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Abnormal illness attitudes in patients with irritable bowel syndrome
Journnl
of P.sychosomuric
Pergamon
Rwmh. Vol 39, No. 2, pp. 221 230, 1995 CopyrIght 0 1995 Elsewer Science Ltd Printed in Great Britain. All rights reserved 0022- 3999/95 $9.50 + 00
0022-3999(94)00126-X
ABNORMAL
JENNIFER
ILLNESS IRRITABLE
ATTITUDES IN PATIENTS BOWEL SYNDROME
GOMBORONE, PAUL DEWSNAP, MICHAEL FARTHING (Received
GERALD
WITH
LIBBY
and
forpublication 21 October 1994)
Abstract-The Illness Attitudes Scales (IAS) and the Beck Depression Inventory (BDI) were administered to 40 patients with irritable bowel syndrome (IBS) and these were compared with 35 patients with organic gastrointestinal (GI) disease, 37 depressed patients, and 40 healthy volunteers. The BDI score was found to be greater in the IBS patients than in either the patients with organic disease or healthy subjects. All the patient groups had abnormal IAS scores compared with the healthy group, but these were most marked among the IBS patients with elevated scores on six out of the eight subscales. Three of these were specific to the IBS patients: bodily preoccupation, hypochondriacal beliefs and disease phobia. The results of this study indicate that clinical IBS is associated with abnormal illness attitudes which are not simply a reflection of either an associated depression or of experiencing physical symptoms.
INTRODUCTION
Symptoms consistent with a diagnosis of irritable bowel syndrome (IBS) have been found to affect approximately a quarter of the population but only a minority of these consult physicians [l, 21. A concept invoked to explain the different ways in which individuals act on their symptoms is that of illness behaviour [3]. This model is essentially one of an interaction between a physiological dimension, which is the basis of the physical sensation, and a psychosocial dimension, which determines how this sensation is perceived and acted upon. The Illness Behaviour Questionnaire (IBQ) is a self-report instrument designed to quantify this psychosocial dimension of illness behaviour [4]. Previous studies have shown that patients presenting with acute non-organic abdominal pain or IBS have elevated IBQ scores [5-71. These findings must be interpreted with caution, however, as patients with depressive symptoms also score highly on the IBQ [8]. Colgan et al. compared the IBQ scores of medical out-patients with organic or functional abdominal pain, stratified according to the presence or absence of diagnosable psychiatric disorder, and found that the abnormal IBQ scores were confined to patients with functional abdominal pain who also had a diagnosable psychiatric disorder. An alternative means of assessing the psychosocial dimension of illness behaviour is provided by the Illness Attitude Scales (IAS) [9]. This is a valid measure of
Department of ECIA 7BE, U.K.
Gastroenterology,
St
Bartholomew’s
227
Hospital,
Charterhouse
Square,
London,
228
J. GOMBORONE
rt ul
psychopathology associated with abnormal illness behaviour and hypochondriasis and moreover would not appear to be unduly influenced by concomitant psychiatric disorder. Thus, even in psychiatric populations the IAS discriminates sensitively between patients with hypochondriasis and those without [lo]. The IAS has been used in studies of various patient populations including general practice patients and patients with chronic obstructive airways disease [ 11,121. Kellner’s study applying both the IAS and IBQ to patients with idiopathic pelvic pain [ 131 is of particular relevance to the present investigation as the symptoms of idiopathic pelvic pain may overlap with IBS [ 14,151 and, like IBS, it is a disorder ofdisputed pathogenesis [16]. Abnormal scores were found on both the IAS and the IBQ scales, but those on the IBQ correlated with the patients’ concomitant anxiety and depression, while those on the IAS did not. The inference to be drawn is that the IAS offers a superior index of psychosocial dimension of illness behaviour in such disorders. We therefore set out to investigate illness-related fears, beliefs and attitudes using the Illness Attitudes Scales, in a group of patients with clinical IBS. We included comparison groups of patients with organic gastrointestinal disease and patients with depression to control for the presence of gastrointestinal and affective symptoms.
