- Email: [email protected]
A biopsychosocial model for functional dyspepsia
866
SELECTED
[AnnInternMed is not surprising This perceptive
SUMMARIES
GASTROENTEROLOGY
1988;109:449_455;Lancet because the causative piece of clinical
1988;1:960-963), which agent is probably the same.
detective
work by Perkocha
et al.
is complemented by the discovery by Relman et al. that the causative agent for cutaneous bacillary angiomatosis and probably peliosis hepatis in association with HIV infection is a previously uncharacterized quintana. Using
Rickettsia-like the polymerase
organism, closely related chain reaction, sequences
to R. of the
16s rRNA gene can be amplified and compared with a reference sequence data base to construct phylogenetic trees. R. quintana is the cause of trench fever characterized by fever, rash, splenomegaly, and bone and muscle pain: this organism is sensitive to erythromycin and the tetracyclines (Antimicrob Agents Chemother 1984;25:690-693). Bartonella bocilliformis is another member of the order Rickeftsiales and can result in skin lesions very similar to bacillary angiomatosis (Annu Rev Microbial 1981;35:325-338). Because there are no 16s rRNA sequences available for B. bacilliformis yet, cannot be disease has those of the
its relationship to the agent of bacillary angiomatosis ascertained. The bacillus responsible for cat scratch some characteristics (Lancet 1988;1:960-963) similar to organism of bacillary angiomatosis, but the former has
not yet been clearly characterized. The organism responsible for cat scratch disease is currently being investigated by Relman et al. using this same 16s rRNA technique, and when this is accomplished its relationship to the agent of bacillary angiomatosis will be better understood. The powerful techniques used for identification of the organism of bacillary angiomatosis could serve as a paradigm for the characterization of other uncultured organisms in the future. These methods allow genotypic comparisons between organisms instead of the traditional phenotypic comparisons that have been used for many years (N Engl J Med 1991;323:1625-1627). The usefulness of these new techniques to clinical medicine will hopefully become evident over the next decades as more hitherto baffling diseases reveal themselves to more sophisticated molecular-level probes. P. F. MALET, MD. II. MOONKA, MD. Reply. Studies on the composition of environmental microbial communities have demonstrated that reliance on microbial growth in the laboratory may lead to a biased picture (Nature 1990;345:6063; Nature 1990;345:63-65). This finding may have relevance to our understanding of human pathogen diversity. This bias may be avoided by directly amplifying 16s rRNA sequences from relevant human tissue samples with broad-range polymerase chain reaction primers, and the spectrum of known pathogens may be expanded. The agent of bacillary angiomatosis (BA-TF) may be the first of many new human pathogens identified in this manner (N Engl J Med 1990;323:1573-1580). Work is currently underway to identify the causative agents of cat scratch disease and Whipple’s disease. Further characterization of BA-TF now suggests that it is highly related to Bartonella bacilliformis, as well as to Rochalimaea quintana (Relman DA, Falkow S, Schmidt TM, manuscript in preparation). The entire 16s rRNA genes from these three organisms have been amplified and cloned. The exact relationships among these different a-purple eubacteria must await completed analysis of their 16s rRNA gene sequences. At the time we reported the identification of the agent of bacillary angiomatosis (BA-TF) (NEngl J Med 1990;323:1573-1580) we were unaware of work by Slater et al. (N Engl J Med 1990;323:15871593) who had isolated a fastidious bacillus from the blood of some patients with persistent fever. A liver biopsy specimen from one of these patients (patient 1) subsequently revealed bacillary peliosis hepatis (NEngl JMed 1999;323:1581-1586). Since the time of these reports, we have determined partial 16SrRNA sequence from this patient’s blood isolate. The results suggest that this organism is the
Vol. 101, No. 3
as or highly related to BA-TF [N Engl J Med 1991;324 (in press)]. These findings further suggest that the same organism may cause bacillary angiomatosis, bacillary peliosis hepatis, and persistent fever in some patients. The application of our molecular technique to other tissue samples from patients with bacillary peliosis hepatis will be necessary to confirm these results. However, it seems that the full spectrum of human disease attributable to this organism remains to be defined. same
