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Early abuse, psychiatric diagnoses and irritable bowel syndrome
Behaviour Research and Therapy 40 (2002) 289–298 www.elsevier.com/locate/brat
Shorter communication
Early abuse, psychiatric diagnoses and irritable bowel syndrome Edward B. Blanchard *, Laurie Keefer, Annette Payne, Shannon M. Turner, Tara E. Galovski University at Albany, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, NY 12203, USA Accepted 13 March 2001
Abstract In a population of 71 (57 female, 14 male) IBS patients seeking psychological treatment, we found expected levels of childhood sexual and physical abuse (57.7%) and expected levels of current Axis I psychiatric disorders (54.9%). Moreover, we found those who had been victims of early abuse had higher current Beck Depression Inventory scores. However, contrary to expectations, there were no significant associations between early abuse and current psychiatric disorder in this population, suggesting that those individuals with psychological distress are not exactly the same group with a history of abuse. 2002 Elsevier Science Ltd. All rights reserved.
It is reasonably well-established that patients with irritable bowel syndrome (IBS) are highly likely to meet criteria for one or more Axis I psychiatric disorders (for a summary see Blanchard, 2001, Chapter 7). Rates of diagnosable disorders have ranged from about 50% to 100%, beginning with the pioneering studies of Liss, Alpers, & Woodruff (1973) who found that 92% of a university medical GI clinic met Feighner criteria for a psychiatric disorder. A report from our center (Blanchard, Scharff, Schwarz, Suls, & Barlow, 1990) found 56% of IBS patients met criteria for one or more Axis I disorders. The exceptions to this range are two relatively recent reports from the United Kingdom on apparently the same sample of 70 IBS patients attending a GI specialty clinic. In the first report (Sullivan, Jenkins, & Blewett, 1995), although 53% (n=37) of the sample scored in the pathological range (⬎15) on the Hospital Anxiety and Depression Scale (Zigmund & Snaith, 1983), only 23 (33%), met criteria for a current Axis I disorder using the Composite International Diagnostic Interview (CIDI Robins et al., 1988). In the second report (Blewett et * Corresponding author. Tel.: +1-518-442-4025. E-mail address: [email protected] (E.B. Blanchard).
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al., 1996) out of 63 of the 70 who completed all assessments, 21 (33%) met CIDI criteria for a current Axis I disorder and 56% had a lifetime psychiatric diagnosis. The lower rate of positive diagnoses could be due to the structured interview used, the CIDI. 1. IBS and early abuse A pioneering study by Drossman et al. (1990) found a significantly higher rate of reported early (under age 14) sexual and physical abuse among female patients with functional GI disorders in comparison to women with organic GI diseases (53% versus 37%, respectively). Several other research teams have replicated this finding including Talley, Fett, Zinsmeister and Melton (1994) and Walker, Katon, Roy-Byrne, Jemelka and Russo (1993). Despite the inclusion of males in the latter two studies, separate results for males and females were not reported. A second study by Drossman’s team (Leserman et al., 1996), surprisingly, did not replicate the finding in a sample of 239 women attending a medical school GI clinic. However, for the most part the GI community has accepted that there are high rates of early sexual and physical abuse among IBS patients, especially those attending tertiary care centers. Since it is reasonably well established that early abuse, especially sexual abuse, predisposes one to develop later psychological and psychiatric problems (e.g., Kendler et al., 2000; Dinwiddie et al., 2000), we wondered if the high rate of current psychiatric disorder typically found among a population of IBS patients could be the result of early abuse. To the best of our knowledge, only one study (Walker, Gelfand, Gelfand, Koss, & Katon, 1995) has gathered data on this point. They examined 71 IBS patients and 40 patients with inflammatory bowel disease (IBD) using the Diagnostic Interview Schedule (DIS), (Robins, Helzer, Croughan, & Ratcliff, 1981) and Briere Child Maltreatment Interview (BCMI), (Briere, 1992). They found 94% of the IBS patients met criteria for one or more DSM-III-R disorders (lifetime) and 54% had suffered some form of sexual assault, including 43% who were sexually molested as a child. These values were significantly higher for the IBS patients than for those with IBD. Unfortunately, they never examined the relation of abuse to psychiatric diagnosis. Following the suggestion implicit in the 1995 review of early abuse and gastrointestinal illness by Drossman, Talley, Leserman, Olden, & Barreiro (1995), especially Figure 2 (p. 788), in this paper we examined the possible association of current psychiatric diagnoses to early abuse in a population of IBS patients seeking psychological treatment for their IBS. Moreover, we also report the results separately for males and females as well as for the combined sample. 2. Methods 2.1. Participants The participants were 71 patients with IBS (57 female, 14 male), ranging in age from 22 to 72 with an average age of 41.4 (SD=10.9). They had been suffering from IBS for an average of 16.1 years (SD=12.7) average duration. All were seeking psychological treatment for their IBS; some were referred by their physician, the others were self-referred.