SUBJECTS
AND METHODS
One hundred and fifty-two subjects were included in this study. The IBS group were 40 consecutive gastroenterology out-patients with a clinical diagnosis of irritable bowel syndrome (median age 36yr. range 20-55, M:F = 1:2.3). The criteria for inclusion was a history of six or more episodes in the previous year of abdominal pain accompanied by three or more of the Manning criteria [17]. The organic gastrointestinal disease group were 35 consecutive out-patients (median age 31 yr, range IX 42, M:F = I: 1.7) with a confirmed diagnosis of ulcerative colitis (n = 14) or Crohn’s disease (n = 21). Both the IBS and organic disease patients had a duration of gastrointestinal symptoms of at least 2yr, and were experiencing symptoms at the time of the study. The depressed group were 37 consecutive psychiatric patients fulfilling DSM-III-R criteria [18] for major depression, but without a history of IBS (median age 37yr, range 21-64, M:F = 1:2.1). Forty hospital employees without a history of depression or IBS constituted a healthy volunteer group (median age 34yr, range 19 61, M:F = 1:2.5). Subjects were asked to complete the Illness Attitudes Scales (IAS). The IAS is a self-rating questionnaire of established validity and reliability which enumerates illness-related fears, beliefs and attitudes. It includes nine subscales: worry about illness, concern about pain, health habits, hypochondriacal beliefs, death phobia, disease phobia, bodily preoccupation, treatment experience and effects of symptoms. Each subscale score is the sum of the scores of three questions, and varies from 0 through to a maximum of 12. In the present study only eight subscales were used. The treatment experience subscale was omitted as the study included a group (healthy volunteers) who were not receiving treatment. As a simple measure of their current levels of emotional disturbance subjects were also asked to complete the Beck Depression Inventory (BDI) [19]. Scores were expressed as a group mean and standard deviation. Between group differences were compared using the Wilcoxon rank sum test. Pearson’s coefficient was calculated to assess correlations between the BDI and pertinent IAS subscales within the IBS group.
RESULTS
On the Beck Depression Inventory (BDI) there was no significant difference between the healthy group, mean (SD) 2.6 (2.6) and the organic disease patients, 4.7 (4.8). The BDI score in the IBS patients, 9.3 (6.2) was significantly higher than either of these (~7~0.03). The depressed patients had a score of 17.0 (5.9) which indicates a moderate to severe degree of depression, and which differed significantly from all the other groups (p
Illness attitudes
in IBS
229
IAS subscale score 6 7 6 6 4
Figure
1
The IAS subscale scores are displayed for clarity as a profile in Fig. 1. The organic disease group scored higher than the healthy volunteers only on the effects of symptoms subscale (p
DISCUSSION
The Illness Attitudes Scales have provided a simple means of detecting abnormal illness-related fears, beliefs and attitudes in IBS patients which are distinct from those in patients with organic gastrointestinal disease or depression. It is therefore unlikely that these abnormal scores in the IBS group are a consequence of having either gastrointestinal symptoms or an associated depression and an alternative explanation must be sought. The latter was confirmed by the failure to find a correlation between the pertinent IAS subscales and the depression scores within the IBS group. Elevated scores on the bodily preoccupation, disease phobia and hypochondriacal beliefs subscales were confined to the IBS group. It has been shown that elevated hypochondriacal beliefs and disease phobia scores are particularly characteristic of patients with a DSM-III-R diagnosis hypochondriasis [lo]. It is unlikely that all the IBS patients in this study would have a diagnosis of hypochondriasis, but the implication is that, as a group, they certainly show hypochondriacal features. Studies using the Minnesota Multiphasic Personality Inventory (MMPI) have shown that
230
J. GOMBORONE
rt al.
