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ORIGINAL ARTICLE |
From the Departments of Psychiatry and Behavioral Sciences (P.T., N.P.), Biostatistics (I.V.), Internal Medicine (N.F., O.M.), and General Surgery (S.V.), Faculty of Medicine, University of Crete, Stavrakia, Heraklion, Crete, Greece.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSNOTESREFERENCES |
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METHODS: The criteria of Manning et al., as modified by Thompson et al., were used to make the diagnoses of IBS. Psychiatric assessment was performed by using a structured interview in 64 women, aged 20 to 70 years, 36 with IBS and 28 with chronic cholelithiasis. Diagnosis of chronic cholelithiasis was made by histopathological examination. The final diagnoses were confirmed by interview after 1 year. The diagnostic system based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was used to make the current diagnoses. The Present State Examination (PSE)-Index of Definition (ID) computer program (CATEGO) was used to define total psychopathology (total PSE score), current clinical severity (ID), and clusters of psychiatric symptoms.
RESULTS: No difference in the specific DSM-IV diagnostic categories was found, but there were more total depressive disorders in the IBS group. The ID and total PSE score were high among patients with IBS. Multiple logistic regression analysis showed that duration of gastrointestinal pain, and the symptoms of general anxiety, and hypochondriasis significantly predicted a diagnosis of IBS.
CONCLUSIONS: Female patients with IBS are categorized into the general DSM-IV category of depressive disorder, their current psychiatric severity is high compared with that of women with chronic cholelithiasis, and patients with IBS are characterized by the psychiatric syndromes of general anxiety and hypochondriasis. The implications of these findings and areas for future research are discussed.
Key Words: irritable bowelsyndrome • core psychiatric symptoms
Abbreviations: CATEGO = computer program; CC = chroniccholelithiasis; DSM-III-R = Diagnostic and StatisticalManual of Mental Disorders, third edition revised; DSM-IV= Diagnostic and Statistical Manual of Mental Disorders,fourth edition; GI = gastrointestinal; IBS = irritable bowelsyndrome; ID = index of definition; PSE = Present StateExamination; NOS = not otherwise specified.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSNOTESREFERENCES |
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A number of studies have shown that definite psychiatric illness is higher in IBS patients than in healthy subjects (1–3), patients with benign organic GI illness, and general medical patients (4–7). However, comparative studies of these groups and various functional disorders, including GI disorders, have shown that psychiatric illness in patients with functional disorders is as high as in patients with IBS (7–10). Thus, the presence of high psychiatric morbidity cannot be considered to be a specific characteristic of IBS patients. In addition, no difference has been found in the prevalence of psychiatric diagnosis between IBS patients with chronic GI symptoms and those with recent symptoms (11) or between patients with different types of IBS (12). There is also strong evidence that the psychiatric symptoms among patients with IBS are present before the onset of GI symptoms (3–7, 9).
It is also clear that most people with restrictive IBS criteria do not seek health care (1). They exhibit no more psychiatric trait (1) or state (13) symptoms than healthy control subjects. However, IBS patients have more psychopathology than healthy control subjects (1, 13, 14).
The association of psychiatric illness and IBS has been discussed in a number of reviews (1–3, 11, 12, 14). An emerging finding from the literature is that IBS patients have psychiatric symptoms that are common in pure mood or anxiety disorders (3, 14), and some researchers have concluded that this feature of IBS patients (ie, the combination per se of GI and psychiatric symptoms) seems to separate IBS patients from patients with other GI disorders or pure psychiatric illness (3).
Although psychiatric illness is a frequent finding among IBS patients, a specific psychiatric disorder or a specific psychopathology has not been found (2, 3, 13). Likewise, a specific personality profile has not been found (13), even though personality disturbance has been found to be high among IBS patients as compared with healthy subjects and other medical groups (1). Thus, the field for the identification of any characteristic psychological markers for IBS patients who seek health care remains open (2, 3). Of these factors (state and trait), this study focused on psychiatric state.
In light of these studies, we decided to conduct a study at the University Hospital of Heraklion, Crete, Greece. The study examined IBS patients who seek medical care to determine 1) coexisting mental illness (using strict diagnostic criteria), 2) the degree of current psychiatric severity, and 3) existing psychiatric symptoms.