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All participants met “Rome criteria” for IBS. They received two diagnostic evaluations, the first by an advanced doctoral student in clinical psychology using a structured interview (Blanchard, 2001) to assess the participant’s GI symptoms to see if they met the inclusion criteria. The second evaluation was by their personal physician and included completion of a checklist to be certain that the necessary laboratory tests had been performed to rule out organic causes for the symptom picture. 2.2. Procedures As part of the initial assessment, all participants were assessed for current Axis I disorders using structured clinical interviews of proven reliability and validity (either the ADIS-R, DiNardo & Barlow, 1988 or ADIS-IV [Anxiety Disorders Interview Schedule for DSM-IV], Brown, DiNardo, & Barlow, 1994, or SCID [Structured Clinical Interview for DSM-IV], First, Spitzer, Gibbon, & Williams, 1994). Assessors had gone through extensive training in the use of these interviews. All participants also completed a self-report questionnaire about various forms of sexual and physical abuse occurring either in childhood (age 13 or under) or as an adolescent and adult. The questionnaire came directly from the original report of Drossman et al. (1990). Finally, participants completed two psychological tests to measure current level of psychological distress: the Beck Depression Inventory (BDI) (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) a well validated measure of depressive symptoms, and the State–Trait Anxiety Inventory (STAI) (Spielberger, 1983), a well validated measure of both state and trait anxiety. All participants gave written informed consent for all procedures.
3. Results In Table 1 are summarized the responses to the abuse questionnaire, separately for each gender and for the entire sample. As has been reported many times, we found that a large proportion of the sample acknowledged some form of sexual and/or physical abuse: 59.6% of females and 50% of males acknowledged some form of childhood abuse. For the summary category any childhood sexual abuse, however, the females (52.6%) were significantly more likely to report it than the males (21.4%) (X2[1, N=71]=4.40, p=0.036). Interestingly, 38.6% of females and 21.4% of males also acknowledged some form of abuse as an adolescent or adult. We also found a trend for those who were abused as a child to be more likely to be abused as an adolescent or adult. For those abused as a child, 25.4% reported abuse as an adolescent or adult versus 9.9% for those adults who were not abused as a child (X2[1, N=71]=3.21, p=0.07). Of course, because of the nature of the abuse assessment, we cannot tell if the adolescent or adult abuse was a new victimization or the continuation of ongoing abuse from age 13 to age 14. Table 2 summarizes the results of the psychiatric interviews for primary current diagnosis, again separately by gender and for the combined sample. As we have noted previously (Blanchard et al., 1990), Anxiety Disorders are the most common
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Table 1 Incidence of various forms of abuse for IBS sample
Form of abuse As a child (13 or younger) Exposed their sex organs to you Threatened sex Touched your sex organs Made you touch their sex organs Rape Any sex abuse Any physical abuse Any abuse As an adolescent or adult (14 or older) Exposed Threatened sex Touched Made you touch Rape Any sex abuse Any physical abuse Any abuse
Population (percent positive) Female % (n=57) Male %
(n=14)
Combined %
(n=71)
43.9
n=25
21.4
n=3
30.4
n=28
19.3 31.6
n=11 n=18
14.3 14.3
n=2 n=2
18.3 28.2
n=13 n=20
21.1
n=12
7.1
n=1
18.3
n=13
14.0 52.6 19.3 59.6
n=8 n=30 n=11 n=34
7.1 21.4 50.0 50.0
n=1 n=3 n=7 n=7
12.7 45.1 25.4 57.7
n=9 n=33 n=18 n=41
19.3 21.1 21.1 19.3 26.3 33.3 16.9 38.6
n=11 n=12 n=12 n=11 n=15 n=19 n=12 n=22
21.4 14.3 21.4 14.3 21.4 21.4 7.1 21.4
n=3 n=2 n=3 n=2 n=3 n=3 n=1 n=3
19.7 19.7 21.1 18.3 25.4 29.6 19.3 35.2
n=14 n=14 n=15 n=13 n=18 n=21 n=11 n=25
diagnosis we find. Overall, 54.9% of the combined sample met the criteria for at least one current Axis I disorder. In Table 3 are summarized a series of cross-tabs of abuse with psychiatric diagnoses. In the interest of brevity, we have collapsed the psychiatric diagnoses into four categories: Any anxiety disorder, any mood disorder, any other Axis I disorder, and an overall category of any current Axis I disorder. We also collapsed the abuse categories into rape, any sexual abuse, physical abuse, and any abuse, physical, sexual or both. Contrary to expectations, we found no significant relations between childhood abuse and current psychiatric disorders in a population of IBS patients, for females or males separately, or for the combined sample. Likewise, we found no significant relations between any abuse category suffered as an adolescent or adult and presence of a current Axis I disorder. Although all of the ratios are in the expected direction, including the strongest relation, which was for females, with 75% of those reporting rape as a child meeting criteria for a current Axis I disorder, compared with 55.1% of those who did not report such rape, the X2 for this array is 1.12, p=0.29. It would require a sample of 273 to have a power of 0.8 and an alpha level of 0.05, almost five times larger than our sample.
