Psychological interventions for non-ulcer dyspepsia

BACKGROUND

Studies have also shown that NUD patients have higher scores of anxiety, depression, neurotism, chronic tension, hostility, hypochondriasis, and tendency to be more pessimistic when compared with the community controls. However, the role of psychological interventions in NUD remains uncertain.

OBJECTIVES

This review aims to determine the effectiveness of psychological interventions including psychotherapy, psychodrama, cognitive behavioral therapy, relaxation therapy and hypnosis in the improvement of either individual or global dyspepsia symptom scores and quality of life scores patients with NUD.

SEARCH STRATEGY

Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and PsycLIT, using very broad subject headings and text words. Bibliographies of retrieved articles were also searched and experts in the field were contacted.

SELECTION CRITERIA

All randomised controlled trials (RCTs) or quasi-randomised studies assessing the effectiveness of psychological interventions (including psychotherapy, psychodrama, cognitive behavioural therapy, relaxation therapy and hypnosis) for non-ulcer dyspepsia (NUD) were identified.

DATA COLLECTION AND ANALYSIS

Data collected included individual, global dyspepsia symptom scores and quality of life (QoL) scores.

MAIN RESULTS

We identified only four trials, each using different psychological interventions and three presenting results in a manner, that did not allow synthesis of the data to form a meta-analysis. All trials suggest that psychological interventions benefit dyspepsia symptoms and this effect persists for one year. However, all trials use statistical techniques that adjusted for baseline differences between groups. This should not be necessary for a randomised trial that is adequately powered suggesting that the sample size of these papers was too small. Unadjusted data was not statistically significant. The other problem of psychological intervention include low recruitment and high drop out rate which has been shown to be greater in patients receiving group therapy.

REVIEWER'S CONCLUSIONS

There is currently insufficient evidence from this review to confirm the efficacy of psychological intervention in NUD. There is also no evidence on the combined effects of pharmacological and psychological therapy. Nevertheless, if there are any benefits of psychological therapies, they are likely to persist long-term and NUD is a chronic relapsing and remitting disorder. Psychological therapies may therefore be offered to patients with severe symptoms that have not responded to pharmacological therapies.

Role of cognitive factors in symptom induction following high and low fat meals in patients with functional dyspepsia

BACKGROUND

and aims: Dietary fat plays a role in the pathophysiology of symptoms in functional dyspepsia (FD). In healthy subjects, cognitive factors enhance postprandial fullness; in FD patients, attention increases gut perception. We hypothesised that the information given to patients about the fat content of a meal would affect dyspeptic symptoms.

METHODS

Fifteen FD patients were each studied on four occasions in a randomised double blind fashion. Over two days they ingested a high fat yoghurt (HF) and over the other two days a low fat yoghurt (LF). For each yoghurt, the patients received the correct information about its fat content on one day (HF-C, LF-C) and the opposite (wrong) information on the other day (HF-W, LF-W). Dyspeptic symptoms, plasma cholecystokinin (CCK) concentrations, and gastric volumes were evaluated.

RESULTS

Both the fat content and information about the fat content affected fullness and bloating scores-both were higher after HF-C compared with LF-C, and LF-W compared with LF-C, with no differences between HF-C and HF-W. Nausea scores were higher after HF compared with LF, with no effect of the information about fat content. No differences between discomfort and pain scores were found between study conditions. Plasma CCK and gastric volumes were greater following HF compared with LF, with no effect of the information given to the patients. All differences are p<0.05.

CONCLUSIONS

Cognitive factors contribute to symptom induction in FD. Low fat foods may also elicit symptoms if patients perceive foods as high in fat, while CCK and gastric volumes do not appear to be affected by cognitive factors.

Health-related quality of life in functional dyspepsia

BACKGROUND

We performed a systematic review of the literature to compare the health-related quality of life (HRQOL) of patients with functional dyspepsia with either healthy controls or those with other diseases.

METHODS

Full-length published manuscripts during 1980-2002 were included if (a) patients had functional dyspepsia, but not uninvestigated dyspepsia; and (b) HRQOL was measured using a validated generic or dyspepsia-specific instruments, but not global assessment alone.

RESULTS

Twelve studies were reviewed; six fulfilled the selection criteria. None examined HRQOL among samples of the general population. None used dyspepsia-specific HRQOL instruments. Three studies contained four comparisons of HRQOL between functional dyspepsia patients and controls; two studies examined HRQOL changes in response to therapy. Two studies demonstrated a significant reduction at least in some domains of HRQOL among patients with functional dyspepsia compared to controls, while one study was negative. In general, studies that reported a decline in HRQOL Short Form-36 (SF-36) showed that changes in the physical domain were similar to those on mental domain of the SF-36.

CONCLUSIONS

There is some evidence for a decrease in HRQOL in patients with moderate to severe functional dyspepsia who seek care for their symptoms; however, more studies are needed. A therapeutic response in functional dyspepsia-related pain or discomfort might result in a corresponding improvement in HRQOL.

Development and validation of a patient-assessed gastroparesis symptom severity measure: the Gastroparesis Cardinal Symptom Index

BACKGROUND

Patient-based symptom assessments are necessary to evaluate the effectiveness of medical treatments for gastroparesis.

AIM

To summarize the development and measurement qualities of the Gastroparesis Cardinal Symptom Index (GCSI), a new measure of gastroparesis-related symptoms.

METHODS

The GCSI was based on reviews of the medical literature, clinician interviews and patient focus groups. The measurement qualities (i.e. reliability, validity) of the GCSI were examined in 169 gastroparesis patients. Patients were recruited from seven clinical centres in the USA to participate in this observational study. Patients completed the GCSI, SF-36 Health Survey and disability day questions at a baseline visit and again after 8 weeks. Clinicians independently rated the severity of the patients' symptoms, and both clinicians and patients rated the change in gastroparesis-related symptoms over the 8-week study.

RESULTS

The GCSI consists of three sub-scales: post-prandial fullness/early satiety, nausea/vomiting and bloating. The internal consistency reliability was 0.84 and the test-re-test reliability was 0.76 for the GCSI total score. Significant relationships were observed between the clinician-assessed symptom severity and the GCSI total score, and significant associations were found between the GCSI scores and SF-36 physical and mental component summary scores and restricted activity and bed disability days. Patients with greater symptom severity, as rated by clinicians, reported greater symptom severity on the GCSI. The GCSI total scores were responsive to changes in overall gastroparesis symptoms as assessed by clinicians (P = 0.0002) and patients (P = 0.002).