We hypothesized that 1) the frequency of psychiatric disorders is higher in patients with IBS as compared with patients with an organic GI disorder and 2) the severity and frequency of certain psychiatric symptoms and general psychopathology are higher among IBS patients as compared with patients with an organic GI disorder.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSNOTESREFERENCES |
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The first group (IBS patients) consisted of patients with chronic abdominal symptoms who were admitted to the Gastroenterology Department of the University Hospital of Heraklion for medical examination with a provisional diagnosis of IBS. In the majority of these patients, an IBS diagnosis had been previously made elsewhere, but they were admitted to this hospital for first time. Their GI symptoms fulfilled the criteria for a diagnosis of IBS, and their clinical and laboratory examinations, except for colonoscopy, were completed before the psychiatric examination. The patients were carefully reassured that their condition was not life-threatening, and they were informed about their provisional diagnosis.
The second group (CC patients) consisted of patients with chronic abdominal symptoms admitted to the Surgical Department of the same hospital for gallbladder removal. They were informed about the benign nature of their disease and the consequent surgery. Asymptomatic patients or patients with abdominal symptoms that persisted for <3 months before the surgery were not included; the latter exclusion criterion added to the homogeneity of the sample, because this is the shortest duration required for a diagnosis of IBS (15, 16).
Patients with CC were chosen for the control group because CC has two important similarities with IBS. First, it is a GI disorder that is more prevalent in women than in men (17). Second, the perceived stress caused by the reason for admittance to the hospital is common for both groups: They suffer from a physical illness (IBS or CC) of an objectively minor importance (18). Furthermore, in studies examining the relationship between psychological disorder and IBS, it has been proposed that patients with organic GI disorders be used to control for the severity and duration of bowel symptoms (12).
To determine mental state, patients in the IBS group were evaluated before the final medical diagnosis, and patients in the CC group were evaluated 1 day before surgery. All patients gave informed consent. Patients were initially placed in two groups: those with a diagnosis of IBS and those with a diagnosis of CC; the latter group served as the control group.
Tools and Methods of Assessment
Medical Examination.
The IBS diagnoses were based on the criteria of Manning et al. (15), as modified by Thompson et al. (16). In brief, the IBS criteria are met under the following conditions: 1) abdominal pain of particular character accompanied by three or more defined symptoms of disturbed defecation, 2) duration of the above GI symptoms for at least 3 months, and 3) appropriate exclusion of other medical diseases. A full description of the criteria is provided elsewhere (16). The IBS patients were medically examined by two gastroenterologists; the medical examination included a detailed medical history, clinical and laboratory examination, ultrasonography of the upper abdomen, and colonoscopy.
The preoperative CC diagnoses were made by a surgeon, who also recorded the duration of GI symptoms (including pain). Further confirmation of the CC diagnoses was made after the histopathological examination, which required the presence of gall stones and a diagnosis of chronic cholecystitis based on biopsy specimens of gallbladder tissue. The final IBS and CC diagnoses were made 12 months after discharge by a gastroenterologist, who invited all patients to return for interview on the basis of the above criteria (16).
Psychiatric Examination.
All patients were interviewed by a psychiatrist blinded to the final GI diagnoses. The IBS patients were interviewed before colonoscopy, and the CC patients were interviewed on the day before surgery. During this interview, which lasted for 60 to 90 minutes, the following information was elicited: 1) demographic data; 2) data on past psychiatric history, including previous psychiatric hospitalizations or visits to professionals, use, kinds, and efficacy of psychotropic drugs, and suicide attempts; 3) information from a formal psychiatric examination, performed to make a DSM-IV diagnosis (19); and 4) information on recent psychiatric symptoms, obtained through a structured interview, the PSE of Wing et al. (20). At the end of the interview, the records were studied by two clinicians (P.T., N.P.), and a decision leading to a DSM-IV diagnosis was made.
The PSE is a structured psychiatric interview for eliciting psychiatric symptoms (21), including substance abuse (20), experienced during the previous month; these symptoms are defined in a glossary of definitions (22). This procedure ensures maximum reliability and objectivity when the answers are judged and rated by an adequately trained clinician (23).