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Table 2 Incidence of any current Axis I diagnoses for IBS sample Diagnosis
Any mood disorder Major depression Dysthymia Any anxiety disorder Panic with ag Panic disorder Agoraphobia GAD Social phobia Simple phobia PTSD Other Axis I disorder Somatization Hypochondriasis Bulimia Any Axis I disorder
Populations (percent positive) Female (n=57) Male (n=14)
Combined (n=71)
24.6 (n=14) 14.0 (n=8) 14.0 (n=8) 52.6 (n=30) 7.0 (n=4) 7.0 (n=4) 3.5 (n=2) 40.4 (n=23) 24.6 (n=14) 14.0 (n=8) 10.5 (n=6) 14.0 (n=8) 3.5 (n=2) 8.8 (n=5) 1.8 (n=1) 57.9 (n=33)
25.4 (n=18) 14.1 (n=10) 14.1 (n=10) 50.7 (n=36) 8.5 (n=6) 5.6 (n=4) 2.8 (n=2) 36.6 (n=26) 26.8 (n=19) 12.7 (n=9) 9.9 (n=7) 12.7 (n=9) 4.2 (n=3) 8.5 (n=6) 1.4 (n=1) 54.9 (n=39)
28.6 (n=4) 14.3 (n=2) 14.3 (n=2) 42.9 (n=6) 14.3 (n=2) – – 21.4(n=3) 35.7 (n=5) 7.1 (n=1) 7.1 (n=1) 7.1 (n=1) 7.1 (n=1) 7.1 (n=1) – 42.9 (n=6)
3.1. Current psychological state Lastly, we have subdivided the sample into those with any childhood abuse and those with no history of early abuse and compared their scores on current measures of psychological distress, the BDI and STAI. These scores are presented in Table 4. We found significantly higher current levels of depression, as measured by the BDI, for both females who were sexually abused (p=0.003) and for the combined sample (p=0.013). For the females with early sexual abuse, the current average BDI score was 15.7, well within the range of noticeable depression, as compared to 9.8 for those who were not abused. Trait anxiety scores were in the same direction but non-significant.
4. Discussion We found the typical rates of reported childhood abuse (45.1% reporting some form of sexual abuse and 57.5% reporting some form of child abuse) and of current Axis I psychiatric disorders (54.9% of the combined sample). However, contrary to our hypothesis, there were no statistical associations between either early abuse or later (adolescent or adult) abuse and presence of a current Axis I disorder among treatment seeking IBS patients. In fact, the lack of any statistically significant association is a bit surprising since we calculated 96 different X2s. By chance, about 5 of these should have been significant. It thus seems clear that the IBS patients who suffered early abuse are not exactly the same part of the IBS population who meet criteria for a current
Any child abuse
Any physical abuse
Any sex abuse
Female sample (n=57) As a child (13 or less) Rape
Any Abuse
Any physical abuse
Any sex abuse
As an adult (14+) Rape
Any child abuse
Any physical abuse
Any sex abuse
Male sample (n=14) As a child (13 or less) Rape
Abuse category
Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
5 25 18 12 4 26 19 11
1 4 2 4 1 5 1 5
0 6 1 5 4 2 3 3
3 24 12 15 7 20 15 12
2 7 1 7 0 8 2 6
1 7 2 6 3 5 4 4
–
–
–
–
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
3 11 10 4 3 11 11 3
2 2 2 2 1 3 1 3
0 4 1 3 3 1 2 2
5 38 20 23 8 35 23 20
1 9 1 9 0 10 2 8
1 9 2 8 4 6 5 5
–
–
–
–
–
–
–
–
–
–
–
–
Psychiatric diagnoses categories Anxiety disorders Mood disorders p Yes No X2 Yes No X2
Table 3 Relations of abuse to psychiatric diagnoses in IBS patients
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
p
0 8 3 5 1 7 4 4
0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1
8 41 27 22 10 39 30 19
3 10 3 10 1 12 3 10
1 12 3 10 6 7 6 7
–
–
–
–
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
1 7 1 7 0 8 2 6
1 7 2 6 3 5 4 4
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
6 2 – ns 27 22 18 12 – ns 15 12 5 6 – ns 28 18 20 14 – ns 13 10 (continued on next page)
2 4 2 4 1 5 1 5
0 6 1 5 4 2 3 3
Other Axis I disorders Any Axis I disorder Yes No X2 p Yes No X2 p
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Any abuse
Any physical abuse
Any sex abuse
As an adult (14+) Rape
Any child abuse
Any physical abuse
Any sex abuse
Combined sample (n=71) As a child (13 or less) Rape
Any abuse
Any physical abuse
Any sex abuse
As an adult (14+) Rape
Abuse category
Table 3 (continued)
Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
8 28 10 26 8 28 12 24
5 31 19 17 8 28 22 14
6 24 8 22 7 23 11 19
10 25 12 23 4 31 13 22
4 31 14 21 10 25 19 16
9 18 11 16 4 23 11 16
–
–
–
–
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
5 13 6 12 4 14 6 12
3 15 11 7 6 12 13 5
3 11 4 10 3 11 5 9
13 40 16 37 8 45 19 34
6 47 22 31 12 41 28 25
12 31 15 28 8 35 17 26
–
–
–
–
–
–
–
–
–
–
–
–
Psychiatric diagnoses categories Anxiety disorders Mood disorders p Yes No X2 Yes No X2
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
p
2 7 3 6 1 8 3 6
0 9 3 6 2 7 5 4
2 6 3 5 1 7 3 5
16 46 19 43 11 51 22 40
9 53 30 32 16 46 36 26
13 36 16 33 10 39 19 30
–
–
–
–