D. A. RELMAN, M.D.
A BIOPSYCHOSOCIAL MODEL FOR FUNCTIONAL DYSPEPSIA Hui W, Shiu LP, Lam SK (University Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong]. The perception of life events and daily stress in nonulcer dyspepsia. Am J Gastroenterol 1991;86:292-296 (March). The association of dyspepsia of unknown cause (functional dyspepsia) and stress in life is often suggested, but so far, inconsistent results have been reported. Methodological problems may be at fault because most studies have emphasized the number of major life events but have neglected the fact that the severity of an event depends on the way the person perceives it. Therefore, an accurate assessment of life stresses should include an individual’s rating of the impact and desirability of the events. The present study examined the perception of major life events and, in addition, the role of daily “hassles” (annoying daily events) in patients with functional dyspepsia. Thirty-three consecutive patients were identified who complained of epigastric pain, nausea, vomiting, and belching without evidence of peptic ulcer disease or gallstones as defined by normal endoscopy and ultrasonography. Severity of dyspeptic symptoms was recorded and graded as mild (bothersome but not interfering with work), moderate (interfering with work and/or resulting in sick leave), or severe (requiring immediate medical care). Thirty-three healthy unpaid volunteers of comparable sex, age, and social class were recruited as the control group for this study. Both groups completed two self-report questionnaires translated into Chinese that could be finished within 15-20 minutes. The first part was the Life Experience Survey (LES), which listed 56 major life events such as marriage, death of a spouse, pregnancy, and retirement. Subjects were asked to circle those events experienced in the preceding 6 months and rate the desirability and severity of each circled event. The rating scale involved seven points ranging from -3 to +3. A negative sign indicated a negative impact of the event on the person’s life, whereas a positive sign indicated the converse. The number indicated the perceived magnitude of the impact, with 3 being the strongest. Five scores were derived from the LES: number of negative and number of positive events, magnitude of negative and magnitude of positive events, and life-change score obtained by adding the magnitude scores of negative and positive events together. The second part was a “hassles scale” designed to measure daily activities or events that were irritating, frustrating or distressing. For example, these included misplacing and losing things, not having enough time for
September
SELECTED SUMMARIES
1991
family, and concerns about pollution. Subjects selected from 113 items those hassles that they had experienced in the last month and rated the severity of each item (range, l-3). Two summation scores were generated: [a) frequency, a simple count of the number of items checked, and (b] cumulative perceived severity, the sum of the severity ratings; possible scores ranged from 0 to 339 (3 x 113). The results showed that the number of positive and number of negative events and the magnitude of the positive events on the LES were similar in both dyspeptic patients and controls. However, dyspeptic patients had a higher perceived magnitude of negative events (i.e., they viewed these events as more stressful) and a higher score of total life changes as given by the summation of magnitude of positive and magnitude of negative events (both P < 0.05). A breakdown of the frequency showed the differences to be mainly attributable to patients with more negative scores and a higher magnitude in life-change score. The scores did not differ based on the severity of dyspeptic symptoms. The “hassles” scores were not significantly different between patients and controls. Analysis of individual life events showed that dyspeptic patients had significantly (P < 0.05) higher scores than controls on items of minor law violations, major changes in closeness of family members, and major personal illness or injury. The authors conclude that patients with functional dyspepsia have greater negative perceptions of major life events but not daily hassles, especially in the areas of personal health and interpersonal relationships. Although not specifically studied, the impact of these events may be important in the pathogenesis of functional dyspepsia via a complex “biopsychosocial” interaction of the stressors, availability of social support, individual coping skills, and personality traits. Comment. The term “dyspepsia” is broadly used to imply episodic or persistent symptoms referable to the upper gastrointestinal tract (Dig Dis Sci 1989;34:1272-1276). Relevant symptoms include abdominal pain, postprandial fullness, early satiety, anorexia, nausea, vomiting, bloating, belching, heartburn, and regurgitation. Many cases of dyspepsia are secondary to organic causes, particularly peptic ulcer disease, gastroesophageal reflux disease, biliary tract disease, or gastric cancer. However, dyspepsia of unknown origin is a common clinical problem, accounting for some 30%-50% of cases of chronic upper abdominal complaints seen by gastroenterologists [Ann Intern Med 1988;108:865-879). Despite its general importance and health care impact, this syndrome is an enigma. Authorities