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Psychosomatic Medicine 61:148-153 (1999)
© 1999 American Psychosomatic Society

ORIGINAL ARTICLES

Psychological Factors in Functional Gastrointestinal Disorders: Characteristics of the Disorder or of the Illness Behavior?

Peter Herschbach, PhD, Gerhard Henrich, PhD and Michael von Rad, MD

From the Institute and Outpatient Clinic for Psychosomatic Medicine, Psychotherapy and Medical Psychology, Technical University of Munich, Munich, Germany.

Address reprint requests to: Peter Herschbach, PhD, Institut und Poliklinik für psychomatische Medizin, medizinische Psychologie und Psychotherapie, Technische Universität München, Langerstr. 3, 81675 Munich, Germany.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
OBJECTIVE: This study examines factors affecting the frequency of physician consultations by individuals with functional gastrointestinal disorders (FGD) in a group of subjects with functional dyspepsia or irritable bowel syndrome. Systematic selection of persons who were already seeing a physician for one of these problems was avoided by conducting an epidemiological field study rather than a clinical study.

METHODS: A representative sample of the German population (N = 2201) completed a questionnaire that included, in addition to the criterion (number of physician visits in the past 12 months), items aimed at identifying the target group and questions about physical symptoms, illness behavior, living situation, personality features, and sociodemographic status (a total of 31 predictors).

RESULTS: Individuals with functional gastrointestinal disorders who consulted a physician for their gastrointestinal disorders and those who did not differed significantly, especially on psychological measures. The differences between these individuals and the general population were greater for the consulters than for the nonconsulters. Multiple regression analyses yielded nine predictors that explained 40.2% of the variance of the criterion. The best predictors of frequency of physician consultations were the duration of periods with symptoms and psychological factors, such as the severity of depression and the patients’ views on the cause of their illness.

CONCLUSIONS: The psychopathology seen in people with functional gastrointestinal disorders is of two types: one is a characteristic of the illness itself and the other leads the individual to consult a physician. When gastroenterologists see patients with such disorders, they can assume that they may be dealing with a self-selected group of individuals with psychological stress. Psychological assessment would, therefore, be useful to determine whether a given individual with FGD might benefit from psychotherapy.

Key Words: irritable bowel syndrome, • functional dyspepsia, • psychological factors, • illness behavior, • physician consultation.

Abbreviations: FD = functional dyspepsia;; FGD = functional gastrointestinal disorder;; GI = gastrointestinal;; IBS = irritable bowel syndrome.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
It is well known that psychopathology plays an important role in individuals with functional gastrointestinal disorders (defined as "variable combination[s] of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities" (Ref. 1, p. 1). But it is still not clear whether these abnormalities are the cause, the result, or side effects of the disorder. Most research has been on personality patterns, stressful life events, and abnormal illness behavior in individuals with irritable bowel syndrome and functional dyspepsia. Compared with healthy control subjects, patients with FD are more anxious, depressed, neurotic, and hypochondriac. Compared with patients with upper abdominal symptoms of organic origin, they are more anxious and tense (2–6). Well-designed, carefully conducted studies have shown that about 50% of all patients with IBS have psychological abnormalities. The frequency and severity of the psychopathology is between that in healthy subjects and patients with medical illnesses, on the one hand, and those with neuroses, on the other (6–10). Although it is not clear whether stress, for example resulting from major life events, is associated with the onset of illness, most of the more recent studies conclude that there is an association with both the presence and severity of symptoms. This is true for both FD (11–15) and IBS (8, 16–19).

Most of the findings on functional GI disorders are from studies with patients, that is with individuals who were seeing a physician. But, if instead we compare people (without treatment, nonconsulters) and patients (with treatment, consulters), all of whom have a given type of GI disorder, we find the following: People with IBS differ very little from control subjects (either normal subjects or subjects with somatic disorders). In contrast, patients with IBS have more psychopathology than either of the other two groups, greater fear of a "serious illness," and more severe specific and unspecific complaints, and they are more affected by stress and life events (5, 16, 19–25). Similarly, FD consulters and nonconsulters differ chiefly in how serious they perceive their symptoms to be (26). In other words, a large proportion of the variance in the "psychopathology" found in patient populations cannot be regarded as a characteristic of the disorder itself, but rather is an artifact of sampling bias inherent in patient samples. "This suggests that psychological symptoms do not cause bowel symptoms but do influence the decision to consult a physician" (Ref. 19, p. 606) (27).