Symptom ratings can be classified using a set of rules described by Wing et al. (20), which have been translated into a computer program (CATEGO) (24). Comparisons of a wide range of clinical diagnoses, based on classification using the PSE-ID-CATEGO computer program, have been made in Zurich, Switzerland (25), and Munich, Germany (26), and the concordance in both studies was good. The reliability and validity of PSE are established (21–23, 27, 28). On the basis of these symptoms, the PSE-ID-CATEGO system yielded 1) the Syndrome Check List, 2) total PSE score, 3) PSE subscores. and 4) ID. A detailed description of the PSE-ID-CATEGO system is provided elsewhere (22).
In short, the CATEGO program sorts the symptoms into 36 clusters, called syndromes. The total PSE score is the sum of the syndrome scores and reflects general psychopathology. PSE subscores are four summed ratings consisting of the grouping of the mentioned 36 clusters into the following categories: 1) syndromes of delusions and hallucinations; 2) behavioral and speech syndromes; 3) specific neurotic syndromes; and 4) nonspecific neurotic syndromes, consisting of symptoms common to either mood or anxiety disorders. The ID provides a measure of current clinical severity, incorporating rules for deciding whether a subject suffers from a current psychiatric disorder. The rules operate on total PSE score and type and combination of symptoms with eight increasing degrees (or levels) of current severity. Levels 1 to 4 indicate low clinical severity and represent symptoms that cannot be classified into any conventional category of psychiatric disorder (22). Levels 5 to 8 indicate increasing degrees of clinical severity for classification to one of the conventional diagnostic categories through a tentative diagnosis based on criteria of the International Classification of Diseases, ninth edition, by using the CATEGO program (24).
The so-called tentative diagnosis is provided with the limitation that the psychiatric symptoms rated are those exclusively present during a restricted period of 1 month before the interview. This limited time results in an obvious omission of several symptoms, and the consequent diagnoses, that might be present during a time longer than 1 month before the interview. In this study, the Greek translation of PSE was used; this translation has been validated and used in other studies in Greece (29).
The main differences between the two diagnostic systems are as follows: Axis I of the DSM system, compared with the PSE-ID-CATEGO system, covers a wider range of psychiatric syndromes, has a lower threshold for the definition of "caseness" for some disorders, and has a wider time frame. Thus, not all DSM adjustment, anxiety, and depressive disorders are expected to reach the PSE-ID-CATEGO threshold level. A detailed description of these differences is provided elsewhere (30).
Statistical Analysis
The association between group membership and DSM-IV diagnoses, as well as between group membership and medication taken currently or during the past month, was tested by means of cross-table analysis (Pearson’s 
2 tests with Yate’s correction or Fisher’s exact test when appropriate). Differences in age and duration of GI pain between the two groups were tested by means of Student’s t test. Differences between the two groups related to scores measured on ordinal scales, such as the various PSE-ID-CATEGO syndromes, total PSE score, PSE subscores, and ID, were tested by means of the Wilcoxon rank sum test (Mann-Whitney U test) (31). The independent influence on the incidence of IBS of several psychiatric factors, currently taken medication, and GI pain duration was analyzed by logistic regression analysis (31, 32). All statistical tests were two tailed.
Corrections for Type I errors were made by using a modified Bonferroni’s procedure. According to this procedure, the level of significance, 
, is adjusted according to the equation = */k, where * is the probability of committing at least one Type I error in a number of tests, k (33). In addition, because the probability of making Type II errors is positively correlated with the number of tests, k, a more generous value, up to 0.25, has been proposed for * (34, 35). The adjustment of for entry (or removal) in multiple regression is obtained throughout the same equation, where k corresponds to the number of variables not included in the model (33).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSNOTESREFERENCES |
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Table 1 shows the demographic characteristics, medications taken during the past month, and duration of GI pain of patients in the two groups. More IBS patients had a longer duration of GI pain, and more had taken benzodiazepines during the past month. These two and other potentially confounding factors were therefore controlled in the analysis.
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The general diagnostic category of depressive disorders was more common among IBS patients (N = 13) than CC patients (N = 2) (36.1% vs. 7.1%, 2 = 5.84, df = 1, p = .016).