cannot even agree on terminology-should this be called “nonulcer dyspepsia,” “nonorganic dyspepsia,” “X-ray-negative “essential dyspepsia,” dyspepsia,” or “flatulent dyspepsia”? After much discussion, a recent international working team settled on the term “functional dyspepsia” to identify this syndrome and distinguish it from “organic dyspepsia,” in which underlying disease process can be found to account for the patient’s complaints. Unfortunately, this nomenclature still may be confusing for many physicians. For example, the terminology “functional” often is used interchangeably with the term “psychogenic” (i.e., a disease with a psychological cause only). In fact, functional dyspepsia represents a disease which is neither purely organic or psychogenic. Rather, it may be best characterized by a “biopsychosocial model” in which psychological, social, and cultural factors interact with biological variables (acid secretion, gastroesophageal reflux, upper gut motility disturbances] to determine the onset, severity, and course of illness [Science 1977;196:129-135). Physi-
cians frequently
spend
a great deal of time and money
867
investigating
and treating these difficult cases, many times with less than satisfactory outcomes. Application of the biopsychosocial model demands that equal time be spent understanding the interactions of personality traits, life events, availability of social support, and coping skills that culminate in the individuals’ feelings of “stress” and may be important in their reports of symptoms. Therefore, let us look more critically at these psychosocial factors in patients with functional dyspepsia. The personality traits of patients with functional becoming better characterized by comparison studies
dyspepsia are with age- and
gender-matched healthy controls, patients with organic pain syndromes, and patients with the irritable bowel syndrome. These studies indicate that there is no unique personality profile for patients with functional dyspepsia. Instead, the personality profile is similar to that of other patients with pain syndromes, be they organic or functional in nature. In general, patients with functional dyspepsia score higher on measures of anxiety, neuroticism, depression, and hypochondriasis than healthy controls. However, their personality scores are similar to those of patients with organic causes of upper abdominal pain (ulcer disease, biliary tract disease], and irritable bowel patients and are markedly different from those psychiatric patients with chronic pain or somatoform disorders (Gastroenterology 1990;99:327-333). Whether these high levels of anxiety and depression characterize patients with functional dyspepsia as a group or only those who seek medical attention, as has been found in the irritable bowel syndrome (Gastroenterology 1988;95:701-708),is an unresolved issue. Major life events such as marriage or loss of a job may be powerful social stressors in a person’s life. Many clinical case studies have suggested that stressful life events often precede the onset of illness such as sudden cardiac death (Arch Intern Med 1974;133:221-2281, athletic injury (J Hum Stress 1975;1:66-ZO), or general illness in a large military population [Ann Clin Res 1972;4:250-265). Two studies (J Psychosom Res 1985;29:191-198; Gut 1986;27:127-134) previously found that the numbers of positive and negative life events were not different in patients with functional dyspepsia from those in healthy controls or patients with organic causes of abdominal pain. However, another study (Stand J Gastroenterol 1986;21:605-613) observed that patients with functional dyspepsia compared with control subjects obtained from an orthopedic ward tween increased workload, the onset or exacerbation drawback of these studies
reported a significant relationship bedomestic and personal problems, and of their abdominal pain. The main was the failure to assess the patients’
perception of the different life events and daily stresses. The current questionnaires allowed the subjects to give an individual rating of the desirability of these events, therefore making it possible to assess the severity of these events as perceived by the patients. This study showed that patients with functional dyspepsia have a higher incidence of negative major life events, particularly family problems and personal medical illnesses, and that the impact of these events was significantly stronger. Thus, these patients encountered more changes in their lives, and the resultant adjustment and adaptation (both potentially stressful events] might also be greater. Although negative life events may herald the onset of illness, the relationship is not a strong one because other factors can influence individual reactions to stress. In particular, social support and coping skills may act as important buffers to protect individuals from the negative effects of stress (Psychosom Med 1976;38:300314). Social support is defined as the comfort, assistance, and/or information that a person receives through interactions with individuals or groups. Coping is defined as constantly changing cognitive or behavioral efforts to manage a specific stressful event. Some coping strategies are problem focused (i.e., attempt to control the stressor). and others emotionally focused (i.e., attempt to
868
SELECTED SUMMARIES
