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ORIGINAL ARTICLES |
From the Division of Social Science, Hong Kong University of Science and Technology (C.C.), and the University Department of Medicine, University of Hong Kong (W.H., S.L.), Hong Kong.
Address correspondence and reprint requests to Cecilia Cheng, PhD, Division of Social Science, Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong. E-mail: c.cheng{at}ust.hk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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METHODS: In a population-based survey, 4038 Hong Kong subjects (age 18–80 years) were interviewed. Five hundred ninety interviewees (14.6%) met the diagnostic criteria for functional dyspepsia (FD), and 396 of them participated in this study.
RESULTS: Results from multiple regression analyses revealed significant main effects of monitoring, emotional support, and coping flexibility on perceived FD symptom severity. A significant emotional support by coping flexibility interaction effect was also found.
CONCLUSIONS: The present findings provided support for the psychosocial interactionist model in showing that (1) monitoring is a risk factor related to greater perceived symptom severity, (2) emotional support and coping flexibility are resource factors related to lower perceived symptom severity, and (3) the beneficial role of emotional support is present only among those higher in coping flexibility but not among those lower in coping flexibility.
Key Words: psychosocial factors, • perceptual style, • coping, • social support, • functional dyspepsia, • functional gastrointestinal disorders.
Abbreviations: ANOVA = analysis of variance;; CFQ = Cognitive Flexibility Questionnaire;; EMBSS = Extended Miller Behavioral Style Scale;; EPQ = Eysenck Personality Questionnaire;; FD = functional dyspepsia;; ISSB = Inventory of Socially Supportive Behaviors;; MCSD = Marlowe-Crowne Social Desirability scale.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Although the prevalence of FD has aroused much research attention, two knowledge gaps remain. First, most studies (6–9) have examined differences in psychological characteristics between subjects with FD and those without this illness. No research on FD to date has examined within-group differences. A further reason for examining the differences within this group is the heterogeneity of the symptom characteristics associated with this condition (7,10). Second, there is no work on conceptual frameworks to guide current understanding of FD and functional illnesses with unexplained somatic symptoms. To fill these gaps, a multivariate interactionist approach was adopted to (1) explicate the mechanisms underlying individual differences in perceived FD symptom severity and (2) provide a systematic account of the relations between psychosocial variables and perceived FD symptom severity. The psychosocial interactionist model underscores interrelations among factors at the cognitive, behavioral, and social levels.
Psychosocial Risk and Resource Factors
According to Barsky and Wyshak (11) and Barsky et al. (12), some people are especially sensitive to their bodies, and these people may have a lower threshold for bodily discomfort. Such a notion suggests a link between perceptual style and the experience of symptoms. In the present psychosocial interactionist model, monitoring (13) was proposed to be related to individual differences in perceived symptom severity among people with FD. People with a monitoring tendency seek out information relevant to health threats. People with a blunting tendency prefer to avoid threat-relevant information and distract themselves from such information about their health conditions (13,14). A recent study (3) showed that people with FD who sought medical consultations tended to have a greater tendency to monitor danger cues than did their counterparts who did not seek medical consultations. Because symptom perception plays a role in the decision-making process of healthcare seeking (15), it is possible that the group with higher monitoring scores may perceive their dyspeptic symptoms as being more severe, thus increasing their motivation to consult physicians for their illness. Hence, monitoring was included in the psychosocial interactionist model as a cognitive risk factor related to greater perceived symptom severity.
Health perception is substantially formed in association with a person’s relationship with others and with their social well being (16). Social support is thus deemed relevant to symptom perception of people with FD. Social network members can provide two types of social support (17). The first is instrumental support, which can reduce stress by directly solving problems at hand or facilitating goal attainment. The other type is emotional support, which can reduce stress by fulfilling a strong affiliative need or boosting positive affective moods. Studies (18,19) have shown that patients with more social support were in a better state of health than those with less social support. In light of these findings, the psychosocial interactionist model proposed that social support may be a social resource factor related to lower perceived symptom severity.
Moderating Role of Coping
It is noteworthy that social support may be considered as a remote factor. Its effects on health and psychological well being may depend largely on the actual use of these resources through the coping process. Thus, coping was proposed to be a moderating mechanism that modifies the relationship between social support and perceived FD symptom severity.
In the psychosocial interactionist model, coping flexibility, rather than coping per se, was proposed to be related to FD symptoms. The adaptive nature of coping flexibility has been proposed in theoretical discussions (20,21). Our program of studies (3,6,22,23) has shown that coping flexibility is associated with coping effectiveness, which is indicated by adjustment to life transitions and psychological well being. People with the lowest anxiety and depression levels tended to use more action-oriented strategies in controllable situations but use more passive or emotional-focused strategies in uncontrollable situations. In contrast, people who experienced the highest anxiety and depression levels were those who consistently used action-oriented coping to handle every stressful event. These findings revealed that coping flexibility is related to coping effectiveness.