As Table 2 shows, the first hypothesis was tested through six qualitative characteristics (diagnostic categories), which are the sum of several subcategories. It is known, however, that multiple statistical comparisons inflate Type I error. To control for this, we adjusted the level of significance (33–35). Because the variable depressive disorders showed a level of significance of p = .016, it is not considered to be detected by chance alone.
Hypothesis 2
The second hypothesis was that the severity and frequency of certain psychiatric symptoms and general psychopathology are higher among IBS patients than among patients with an organic GI disorder. The difference of general psychopathology between the two studied groups was tested through use of the total PSE score. The ID was applied to determine the clinical severity of the symptoms at the interview and during the month before interview. Using the Wilcoxon test for two independent samples, the ID showed higher levels of clinical severity in the IBS group than in the CC group (median, 5 vs. 4, respectively; W = 669.5, p = .001). The total PSE score, reflecting general psychopathology, was higher in the IBS group than in the CC group (median, 17.5 vs. 6.5; W = 666.0, p = .001).
In the study described here, 20 of the 36 syndromes available in the PSE-ID-CATEGO system were rated for both groups; thus, the difference in psychiatric syndromes between the two studied groups was examined by use of 20 Wilcoxon tests for two independent samples. The following 10 syndromes, which are clusters of sorted symptoms, were higher in the IBS group than in the CC group: depressed mood (mean rank, 37.17 vs. 26.50; W = 742.0, p = .013); general anxiety (mean rank, 37.92 vs. 25.54; W = 715.0, p = .001); ideas of reference (mean rank, 35.22 vs. 29.00; W = 812.0, p = .014); tension (mean rank, 37.50 vs. 26.07; W = 730.0, p = .010); lack of energy (mean rank, 36.28 vs. 27.64; W = 774.0, p = .032); worrying, etc. (mean rank, 37.78 vs. 25.71; W = 720.0, p = .005); irritability (mean rank, 36.75 vs. 27.04; W = 757.0, p = .017); social unease (mean rank, 36.33 vs. 27.57; W = 772.0, p = .018); loss of interest and concentration (mean rank, 38.24 vs. 25.13; W = 703.5, p = .001); and hypochondriasis (mean rank, 38.28 vs. 25.07; W = 702.0, p = .001).
After adjusting the level of significance for multiple tests to = 0.013 (33), the following six syndromes were found to be significantly different between the two groups: 1) depressed mood, 2) general anxiety, 3) tension, 4) worrying, etc., 5)loss of interest and concentration, and 6) hypochondriasis (Figure 1).
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= 0.05. The backward logistic regression chose five variables: duration of GI pain, use of antidepressants, use of benzodiazepines, general anxiety, and hypochondriasis. To control for Type I errors when applying stepwise regression analysis (33), an adjustment of for removal resulted in a cutoff level of significance of 0.026 instead of 0.05. Thus, we repeated the same regression with = 0.026, and the results indicated three factors predicting a diagnosis of IBS: duration of GI pain, general anxiety, and hypochondriasis (Table 3); all other variables had a nonsignificant effect.
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DISCUSSION AND CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSNOTESREFERENCES |
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Our results related to the high current psychiatric severity among patients with IBS support previous findings (4–7). The previous studies showed that definite psychiatric illness is higher in IBS patients than in healthy control subjects, patients with benign organic GI illness, and general medical patients, although in all of them the control groups did not include patients with medical conditions with a female prevalence (unlike IBS); also, in some of the studies, either the control group (4, 5) or both the experimental and control groups (6, 9) included subjects with more than one medical disease. In contrast, each of our studied groups consisted of women with a single GI disease (IBS or CC). Both of these GI disorders are more common in women than in men, which adds to the homogeneity of the sample.