manage one’s emotional responses to the stressful stimulus]. The problem-focused coping strategies are likely used when the individual appraises that direct action can change the encounter with the stressful stimulus. Emotionally focused coping strategies tend to be used when the person’s appraisal indicates that nothing can be done to modify the encounter with the stimulus. Both types of coping strategies, however, may be used at once. The two types may enhance or reduce each other’s effectiveness (J Personal Sot Psycho1 1985;48:150-170). Despite the important modulating effects of stress, social support, and coping skills, surprisingly little investigation into these areas has been done in patients with functional dyspepsia. Talley and Piper (Stand J Gastroenterol 1987;22:268-272) found that increased age, male gender, being unmarried (single, divorced, widowed), and social class incongruity [simultaneously possessing markers of different classes, i.e., home, occupation, or education) were social factors associated with increased frequency and severity of dyspeptic symptoms. Nevertheless, these authors could find no evidence that these factors alone contributed to increased illness behavior as characterized by days lost from work, frequent physician visits, or interference with lifestyles. No data are available about the specific coping strategies used by patients with functional dyspepsia. However, we know that these patients frequently have adult role models during childhood who experience chronic lower abdominal pain complaints (Gut 1967;8:221-229). As has
GASTROENTEROLOGY Vol. 101, No. 3
been shown with irritable bowel patients (Dig Dis Sci 1982;27:202208), these childhood experiences may be important in the genesis of adult personality and coping skills. To date, studies of psychosocial factors and functional dyspepsia have been limited because investigators chose to study only one or two factors in the complex interplay of biological, psychological, and social variables (Gut 1986;27:123-126). Each of these classes of variables may play either a necessary or a contributory causal role, as has been shown in patients with the irritable bowel syndrome (Gastroenterology 1988;95:701-708). Thus, we should not be asking whether life events alone are related to the onset or severity of illness, but rather to what extent life events are related to the onset of this particular illness, in this particular person, at this particular time. This means that we need to be simultaneously measuring personality traits and assessing patients’ coping strategies and the extent and quality of available social support. These studies are not easily performed, requiring large population samples with appropriate controls as well as close collaborations between gastroenterologists and health psychologists. Nevertheless, we need to be turning in this direction as further studies into the appropriate technical investigations and/or empiric drug trials in these patients seem to be giving us less and less useful information on how to help these difficult patients with functional dyspepsia. J.E.RICHTER,M.D.
SELECTED
[AnnInternMed is not surprising This perceptive
SUMMARIES
GASTROENTEROLOGY
1988;109:449_455;Lancet because the causative piece of clinical
1988;1:960-963), which agent is probably the same.
detective
work by Perkocha
et al.
is complemented by the discovery by Relman et al. that the causative agent for cutaneous bacillary angiomatosis and probably peliosis hepatis in association with HIV infection is a previously uncharacterized quintana. Using
Rickettsia-like the polymerase
organism, closely related chain reaction, sequences
to R. of the
16s rRNA gene can be amplified and compared with a reference sequence data base to construct phylogenetic trees. R. quintana is the cause of trench fever characterized by fever, rash, splenomegaly, and bone and muscle pain: this organism is sensitive to erythromycin and the tetracyclines (Antimicrob Agents Chemother 1984;25:690-693). Bartonella bocilliformis is another member of the order Rickeftsiales and can result in skin lesions very similar to bacillary angiomatosis (Annu Rev Microbial 1981;35:325-338). Because there are no 16s rRNA sequences available for B. bacilliformis yet, cannot be disease has those of the
its relationship to the agent of bacillary angiomatosis ascertained. The bacillus responsible for cat scratch some characteristics (Lancet 1988;1:960-963) similar to organism of bacillary angiomatosis, but the former has
not yet been clearly characterized. The organism responsible for cat scratch disease is currently being investigated by Relman et al. using this same 16s rRNA technique, and when this is accomplished its relationship to the agent of bacillary angiomatosis will be better understood. The powerful techniques used for identification of the organism of bacillary angiomatosis could serve as a paradigm for the characterization of other uncultured organisms in the future. These methods allow genotypic comparisons between organisms instead of the traditional phenotypic comparisons that have been used for many years (N Engl J Med 1991;323:1625-1627). The usefulness of these new techniques to clinical medicine will hopefully become evident over the next decades as more hitherto baffling diseases reveal themselves to more sophisticated molecular-level probes. P. F. MALET, MD. II. MOONKA, MD. Reply. Studies