CONCLUSION

The findings of this study indicate that the GCSI is a reliable and valid instrument for measuring the symptom severity in patients with gastroparesis.

Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review

OBJECTIVE

Our objective was to review and compare, with meta-analytic methods, observational studies on the association of medically unexplained physical symptoms, anxiety, and depression with special emphasis on healthy and organically ill control groups and on different types of symptoms, measures, and illness behavior.

METHODS

A search of MEDLINE and PsycLIT/PsycINFO for abstracts from 1980 to April 2001 was performed; principal investigators in the field were contacted and article reference lists were used to retrieve additional relevant articles. Two hundred forty-four studies were included on the basis of consensus ratings if they fulfilled seven of eight inclusion criteria pertaining to diagnostic accuracy and statistical appropriateness. Five hundred twenty-two studies were deferred or excluded. We focused specifically on the four functional somatic syndromes for which there were sufficient numbers for meta-analytic integration: irritable bowel syndrome (IBS), nonulcer dyspepsia (NUD), fibromyalgia (FM), and chronic fatigue syndrome (CFS). Data were extracted independently by two authors according to a prespecified coding manual with up to 70 parameters per study.

RESULTS

Effect sizes for the association of the four functional somatic syndromes with depression and anxiety were of moderate magnitude but were highly significant statistically when compared with healthy persons and controls with medical disorders of known organic pathology. Moreover, this association was significant whether depression was measured with or without somatic items. Chronic fatigue syndrome is characterized by higher scores of depression, fibromyalgia by lower scores of anxiety than irritable bowel syndrome. Consulting behavior and severity of somatization is related to higher levels of anxiety and depression.

CONCLUSIONS

Meta-analytic integration confirms that the four functional somatic syndromes (IBS, NUD, FM, CFS) are related to (but not fully dependent on) depression and anxiety. At present, there is only limited meta-analytic evidence for the same sort of association for medically unexplained physical symptoms in general. In view of the relative independence from depression and anxiety, classification and treatment of these symptoms and syndromes as "common mental disorders" does not seem fully appropriate.

Mutilation anxiety differs among females with fibromyalgia and functional dyspepsia and population controls

BACKGROUND

Studies using self-report rating scales suggest a considerable overlap regarding symptom complaints in patients with fibromyalgia (FM) and functional dyspepsia (FD), while clinical assessments point to important psychological differences.

PURPOSE

To test the hypothesis that measurement of psychological state by means of content analysis of speech will demonstrate differentiation between the two patient groups and between patients with these disorders and age-matched population-based random sample controls.

METHOD

The Giessener Symptom Complaints Checklist assessed somatic complaints. The computerised Gottschalk-Gleser content analysis method assessed psychological state in 42 females with FM, 17 females with FD and 48 population-based, randomly selected control subjects.

RESULTS

FM patients score higher on mutilation anxiety than FD and control subjects. FD patients had the highest score for death anxiety. Mutilation anxiety and low hope score identified FM patients (sensitivity 68%, specificity 81%, overall classification 75%), but only 19% of the variation in total somatic complaints could be predicted from these or other psychological state scores. In FD patients, however, death anxiety explained 59% of the variance in gastrointestinal complaints.

INTERPRETATION

Psychological state was differentiated among the three groups. Mutilation anxiety may be a psychological marker of an underlying neurobiological vulnerability for FM or may represent a secondary long-term consequence of chronic illness. In FD, death anxiety is directly related to symptom complaints, suggesting a stronger etiological association between emotions and somatic complaints in this disorder.

Heterogeneity of symptom pattern, psychosocial factors, and pathophysiological mechanisms in severe functional dyspepsia

BACKGROUND & AIMS

Categorization of functional dyspepsia into subgroups is based on expert opinion according to (dominant) symptoms or on underlying pathophysiological mechanisms. We used an evidence-based approach to the determination of subtypes of functional dyspepsia.

METHODS

Consecutive functional dyspepsia patients were recruited from a tertiary referral center. The following were performed: (1) exploratory (EFA) and confirmatory factor analysis (CFA) of symptom patterns in a large group of patients with functional dyspepsia; (2) external validation of these factors by the determination of their association pattern with physio- and psychopathological mechanisms, and with health-related quality of life and sickness behavior; and (3) cluster analysis of their distribution in this population.

RESULTS

Both EFA and CFA do not support the existence of functional dyspepsia as a homogeneous (unidimensional) condition. A 4-factor model is found to be valid, with differential distribution within the patient population according to cluster analysis. Factor 1 is characterized by nausea, vomiting, early satiety, and weight loss and factor 2 by postprandial fullness and bloating. Both factor 1 and 2 are associated with delayed emptying, but only factor 1 is associated with younger age, female sex, and sickness behavior. Factor 3 is characterized by pain symptoms and associated with gastric hypersensitivity and several psychosocial dimensions including medically unexplained symptoms and health-related quality of life dimensions. Factor 4, characterized by belching, is also associated with hypersensitivity, but is unrelated to psychosocial dimensions.

CONCLUSIONS

In a tertiary care population, functional dyspepsia is a heterogeneous condition characterized by 4 major dimensions differentially associated with psychopathological and physiopathological mechanisms.

Predictors of conventional and alternative health care seeking for irritable bowel syndrome and functional dyspepsia

BACKGROUND

The drivers of conventional and, especially, alternative health care use for irritable bowel syndrome and functional dyspepsia are not clear.

AIM

To determine the predictors of conventional and alternative health care use for irritable bowel syndrome and functional dyspepsia.

METHODS

Two hundred and seven subjects with irritable bowel syndrome or functional dyspepsia, identified from a previous population survey, were included in the study. Individuals with irritable bowel syndrome/functional dyspepsia were defined as consulters (n = 103) if they had visited their doctor for gastrointestinal symptoms more than once in the past year. Controls (n = 100) did not report having any abdominal pain. Subjects were given structured interviews to assess the Diagnostic and Statistical Manual - version IV (DSM-IV) and International Classification of Disorders - version 10 (ICD-10) psychiatric diagnosis for anxiety, depression, somatization or any psychiatric diagnosis, aspects of health care use and symptom factors.