Effective coping involves not only solving problems and mitigating emotions by oneself but also receiving assistance from others in handling problems and reducing emotional distress (24,25). The intricate relationship between coping and social support can be traced from two sources. First, coping rarely takes place in a social vacuum, because most problems or events involve other people (26). Second, social support can change coping patterns (27) and strengthen coping efforts (24,28). Consistent with these notions, longitudinal studies (29–31) have shown that depressed participants with abundant social support who also coped effectively had a greater reduction in depressive symptoms than did either those with abundant social support only or those with effective coping only. In this light, the psychosocial interactionist model proposed that coping flexibility may moderate the effects of social support on perceived FD symptom severity.
Methodological Considerations
In this study, self-report questionnaires were used. These measures may be susceptible to respondents’ tendency to provide socially desirable answers (32,33). Also, questionnaires may include the component of negative affectivity (34,35). The possible influence of social desirability and negative affectivity was examined.
Participants in most previous studies on FD were recruited from outpatient sections of hospitals and clinics, with a few exceptions that include participants with FD who did not consult medical professionals (3,4). Findings from patients who seek medical consultation are confounded by the problem of self-selection (36). To provide a more representative sample of people, the present study examined both consulters and nonconsulters through a population-based survey.
Overview of This Study
Based on previous theories and research findings, three hypotheses were derived from the psychosocial interactionist model and were tested in this study. First, monitoring may be positively related to perceived FD symptom severity. Second, social support may be inversely related to perceived FD symptom severity. Third, coping flexibility may moderate social support, and these two variables may jointly relate to perceived symptom severity.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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A total of 590 interviewees (14.6%) met the diagnostic criteria for FD. This prevalence rate is similar to that reported in a previous Hong Kong population-based study (4). Of these, 396 (234 women, 162 men) returned the questionnaires. Their ages ranged from 18 to 80 years (mean, 43.29; SD, 13.76). There were no significant differences in all the sociodemographic variables (ie, sex, age group, marital status, education level, occupational status, and monthly household income) between the participants who took part in this study and those who did not participate(
2[590] < 1.61, NS).
Frequencies (expressed as percentages) of various sociodemographic variables are listed in Table 1. The sociodemographic characteristics of this sample were highly similar to those of the Hong Kong population at large (Hong Kong Census and Statistics Department, 1997), thus indicating that the present sample was representative of the general population.
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The diagnosis of FD was established according to the Rome II criteria (1). Respondents answered a set of symptom-based diagnostic questions such as, "Over the last 3 months, have you often had discomfort or pain centered in your upper abdomen?" Only participants who met the diagnostic criteria of FD, rather than those with other functional gastrointestinal problems (eg, irritable bowel syndrome, functional constipation), were included in the main study. The diagnostic criteria were found to be reliable, valid, and suitable for use in telephone surveys of the Hong Kong population (4).
The Extended Miller Behavioral Style Scale (EMBSS) (37,38) was used to assess monitoring and blunting. The monitoring score ranges from 0 (does not use monitoring/uses blunting all the time) to 1 (uses monitoring all the time/does not use blunting). Previous studies (22,37,38) have shown that the EMBSS displays good test–retest reliability, internal consistency, and criterion-related validity.
Social support was measured by the Inventory of Socially Supportive Behaviors (ISSB) (39). Respondents rated the frequency with which instrumental (19 items) and emotional (13 items) support was available to them when needed. Previous Hong Kong studies have shown that the reliability and criterion-related validity of the Chinese ISSB are sufficiently high (40,41).
The Cognitive Flexibility Questionnaire (CFQ) (23) was used to examine coping flexibility. Participants were instructed to describe two controllable and two uncontrollable hassling events experienced in the past 3 months. They were then asked to report all the strategies deployed to handle each event, and then to classify each strategy into one of two goals: "strategy used for managing the event" (ie, problem-focused) and "strategy used for regulating the emotion associated with the event" (ie, emotion-focused). Coping flexibility is operationalized by a strategy-situation fit index, which reflects the extent of situation-appropriateness of coping patterns. The scoring criterion derived from the goodness-of-fit theories (42,43) was adopted. A score of 1 was given to the use of (1) problem-focused coping in a controllable stressful situation or (2) emotion-focused coping in an uncontrollable stressful situation. A score of 0 was given to the use of (1) problem-focused coping in an uncontrollable stressful situation or (2) emotion-focused coping in a controllable stressful situation. Because there are considerable individual differences in the number of coping strategies used, the scores were aggregated and then divided by the total number of coping strategies. The index ranges from 0 (not flexible at all) to 1 (extremely flexible). The CFQ displayed good reliability and criterion-related validity (23).