on the composition of environmental microbial communities have demonstrated that reliance on microbial growth in the laboratory may lead to a biased picture (Nature 1990;345:6063; Nature 1990;345:63-65). This finding may have relevance to our understanding of human pathogen diversity. This bias may be avoided by directly amplifying 16s rRNA sequences from relevant human tissue samples with broad-range polymerase chain reaction primers, and the spectrum of known pathogens may be expanded. The agent of bacillary angiomatosis (BA-TF) may be the first of many new human pathogens identified in this manner (N Engl J Med 1990;323:1573-1580). Work is currently underway to identify the causative agents of cat scratch disease and Whipple’s disease. Further characterization of BA-TF now suggests that it is highly related to Bartonella bacilliformis, as well as to Rochalimaea quintana (Relman DA, Falkow S, Schmidt TM, manuscript in preparation). The entire 16s rRNA genes from these three organisms have been amplified and cloned. The exact relationships among these different a-purple eubacteria must await completed analysis of their 16s rRNA gene sequences. At the time we reported the identification of the agent of bacillary angiomatosis (BA-TF) (NEngl J Med 1990;323:1573-1580) we were unaware of work by Slater et al. (N Engl J Med 1990;323:15871593) who had isolated a fastidious bacillus from the blood of some patients with persistent fever. A liver biopsy specimen from one of these patients (patient 1) subsequently revealed bacillary peliosis hepatis (NEngl JMed 1999;323:1581-1586). Since the time of these reports, we have determined partial 16SrRNA sequence from this patient’s blood isolate. The results suggest that this organism is the
Vol. 101, No. 3
as or highly related to BA-TF [N Engl J Med 1991;324 (in press)]. These findings further suggest that the same organism may cause bacillary angiomatosis, bacillary peliosis hepatis, and persistent fever in some patients. The application of our molecular technique to other tissue samples from patients with bacillary peliosis hepatis will be necessary to confirm these results. However, it seems that the full spectrum of human disease attributable to this organism remains to be defined. same
D. A. RELMAN, M.D.
A BIOPSYCHOSOCIAL MODEL FOR FUNCTIONAL DYSPEPSIA Hui W, Shiu LP, Lam SK (University Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong]. The perception of life events and daily stress in nonulcer dyspepsia. Am J Gastroenterol 1991;86:292-296 (March). The association of dyspepsia of unknown cause (functional dyspepsia) and stress in life is often suggested, but so far, inconsistent results have been reported. Methodological problems may be at fault because most studies have emphasized the number of major life events but have neglected the fact that the severity of an event depends on the way the person perceives it. Therefore, an accurate assessment of life stresses should include an individual’s rating of the impact and desirability of the events. The present study examined the perception of major life events and, in addition, the role of daily “hassles” (annoying daily events) in patients with functional dyspepsia. Thirty-three consecutive patients were identified who complained of epigastric pain, nausea, vomiting, and belching without evidence of peptic ulcer disease or gallstones as defined by normal endoscopy and ultrasonography. Severity of dyspeptic symptoms was recorded and graded as mild (bothersome but not interfering with work), moderate (interfering with work and/or resulting in sick leave), or severe (requiring immediate medical care). Thirty-three healthy unpaid volunteers of comparable sex, age, and social class were recruited as the control group for this study. Both groups completed two self-report questionnaires translated into Chinese that could be finished within 15-20 minutes. The first part was the Life Experience Survey (LES), which listed 56 major life events such as marriage, death of a spouse, pregnancy, and retirement. Subjects were asked to circle those events experienced in the preceding 6 months and rate the desirability and severity of each circled event. The rating scale involved seven points ranging from -3 to +3. A negative sign indicated a negative impact of the event on the person’s life, whereas a positive sign indicated the converse. The number indicated the perceived magnitude of the impact, with 3 being the strongest. Five scores were derived from the LES: number of negative and number of positive events, magnitude of negative and magnitude of positive events, and life-change score obtained by adding the magnitude scores of negative and positive events together. The second part was a “hassles scale” designed to measure daily activities or events that were irritating, frustrating or distressing. For example, these included misplacing and losing things, not having enough time for
September
SELECTED SUMMARIES
1991