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
9 30 11 28 9 30 13 26
6 33 19 20 9 30 23 16
7 26 9 24 8 25 12 21
9 23 11 21 3 29 12 20
3 29 14 18 9 23 18 14
8 16 10 14 3 21 10 14
–
–
–
–
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
Other Axis I disorders Any Axis I disorder Yes No X2 p Yes No X2 p
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Table 4 Psychological test scores and early sex abuse in IBS sample Measure
Females (n=51) Mean (SD)
Child sex abuse BDI State anxiety Trait anxiety
Yes No Yes No Yes No
15.7 (8.4) 9.8 (4.2) 47.7 (16.8) 47.8 (11.7) 49.0 (9.3) 45.5 (6.7)
p 0.003 ns ns
Males (n=12) Mean (SD) 18.3 13.3 79.0 50.3 45.0 45.5
(8.1) (10.1)
p ns ns
(15.8) ns (8.4)
Combined (n=63) Mean (SD) 15.7 (8.2) 10.9 (6.7) 48.89 (17.5) 48.64 (12.9) 48.81 (9.1) 45.5 (7.2)
p 0.013 ns ns
psychiatric disorder. There is probably some overlap between the two sub-populations, but they are far from identical. This is not to say that early child abuse does not lead to consequences. The portion of the IBS patients who did report early abuse were currently significantly more depressed as measured by the BDI. There was also a non-significant trend for them to report higher levels of trait anxiety. Moreover, the victims of early abuse (age 13 or younger) were also more likely to have been abused again later as an adolescent or adult. As we have noted elsewhere (Blanchard, Keefer, Galovski, Taylor, & Turner, 2001), there can be differences in the degree of psychological distress manifested by IBS patients depending, for example, upon whether one measures depression continuously based on BDI scores or categorically based on diagnoses of Major Depressive Disorder. Female IBS patients in that study had significantly higher BDI scores than males but showed no difference in prevalence of meeting criteria for major depression. What are we are to make of these results? The IBS population seems fairly typical of those presenting for tertiary care both in terms of their level of early abuse and their level of current psychiatric disorders. Thus, this does not seem, on those bases, to be an unusual sample of IBS patients. Moreover, the absence of any significant relation in Table 3, with its 96 separate analyses, seems to indicate that if the relation is truly there it is hard to find. Even when we examined the case with the greatest potential for showing a relation, a comparison of the 8 women (14%) who reported rape as a child and the 49 women who did not report this kind of abuse, on the variable of any current Axis I disorder (75% of the female victims of childhood rape were positive), the relation was not significant. As stated previously, a power analysis based on this observed association showed that a sample of 273 would be necessary to have a power of 0.8 and an alpha level of 0.05. It may be that the relation is there but that much greater sized samples would be necessary to show statistically significant effects. In fact, almost all of the cross tab contrasts are in the “right” direction of showing higher likelihood of current psychiatric disorder among abused versus non-abused sub-samples. However, the associations are very weak. Thus, it may be that, for some part of the population with a history of early abuse, the manifestation of IBS symptoms is the long-term consequence rather than psychiatric disorder.
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Acknowledgements Preparation of this manuscript was supported in part by a grant from NIDDK, DK-54211. Dr Annette Payne is currently part of Capital Psychological Associates, Albany, NY. Dr Turner is currently in the Department of Family Medicine, Tulsa, OK. Dr Galovski is a psychology intern at the University of Mississippi Medical School in Jackson, MS. References Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 5, 561–571. Blanchard, E. B. (2001). Irritable bowel syndrome: psychosocial assessment and treatment. Washington, DC: American Psychological Association. Blanchard, E.B., Keefer, L., Galovski, T.E., Taylor, A.E., & Turner, S.M. (2001). Gender differences in psychological distress among patients with irritable bowel syndrome. Journal of Psychosomatic Research. Blanchard, E. B., Scharff, L., Schwarz, S. P., Suls, J. M., & Barlow, D. H. (1990). The role of anxiety and depression in the irritable bowel syndrome. Behaviour Research and Therapy, 28, 401–405. Blewett, A., Allison, M., Calcraft, B., Moore, R., Jenkins, P., & Sullivan, G. (1996). Psychiatric disorder and outcome in irritable bowel syndrome. Psychosomatics, 37 (2), 155–160. Brown, T. A., DiNardo, P. A., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSM-IV. Graywind Publications Incorporated. DiNardo, P. A., & Barlow, D. H. (1988). Anxiety Disorders Interview Schedule — Revised (ADIS-R). Boston, MA: Center for Anxiety and Related Disorders. Dinwiddie, S., Heath, A. C., Dunne, M. P., Bucholz, K. K., Madden, P. A. F., Slutske, W. S., Bierut, L. J., Statham, D. M., & Martin, N. E. (2000). Early sexual abuse and lifetime psychopathology: A co-twin control study. Psychological Medicine, 30, 41–52. Drossman, D. A., Leserman, J., Nachman, G., Li, Z., Cluck, H., Toomey, T. C., & Mitchell, C. M. (1990). Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Annals of Internal Medicine, 113, 828–833. Drossman, D. A., Talley, N. J., Leserman, J., Olden, K. W., & Barreiro, M. A. (1995). Sexual and physical abuse and gastrointestinal illness. Annals of Internal Medicine, 123, 782–794. First, M.B., Spitzer, R.L., Gibbon, M., & Williams, J.B.W. (1994). Structured Clinical Interview for Axis I DSM-IV Disorders, Version 2.0. NY: Biometrics Research Department. Kendler, K. S., Bulik, C. M., Siberg, J., Hettema, J. M., Myers, J., & Prescott, C. A. (2000). Childhood sexual abuse and adult psychiatric and substance use disorders in women. Archives of General Psychiatry, 57, 933–959. Leserman, J., Drossman, D. A., Li, Z., Toomey, T. C., Nachman, G., & Giogau, L. (1996). Sexual and physical abuse history in gastroenterology practice: How types of abuse impact health status. Psychosomatic Medicine, 58, 4–15. Liss, J. L., Alpers, D. H., & Woodruff, R. A. (1973). The irritable colon syndrome and psychiatric illness. Diseases of the Nervous System, 34, 151–157. Robins, L. N., Helzer, J. E., Croughan, J., & Ratcliff, K. (1981). National Institutes of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity. Archives of General Psychiatry, 38, 381–389. Robins, L., Wing, J. K., Wittchen, H. V., Helzer, J. E., Babor, T. F., Burke, J., Farmer, A., Jablenski, A., Pickens, R., & Regier, D. A. (1988). The Composite International Diagnostic Interview. Archives of General Psychiatry, 45, 1069–1078. Spielberger, C. D. (1983). State–Trait Anxiety Inventory (STAI-Form Y). Palo Alto, CA: Consulting Psychologists Press, Inc. Sullivan, G., Jenkins, P. J., & Blewett, A. E. (1995). Irritable bowel syndrome and family history of psychiatric disorder: A preliminary study. General Hospital Psychiatry, 17, 43–46. Talley, N. J., Fett, S. L., Zinsmeister, A. R., & Melton, L. J. (1994). Gastrointestinal tract symptoms and self-reported abuse: A population-based study. Gastroenterology, 107, 1040–1049.
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Shorter communication
Early abuse, psychiatric diagnoses and irritable bowel syndrome Edward B. Blanchard *, Laurie Keefer, Annette Payne, Shannon M. Turner, Tara E. Galovski University at Albany, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, NY 12203, USA Accepted 13 March 2001
Abstract In a population of 71 (57 female, 14 male) IBS patients seeking psychological treatment, we found expected levels of childhood sexual and physical abuse (57.7%) and expected levels of current Axis I psychiatric disorders (54.9%). Moreover, we found those who had been victims of early abuse had higher current Beck Depression Inventory scores. However, contrary to expectations, there were no significant associations between early abuse and current psychiatric disorder in this population, suggesting that those individuals with psychological distress are not exactly the same group with a history of abuse. 2002 Elsevier Science Ltd. All rights reserved.
It is reasonably well-established that patients with irritable bowel syndrome (IBS) are highly likely to meet criteria for one or more Axis I psychiatric disorders (for a summary see Blanchard, 2001, Chapter 7). Rates of diagnosable disorders have ranged from about 50% to 100%, beginning with the pioneering studies of Liss, Alpers, & Woodruff (1973) who found that 92% of a university medical GI clinic met Feighner criteria for a psychiatric disorder. A report from our center (Blanchard, Scharff, Schwarz, Suls, & Barlow, 1990) found 56% of IBS patients met criteria for one or more Axis I disorders. The exceptions to this range are two relatively recent reports from the United Kingdom on apparently the same sample of 70 IBS patients attending a GI specialty clinic. In the first report (Sullivan, Jenkins, & Blewett, 1995), although 53% (n=37) of the sample scored in the pathological range (⬎15) on the Hospital Anxiety and Depression Scale (Zigmund & Snaith, 1983), only 23 (33%), met criteria for a current Axis I disorder using the Composite International Diagnostic Interview (CIDI Robins et al., 1988). In the second report (Blewett et * Corresponding author. Tel.: +1-518-442-4025. E-mail address: [email protected] (E.B. Blanchard).