RESULTS

About one-half (n = 103, 49.8%) of community subjects with irritable bowel syndrome/functional dyspepsia had sought conventional care for gastrointestinal symptoms in the past 12 months. Lifetime rates for alternative health care use for gastrointestinal symptoms were 20.8% (n = 43). Independent predictors of conventional health care use were more frequent abdominal pain, greater interference of gastrointestinal symptoms with work and activities and a greater satisfaction with the physician-patient relationship. Being female independently predicted alternative health care use.

CONCLUSIONS

Psychological morbidity did not predict conventional or alternative health care use for gastrointestinal symptoms. Other factors were more important.

Health-related anxiety and the effect of open-access endoscopy in US patients with dyspepsia

BACKGROUND

The role of endoscopy in dyspepsia is the subject of debate. The detection of lesions is infrequent, but patients may benefit from the knowledge that the examination is normal. We sought to determine the prevalence of health-related anxiety in dyspeptic patients referred for open-access endoscopy and to investigate the effect of endoscopy on health-related anxiety.

METHODS

Consecutive patients referred for open-access endoscopy from primary care were studied using a validated questionnaire for health-related anxiety before and after endoscopy, at 1 month and 6 months. Symptoms were assessed using a validated questionnaire at 1 and 6 months.

RESULTS

One hundred and nine patients were studied (69 women and 40 men; mean age, 49 +/- 15 years). Thirty-six of the 109 patients (33%) had high anxiety scores at baseline (mean score, 41 +/- 1), which decreased after endoscopy to 35 +/- 1 (P < 0.05). The changes persisted at 1 month (33 +/- 1) and 6 months (33 +/- 1). Endoscopic findings were as follows: normal examination, 120; erosive oesophagitis, 11 (Grade A); erosive duodenitis (all Helicobacter pylori-negative), 6. Scales for preoccupation with health and fear of illness and death showed significant improvement after endoscopy, and the effects were preserved for 6 months. Anxiety scores in our population were substantially higher than in a corresponding UK population.

CONCLUSIONS

Health-related anxiety is common in dyspeptic patients referred for endoscopy. Endoscopy decreases the preoccupation with health and fear of illness and death in patients with severe anxiety, and the effects persist for 6 months.

Impact of upper endoscopy on satisfaction in patients with previously uninvestigated dyspepsia

BACKGROUND

In patients with uninvestigated dyspepsia who undergo endoscopy, the presence of abnormal findings guides subsequent management. However, upper endoscopy is "negative" in the majority of these patients, and the value of endoscopy in these individuals has been questioned. This study evaluated the impact of endoscopy on patient satisfaction in patients with previously uninvestigated dyspepsia.

METHODS

The study was a secondary analysis of data obtained from a double-blind, randomized placebo-controlled trial, evaluating a 6-week course of omeprazole versus placebo in 140 patients with uninvestigated dyspepsia who were followed for up to 1 year. The setting was the primary care outpatient clinics at the Houston Veterans Affairs Hospital. Participants had to be 18 years of age or older with at least a 1-week history of dyspepsia (epigastric discomfort) without alarm features. Satisfaction was measured at each visit with the Severity of Dyspepsia Assessment, a validated, reliable dyspepsia-related health measure that has a satisfaction scale (scores 2-23; higher scores indicate greater satisfaction). Patients unresponsive to empiric therapy with placebo or omeprazole based on predefined criteria underwent endoscopy. Severity of Dyspepsia Assessment satisfaction scores were analyzed for 5 visits: 2 closest in time to, but before, the day of endoscopy (Times 1 and 2); immediately before endoscopy (Time 3); and the 2 visits closest in time after endoscopy (Times 4 and 5). After determining there was no difference in treatment failure rates between patients who received placebo or omeprazole, data from these groups were combined. The mean Severity of Dyspepsia Assessment satisfaction scores for Times 1 through 5 in all patients who underwent endoscopy were compared as well as for subgroups with positive and negative endoscopic findings with a repeated-measures analysis of variance.

RESULTS

Data on all 5 visits were available in 62 patients, 36 of whom had a negative endoscopy. For all patients the mean scores for Time 2 (8.5; 95% CI [7.4, 9.6]), and Time 3 (7.6; 95% CI [6.6, 8.6]) were significantly lower than those for Time 4 (13.7; 95% CI [12.2, 15.3]) and Time 5 (14.4; 95% CI [12.9, 15.9]). The mean score for Time 1 (11.1; 95% CI [9.5, 12.6]) was significantly lower than the mean score for Time 5. Similar significant improvements in satisfaction scores were observed in subgroups with negative and positive findings.

CONCLUSIONS

In patients with previously uninvestigated dyspepsia, endoscopy leads to improved patient satisfaction regardless of the endoscopic findings.

Changes in food tolerance and lifestyle after eradication of Helicobacter pylori

BACKGROUND

It is known that patients with peptic ulcer disease (PUD) often have an unhealthy lifestyle that results in increased mortality because of smoking-related diseases. No thorough study has been done to see what changes, if any, the patient makes to lifestyle after eradication of Helicobacter pylori.

METHODS

One-hundred-and-eighty-three patients were enrolled in an open-endoscopy setting; 58% had PUD and 42% gastritis and/or duodenitis (G/D). They filled out a lifestyle questionnaire before the start of anti-Helicobacter therapy and again 1 year later.

RESULTS

The prevalence of food intolerance decreased from 71% to 44% among patients with PUD (P < 0.0001) and from 76% to 63% among patients with G/D (P = 0.09). Tolerance improved for coffee, orange juice, fried foods, spicy foods and fruits. There was no significant change in smoking or alcohol consumption after eradication. Coffee and tea consumption was unchanged. Milk consumption decreased from 4.2 dL/day to 3.3 (P = 0.01). The number of meals decreased from 3.5/day to 3.4 (P = 0.005) and snacking from 1.3 snacks/day to 1.1 (P = 0.02). Consumption of fruit increased from 4.0 to 4.3 times/week (P = 0.04), but the frequency of meat, fish, vegetables, spicy foods, salty foods, sweets and cakes did not change. The time spent on each meal was unchanged. There was no change in the time spent exercising. There were few significant differences between PUD and G/D patients.