Several methodological factors affect the validity of the studies, however.

1. One major problem is the study samples. Drossman et al. (16), Enck et al. (20), Guthrie et al. (21), Heaton et al. (22), and Whitehead et al. (24) studied mainly women; Sandler et al. (23), Drossman et al. (16), and Whitehead et al. (24) drew their subjects from student populations, hospital employees, or members of social service organizations. Hence, none of the findings are based on a truly representative sample of the general population.
2. Whereas in the studies just mentioned a great many psychological factors were often evaluated, in other studies the sample was appropriate but no psychological hypotheses were tested (22, 28).
3. Another problem is the intercorrelation of the measures studied. As already mentioned, some studies used a large number of psychological tests, but the authors interpreted the findings without taking into consideration the possible intercorrelations of the scales. As a result, the importance of psychopathology in general was demonstrated, but little information was gained about specific interactions.
4. Furthermore, diagnosis was more difficult when these earlier studies were performed than now, because we now have available the Research Diagnostic Questions for Functional Gastrointestinal Disorders (1).
5. Finally, almost all of the studies cited dealt with people with IBS.

With this in mind, we conducted the present study to elucidate the role of psychological factors in the development and treatment of IBS and FD. The study was based on a representative sample of the general population and included multivariate analysis of the data.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Procedure
A representative sample of the general population in Germany was studied. Sample selection and data collection were made by an institute specializing in social science studies of this nature. As part of a household population study, the subjects were selected with a three-phase random sampling procedure (selection of sampling points, in this case voting precincts in Germany, and combination into representative, mutually exclusive sampling networks; selection of households within three of the sampling networks; selection of individuals within the households). They received information about the group that had commissioned the study and about the purpose of the study. Participation was voluntary. Of the original sample (N = 3677), 2571 individuals were interviewed, and of these the data for 2562 could be evaluated. As a result of a statistical weighting procedure this sample of 2562 was reduced to N = 2201. Thus 70% of the original sample were included in the present study. The sample is representative of the adult population in Germany.

The subjects completed several questionnaires and gave them to the interviewer in a sealed envelop.

Measures
The instrument used was a standardized questionnaire that included 31 predictors and the criterion. The criterion was the number of physician visits because of the symptoms in the previous 12 months. The predictors were:

1. Sociodemographic variables (including size of community where the subject lived and distance to the nearest physician).
2. Information about the illness and symptoms (duration of illness, severity and seriousness of symptoms).
3. Illness behavior (sick days, health rating, causal attribution, control attribution, opinion about the health care system, previous experience with treatment, learned illness behavior).
4. Relevant life events in the previous 12 months (four items: number of positive and negative life events relating to family, friends, work, and financial situation.
5. Social support. This factor was operationalized in two ways. The more objective aspect was assessed with the item from Blake and McKay (29) about the number of helpful individuals in one’s social environment. The more subjective aspect was assessed with the question: "How often do you feel lonely and alone?"
6. Quality of life. This was assessed with the instrument Questions on Life Satisfaction (QSD, in the original German version) developed by the authors (30).
7. Emotional problems/psychopathology (depression, somatization, hypochondriasis, and neuroticism/emotionality). These were assessed with scales from the Hopkins Symptom Checklist (31) and the German-language Freiburger Personality Inventory (32).

As the criteria for diagnosing FD and IBS, we used the Research Diagnostic Questions for Functional Gastrointestinal Disorders (1) in a German version prepared by one of the authors (P.H.). This instrument is the result of consensus achieved within an international group of clinical investigators and is a diagnostic checklist based on symptoms. In contrast to the original English version, the questions about symptoms were not restricted to the past 3 months, but instead asked whether the subject had ever had such symptoms.

Subjects and Diagnosis
Individuals with IBS or FD (or both) were identified in the representative sample of the German population with the Research Diagnostic Questions for Functional Gastrointestinal Disorders. Individuals were then excluded whose physician had told them a diagnosis that was not compatible with the diagnosis of functional GI disorder.