IBS patients show various abnormalities including higher scores than normal subjects on the hypochondriasis scale [7]. The bodily preoccupation, disease phobia and hypochondriacal beliefs that we have found among our IBS patients indicate that they experience bodily sensations as worrisome and difficult to ignore, that they fear that they have a serious illness, and that they believe that their doctors have failed to diagnose their condition correctly. Such a constellation of beliefs is likely to underpin illness behaviour in terms of repeated consultations in primary care which might subsequently lead to referral to hospital. Illness attitudes may also exert an influence on subjective symptom severity, by prompting the individual to focus anxiously on physical sensations, which are in turn amplified [20]. In this way abnormal illness attitudes might contribute not only to consultation behaviour but also to the pathogenesis of the ‘functional’ syndrome. To explore this further we are studying a non-clinical population with symptoms of IBS and also other clinical populations with ‘functional’ disorders. Acknowledgements-This
work was supported
by the Priory
Hospitals
Group.
REFERENCES S. Irritable bowel syndrome in the general population. Br Med J 1992; 304: 1. JONES R, LYDEARD 87-90. 2. TALLEY NJ, ZINSMEISTER AR, VAN DYKE C et al. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology 1991; 101: 9277934. 3. MECHANIC D. The concept of illness behaviour. J Chron Dis 1962; 15: 189-194. 4. PILOWSKY I, SPENCE ND. Manualfor the Illness Behaviour Questionnaire (IBQ). Second Edn. Adelaide: University Adelaide, 1983. G, SANTONASTASO P, FRACCON IG. Life events, abnormal illness behaviour and 5. CANTON appendicectomy. Gen Hasp Psychiatry 1984; 6: 191Ll95. 6. JOYCE PR, BUSHNELL JA, WALSHE JWB, MORTON JG. Abnormal illness behaviour and anxiety in acute non-organic abdominal pain. Br J Psychiatry 1986; 149: 57.-62. 7. DROSSMAN PA, MCKEE DC, SANDLER RS, MITCHELL MC, CRAMER EM, LOWMAN BC, BURGER AL. Psychosocial factors in the irritable bowel syndrome. Gastroenterolgy 1988; 95: 701I708. 8. COLGAN S, CREED F, KLASS H. Symptom complaints, psychiatric disorder and abnormal illness behaviour in patients with upper abdominal pain. Psycho1 Med 1988; 88: 887-892. 9. KELLNER R. Manual of the IAS (Illness Attitudes Scales). Albuquerque, University of New Mexico 198 1. Mimeographed. R, ABBOTT P, WINSLOW WW, PATHAK D. Fears, beliefs and attitudes in DSM-III 10. KELLNER hypochondriasis. J Nerv Ment Dis 1987; 175: 20-25. R, ABBOTT P, PATHAK D, WINSLOW WW, UMLAND BE. Hypochondriac beliefs 11. KELLNER and attitudes in family practice and psychiatric patients. Znt J Psychiat Med 1983-84; 13: 127-139. concerns and somatic symptoms in patients 12. KELLNER R, SAMET JM, PATHAK D. Hypochondriacal with chronic airflow obstruction. J Psychosom Res 1987; 31: 5755582. R, SLOCUMB JC, ROSENFELD RC, PATHAK D. Fears and beliefs in patients with the 13. KELLNER pelvic pain syndrome. JPsychosom Res 1988; 32: 303- 310. 14. WHORWELL PJ, MCCALLUM M, CREED FH, ROBERTS CT. Non-colonic features of the irritable bowel syndrome. Gut 1986; 27: 37-40. 15. PEPPERCORN MA. Gynecologic disorders presenting as the irritable bowel syndrome. Gastroenterology 1981; 80: 1250. 16. PEARCE S, BEARD RW. Chronic pelvic pain in women. In Somatization: Physical Symptoms and Psychological INness (Edited Bass C). Oxford: Blackwell Scientific Publications, 1990. 17. MANNING AP, THOMPSON WG, HEATON KW, MORRIS AF. Towards a positive diagnosis of the irritable bowel syndrome. Br Med J 1978; 2: 653-654. 18. DiagnosticandStatisticalManualofMentalDisorders. Third Edition Revised(DSM-III-R). Washington DC: American Psychiatric Association, 1987. 19. BECK AT, WARD CH, MENDELSON M, et uf. An inventory for measuring depression, Arch Cm Psychiat 1961; 4: 53-63. 20. BARSKY AJ. Patients who amplify bodily sensations. Ann Int Med 1979; 91: 63-70.