CONCLUSIONS

Food was better tolerated, but there were no major changes in lifestyle after eradication of H. pylori. Patients therefore do not abuse the privilege of a more tolerant digestion by indulging in a more unhealthy lifestyle.

[Functional dyspepsia. The physician and the patient]

Functional dyspepsia is defined by the presence of pain/discomfort in the upper abdomen without evident of organic disease which explain it; it must not be relief by defecation and its onset must not be related to changes in freqfrecuentlyuency or consistency feces. Diagnosis also requires pain or discomfort to be present for 12 weeks, not necessarily consecutives, in the last year. It is classified in three subgroups: ulcer-like, dysmotility-like and unspecified). Functional dyspepsia represents not only a diagnostic challenge but also a therapeutic problem, since no specific drug is available. An appropriate management of functional dyspepsia should consider patient's personality, diagnostic work-up, therapeutic alternatives and patient-doctor relationship. Many patients "live" their disease as the center of their life, sometimes creating great problems to physicians. Doctors should dedicate enough time to the patient, show interest in patient's problems, make a rigorous physical examination, and perform an appropriate work-up individualized for each patient. Regarding therapeutic decisions, it is important to reassure patients about the absence of organic disease. However it should be avoid to tell them that no disease exist at all; instead, the functional nature of the disease must be emphasized, explaining what and how upper GI tract is malfunctioning; Patients should know that doctor understand their symptoms are true symptoms; also, they must be informed bout the excellent outcome, without changes in life expectancy and a natural trend to improve with time; doctor should help patients to recognize that emotional situation have a great impact in disease course; and a therapeutic plan should be discussed and agreed with patients.

Anxiety but not depression determines health care-seeking behaviour in Chinese patients with dyspepsia and irritable bowel syndrome: a population-based study

AIMS

To study the prevalence of dyspepsia and irritable bowel syndrome and the effects of co-existing anxiety and depression on health care utilization by a population survey in Chinese.

METHODS

Ethnic Chinese households were invited to participate in a telephone survey using a validated bowel symptom questionnaire and the hospital anxiety and depression scale. Gastrointestinal symptoms were classified as dyspepsia and irritable bowel syndrome according to the Rome I criteria and gastro-oesophageal reflux disease by the presence of weekly heartburn or acid regurgitation. The anxiety and depression scores were compared between patients who sought medical attention and those who did not, using multiple logistic regression analysis.

RESULTS

One thousand, six hundred and forty-nine subjects completed the interview (response rate, 62%). The population prevalences of dyspepsia, irritable bowel syndrome and gastro-oesophageal reflux disease were 18.4%, 4.1% and 4.8%, respectively. Dyspepsia and irritable bowel syndrome were associated with anxiety, depression, medical consultation, sick leave and adverse effects on social life. The degree of anxiety was an independent factor associated with health care-seeking behaviour in both dyspeptics (P = 0.003) and irritable bowel syndrome patients (P = 0.036).

CONCLUSIONS

Irritable bowel syndrome and dyspepsia are associated with anxiety, depression, significant social morbidity, health care utilization and days off work. Anxiety is an independent factor in determining health care utilization in patients with dyspepsia and irritable bowel syndrome.

Coping with first-time endoscopy for a select sample of Chinese patients with functional dyspepsia and duodenal ulcer: an observational study

OBJECTIVE

This study examined how patients with functional dyspepsia (FD) and duodenal ulcer (DU) coped with first-time endoscopy, a highly relevant real-life stressor. We adopted an observational method to enhance the ecological validity of the study on stress and coping.

METHODS

A matched case-control design was adopted to compare differences between 30 Chinese FD patients from a select sample and 30 Chinese DU patients (13 females and 17 males in each group) in observed coping behaviors, mood states, and subjective appraisals of endoscopy. A new observation checklist was developed for recording subjects' coping behaviors, and our validation study showed that this newly developed measure had adequate reliability and criterion-related validity.

RESULTS

Compared with their DU counterparts, FD subjects 1) used more problem-focused coping, 2) used less emotion-focused coping, and 3) sought more instrumental support. They also had higher levels of anxious mood both before and after the endoscopy than did DU subjects. Moreover, compared with DU subjects, FD subjects reported having more pains and discomfort during the endoscopy and more dissatisfaction with the endoscopy.

CONCLUSIONS

Using an objective observational method in a select sample of FD patients, the present study provided tentative evidence that FD subjects tend to adopt an action-oriented coping pattern when encountering first-time endoscopy.

Behavioral and physiological sleep characteristics in women with irritable bowel syndrome

OBJECTIVES

The goal of this study was to investigate behavioral (self-reported) and physiological sleep characteristics in irritable bowel syndrome (IBS) patients with and without concurrent dyspeptic symptoms, as compared to control subjects.

METHODS

A total of 31 women with IBS were stratified into two groups: 15 with bowel symptoms only (IBS-only) and 16 with both lower and upper dyspeptic symptoms (IBS+D). In addition, 23 healthy women served as controls. For 4 consecutive days, subjective sleep quality, insomnia symptoms, alertness, state anxiety, perceived daytime stress, and daytime and nighttime GI symptoms were assessed. On night 4, subjects underwent polysomnographic (PSG) monitoring for an objective assessment of sleep quality including microarousals and respiratory parameters. Saliva samples were collected for cortisol analyses each morning and evening across the 4 days of the study. Psychological disturbances were assessed with the SCL.

RESULTS

Patients reported significantly more dissatisfaction with their sleep quality and increased daytime fatigue as a result of both insomnia-type symptomatology and nonrestful sleep. These complaints were significantly greater in IBS+D compared to IBS-only for some measures. A significant proportion of patients, particularly IBS+D patients, reported nighttime GI symptoms. Patients reported significantly greater average anxiety across the 4 days, which was greatest in IBS+D. Although both patient subgroups showed normal levels and circadian changes in cortisol compared to controls, IBS+D had significantly increased morning salivary cortisol levels compared to IBS-only. PSG data showed no significant differences between the patient groups and controls. Significant correlations were found between psychological distress and retrospective subjective sleep complaints for patients.