Participants were asked to report the severity of four main symptoms (ie, epigastric pain, nausea, vomiting, and belching) commonly reported by FD patients in Hong Kong (44). They rated each symptom along a visual analogue scale, with 0 (having no symptoms at all) at one end and 10 (extremely severe) at the other. This measure of perceived FD symptom severity has good internal consistency (
= 0.87), test–retest reliability (r = 0.76, p < .0001), and discriminant validity among FD patients in Hong Kong (22,44,45).
The neuroticism subscale of the EPQ (46) was used to assess negative affectivity. This subscale is composed of 19 items, and respondents give "yes" or "no" answers to these items. The Chinese EPQ has good reliability and criterion-related validity in Hong Kong samples (47).
For the assessment of social desirability, the Marlowe-Crowne Social Desirability scale (MCSD) (48) was used. The MCSD consists of 33 items with "yes" or "no" responses. The Chinese MCSD displays good reliability and criterion-related validity (49).
Procedure
Participants were first contacted by telephone using random digit dialing. At the end of the telephone interview, participants who met the diagnostic criteria of FD were asked whether they would be interested in participating in a study. They were told about a reward of 50 Hong Kong dollars (approximately US$6.25) for completing a questionnaire. If participants showed interest, they were asked to provide their name and address. Participants were reassured that their name and number would be stored in a database separate from the database containing their answers.
A package of questionnaires with full instructions and a sample was mailed to participants. They were instructed to fill in the questionnaire by themselves in a quiet place, and a contact number and e-mail address were provided so that they could contact the research assistant if they had difficulties in completing the questionnaires. A stamped, self-addressed envelope was attached for returning the completed questionnaires. Participants were asked to mail back the questionnaires within 2 weeks. Reminder notes were sent to those who did not return the questionnaires by that time. A check and debrief note with brief descriptions of the aims and design of this study were sent on receipt of the questionnaires.
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RESULTS |
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Analysis of variance (ANOVA) was then conducted to identify the variables on which sex and marital status have significant effects. The ANOVA results showed significant sex differences in monitoring, instrumental support, and coping flexibility (F values >6.77, p values <.05). Female participants tended to have lower scores for monitoring and instrumental support (mean, 0.57, SD, 0.20; and mean, 34.53, SD, 14.96, respectively) than did male participants (mean, 0.62, SD, 0.18; and mean, 45.62, SD, 15.03, respectively). However, female participants had higher scores for coping flexibility (mean, 0.59; SD, 0.19) than did male participants (mean, 0.51; SD, 0.20).
The ANOVA results also revealed a significant effect of marital status on emotional support (F[3,396]=26.29, p < .001). As shown in the post hoc Tukey honestly significant difference tests, married participants (mean, 37.64; SD, 7.38) reported more emotional support than did never-married participants (mean, 33.88; SD, 10.08), who in turn reported more emotional support than divorced or separated and widowed participants (mean, 27.09, SD, 11.81; and mean, 19.71, SD, 10.29, respectively).
Test of Psychosocial Interactionist Model
Hierarchical multiple regression was used to test the main and interaction effects of the elements of the psychosocial interactionist model on perceived FD symptom severity (Table 3). Sex and negative affectivity were included as control variables. All of the elements of the model—monitoring, instrumental support, emotional support, and coping flexibility—were included. The hypothesized instrumental support by coping flexibility and emotional support by coping flexibility interaction effects were also examined. These interaction terms were represented by multiplying the two variables and then linearly partitioning out each variable from the product. All of the variables were normalized before calculating the cross-product terms to minimize the potential problems of multicolinearity (50).
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Further Analysis of Emotional Support by Coping Flexibility Interaction
Figure 1 shows a graphical presentation of the mean patterns of the emotional support by coping flexibility interaction. Analysis of simple main effects (51) was conducted to obtain a detailed examination of this interaction effect. The results revealed that for participants with lower scores on emotional support (left panel), there were no significant differences between participants higher in coping flexibility and those lower in coping flexibility (p > .05). However, for participants with higher scores on emotional support (right panel), significant differences in perceived symptom severity were found between the two groups (p < .001). Participants higher in coping flexibility reported less perceived symptom severity, whereas those lower in coping flexibility reported greater perceived symptom severity. These results indicate that the buffering effects of coping flexibility on perceived FD symptom severity were present only in people with higher levels of emotional support, not in those with lower levels of emotional support. Such a difference in symptom-buffering effects of coping flexibility among people with distinct levels of emotional support constitutes the interaction between emotional support and coping flexibility.