of P.sychosomuric
Pergamon
Rwmh. Vol 39, No. 2, pp. 221 230, 1995 CopyrIght 0 1995 Elsewer Science Ltd Printed in Great Britain. All rights reserved 0022- 3999/95 $9.50 + 00
0022-3999(94)00126-X
ABNORMAL
JENNIFER
ILLNESS IRRITABLE
ATTITUDES IN PATIENTS BOWEL SYNDROME
GOMBORONE, PAUL DEWSNAP, MICHAEL FARTHING (Received
GERALD
WITH
LIBBY
and
forpublication 21 October 1994)
Abstract-The Illness Attitudes Scales (IAS) and the Beck Depression Inventory (BDI) were administered to 40 patients with irritable bowel syndrome (IBS) and these were compared with 35 patients with organic gastrointestinal (GI) disease, 37 depressed patients, and 40 healthy volunteers. The BDI score was found to be greater in the IBS patients than in either the patients with organic disease or healthy subjects. All the patient groups had abnormal IAS scores compared with the healthy group, but these were most marked among the IBS patients with elevated scores on six out of the eight subscales. Three of these were specific to the IBS patients: bodily preoccupation, hypochondriacal beliefs and disease phobia. The results of this study indicate that clinical IBS is associated with abnormal illness attitudes which are not simply a reflection of either an associated depression or of experiencing physical symptoms.
INTRODUCTION
Symptoms consistent with a diagnosis of irritable bowel syndrome (IBS) have been found to affect approximately a quarter of the population but only a minority of these consult physicians [l, 21. A concept invoked to explain the different ways in which individuals act on their symptoms is that of illness behaviour [3]. This model is essentially one of an interaction between a physiological dimension, which is the basis of the physical sensation, and a psychosocial dimension, which determines how this sensation is perceived and acted upon. The Illness Behaviour Questionnaire (IBQ) is a self-report instrument designed to quantify this psychosocial dimension of illness behaviour [4]. Previous studies have shown that patients presenting with acute non-organic abdominal pain or IBS have elevated IBQ scores [5-71. These findings must be interpreted with caution, however, as patients with depressive symptoms also score highly on the IBQ [8]. Colgan et al. compared the IBQ scores of medical out-patients with organic or functional abdominal pain, stratified according to the presence or absence of diagnosable psychiatric disorder, and found that the abnormal IBQ scores were confined to patients with functional abdominal pain who also had a diagnosable psychiatric disorder. An alternative means of assessing the psychosocial dimension of illness behaviour is provided by the Illness Attitude Scales (IAS) [9]. This is a valid measure of
Department of ECIA 7BE, U.K.
Gastroenterology,
St
Bartholomew’s
227
Hospital,
Charterhouse
Square,
London,
228
J. GOMBORONE
rt ul
psychopathology associated with abnormal illness behaviour and hypochondriasis and moreover would not appear to be unduly influenced by concomitant psychiatric disorder. Thus, even in psychiatric populations the IAS discriminates sensitively between patients with hypochondriasis and those without [lo]. The IAS has been used in studies of various patient populations including general practice patients and patients with chronic obstructive airways disease [ 11,121. Kellner’s study applying both the IAS and IBQ to patients with idiopathic pelvic pain [ 131 is of particular relevance to the present investigation as the symptoms of idiopathic pelvic pain may overlap with IBS [ 14,151 and, like IBS, it is a disorder ofdisputed pathogenesis [16]. Abnormal scores were found on both the IAS and the IBQ scales, but those on the IBQ correlated with the patients’ concomitant anxiety and depression, while those on the IAS did not. The inference to be drawn is that the IAS offers a superior index of psychosocial dimension of illness behaviour in such disorders. We therefore set out to investigate illness-related fears, beliefs and attitudes using the Illness Attitudes Scales, in a group of patients with clinical IBS. We included comparison groups of patients with organic gastrointestinal disease and patients with depression to control for the presence of gastrointestinal and affective symptoms.