CONCLUSIONS

This study confirms the importance of sleep complaints and nighttime GI symptoms in women with IBS that are not substantiated by any objective, physiological evidence. Rather, there is a reporting bias regarding sleep disturbances, which appears to be related to symptom severity and psychological disturbances.

The link between psychosocial factors and functional dyspepsia: an epidemiological study

OBJECTIVE

To investigate the prevalence of functional dyspepsia (FD) and the psychological disorders in Chinese population and their relation.

METHODS

A total of 1016 apparently healthy people (study population) randomly selected from population were interviewed. A general questionnaire, Zung self-rating depression scales (SDS), and anxiety scales (SAS) were given to each subject. Seventy-two inpatients with confirmed diagnosis of FD, 84 with organic dyspepsia, and 197 with other organic diseases were also studied.

RESULTS

Among the study population, 23.5% had FD and 9. 1% had disturbances of depression and/or anxiety. The prevalence of psychological disturbances in FD group (15.5%) differed significantly from that in non-FD group (7.1%, P < 0.01 ) . In the survey of inpatients, the rate of depression/anxiety in FD group (54.2%) was greater than that in organic dyspepsia group (19.0%) and other organic diseases group (28.9%), P < 0.05, and was also significantly higher than that of the FD cases in the study population (15.5%), P < 0.01. Further analysis showed that some psychosocial disturbances were risk factors of FD.

CONCLUSION

Both FD and depression/anxiety disturbances are common in China, and there is a link between them.

Food and hypersensitivity in functional dyspepsia

It has long been known that stress affects both the stomach and colon, as shown by the very high prevalence of gastrointestinal symptoms among patients with psychiatric illness. The source may be limbic or peripheral, involving encoded memories or physiological changes. It is important to realise that physical symptoms such as those of functional dyspepsia do not only mean that the patient has a stomach disorder which needs to be identified and treated with specific pharmacological remedies, they often represent, in metaphorical and symbolic form, a state of disharmony brought about a specific psychosocial situation. It is only when that situation is understood and acknowledged that the patient can begin to get better.

Orocecal transit time in patients with functional dyspepsia

BACKGROUND

The importance of intestinal dysmotility in functional dyspepsia is a controversial issue.

GOALS

To investigate the orocecal transit time in patients with functional dyspepsia, as well as a possible association between intestinal transit and the presence of anxiety or Helicobacter pylori infection in these patients.

STUDY

The participants in this study were 23 patients with dysmotility-like functional dyspepsia and 24 control subjects. Orocecal transit time was measured by the lactulose hydrogen breath test. The presence of anxiety was assessed by the Hospital Anxiety and Depression (HAD) scale.

RESULTS

No significant difference in orocecal transit times was found between patients (median, 55 minutes; 95% confidence interval [CI], 40-60 minutes) and control subjects (median, 50 minutes; 95% CI, 40-60 minutes; p = 1). In the assessment, 15 patients (73%) scored for anxiety on the HAD scale, and 15 patients (65%) had positive test results for H. pylori. There was no significant difference in orocecal transit times between the patients with (median, 55 minutes; 95% CI, 40-63 minutes) and those without H. pylori infection (50 minutes; 95% CI, 40-68 minutes; p = 0.85), or between the patients with (median, 45 minutes; 95% CI, 40-68 minutes) and those without (60 minutes; 95% CI, 40-63 minutes; p = 0.77) anxiety.

CONCLUSIONS

Orocecal transit time is within the normal range in patients with functional dyspepsia. Anxiety and H. pylori infection do not seem to influence orocecal transit time in these patients.

[Functional dyspepsia--a psychosomatic disease]

About 4% of consultations in general practice involve patients with upper gastrointestinal complaints. Evidence of peptic ulcer disease is identified in only 20-30% of the patients. No organic explanation of the symptoms is found using endoscopy in 20-50%; these patients are given the diagnosis non-ulcer dyspepsia or functional dyspepsia. Hypersecretion of gastric acid and the bacteria Helicobacter pylori, which seem to be major aetiologic factors in duodenal ulcer, are not important in functional dyspepsia. In these patients gastric motor abnormalities and visceral hypersensitivity are the most important pathophysiological mechanisms. The gastric motility is influenced by stress; there is a strong relationship between anxiety, depression and functional dyspepsia. Antacids, H2-blockers and prokinetics are hardly more effective than placebo in patients with functional dyspepsia, while antidepressants have been proven effective in reducing dyspeptic symptoms. Likewise, psychological treatment like bio-feedback, stress management, interpersonal psychotherapy and cognitive therapy has also been proven effective in reducing dyspeptic symptoms in patients with functional dyspepsia.

[Possibilities of thermal medicine in gastrointestinal functional disorders]

The aim of this review is that of offer an update on the real therapeutic possibility of the thermal medicine in the functional gastrointestinal disorders. The functional dyspepsia, the irritable bowel syndrome, the functional constipation and the functional disorders of the biliary tract (in accordance with Roma II criteria), are the illness for which the drinking mineral waters could give a valid therapeutic support.

Gender differences in the symptoms and physical and mental well-being of dyspeptics: a population based study

PURPOSE

To compare women and men with dyspepsia in terms of symptoms, physical and mental well-being and the relationships between individual symptoms and well-being.

METHODS

A cross-sectional random telephone survey of 2300 Australians identified 748 people with dyspepsia who were interviewed regarding the number, types and severity of symptoms and physical (PCS) and mental well-being (MCS) measured by the SF-12.

RESULTS

There were no significant gender differences in number or average severity of symptoms. Bloating, nausea, and early satiety were significantly more frequent among women; food regurgitation and heartburn in men. Dyspeptics (PCS = 47.1, MCS = 46.0) had poorer physical (p < 0.001) and mental well-being (p < 0.001) than did non-dyspeptics (PCS = 53.5, MCS = 55.3). Among dyspeptics, women (PCS = 46.4, MCS = 44.7) had poorer physical (p < 0.05) and mental well-being (p < 0.001) than males (PCS = 47.9, MCS = 47.5). Some symptoms were associated with low well-being for both sexes e.g. nausea. For women retching was related to poor physical well-being, and food regurgitation, dysphagia. bloating and epigastric pain to poor mental well-being. Among men epigastric pain and heartburn were associated with poor physical well-being, acid regurgitation with poor mental well-being, and vomiting with both.