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al., 1996) out of 63 of the 70 who completed all assessments, 21 (33%) met CIDI criteria for a current Axis I disorder and 56% had a lifetime psychiatric diagnosis. The lower rate of positive diagnoses could be due to the structured interview used, the CIDI. 1. IBS and early abuse A pioneering study by Drossman et al. (1990) found a significantly higher rate of reported early (under age 14) sexual and physical abuse among female patients with functional GI disorders in comparison to women with organic GI diseases (53% versus 37%, respectively). Several other research teams have replicated this finding including Talley, Fett, Zinsmeister and Melton (1994) and Walker, Katon, Roy-Byrne, Jemelka and Russo (1993). Despite the inclusion of males in the latter two studies, separate results for males and females were not reported. A second study by Drossman’s team (Leserman et al., 1996), surprisingly, did not replicate the finding in a sample of 239 women attending a medical school GI clinic. However, for the most part the GI community has accepted that there are high rates of early sexual and physical abuse among IBS patients, especially those attending tertiary care centers. Since it is reasonably well established that early abuse, especially sexual abuse, predisposes one to develop later psychological and psychiatric problems (e.g., Kendler et al., 2000; Dinwiddie et al., 2000), we wondered if the high rate of current psychiatric disorder typically found among a population of IBS patients could be the result of early abuse. To the best of our knowledge, only one study (Walker, Gelfand, Gelfand, Koss, & Katon, 1995) has gathered data on this point. They examined 71 IBS patients and 40 patients with inflammatory bowel disease (IBD) using the Diagnostic Interview Schedule (DIS), (Robins, Helzer, Croughan, & Ratcliff, 1981) and Briere Child Maltreatment Interview (BCMI), (Briere, 1992). They found 94% of the IBS patients met criteria for one or more DSM-III-R disorders (lifetime) and 54% had suffered some form of sexual assault, including 43% who were sexually molested as a child. These values were significantly higher for the IBS patients than for those with IBD. Unfortunately, they never examined the relation of abuse to psychiatric diagnosis. Following the suggestion implicit in the 1995 review of early abuse and gastrointestinal illness by Drossman, Talley, Leserman, Olden, & Barreiro (1995), especially Figure 2 (p. 788), in this paper we examined the possible association of current psychiatric diagnoses to early abuse in a population of IBS patients seeking psychological treatment for their IBS. Moreover, we also report the results separately for males and females as well as for the combined sample. 2. Methods 2.1. Participants The participants were 71 patients with IBS (57 female, 14 male), ranging in age from 22 to 72 with an average age of 41.4 (SD=10.9). They had been suffering from IBS for an average of 16.1 years (SD=12.7) average duration. All were seeking psychological treatment for their IBS; some were referred by their physician, the others were self-referred.
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All participants met “Rome criteria” for IBS. They received two diagnostic evaluations, the first by an advanced doctoral student in clinical psychology using a structured interview (Blanchard, 2001) to assess the participant’s GI symptoms to see if they met the inclusion criteria. The second evaluation was by their personal physician and included completion of a checklist to be certain that the necessary laboratory tests had been performed to rule out organic causes for the symptom picture. 2.2. Procedures As part of the initial assessment, all participants were assessed for current Axis I disorders using structured clinical interviews of proven reliability and validity (either the ADIS-R, DiNardo & Barlow, 1988 or ADIS-IV [Anxiety Disorders Interview Schedule for DSM-IV], Brown, DiNardo, & Barlow, 1994, or SCID [Structured Clinical Interview for DSM-IV], First, Spitzer, Gibbon, & Williams, 1994). Assessors had gone through extensive training in the use of these interviews. All participants also completed a self-report questionnaire about various forms of sexual and physical abuse occurring either in childhood (age 13 or under) or as an adolescent and adult. The questionnaire came directly from the original report of Drossman et al. (1990). Finally, participants completed two psychological tests to measure current level of psychological distress: the Beck Depression Inventory (BDI) (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) a well validated measure of depressive symptoms, and the State–Trait Anxiety Inventory (STAI) (Spielberger, 1983), a well validated measure of both state and trait anxiety. All participants gave written informed consent for all procedures.
3. Results In Table 1 are summarized the responses to the abuse questionnaire, separately for each gender and for the entire sample. As has been reported many times, we found that a large proportion of the sample acknowledged some form of sexual and/or physical abuse: 59.6% of females and 50% of males acknowledged some form of childhood abuse. For the summary category any childhood sexual abuse, however, the females (52.6%) were significantly more likely to report it than the males (21.4%) (X2[1, N=71]=4.40, p=0.036). Interestingly, 38.6% of females and 21.4% of males also acknowledged some form of abuse as an adolescent or adult. We also found a trend for those who were abused as a child to be more likely to be abused as an adolescent or adult. For those abused as a child, 25.4% reported abuse as an adolescent or adult versus 9.9% for those adults who were not abused as a child (X2[1, N=71]=3.21, p=0.07). Of course, because of the nature of the abuse assessment, we cannot tell if the adolescent or adult abuse was a new victimization or the continuation of ongoing abuse from age 13 to age 14. Table 2 summarizes the results of the psychiatric interviews for primary current diagnosis, again separately by gender and for the combined sample. As we have noted previously (Blanchard et al., 1990), Anxiety Disorders are the most common
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Table 1 Incidence of various forms of abuse for IBS sample
Form of abuse As a child (13 or younger) Exposed their sex organs to you Threatened sex Touched your sex organs Made you touch their sex organs Rape Any sex abuse Any physical abuse Any abuse As an adolescent or adult (14 or older) Exposed Threatened sex Touched Made you touch Rape Any sex abuse Any physical abuse Any abuse
Population (percent positive) Female % (n=57) Male %
(n=14)
Combined %
(n=71)
43.9
n=25
21.4
n=3
30.4
n=28
19.3 31.6
n=11 n=18
14.3 14.3
n=2 n=2
18.3 28.2
n=13 n=20
21.1
n=12
7.1
n=1
18.3
n=13
14.0 52.6 19.3 59.6
n=8 n=30 n=11 n=34
7.1 21.4 50.0 50.0
n=1 n=3 n=7 n=7
12.7 45.1 25.4 57.7
n=9 n=33 n=18 n=41
19.3 21.1 21.1 19.3 26.3 33.3 16.9 38.6
n=11 n=12 n=12 n=11 n=15 n=19 n=12 n=22
21.4 14.3 21.4 14.3 21.4 21.4 7.1 21.4
n=3 n=2 n=3 n=2 n=3 n=3 n=1 n=3
19.7 19.7 21.1 18.3 25.4 29.6 19.3 35.2
n=14 n=14 n=15 n=13 n=18 n=21 n=11 n=25
diagnosis we find. Overall, 54.9% of the combined sample met the criteria for at least one current Axis I disorder. In Table 3 are summarized a series of cross-tabs of abuse with psychiatric diagnoses. In the interest of brevity, we have collapsed the psychiatric diagnoses into four categories: Any anxiety disorder, any mood disorder, any other Axis I disorder, and an overall category of any current Axis I disorder. We also collapsed the abuse categories into rape, any sexual abuse, physical abuse, and any abuse, physical, sexual or both. Contrary to expectations, we found no significant relations between childhood abuse and current psychiatric disorders in a population of IBS patients, for females or males separately, or for the combined sample. Likewise, we found no significant relations between any abuse category suffered as an adolescent or adult and presence of a current Axis I disorder. Although all of the ratios are in the expected direction, including the strongest relation, which was for females, with 75% of those reporting rape as a child meeting criteria for a current Axis I disorder, compared with 55.1% of those who did not report such rape, the X2 for this array is 1.12, p=0.29. It would require a sample of 273 to have a power of 0.8 and an alpha level of 0.05, almost five times larger than our sample.