Data Analysis
The subjects with IBS or FD with and without physician visits were compared with each other and with the general population. Procedures used were univariate comparisons of means, {chi}2 tests, and analyses of correlation. The role of the "predictor variables" listed earlier, taking into account their intercorrelations for the criterion "number of physician visits in the past 12 months," was assessed with multiple linear regression analysis and stepwise multiple regression analysis. The statistics program SPSS for the Macintosh 6.1 (33) was used for this purpose.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 NOTES
 REFERENCES
 
Characteristics of the Study Group
The representative sample of the German population (N = 2201) consisted of 52.9% women and 47.1% men. 2The mean age was 46.9 years (SD 17.23). In this group, 57 people were identified who met the diagnostic criteria for IBS and 298 who met the criteria for FD. Of these 355 individuals, 68 were then excluded because their physician thought their symptoms could be explained by a somatic disorder. The remaining 288 individuals1 (47 IBS, 240 FD; 13.1% of the representative sample) were included in the subsequent analysis.

Table 1 shows the demographic, psychological, and medical characteristics of the two groups. The groups differed only in age and duration of illness. The FD group was older and their duration of illness had a different distribution. More FD subjects had a duration of illness near the mean, and more IBS subjects had had symptoms since childhood. Because there were no marked differences between the groups in ratings of symptoms or in the psychosocial variables, the groups were combined. The newly formed group was referred to as the functional gastrointestinal disorder group.


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  		Table 1. Demographic, Psychological, and Medical Characteristics of Persons With IBS and FD
 
Of these subjects, 59.6% had seen a physician because of their gastrointestinal symptoms in the previous 12 months, and 40.4% had not; 15.4% had never consulted a physician for this reason.

Comparison of Subjects With and Without Physician Visits With Each Other and With the General Population
A comparison of the psychological characteristics of the FGD group as a whole and the general population (Table 2, columns 1 to 4) shows that the FGD group had significantly higher scores for depression, emotionality, and physical symptoms, and worried more about their health than the general population. Furthermore, their quality of life was not as good and they had had more negative life events in the previous 12 months. Their ratings of their overall health were worse and they had less social support.


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  		Table 2. Consulters and Nonconsulters Among Persons With FGD Compared With Each Other and the General Population
 
Columns 2 and 3 of Table 2 show the values separately for the subjects with and without physician visits in the previous 12 months. Whereas the FGD consulters also differed significantly from the general population on all eight variables (and to a greater extent than the FGD group as a whole) (columns 3 and 4), this was not the case for the FGD nonconsulters (columns 2 and 4). The nonconsulters had higher scores for somatization, emotionality, quality of life, health rating, and social support, but they did not differ from the general population on depression, concerns about health, and life events. FGD consulters differed from FGD nonconsulters with respect to somatization, depression, emotionality, life events, and health rating (columns 2 to 3).

Correlation Analysis
Another way of analyzing the data is to look at the relationship between the variables of interest and the number of visits to a physician in the past 12 months. Of 31 variables, 17 showed a significant correlation with the frequency of physician visits. The highest correlations found were for depression (.39; p = .000), subjective health rating (.32; p = .000), somatization (.31; p = .000), and duration of periods with symptoms. Among the symptom characteristics, the duration of periods with symptoms was most important (.29; p = .000).

Multiple Regression Analysis
The 31 predictors correlate relatively highly with one another. For this reason we performed a (stepwise) multiple regression analysis. With only 9 of the predictors, 40.2% of the variance of the criterion (frequency of physician visits in the previous 12 months) can be explained. The most important single predictor is the duration of periods with symptoms (ß = .27), followed by the main psychological factor, namely depression (ß = .21), which covers almost all of the psychopathology. In addition, it is very important that the individuals do not think their illness has a psychological basis (ß = -.20) and that they have had GI problems for a relatively short period of time (ß = -.19). Of the symptom characteristics, the most important factor, aside from duration, is seriousness (ß = .15). Two general, unspecific ratings also play a role—the rating of one’s overall health (ß = .15) and the opinion of the health care system (ß = -.15).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
NOTES
 REFERENCES
 
The purpose of the present study was to elucidate the role of psychological factors in the frequency of physician consultations by individuals with FGDs. This study extends previous investigations by 1) investigation of a representative sample of the general population, 2) use of generally accepted operational diagnostic criteria [Research Diagnostic Questions for Functional Gastrointestinal Disorders (1)], and 3) use of a multivariate strategy for data analysis.