CONCLUSIONS

Dyspeptics report poorer physical and mental well-being than do non-dyspeptics. The difference between groups is greater for mental well-being, especially among women. Both physical and social factors may contribute to gender differences.

Sociodemographics, general health, and psychologic health in uninvestigated dyspepsia: a comparison of public and private patients

GOALS

To compare the dyspepsia severity, general health, and psychologic health of patients with uninvestigated dyspepsia presenting in private and public settings.

STUDY

Patients in this cross-sectional study were recruited from the Houston Veterans Administration (VA) General Medicine Outpatient Clinic and from the nearby private practice of a family physician. To be included, patients had to be at least 18 years of age and had to report a history of dyspepsia (epigastric discomfort) without alarm of at least 1 week's duration. Clinical information was obtained. Dyspepsia severity was measured using dyspepsia-related health scales, general health was measured using the Short Form 36, and psychologic health was measured using six scales.

RESULTS

The authors enrolled 159 patients (59 VA). There were no differences in VA and private patients in most of the clinical characteristics related to dyspepsia. Compared with the private patients, the VA patients had worse scores on all Short Form 36 subscales, had lower expectations for treatment outcome, were more depressed, and had less optimism about life.

CONCLUSIONS

Burden of illness and psychologic factors such as patient expectations are known to have important effects on patient outcomes. Striking differences in these factors exist in patients with uninvestigated dyspepsia seen in private and public settings. In the future, these factors must be taken into account both in conducting studies in dyspepsia and in interpreting the results for different practice settings.

The benefit of negative tests in non-ulcer dyspepsia

OBJECTIVES

Negative diagnostic tests are usually evaluated by their ability to advance a diagnostic search, or they are considered redundant expenditures in establishing a definitive diagnosis. It has remained difficult to assess their benefit in terms of their own merit and the reassurance that they provide to a patient. The aim of the present study is to develop a mathematical model for quantifying the impact of diagnostic tests on a patient's health-related quality of life (HRQL).

METHODS

An influence diagram is used to model how non-ulcer dyspepsia (NUD) and its medical care affect HRQL. Diagnostic tests and medical therapy benefit HRQL by alleviating fear of disease and NUD symptoms. Medical care can also adversely affect HRQL, lead to expenses in time and money, and compromise a patient's sense of autonomy. HRQL is modeled as the focal point of multiple influences detracting from its value.

RESULTS

Negative diagnostic tests can improve HRQL in NUD. The improvement of HRQL by diagnostic tests depends on a multitude of individual influences and the interactions between them, such as the severity of NUD symptoms andfear of disease, as well as the impact of medical care itself on HRQL. If a patient harbors a strong fear of serious disease or cancer, more extensive testing is likely to improve the patient's well-being and appears a worthwhile endeavor. Other patients, however, would be served perfectly well by empirical therapy only. For the vast majority of subjects with NUD who never seek medical advice, the unpleasantness of the disease itself does not outweigh the anticipated downside of obtaining medical care.

CONCLUSION

The analysis illustrates the applicability of the influence diagram in modeling disease behavior. This method helps to assess the benefit of negative tests beyond their means of generating information.

Somatization, sensitization, and functional dyspepsia

Functional dysepsia (FD) is defined as persistent or recurrent pain or discomfort centered in the upper abdomen without evidence of organic disease likely to explain the symptoms. Visceral hypersensitivity, motor dysfunction, and impaired gastric accommodation are found in some patients with FD, and psychological factors like chronic stress, attention and perception bias are also likely to play a part in the symptom formation. There is considerable overlap of non-specific symptoms like fatigue, headache, abdominal discomfort, muscle pain, and sleep disturbance in patients with different functional disorders, in this article exemplified by FD, fibromyalgia, and chronic fatigue syndrome. This overlap of symptoms indicates a common underlying sensitization process, leading to somatization.

How do younger patients view long-term treatment with proton pump inhibitors?

Dyspepsia (also called indigestion or heartburn) is a common reason for consulting a general practitioner (GP). One of the medicines available for treating dyspepsia is a type of acid suppressant called a proton pump inhibitor or PPI. There is a growing concern over the rapid increase in prescribing PPI drugs and the escalating costs associated with this trend. There has been an effort to reduce prescribing of PPIs. Most patients who are prescribed these drugs are aged over 45 years. Younger patients (those under 45) are a minority but, in absolute terms, a sizeable number who could potentially be taking PPIs for many years and therefore be expensive. This is a group for whom the appropriateness of prescribing PPIs is often questioned because of the everyday and non-life threatening nature of gastric disorders. A widespread association between dyspeptic symptoms and features of adverse lifestyle that are, at least in principle, easily avoidable has led to the suggestion that PPIs might be used to support unhealthy lifestyles. The perspective of younger patients taking PPIs in the long term has been neglected. In this paper the accounts of ten younger respondents, from a large qualitative investigation of patient and GP perspectives on long-term PPI prescribing, are examined to gain insight into how younger patients viewed their stomach problem, the effectiveness of PPIs and long-term PPI taking. The findings showed a gap between patient experience and medical perception. The perspectives of younger patients need to be recognised in order to deal adequately with their concerns about illness and treat their gastrointestinal conditions effectively.

Role of stress in functional gastrointestinal disorders. Evidence for stress-induced alterations in gastrointestinal motility and sensitivity