Our result of the presence of more total depressive disorders, based on DSM-IV criteria, in patients with IBS is consistent with the finding of Rose et al. (10) and is also in line with previous findings of no specific psychiatric disorder in patients with IBS (1–2, 13) because our finding refers to a general diagnostic category and not to a specific disorder. Regarding the study of Rose et al. (10), it is difficult to compare our differences between the IBS and CC groups (36.1% vs. 7.1%) with those found between their experimental and control groups (50% vs. 19%) because there are many methodological differences between the two studies. Unlike us, Rose et al. investigated only depression, using the self-report Beck Depression Inventory; furthermore, both of their groups included patients with more than one medical disease, including GI and other non-GI diseases. They reported that the proportions of cases of clinically diagnosed depression were as twice as low as cases indicated by the self-report (10), which makes their results more similar to ours. However, they offered no description of the clinical criteria used for depression; they considered that a clinical diagnosis of depression had been made if an antidepressant had been prescribed. In contrast, in our study, the specific disorders of major depression, dysthymia, and depressive disorder NOS, assessed by strict DSM-IV criteria, were not higher in the IBS group than in the CC group (Table 2); even though these disorders are discrete clinical entities with different prognoses, courses, impairments, and complications, the Beck Depression Inventory does not distinguish between them.
The results of this study are also comparable, within the scope of the PSE-ID-CATEGO system, with those of Ford et al. (6), who used the same ID criterion for current psychiatric disorders. To obtain comparability, we considered current psychiatric caseness, which is ID levels 5 to 8. In our sample, current psychiatric caseness was more common among IBS patients (N = 23) than among CC patients (N = 7) (63.9% vs. 25.0%, 2 = 8.06, df = 1, p = .005). Our proportions are higher than those of Ford et al. (42% vs. 6%) (6). Their lower proportions may be a result of the use of patients with more than one medical disease in their experimental and control groups. First, their functional group consisted of patients with IBS and functional dyspepsia, and their organic group comprised patients with peptic ulceration and inflammatory bowel disease. Second, regarding the sex ratio of these diseases, functional dyspepsia, peptic ulceration, and inflammatory bowel disease, unlike IBS, are not considered to affect more women than men. Third, their sample included both women and men, whereas ours included only women. The latter point also attributes to our high rate of psychopathology, because a higher prevalence of psychiatric disorder among women than men has been observed in community surveys using the same (PSE) and different instruments (21, 29).
Furthermore, some previous, seemingly discrepant findings may be integrated and better explained in light of the results found in this study, particularly the findings of no specific psychiatric diagnosis in the IBS group (1–2, 13) and the seemingly contradictory finding of high psychopathology among IBS patients in comparison with patients with other organic GI disorders (4–8). This discrepancey may reflect the different instruments or the different forms of measures used in these studies (eg, self-report vs. interview). Our study used two methods, each of which was specific to its purpose (ie, the DSM-IV system for definitive diagnoses and the PSE-ID-CATEGO system for current psychiatric severity). Thus, it was shown that definitive diagnoses did not differ between the groups, whereas current psychiatric severity was higher among patients with IBS than among those with CC. The latter finding is a result of the sensitivity of the PSE-ID-CATEGO system in identifying, in a detailed, qualitative way, current clinical severity, which is not accessible by the DSM system.
In particular, our findings are comparable with those of Walker et al. (4) in regard to the percentage of total psychiatric diagnoses of IBS patients. They found psychiatric disorders in 93% of patients, which is almost identical to the prevalence of 94.4% we found in our IBS patients. Their diagnostic criteria, based on DSM-III-R, and ours, based on DSM-IV, are from the same diagnostic system. The prevalence of panic disorder with agoraphobia in our IBS group was 5.6%, whereas in the Walker et al. study (4), it was up to 29%. This difference could be an overestimation of the disorder because these authors omitted the exclusion criteria to allow the maximum number of valid DSM-III-R diagnoses (4). In contrast, our findings (Table 2) suggest that panic disorder and a diagnosis of IBS patients are not related. However, the total diagnoses present in our control group were much higher than those of Walker et al. (78.5% vs. 19%, respectively). This difference could be a result of the heterogeneity of the groups they studied. First, their control group included patients with two different GI conditions, Crohn’s disease and ulcerative colitis (4). Second, these two medical conditions (unlike IBS) are not considered to affect more women than men. Third, their sample comprised both women and men, whereas our sample included only women. This is another factor attributing to our higher rate of psychopathology in both groups, because a higher prevalence of psychiatric disorders would be expected among women (21, 29). Finally, unlike us, they did not mention whether pain duration was assessed and controlled in their groups (4); therefore, our results on pain duration are not comparable with theirs. In our study, the mean duration of GI pain, which is associated with increased psychopathology (6, 9, 10, 14), was high in both groups (Table 1). Thus, the high rate of psychiatric disorders in our CC patients (78.5%) mostly reflects two conditions, an expected high prevalence of psychiatric disorders among women and a long duration of pain.