family, and concerns about pollution. Subjects selected from 113 items those hassles that they had experienced in the last month and rated the severity of each item (range, l-3). Two summation scores were generated: [a) frequency, a simple count of the number of items checked, and (b] cumulative perceived severity, the sum of the severity ratings; possible scores ranged from 0 to 339 (3 x 113). The results showed that the number of positive and number of negative events and the magnitude of the positive events on the LES were similar in both dyspeptic patients and controls. However, dyspeptic patients had a higher perceived magnitude of negative events (i.e., they viewed these events as more stressful) and a higher score of total life changes as given by the summation of magnitude of positive and magnitude of negative events (both P < 0.05). A breakdown of the frequency showed the differences to be mainly attributable to patients with more negative scores and a higher magnitude in life-change score. The scores did not differ based on the severity of dyspeptic symptoms. The “hassles” scores were not significantly different between patients and controls. Analysis of individual life events showed that dyspeptic patients had significantly (P < 0.05) higher scores than controls on items of minor law violations, major changes in closeness of family members, and major personal illness or injury. The authors conclude that patients with functional dyspepsia have greater negative perceptions of major life events but not daily hassles, especially in the areas of personal health and interpersonal relationships. Although not specifically studied, the impact of these events may be important in the pathogenesis of functional dyspepsia via a complex “biopsychosocial” interaction of the stressors, availability of social support, individual coping skills, and personality traits. Comment. The term “dyspepsia” is broadly used to imply episodic or persistent symptoms referable to the upper gastrointestinal tract (Dig Dis Sci 1989;34:1272-1276). Relevant symptoms include abdominal pain, postprandial fullness, early satiety, anorexia, nausea, vomiting, bloating, belching, heartburn, and regurgitation. Many cases of dyspepsia are secondary to organic causes, particularly peptic ulcer disease, gastroesophageal reflux disease, biliary tract disease, or gastric cancer. However, dyspepsia of unknown origin is a common clinical problem, accounting for some 30%-50% of cases of chronic upper abdominal complaints seen by gastroenterologists [Ann Intern Med 1988;108:865-879). Despite its general importance and health care impact, this syndrome is an enigma. Authorities cannot even agree on terminology-should this be called “nonulcer dyspepsia,” “nonorganic dyspepsia,” “X-ray-negative “essential dyspepsia,” dyspepsia,” or “flatulent dyspepsia”? After much discussion, a recent international working team settled on the term “functional dyspepsia” to identify this syndrome and distinguish it from “organic dyspepsia,” in which underlying disease process can be found to account for the patient’s complaints. Unfortunately, this nomenclature still may be confusing for many physicians. For example, the terminology “functional” often is used interchangeably with the term “psychogenic” (i.e., a disease with a psychological cause only). In fact, functional dyspepsia represents a disease which is neither purely organic or psychogenic. Rather, it may be best characterized by a “biopsychosocial model” in which psychological, social, and cultural factors interact with biological variables (acid secretion, gastroesophageal reflux, upper gut motility disturbances] to determine the onset, severity, and course of illness [Science 1977;196:129-135). Physi-
cians frequently
spend
a great deal of time and money
867
investigating
and treating these difficult cases, many times with less than satisfactory outcomes. Application of the biopsychosocial model demands that equal time be spent understanding the interactions of personality traits, life events, availability of social support, and coping skills that culminate in the individuals’ feelings of “stress” and may be important in their reports of symptoms. Therefore, let us look more critically at these psychosocial factors in patients with functional dyspepsia. The personality traits of patients with functional becoming better characterized by comparison studies
dyspepsia are with age- and
gender-matched healthy controls, patients with organic pain syndromes, and patients with the irritable bowel syndrome. These studies indicate that there is no unique personality profile for patients with functional dyspepsia. Instead, the personality profile is similar to that of other patients with pain syndromes, be they organic or functional in nature. In general, patients with functional dyspepsia score higher on measures of anxiety, neuroticism, depression, and hypochondriasis than healthy controls. However, their personality scores are similar to those of patients with organic causes of upper abdominal pain (ulcer disease, biliary tract disease], and irritable bowel patients and are markedly different from those psychiatric patients with chronic pain or somatoform disorders (Gastroenterology 1990;99:327-333). Whether these high levels of anxiety and depression characterize patients with functional dyspepsia as a group or only those who seek medical attention, as has been found in the irritable bowel syndrome (Gastroenterology 1988;95:701-708),is an unresolved issue. Major life events such as marriage or loss of a job may be powerful social stressors in a person’s life. Many clinical case studies have suggested that stressful life events often precede the onset of illness such as sudden cardiac death (Arch Intern Med 1974;133:221-2281, athletic injury (J Hum Stress 1975;1:66-ZO), or general illness in a large military population [Ann Clin Res 1972;4:250-265). Two studies (J Psychosom Res 1985;29:191-198; Gut 1986;27:127-134) previously found that the numbers of positive and negative life events were not different in patients with functional dyspepsia from those in healthy controls or patients with organic causes of abdominal pain. However, another study (Stand J Gastroenterol 1986;21:605-613) observed that patients with functional dyspepsia compared with control subjects obtained from an orthopedic ward tween increased workload, the onset or exacerbation drawback of these studies