SUBJECTS
AND METHODS
One hundred and fifty-two subjects were included in this study. The IBS group were 40 consecutive gastroenterology out-patients with a clinical diagnosis of irritable bowel syndrome (median age 36yr. range 20-55, M:F = 1:2.3). The criteria for inclusion was a history of six or more episodes in the previous year of abdominal pain accompanied by three or more of the Manning criteria [17]. The organic gastrointestinal disease group were 35 consecutive out-patients (median age 31 yr, range IX 42, M:F = I: 1.7) with a confirmed diagnosis of ulcerative colitis (n = 14) or Crohn’s disease (n = 21). Both the IBS and organic disease patients had a duration of gastrointestinal symptoms of at least 2yr, and were experiencing symptoms at the time of the study. The depressed group were 37 consecutive psychiatric patients fulfilling DSM-III-R criteria [18] for major depression, but without a history of IBS (median age 37yr, range 21-64, M:F = 1:2.1). Forty hospital employees without a history of depression or IBS constituted a healthy volunteer group (median age 34yr, range 19 61, M:F = 1:2.5). Subjects were asked to complete the Illness Attitudes Scales (IAS). The IAS is a self-rating questionnaire of established validity and reliability which enumerates illness-related fears, beliefs and attitudes. It includes nine subscales: worry about illness, concern about pain, health habits, hypochondriacal beliefs, death phobia, disease phobia, bodily preoccupation, treatment experience and effects of symptoms. Each subscale score is the sum of the scores of three questions, and varies from 0 through to a maximum of 12. In the present study only eight subscales were used. The treatment experience subscale was omitted as the study included a group (healthy volunteers) who were not receiving treatment. As a simple measure of their current levels of emotional disturbance subjects were also asked to complete the Beck Depression Inventory (BDI) [19]. Scores were expressed as a group mean and standard deviation. Between group differences were compared using the Wilcoxon rank sum test. Pearson’s coefficient was calculated to assess correlations between the BDI and pertinent IAS subscales within the IBS group.
RESULTS
On the Beck Depression Inventory (BDI) there was no significant difference between the healthy group, mean (SD) 2.6 (2.6) and the organic disease patients, 4.7 (4.8). The BDI score in the IBS patients, 9.3 (6.2) was significantly higher than either of these (~7~0.03). The depressed patients had a score of 17.0 (5.9) which indicates a moderate to severe degree of depression, and which differed significantly from all the other groups (p
Illness attitudes
in IBS
229
IAS subscale score 6 7 6 6 4
Figure
1
The IAS subscale scores are displayed for clarity as a profile in Fig. 1. The organic disease group scored higher than the healthy volunteers only on the effects of symptoms subscale (p
DISCUSSION
The Illness Attitudes Scales have provided a simple means of detecting abnormal illness-related fears, beliefs and attitudes in IBS patients which are distinct from those in patients with organic gastrointestinal disease or depression. It is therefore unlikely that these abnormal scores in the IBS group are a consequence of having either gastrointestinal symptoms or an associated depression and an alternative explanation must be sought. The latter was confirmed by the failure to find a correlation between the pertinent IAS subscales and the depression scores within the IBS group. Elevated scores on the bodily preoccupation, disease phobia and hypochondriacal beliefs subscales were confined to the IBS group. It has been shown that elevated hypochondriacal beliefs and disease phobia scores are particularly characteristic of patients with a DSM-III-R diagnosis hypochondriasis [lo]. It is unlikely that all the IBS patients in this study would have a diagnosis of hypochondriasis, but the implication is that, as a group, they certainly show hypochondriacal features. Studies using the Minnesota Multiphasic Personality Inventory (MMPI) have shown that
230
J. GOMBORONE
rt al.