In terms of psychiatric profile, the patients with IBS differed significantly from those with CC. The IBS group had the following syndromes to a greater extent: 1) depressed mood and general anxiety, which are referred to as specific neurotic syndromes (22) because they clearly favor affective disorders and anxiety disorders, respectively; and 2) tension, worrying, etc., loss of interest and concentration, and hypochondriasis, which are referred to (22) as nonspecific neurotic syndromes because they are common to both affective and anxiety disorders. These syndromes could not be conceived as specific for the psychiatric symptomatology of IBS because Arapakis et al. (7) have found, by use of the same instrument (PSE), that both patients with IBS and those with ulcerative colitis had high scores of specific and nonspecific neurotic syndromes. However, the focus of our study was to investigate the specific mental state that could characterize women with IBS who seek medical help for their GI symptoms. To accomplish this, the dependence of the two studied groups on psychiatric factors was analyzed by logistic regression analysis, and the results indicated that in IBS patients, diagnosis is more likely when a longer duration of GI pain is present and when general anxiety or hypochondriasis is present (Table 3). The latter clusters of symptoms could be considered as two markers characterizing the core psychiatric symptomatology of IBS patients who seek medical care for their GI symptoms. It is noted that hypochondriasis is the single symptom of the syndrome of hypochondriasis, whereas the constituent symptoms of general anxiety are free-floating anxiety, panic attacks, and observable anxiety.
There is an emerging body of literature suggesting a relation between panic disorder and functional GI disorders; this literature was reviewed recently by Maunder (14), who concluded that the relation is overrepresented in patients with noncardiac chest pain and IBS. However, for the syndrome of general anxiety, in which the symptom of panic attacks is included, we have to clarify that this symptom is considered an accompanying feature, not as a definite diagnostic category, characterizing IBS patients. In this report, the hypochondriasis syndrome is also considered an accompanying feature.
Considering that psychopathology is frequently present among IBS patients (2, 3, 13), the physician should elicit the following general information: 1) current or past psychiatric treatment of any kind and 2) any complaints of sleep, anxiety, or mood disturbance. Answers to these questions provide clues to the presence of psychopathology (36). These questions could be asked as part of the medical history. After the medical evaluation, IBS patients in whom these factors are present should be directed to psychiatric consultation and parallel therapy because their treatment could be more effective in a biopsychosocial therapeutic context (37). Because many IBS patients would reject a causal relationship between psychiatric and abdominal symptoms (1), the physician could offer a rationale based on their complaints. For example, the physician could explain that the abdominal and psychological symptoms are usually occurring at the same time but that no explanation is available for this troublesome situation; however, experience has shown that both kinds of symptoms are better alleviated when jointly treated.
Whitehead et al. (13) proposed that symptoms of psychological distress may influence those IBS patients who are most likely to visit a medical clinic. From this point of view, the main contribution of our study was the addition to the existing knowledge of information about the specific psychiatric symptoms of IBS patients who are more likely to seek medical assistance for their bowel symptoms.
In conclusion, the whole range of present mental state was compared between two groups of women presenting with GI complaints, 36 with IBS and 28 with CC. Our findings strongly indicate that 1) a specific DSM-IV psychiatric disorder was not found to distinguish patients with IBS from those with CC, 2) IBS patients fall into the general diagnostic category of depressive disorder, 3) current psychiatric severity is higher in IBS patients than in CC patients, and 4) two clusters of psychiatric symptoms, general anxiety and hypochondriasis, differentiated patients with IBS from those with CC.
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSION AND CONCLUSIONSNOTESREFERENCES |
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Received for publication August 3, 1998.
Accepted for publication June 28, 1999.
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) and 28 patients with CC (•). Numbers are percentages of patients with rated PSE-ID-CATEGO syndromes. GA = general anxiety; HY = hypochondriasis; IC = loss of interest and concentration; SD = depressed mood; TE = tension; WO = worrying, etc. *p < .05, **p < .01.