reported a significant relationship bedomestic and personal problems, and of their abdominal pain. The main was the failure to assess the patients’
perception of the different life events and daily stresses. The current questionnaires allowed the subjects to give an individual rating of the desirability of these events, therefore making it possible to assess the severity of these events as perceived by the patients. This study showed that patients with functional dyspepsia have a higher incidence of negative major life events, particularly family problems and personal medical illnesses, and that the impact of these events was significantly stronger. Thus, these patients encountered more changes in their lives, and the resultant adjustment and adaptation (both potentially stressful events] might also be greater. Although negative life events may herald the onset of illness, the relationship is not a strong one because other factors can influence individual reactions to stress. In particular, social support and coping skills may act as important buffers to protect individuals from the negative effects of stress (Psychosom Med 1976;38:300314). Social support is defined as the comfort, assistance, and/or information that a person receives through interactions with individuals or groups. Coping is defined as constantly changing cognitive or behavioral efforts to manage a specific stressful event. Some coping strategies are problem focused (i.e., attempt to control the stressor). and others emotionally focused (i.e., attempt to
868
SELECTED SUMMARIES
manage one’s emotional responses to the stressful stimulus]. The problem-focused coping strategies are likely used when the individual appraises that direct action can change the encounter with the stressful stimulus. Emotionally focused coping strategies tend to be used when the person’s appraisal indicates that nothing can be done to modify the encounter with the stimulus. Both types of coping strategies, however, may be used at once. The two types may enhance or reduce each other’s effectiveness (J Personal Sot Psycho1 1985;48:150-170). Despite the important modulating effects of stress, social support, and coping skills, surprisingly little investigation into these areas has been done in patients with functional dyspepsia. Talley and Piper (Stand J Gastroenterol 1987;22:268-272) found that increased age, male gender, being unmarried (single, divorced, widowed), and social class incongruity [simultaneously possessing markers of different classes, i.e., home, occupation, or education) were social factors associated with increased frequency and severity of dyspeptic symptoms. Nevertheless, these authors could find no evidence that these factors alone contributed to increased illness behavior as characterized by days lost from work, frequent physician visits, or interference with lifestyles. No data are available about the specific coping strategies used by patients with functional dyspepsia. However, we know that these patients frequently have adult role models during childhood who experience chronic lower abdominal pain complaints (Gut 1967;8:221-229). As has
GASTROENTEROLOGY Vol. 101, No. 3
been shown with irritable bowel patients (Dig Dis Sci 1982;27:202208), these childhood experiences may be important in the genesis of adult personality and coping skills. To date, studies of psychosocial factors and functional dyspepsia have been limited because investigators chose to study only one or two factors in the complex interplay of biological, psychological, and social variables (Gut 1986;27:123-126). Each of these classes of variables may play either a necessary or a contributory causal role, as has been shown in patients with the irritable bowel syndrome (Gastroenterology 1988;95:701-708). Thus, we should not be asking whether life events alone are related to the onset or severity of illness, but rather to what extent life events are related to the onset of this particular illness, in this particular person, at this particular time. This means that we need to be simultaneously measuring personality traits and assessing patients’ coping strategies and the extent and quality of available social support. These studies are not easily performed, requiring large population samples with appropriate controls as well as close collaborations between gastroenterologists and health psychologists. Nevertheless, we need to be turning in this direction as further studies into the appropriate technical investigations and/or empiric drug trials in these patients seem to be giving us less and less useful information on how to help these difficult patients with functional dyspepsia. J.E.RICHTER,M.D.