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DISCUSSION |
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Conceptual and Practical Implications
The present study extends the current conception of FD by adopting a social contextual perspective. Current theoretical discussions of functional illnesses (52,53) adopt an individualized conception. Specifically, these discussions focus on a person’s responsibility for the development of the functional illness and view the recovery process as the person’s effort to deal with symptoms and personal contacts with health professionals. The psychosocial interactionist model expands the scope of this approach by including the social environment. As shown in this study, emotional support rendered from a person’s social network can reduce perceived symptom severity, implying that social network members can contribute to the recovery process in FD. Therefore, a more comprehensive view of FD should emphasize the importance of both the person and the social levels of dealing with the condition.
Although personality and social factors may both be important to the study of FD, these two factors, rather than operating independently, may interact with each other. The psychosocial interactionist model advocates the adoption of a more complex conceptualization of FD. In this model, FD is conceptualized as a system of psychosocial processes that occur in transactional relationships. Although person-environment interactionist theories were proposed in psychological and social research decades ago (eg, 54, 55), principles arising from these theories have not been systematically applied to the context of FD. The present study was the first to examine FD in light of the person-environment interactionist approach. The present findings show that a person’s coping effort and emotional support from the social network can jointly relate to perceived FD symptom severity. These results thus provide a new view that patients’ recovery processes involving FD symptoms may be a product of their own efforts and the availability of social resources.
This study contributes to the existing literature by shedding light on an unexplored issue in the study of FD. Functional symptoms are real experiences reported by people with FD, yet no physical or biochemical mechanisms can be found to explain these symptoms (56). This study may provide insight into this unknown phenomenon from a subjective-perceptual point of view. According to Mechanic (16), there is a large pool of somatic symptoms (eg, nausea, headache, fatigue, muscle/joint pain) in the general population. This symptom pool is so ubiquitous that most healthy people have these somatic symptoms at certain points in their lives, but tend to ignore or show little concern for their symptoms. The present results reveal a link between monitoring and functional symptom severity, suggesting that the FD symptom pool may be the basis on which monitoring may act. If people tend to monitor their FD symptoms excessively, then this pool of symptoms may no longer be mild and ignorable but become sufficiently severe that these people report them. Hence, the subjective-perceptual aspect of functional illnesses should receive greater attention in future research.
At an applied level, the present results imply that multiple-component therapies are more effective than single-component therapies. Our findings suggest that the intervention workshop for people with FD should include three components. First, distraction techniques may be beneficial to workshop participants by diverting attention away from painful experiences and modifying pain-related cognitions (57). Second, participants’ coping flexibility may be enhanced by broadening their repertoire of coping strategies, together with illustrations on how to use these skills appropriately to meet different situational demands. Third, the acquisition of flexible coping skills may be more efficacious with a supportive therapist-patient relationship or group therapy setting.
Cautionary Notes, Research Directions, and Concluding Remarks
Before concluding, three cautionary notes should be addressed. First, this study was the first to adopt a psychosocial interactionist model in examining individual differences in perceived FD symptom severity. Our results provide tentative support for the model, but these results should be considered exploratory. Moreover, only the relationships between psychosocial variables and perceived FD symptom severity have been examined. Recent evidence has suggested that certain biochemical mechanisms, such as central gastric dysregulation and visceral hypersensitivity, are associated with FD symptoms (58). Future studies should include biochemical mechanisms to explore the interface between psychological and physical mechanisms and their possible conjoint effects on perceived FD symptom severity.
Second, it is noteworthy that a cross-sectional design was adopted, and thus the directions of relations among variables remain unclear. Although it is tempting to conclude that some psychosocial risk and resource factors may exert an influence on perceived symptom severity, it is equally possible that subjective perceptions of symptom severity may influence such psychosocial factors. To reveal predictive relationships between these psychosocial variables and changes in perceived FD symptom severity over time, future studies should adopt a multiwave panel design in which the same group of participants completes the same measures at different times.
Third, it is important to note that the participants in this study were all Chinese. It is not known whether the present findings are generalizable to Western populations. For example, some cultural differences have been found in the form of somatic problems reported by patients (59). Specifically, Chinese American patients tend to report more abnormal sensations, whereas white patients tend to report more abnormal motor functions. Given the possible cultural influences on the presentation of somatic symptoms (59–61), the present study should be replicated in other cultural settings, or preferably by cross-cultural studies, to address the issue of the generalizability of results across cultures.
This study was the first to explore individual differences in perceived FD symptom severity in a representative group of Hong Kong subjects with FD. Some possible psychosocial risk and resource factors relating to symptom perception were identified. The examination of psychosocial risk and resource factors, and their interactions, should receive greater attention for future research on FD.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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This article has been cited by other articles:
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  C. Cheng, F.-C. Yang, S. Jun, and J. M. Hutton Flexible Coping Psychotherapy for Functional Dyspeptic Patients: A Randomized, Controlled Trial Psychosom Med, January 1, 2007; 69(1): 81 - 88. [Abstract] [Full Text] [PDF]
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