IBS patients show various abnormalities including higher scores than normal subjects on the hypochondriasis scale [7]. The bodily preoccupation, disease phobia and hypochondriacal beliefs that we have found among our IBS patients indicate that they experience bodily sensations as worrisome and difficult to ignore, that they fear that they have a serious illness, and that they believe that their doctors have failed to diagnose their condition correctly. Such a constellation of beliefs is likely to underpin illness behaviour in terms of repeated consultations in primary care which might subsequently lead to referral to hospital. Illness attitudes may also exert an influence on subjective symptom severity, by prompting the individual to focus anxiously on physical sensations, which are in turn amplified [20]. In this way abnormal illness attitudes might contribute not only to consultation behaviour but also to the pathogenesis of the ‘functional’ syndrome. To explore this further we are studying a non-clinical population with symptoms of IBS and also other clinical populations with ‘functional’ disorders. Acknowledgements-This
work was supported
by the Priory
Hospitals
Group.
REFERENCES S. Irritable bowel syndrome in the general population. Br Med J 1992; 304: 1. JONES R, LYDEARD 87-90. 2. TALLEY NJ, ZINSMEISTER AR, VAN DYKE C et al. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology 1991; 101: 9277934. 3. MECHANIC D. The concept of illness behaviour. J Chron Dis 1962; 15: 189-194. 4. PILOWSKY I, SPENCE ND. Manualfor the Illness Behaviour Questionnaire (IBQ). Second Edn. Adelaide: University Adelaide, 1983. G, SANTONASTASO P, FRACCON IG. Life events, abnormal illness behaviour and 5. CANTON appendicectomy. Gen Hasp Psychiatry 1984; 6: 191Ll95. 6. JOYCE PR, BUSHNELL JA, WALSHE JWB, MORTON JG. Abnormal illness behaviour and anxiety in acute non-organic abdominal pain. Br J Psychiatry 1986; 149: 57.-62. 7. DROSSMAN PA, MCKEE DC, SANDLER RS, MITCHELL MC, CRAMER EM, LOWMAN BC, BURGER AL. Psychosocial factors in the irritable bowel syndrome. Gastroenterolgy 1988; 95: 701I708. 8. COLGAN S, CREED F, KLASS H. Symptom complaints, psychiatric disorder and abnormal illness behaviour in patients with upper abdominal pain. Psycho1 Med 1988; 88: 887-892. 9. KELLNER R. Manual of the IAS (Illness Attitudes Scales). Albuquerque, University of New Mexico 198 1. Mimeographed. R, ABBOTT P, WINSLOW WW, PATHAK D. Fears, beliefs and attitudes in DSM-III 10. KELLNER hypochondriasis. J Nerv Ment Dis 1987; 175: 20-25. R, ABBOTT P, PATHAK D, WINSLOW WW, UMLAND BE. Hypochondriac beliefs 11. KELLNER and attitudes in family practice and psychiatric patients. Znt J Psychiat Med 1983-84; 13: 127-139. concerns and somatic symptoms in patients 12. KELLNER R, SAMET JM, PATHAK D. Hypochondriacal with chronic airflow obstruction. J Psychosom Res 1987; 31: 5755582. R, SLOCUMB JC, ROSENFELD RC, PATHAK D. Fears and beliefs in patients with the 13. KELLNER pelvic pain syndrome. JPsychosom Res 1988; 32: 303- 310. 14. WHORWELL PJ, MCCALLUM M, CREED FH, ROBERTS CT. Non-colonic features of the irritable bowel syndrome. Gut 1986; 27: 37-40. 15. PEPPERCORN MA. Gynecologic disorders presenting as the irritable bowel syndrome. Gastroenterology 1981; 80: 1250. 16. PEARCE S, BEARD RW. Chronic pelvic pain in women. In Somatization: Physical Symptoms and Psychological INness (Edited Bass C). Oxford: Blackwell Scientific Publications, 1990. 17. MANNING AP, THOMPSON WG, HEATON KW, MORRIS AF. Towards a positive diagnosis of the irritable bowel syndrome. Br Med J 1978; 2: 653-654. 18. DiagnosticandStatisticalManualofMentalDisorders. Third Edition Revised(DSM-III-R). Washington DC: American Psychiatric Association, 1987. 19. BECK AT, WARD CH, MENDELSON M, et uf. An inventory for measuring depression, Arch Cm Psychiat 1961; 4: 53-63. 20. BARSKY AJ. Patients who amplify bodily sensations. Ann Int Med 1979; 91: 63-70.