Psychological stress is widely believed to play a major role in functional gastrointestinal (GI) disorders, especially irritable bowel syndrome (IBS), by precipitating exacerbation of symptoms. The available data clearly demonstrate that inhibition of gastric emptying and stimulation of colonic transit is the most consistent pattern in the motility response of the GI tract to acute or short-term stress. Thus, one might propose that these alterations might play a pathophysiological role in dyspeptic symptoms and alterations in stool frequency and consistency in patients with stress-related functional GI disorders. Taken together, the above-mentioned studies suggest that the colonic motor response to stress is exaggerated in IBS. There is evidence that an increased emotional response is associated with this difference in colonic, and perhaps also gastric motor responses to certain stressors. However, almost no valid data are available so far from human studies addressing the question if differences in motility responses to stress between patients with functional GI disorders and healthy subjects are due to an altered stress response associated with an imbalance of the autonomic nervous system or increased stress susceptibility. We can summarize that in experimental animals the most consistent pattern of GI motor alterations induced by various psychological and physical stressors is that of delaying gastric emptying and accelerating colonic transit. Endogenous corticotropin-releasing factor (CRF) in the brain plays a significant role in the central nervous system mediation of stress-induced inhibition of upper GI and stimulation of lower GI motor function through activation of brain CRF receptors. The inhibition of gastric emptying by CRF may be mediated by interaction with the CRF-2 receptor, while CRF-1 receptors are involved in the colonic and anxiogenic responses to stress. Endogenous serotonin, peripherally released in response to stress, seems to be involved in stress- and central CRF-induced stimulation of colonic motility by acting on 5HT-3 receptors. Taken together, the limited data available from investigations in healthy subjects and patients with functional GI disorders provide some evidence that stress affects visceral sensitivity in humans. Acute psychological stress seems to facilitate increased sensitivity to experimental visceral stimuli, if the stressor induces a significant emotional change. In summary, studies in experimental animals suggest that stress-induced visceral hypersensitivity is centrally mediated by endogenous CRF and involvement of structures of the emotional motor system, e.g. the amygdala. Stress-induced activation or sensitization of mucosal mast cells in the GI tract seem to be involved in stress-associated alterations of visceral sensitivity.

Quality of life in functional dyspepsia

Our purpose was to assess the quality of life of functional dyspepsia patients using the SF-36 generic scale and the Gastrointestinal Symptoms Rating Scale (GSRS). In all, 328 dyspeptic patients were included in a multicenter, prospective, observational study. Both scales were filled out at baseline and one and three months after a prokinetic agent was given as a single-drug therapy. A total of 250 patients completed the study. An improvement in all SF-36 dimensions was observed, although the final scores were lower than the population reference values. Physical role (27% change), emotional role (20%), and physical pain (16%) dimensions showed the greater change. The GSRS total and domain scores also showed significant decreases. The best predictors of quality of life improvement were certain basal symptoms, drug compliance, and the absence of idiopathic dyspepsia. In conclusion, both the generic and the specific scales provide useful and sensitive measures of quality of life in functional dyspepsia patients on single-drug treatment.

One-year prognosis of primary care dyspepsia: predictive value of symptom pattern, Helicobacter pylori and GP management

BACKGROUND AND AIMS

Dyspepsia is a highly prevalent, heterogeneous condition with a poorly defined clinical course in family practice. We observed its clinical outcome and identified prognostic factors.

PATIENTS

We studied 583 patients presenting to their general practitioner (GP) with a new episode of dyspeptic complaints.

METHODS

A validated dyspepsia severity score was used to observe deterioration of dyspepsia. Furthermore, the general health status and the patient's perception of no improvement were registered. As prognostic determinants, demographic characteristics, concomitant conditions, and management were studied. Univariate and multivariate analyses were performed.

RESULTS

A total of 518 (89%) patients completed the 1-year follow-up. Of these, 111 patients (22%, 95% CI 18% to 25%) had a negative change in their dyspepsia score after 1 year; 46 patients (9%, 95% CI 6% to 11%) noted impairment of general health; and 122 patients (24%, 95% CI 20% to 28%) regarded complaints as not improved. Frequent dyspepsia (>1 episode/year) and a history of peptic ulcer predicted deterioration of dyspepsia, while smoking and little psychological distress predicted impairment of general health. Eradication of Helicobacter pylori reduced the chance of patient's negative judgement for especially those with frequent dyspepsia.

CONCLUSION

One-quarter of the dyspepsia patients had an unfavourable 1-year prognosis, which was predictable because of frequent complaints and previously diagnosed ulcers. Psychological factors need to be identified, since they are related to general health improvement. The observed benefit of H. pylori eradication on perceived improvement of complaints may well be placebo effect.

Psychometric properties of the Illness Attitudes Scale in psychiatric patients

This study assessed the factorial structure of the 29-item Illness Attitudes Scale in a population of 82 psychiatric patients hospitalized for gastrointestinal complaints. Factor analysis yielded three factors of the Illness Attitudes Scale in these patients, which have been interpreted Health Anxiety, Illness Behavior, and Health Habits. The internal consistency of these factors, estimated by Cronbach alpha, were .86, .80, and .58, respectively. The Health Anxiety and Illness Behavior scores were significantly intercorrelated .43, but scores on Health Habits were not significantly correlated with either Health Anxiety (r = .19) or Illness Behavior (r = .14). These findings are consistent with previous reports that two factors of the Illness Attitudes Scale possess reliable psychometric properties. Cross-validation with other patient populations is required to confirm the validity of the Illness Attitudes Scale factor structure testing at least 5 participants per item of the scale.

The correlation of depression and gastric dysrhythmia in functional dyspepsia

Psychologic factors in functional dyspepsia have been discussed in many previous articles. However, the relationship between depression and functional dyspepsia is still obscure. We investigated the impact of depression on clinical symptoms and gastric dysrhythmia in functional dyspepsia. Thirty-nine patients with functional dyspepsia and 18 healthy subjects were included. Patients were investigated with clinical symptoms assessment, Zung's self-rating depression scale, and electrogastrography. Patients with functional dyspepsia were divided into two groups: 21 patients with depression and 18 patients without depression. The depressed patients had similar total gastrointestinal symptom severity scores compared with the nondepressed patients, but with higher total symptom frequency scores (p < 0.05). With regards to symptoms, the depressed patients had higher abdominal fullness severity and frequency scores and nausea frequency scores. The patients with functional dyspepsia had a lower percentage of normal slow wave in both the fasting and fed states and a higher percentage of bradygastria in the fasting state and tachygastria in the postprandial state (p < 0.05). There was no significant difference in the percentage of bradygastria or tachygastria between the depressed and nondepressed patients. There was no correlation between the specific type of electrogastrographic abnormality and the presence or absence of depression in functional dyspepsia patients.

Criterion-related validity of the diagnostic criteria for psychosomatic research for alexithymia in patients with functional gastrointestinal disorders

BACKGROUND

Because of criticism made against psychiatric assessment of somatization, alternative Diagnostic Criteria for Psychosomatic Research (DCPR) have been proposed by an international group of psychosomatic investigators. One of these criteria concerns the alexithymia construct. The main aim of the present study was to investigate the criterion-related validity of the DCPR for alexithymia syndrome (DCPR-A). A secondary aim was to explore the relationship between alexithymia and depressed mood.