In a representative sample of the German population, 13.1% of the subjects met the diagnostic criteria for IBS or FD. These subjects had significantly worse scores than the general population on all psychosocial variables assessed. Of these 288 subjects, 40.4% had not seen a physician for their symptoms in the previous 12 months. These FGD nonconsulters differed markedly from the FGD consulters. They also differed from the general population, having worse scores for somatization, emotionality, quality of life, health rating, and social support. However, the nonconsulters did not differ from the general population on depression, concerns about health, or life events.

Our results confirm to some extent the studies mentioned earlier. It thus seems that the psychopathology seen in people with functional gastrointestinal disorders is of two types: one is a feature of the illness itself (differences between FGD nonconsulters and the general population) and the other leads the individual to consult a physician (differences between FGD consulters and nonconsulters and the general population).

With a multivariate assessment strategy, we were able to predict 40.2% of the variance in the frequency of physician consultations. This value is much higher than those obtained in epidemiological studies of physician utilization (see Refs. 34–36). In addition to illness variables (duration of episodes with symptoms, seriousness of symptoms, health rating), psychological factors play a central role (especially depression, but also the patients’ views on the cause of their illness); a third factor includes general attitudes about the health care system. Contrary to expectations, it made no difference whether the subjects had had symptoms during the period in question. Nor were there any sex differences.

There were a few methodological weaknesses, which somewhat limit the validity of the findings. Use of the Research Diagnostic Questions for Functional Gastrointestinal Disorders had the advantage that we had clear, unambiguous diagnostic criteria with which we could identify the sample needed without a physician’s help. However, it turned out that 68 of the 355 subjects reported diagnoses from their physicians that were not compatible with a functional disorder. In addition, the IBS rate was lower than expected, on the basis of studies in other countries (eg, 9.4% for the USA; see Ref. 1). It may be that this apparent problem with the validity of the diagnosis stems from translation problems. National and cross-cultural validity studies, therefore, would be desirable.

The findings were unexpected for two variables that play a role in the regression analysis (steps 8 and 9), the distance from a physician, and positive life events. The distance from a physician, as a potentially objective predictor of physician visits, has a positive ß weight (ß = .15). The variable was operationalized with the question: "How many minutes do you need (at the minimum) to get to a doctor if you need to?" That the likelihood of a physician visit increases with increasing distance from the nearest physician seems paradoxical. It turns out that this variable cannot be taken as an indication of the number of physicians in the area because it is correlated with the severity of the illness: Those who are seriously ill estimate the distance to the nearest physician as longer than those with a minor illness.

Positive life events also have a positive ß weight (ß = .11). Additional analyses showed that positive and negative life events have a positive correlation. What this means is that events perceived as life events, whether positive or negative, correlate with consultation behavior. It may be that a general sensitivity, rather than specific life events, was measured. If so, and if this general sensitivity is related to symptom perception, this would explain the association with physician consultation.

This study has consequences for both research and clinical practice. When gastroenterologists see patients with functional gastrointestinal disorders, they should be aware that there may be a psychological component. Psychological assessment, therefore, would be useful to determine whether a given individual with FGD might benefit from psychotherapy.

The issue addressed in this study can be seen as a model for other disorders, especially in psychosomatic medicine. The psychological problems found in many of the individuals with psychosomatic disorders need to be assessed to determine whether they should be regarded as correlates of the disorder itself, as results of the disorder, or as a result of a selection effect of patients who have chosen to consult a physician (37). These ideas are not new, but an empirical assessment has yet to be made: "Much confusion has been contributed to the study of diseases, psychosomatic illnesses in particular, by failure to recognize that the psychological component of the phenomenon under study was often the factor which brought the patient to the doctor, not the factor which brought on the disease" (Ref. 38, p. 246).


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
REFERENCES
 
1 The different N values (288 vs. 287) are the result of the statistical weighting procedure. Back

Received for publication October 20, 1997.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 

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