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Table 2 Incidence of any current Axis I diagnoses for IBS sample Diagnosis
Any mood disorder Major depression Dysthymia Any anxiety disorder Panic with ag Panic disorder Agoraphobia GAD Social phobia Simple phobia PTSD Other Axis I disorder Somatization Hypochondriasis Bulimia Any Axis I disorder
Populations (percent positive) Female (n=57) Male (n=14)
Combined (n=71)
24.6 (n=14) 14.0 (n=8) 14.0 (n=8) 52.6 (n=30) 7.0 (n=4) 7.0 (n=4) 3.5 (n=2) 40.4 (n=23) 24.6 (n=14) 14.0 (n=8) 10.5 (n=6) 14.0 (n=8) 3.5 (n=2) 8.8 (n=5) 1.8 (n=1) 57.9 (n=33)
25.4 (n=18) 14.1 (n=10) 14.1 (n=10) 50.7 (n=36) 8.5 (n=6) 5.6 (n=4) 2.8 (n=2) 36.6 (n=26) 26.8 (n=19) 12.7 (n=9) 9.9 (n=7) 12.7 (n=9) 4.2 (n=3) 8.5 (n=6) 1.4 (n=1) 54.9 (n=39)
28.6 (n=4) 14.3 (n=2) 14.3 (n=2) 42.9 (n=6) 14.3 (n=2) – – 21.4(n=3) 35.7 (n=5) 7.1 (n=1) 7.1 (n=1) 7.1 (n=1) 7.1 (n=1) 7.1 (n=1) – 42.9 (n=6)
3.1. Current psychological state Lastly, we have subdivided the sample into those with any childhood abuse and those with no history of early abuse and compared their scores on current measures of psychological distress, the BDI and STAI. These scores are presented in Table 4. We found significantly higher current levels of depression, as measured by the BDI, for both females who were sexually abused (p=0.003) and for the combined sample (p=0.013). For the females with early sexual abuse, the current average BDI score was 15.7, well within the range of noticeable depression, as compared to 9.8 for those who were not abused. Trait anxiety scores were in the same direction but non-significant.
4. Discussion We found the typical rates of reported childhood abuse (45.1% reporting some form of sexual abuse and 57.5% reporting some form of child abuse) and of current Axis I psychiatric disorders (54.9% of the combined sample). However, contrary to our hypothesis, there were no statistical associations between either early abuse or later (adolescent or adult) abuse and presence of a current Axis I disorder among treatment seeking IBS patients. In fact, the lack of any statistically significant association is a bit surprising since we calculated 96 different X2s. By chance, about 5 of these should have been significant. It thus seems clear that the IBS patients who suffered early abuse are not exactly the same part of the IBS population who meet criteria for a current
Any child abuse
Any physical abuse
Any sex abuse
Female sample (n=57) As a child (13 or less) Rape
Any Abuse
Any physical abuse
Any sex abuse
As an adult (14+) Rape
Any child abuse
Any physical abuse
Any sex abuse
Male sample (n=14) As a child (13 or less) Rape
Abuse category
Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
5 25 18 12 4 26 19 11
1 4 2 4 1 5 1 5
0 6 1 5 4 2 3 3
3 24 12 15 7 20 15 12
2 7 1 7 0 8 2 6
1 7 2 6 3 5 4 4
–
–
–
–
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
3 11 10 4 3 11 11 3
2 2 2 2 1 3 1 3
0 4 1 3 3 1 2 2
5 38 20 23 8 35 23 20
1 9 1 9 0 10 2 8
1 9 2 8 4 6 5 5
–
–
–
–
–
–
–
–
–
–
–
–
Psychiatric diagnoses categories Anxiety disorders Mood disorders p Yes No X2 Yes No X2
Table 3 Relations of abuse to psychiatric diagnoses in IBS patients
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
p
0 8 3 5 1 7 4 4
0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1
8 41 27 22 10 39 30 19
3 10 3 10 1 12 3 10
1 12 3 10 6 7 6 7
–
–
–
–
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
1 7 1 7 0 8 2 6
1 7 2 6 3 5 4 4
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
6 2 – ns 27 22 18 12 – ns 15 12 5 6 – ns 28 18 20 14 – ns 13 10 (continued on next page)
2 4 2 4 1 5 1 5
0 6 1 5 4 2 3 3
Other Axis I disorders Any Axis I disorder Yes No X2 p Yes No X2 p
294 E.B. Blanchard et al. / Behaviour Research and Therapy 40 (2002) 289–298
Any abuse
Any physical abuse
Any sex abuse
As an adult (14+) Rape
Any child abuse
Any physical abuse
Any sex abuse
Combined sample (n=71) As a child (13 or less) Rape
Any abuse
Any physical abuse
Any sex abuse
As an adult (14+) Rape
Abuse category
Table 3 (continued)
Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
