705 66 73 77. E-mail address: [email protected]. Bodil Ohlsson Department of Clinical Sciences, Division of Internal Medicine, Skåne University Hospital, Malmö, Lund University, Sweden 12 May 2013