REVIEWARTICLEPsychosocialfactorsinfunctionalgastrointestinaldisorders:anevolvingphenomenonK.
W.
OLDENDivisionofGastroenterology,UniversityofArkansasforMedicalSciences,LittleRock,AR,USAAbstractThe
psychosocial aspect of functional gas-trointestinal disorders
havealongandcomplicatedinvestigativehistory.
Emergingfromthe1930swhentheobservationsofindividualinvestigatorsandclin-icians
was the normwe have evolved in the
last25yearstoanincreasinglysophisticatederaofscien-tic observation
using standardized nosology, vali-dated psychometric instruments
and have made use ofemergingtechnologysuchasbrainimaging,
barostattestingandothertechnologies.Theapplicationofthescienticmethodtohelpimproveoutunderstandingoftherelationshipofpsychosocialfactorsastheyre-latetogastrointestinal
illnessesisslowlybut surelyrevolutionizing gastroenterology
practice. It is thepurpose of this paper to review the history
ofPsychosomatic Gastroenterology to review thedimensions of
psychosocial factors as
theyrelatetogastroenterologyandtoreviewtheemergingtechnol-ogies
which arehelping us todevelop thisknowledge.Finally we will attempt
to speculate on where the
eldwillbegoinginthefuture.Keywordsbiopsychosocial model, functional
gastro-intestinaldisorders,psychosomaticgastroenterology.HISTORICALPERSPECTIVEModern
psychosomaticmedicine beganin theearlytomid-20th century and was
closely linked to thedevelopment of psychoanalytic thinking.
Heavilydependentonpsychoanalyticthought,itenjoyedgreatsuccess and
tremendous interest in the years fromaround 1940 until the 1970s.
The psychoanalyticschool of thoughtfell victimtotwofatal errors.
Therst was that theadherents tothis lineof thinkingforgotthat
allscience isprovisionalanddidnotrevisetheir thinking as biomedical
science advanced. Sec-ondly,
theseinvestigatorsreliedtooheavilyonobser-vationalstudiesanddidnotadjusttheirmethodologyto
newtechniques which were developing in thebehavioural sciences.
These factors ultimately her-aldedthedeclineof
psychoanalyticallybasedpsycho-somatic medicine. Take for instance
this excerptwrittenbyFranzAlexander, thefather of
psychoso-maticmedicinewritingaboutpepticulcerin1950.Whilethesignicanceof
emotional factors
intheideologyofpepticulcerisaccepteduniversallytoday,thereisdivergenceofopinionregardingthespecicityof
the emotions involved. Those who approachtheproblemfromaclinical
sidethenareimpressedbythe pronounced oral-receptive trend,
manifesting itselfeitherinovertdependenceorinits denial.1Oh, if
theyonlyknewabout Helicobacter pylori!Psychoanalytic perspectives
onpeptic ulcer disease,inammatorybowel disease, asthma, eczema,
thyro-toxicosis andrheumatoidarthritis all hadtheir
psy-choanalyticunderpinningsdevastatedbyadvancesinbiomedical
science. The second half of the
20thcenturywascharacterizedanincreasingcontemptforany psychosomatic
perspectivesonanydisease.Thisdarkage of
psychosomaticmedicinehadsubstrates.Theextraordinaryadvancesinbiochemistry,genetics,cell
biology and immunology subsequently lead
toadvancesinpharmacologywhichinturnleadtotheprevious psychosomatic
theories being perceived asbeing a little more than quaint. The
second
factorAddressforcorrespondenceKevinW.OldenMD,DivisionofGastroenterology,Univer-sityofArkansasforMedicalSciences,4301WestMarkham#567,LittleRock,AR72205,USA.Tel:+15016865177;fax:+15016866248;e-mail:[email protected]:23January2008Acceptedforpublication:27January2008NeurogastroenterolMotil(2008)20(Suppl.1),1141202008TheAuthorJournalcompilation
2008BlackwellPublishingLtd 114promotingthe
psychosomaticdarkagewasthatfromthe1930srightthroughthemid-1980sthedominantforceinAmericanpsychiatricteachingwaspsychoan-alytic
thought. When this writer was a psychiatricresident in the late
1970s and early 1980s there was anincreasingly spirited struggle
between the emergingconcepts of biologically based psychiatry and
thepsychoanalysts who relied almost exclusively onbehavioural
interpretation. It is only in the last20years that the biological
model has become thepredominant force driving the eld of
psychiatry.Advances in neurophysiology, brain imagining,descriptive
nosology and the incorporation of theconcept of the randomized
control trial into psychiatricresearch have revolutionized and
rationalized thescienticunderpinningsforthetreatmentofpsychia-tric
disorders. With the emergence of scienticallybasedpsychiatry,
thescienticgapbetweenbiomedi-cineandpsychosocialmedicinehasrapidlynarrowed.However,psychosomaticmedicineisonlynowbegin-ningtoemergefromthisDarkAge.Itwillbethepurposeofthispapertoreviewbrieythe
epidemiological evidence supporting the validity ofpsychiatric
comorbidity as it applies to functionalgastrointestinal (GI)
disorders; toreviewmechanistictheories about howthese variables may
interact toproduce symptoms, disease coping and
healthcareseekingbehaviourandtodiscusstheimplicationsfortreatment.