8 28 10 26 8 28 12 24
5 31 19 17 8 28 22 14
6 24 8 22 7 23 11 19
10 25 12 23 4 31 13 22
4 31 14 21 10 25 19 16
9 18 11 16 4 23 11 16
–
–
–
–
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
5 13 6 12 4 14 6 12
3 15 11 7 6 12 13 5
3 11 4 10 3 11 5 9
13 40 16 37 8 45 19 34
6 47 22 31 12 41 28 25
12 31 15 28 8 35 17 26
–
–
–
–
–
–
–
–
–
–
–
–
Psychiatric diagnoses categories Anxiety disorders Mood disorders p Yes No X2 Yes No X2
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
p
2 7 3 6 1 8 3 6
0 9 3 6 2 7 5 4
2 6 3 5 1 7 3 5
16 46 19 43 11 51 22 40
9 53 30 32 16 46 36 26
13 36 16 33 10 39 19 30
–
–
–
–
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
9 30 11 28 9 30 13 26
6 33 19 20 9 30 23 16
7 26 9 24 8 25 12 21
9 23 11 21 3 29 12 20
3 29 14 18 9 23 18 14
8 16 10 14 3 21 10 14
–
–
–
–
–
–
–
–
–
–
–
–
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
Other Axis I disorders Any Axis I disorder Yes No X2 p Yes No X2 p
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Table 4 Psychological test scores and early sex abuse in IBS sample Measure
Females (n=51) Mean (SD)
Child sex abuse BDI State anxiety Trait anxiety
Yes No Yes No Yes No
15.7 (8.4) 9.8 (4.2) 47.7 (16.8) 47.8 (11.7) 49.0 (9.3) 45.5 (6.7)
p 0.003 ns ns
Males (n=12) Mean (SD) 18.3 13.3 79.0 50.3 45.0 45.5
(8.1) (10.1)
p ns ns
(15.8) ns (8.4)
Combined (n=63) Mean (SD) 15.7 (8.2) 10.9 (6.7) 48.89 (17.5) 48.64 (12.9) 48.81 (9.1) 45.5 (7.2)
p 0.013 ns ns
psychiatric disorder. There is probably some overlap between the two sub-populations, but they are far from identical. This is not to say that early child abuse does not lead to consequences. The portion of the IBS patients who did report early abuse were currently significantly more depressed as measured by the BDI. There was also a non-significant trend for them to report higher levels of trait anxiety. Moreover, the victims of early abuse (age 13 or younger) were also more likely to have been abused again later as an adolescent or adult. As we have noted elsewhere (Blanchard, Keefer, Galovski, Taylor, & Turner, 2001), there can be differences in the degree of psychological distress manifested by IBS patients depending, for example, upon whether one measures depression continuously based on BDI scores or categorically based on diagnoses of Major Depressive Disorder. Female IBS patients in that study had significantly higher BDI scores than males but showed no difference in prevalence of meeting criteria for major depression. What are we are to make of these results? The IBS population seems fairly typical of those presenting for tertiary care both in terms of their level of early abuse and their level of current psychiatric disorders. Thus, this does not seem, on those bases, to be an unusual sample of IBS patients. Moreover, the absence of any significant relation in Table 3, with its 96 separate analyses, seems to indicate that if the relation is truly there it is hard to find. Even when we examined the case with the greatest potential for showing a relation, a comparison of the 8 women (14%) who reported rape as a child and the 49 women who did not report this kind of abuse, on the variable of any current Axis I disorder (75% of the female victims of childhood rape were positive), the relation was not significant. As stated previously, a power analysis based on this observed association showed that a sample of 273 would be necessary to have a power of 0.8 and an alpha level of 0.05. It may be that the relation is there but that much greater sized samples would be necessary to show statistically significant effects. In fact, almost all of the cross tab contrasts are in the “right” direction of showing higher likelihood of current psychiatric disorder among abused versus non-abused sub-samples. However, the associations are very weak. Thus, it may be that, for some part of the population with a history of early abuse, the manifestation of IBS symptoms is the long-term consequence rather than psychiatric disorder.
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