Finally, recommendationsforfuturestudyand potentially promising
areas of investigation will
bediscussed.PSYCHIATRICCOMORBIDITYANDGASTROINTESTINALDISORDERSThe
rst concept one needs to understand
whendiscussingpsychiatriccomorbiditiesastheyrelatetoGI disorders is
that psychiatric comorbidity is notlimitedtothefunctional GI
disorders. Anumber
ofstudieshavedemonstratedhigherlevelsofdepressionandanxietydisordersinchronicliverdisease2inam-matory
bowel disease.3Likewise, psychiatric abnormal-ities have been noted
with functional abnormalities ofthe oesophagus;4functional and
cyclic vomiting;5dys-pepsia6irritable bowel syndrome
(IBS);7functionalconstipation8and sphincter of oddi
dysfunction.9Although the prevalence of comorbid
psychiatricdisorders is high in GI disorders, both
functionalorganic, comparedtonormal
controlsthedifferentialdiagnosis of these psychiatric disorders is
actually quitenarrow.
Moststudieshavedemonstratedthatanxietydisordersparticularlypanicdisorder,
majordepressivedisorder and somatoformdisorders particularly
paindisorderandsomatizationdisorderpredominant.
Thisnarrowpsychiatric differential diagnosis certainly raisesthe
possiblehypothesisof acommonpathophysiologi-cal mechanism for both
the patients bowel symptomsand their CNS dysfunction. Psychiatric
research in thelast
20yearshasdemonstratedquiteclearlyastrongcorrelationbetweenserotonergicdysfunctioninpanicdisorder,
major depressivedisorder,
anxietydisordersandperhapsevensomatoformdisorder.10Responsetoserotonergically
active medication such as tricyclicantidepressants (TCAs)
andselectiveserotoninreup-take inhibitors (SSRIs)11further support
this line ofthinking. Similar ndings have been found using
thesedrugs for the treatment of functional GI disorders.Functional
chest pain, IBS, functional dyspepsia as wellas cyclic and
functional vomiting have all been found torespond well to TCAs
and/or SSRIs.12However,drugdevelopmentforfunctionalGIdisor-ders is
exploringanumber of drugs whichexploit
avarietyofotherCNSneurotransmittersystemmecha-nisms.
TheseincludeNK-1antagonists, substancePantagonists and third
generation serotoninergic drugs.13Clearly, the neurochemical
correlates between
theentericnervoussystem(ENS)andthecentralnervoussystem (CNS) need
to be much better dened. Researchin this area of drug development
has been quite fruitfultodate andcertainlyoffers promise for
achieving amuch better understanding of gut function via the ENSand
its relationship to the CNS and
behaviour.CLINICALIMPLICATIONSOFPSYCHOLOGICALDYSFUNCTIONINGASTROINTESTINALDISORDERSThe
clinical implications of psychological dysfunctionin patients with
GI disorders can have number ofdimensions. Theseinclude:
symptomperception; thepresence or absence of extraintestinal
symptoms offunctionalGIdisorders; GItransit;
copingabilityandclinicaloutcomes.SymptomperceptionOneinterestingstudyregardingsymptomperceptioninvolved
a study of perceived vulnerability to illness inindividualswithIBS.
Inthisstudy, theinvestigatorssurveyed 124 university employees
after a highlypublicized media scare regarding deep vein
thrombosis(DVT). The study subjects were surveyed regarding
thepresence or absence of IBS using the ROME I diagnosticcriteria
for IBS. There were also queried regarding otherconditions suchas
arthritis, asthma, chronicfatiguesyndrome, diabetes, eczema,
bromyalgiaandinsom-Volume20,Supplement1,May2008
PsychosocialfactorsinfunctionalGIdisorders2008TheAuthorJournalcompilation
2008BlackwellPublishingLtd 115nia.
Subjectswereaskedtoratetheirsymptomsona5-point Likert scale.
Subjectswerealsoadministeredthe illness attitude scale (IAS), a
measure of illnessconcerns. The investigators found that IBS
positiverespondents reported higher perceived risk of DVTthan
healthy controls or respondents with knownasthma. This difference
could not entirely be explainedby the presence of concurrent
physical symptoms,exposuretoinformationabout DVTorscoresontheIAS.
TheinvestigatorsconcludedthatIBSwasassoci-atedwithanenhancedperceptionofpersonalvulner-abilitytoillnessthat
wasrelatedtohigher levelsofnegativeaffect
intheIBSgroup.14Theinvestigatorsfurther concluded that individuals
who seek treatmentfor IBStendtohavemoreextraintestinal symptomsthan
non-treatment seekers perhaps based on the
samemechanism.15Alongthislineofthinking,
ithasalsobeenshownthatparentswithIBSmademoreprimarycare visits for
their children than healthy parents for allcauses.16Finally,
treatment
studieshaveshownthatwhenpatientswithrefractoryIBSwithpsychologicalcomorbidityhaveoverall
outcomeswhicharepoorerthanIBSpatientswithpsychologicaldistress.17The
role of chronic life stress in patients withfunctional GI
disordershasalsobeenstudied.
ThesendingsseemtobetruenotjustforIBSbutalsoforfunctional
dyspepsia.18Studies have shownthat in-creased life stressors as
measured by the life eventsurvey(LES), ameasureof self
reportedstress, coulddifferentiate subjects withhigher meanlevels
of GIsymptomsbasedonlifestressorsalone.19In a classic study,
Drossman etal. studied 72subjectswithIBS. Inadditiontwoother
populationswerestudied: therst included82persons withIBSwho had not
sought medical treatment and the secondincluded 80 normal controls.
Using a variety ofpsychological measures they found that
individualswith IBS who chose to be patients had a
higherproportionof abnormal personality patterns, greaterillness
behaviours andlower life events scores thanIBS non-patients (P