METHOD

The study included 190 consecutive outpatients with functional gastrointestinal disorders. Alexithymia was assessed by means of the DCPR-A and the 20-item Toronto Alexithymia Scale (TAS-20). Depressed mood was assessed on the basis of the Depression subscale of the Hospital Anxiety and Depression Scale (HDS) and the DSM-IV criteria.

RESULTS

The sensitivity of the DCPR-A together with the TAS-20 was 70.2%, specificity was 81.6%, positive predictive power 88.9%, negative predictive power 66.0% and overall hit rate 46.8%. DCPR-A positives scored significantly higher than DCPR-A negatives on the TAS-20 scores (t = 9.86, p < 0.001). The TAS-20 was not associated with any measure of depression, while the DCPR-A was significantly associated with the HDS and DSM-IV criteria.

CONCLUSIONS

The DCPR-A had adequate sensitivity, specificity and accuracy, thus proving that the criterion has good validity. The differences in association found between alexithymia and depression suggest that they may be due to differences in the methods of investigation rather than to the constructs per se.

Impact of sex and psychological factors on the water loading test in functional dyspepsia

BACKGROUND

The pathogenesis of upper abdominal symptoms in patients with functional dyspepsia (FD) is still unclear. The water loading test (WLT) is a new method for evaluation of gastric function. Our aim was to determine the impact of sex, age and psychological factors on the results of WLT in FD patients, FD-subgroups and healthy controls (HCs), and to evaluate the safety of the test.

METHODS

Fifty-six HCs and 35 consecutive patients with FD drank mineral water (100 ml/min) until intolerable. Serum samples for sodium, potassium and creatinine was taken before and after drinking. Water quantity was registered and symptoms were assessed after maximal water intake and 30 min later using a VAS scale. Participants also completed questionnaires measuring psychological general well-being (PGWB) and gastrointestinal symptoms (GSRS and Mearin score).

RESULTS

Healthy men drank more than healthy women, 2350 +/- 105 ml versus 1860 +/- 100 ml (P < 0.01), and the same gender difference was noted in FD patients, 1770 +/- 115 ml versus 1180 +/- 110 ml (P < 0.01). Maximal water intake was significantly higher in HC than in FD patients, both in males (P < 0.001) and females (P < 0.0001). Age had no impact on drinking capacity. FD patients had more symptoms 30 min after maximal water intake than HCs. Serum sodium decreased from 141 +/- 0.3 mmol/l to 138 +/- 0.5 mmol/l. Two of the assessed psychological factors, general health and depressed mood, correlated with water intake in FD patients (Rho = 0.47, P < 0.01 respectively Rho = 0.41, P < 0.05).

CONCLUSION

WLT is a useful, simple and safe test for evaluating symptoms in FD patients. Sex, but not age affects the results of the WLT. Furthermore, psychological factors must also be taken into consideration when interpreting the WLT.

Dyspepsia as a somatic expression of guilt: a case report

A 58-year-old woman developed chronic, severe symptoms of heartburn, epigastric pain, and regurgitation that persisted for 2 years. She underwent a thorough evaluation and no organic cause was identified. Therefore, a diagnosis of dyspepsia was made. Her symptoms were refractory to pharmacological treatment. Upon further probing, the patient reported that the onset of her symptoms coincided with the death of her son of cancer 2 years earlier. She blamed herself for the death of her son and admitted to a need for self-punishment. A brief course of treatment using metaphors and hypnosis resulted in a complete resolution of her symptoms, which did not recur during a follow-up of 12 years. This is the first published report of the treatment of dyspepsia using hypnotic methods.

Predictors of health care seeking for irritable bowel syndrome and nonulcer dyspepsia: a critical review of the literature on symptom and psychosocial factors

OBJECTIVES

Health care use is a costly outcome of the irritable bowel syndrome (IBS) and nonulcer dyspepsia (NUD), but the predictors of this behavior remain poorly defined. We aimed to systematically review the literature to determine which symptoms and psychosocial factors drive health care seeking in these disorders.

METHODS

A broad based MEDLINE and Current Contents search between 1966 and 2000 identified 44 relevant publications. References from these articles were also reviewed.

RESULTS

The literature suggests that symptom severity is an important factor, but only explains a small proportion of the health care seeking behavior associated with these disorders in population-based studies. Psychosocial factors including life event stress, psychological morbidity, personality, abuse and abnormal illness attitudes and beliefs have been found to characterize those that seek help versus those that do not. The role of other psychosocial factors such as social support, coping style and knowledge about illness are as yet undetermined.

CONCLUSIONS

A model for health care seeking for IBS and NUD, with an emphasis on psychosocial factors is presented, but remains to be tested.

Measuring change in quality of life in response to Helicobacter pylori eradication in peptic ulcer disease: the QOLRAD

This study was designed to determine if a new condition-specific quality of life measure, the Quality Of Life in Reflux And Dyspepsia (QOLRAD), was responsive to clinical change over a four-week period when evaluating peptic ulcer disease patients undergoing Helicobacter pylori (Hp) eradication. A secondary aim was to evaluate QOLRAD's psychometric performance. Hp-positive patients with peptic ulcer disease were recruited from primary care and gastroenterology clinics (N = 155). QOLRAD scores improved significantly (P < 0.0001) and mean total score increase was 1.07 points on a 7-point scale among 111 subjects who responded to Hp eradication. Effect sizes were moderate for responders (0.64) and low for nonresponders (0.36). Score changes below 0.60 were associated with the smallest improvement in patient and physician condition rating; scores above 1.2 were associated with the greatest improvement. The QOLRAD demonstrates reliability and validity. Changes in QOLRAD score can be meaningfully related to clinical changes, aiding evaluation of health-related quality of life in peptic ulcer disease.

Quality of life in functional dyspepsia: responsiveness of the Nepean Dyspepsia Index and development of a new 10-item short form

BACKGROUND

The Nepean Dyspepsia Index is a reliable and valid measure of quality of life in functional dyspepsia, but responsiveness has been little studied. The Nepean Dyspepsia Index originally contained 42 items designed to measure impairment of a subject's ability to engage in relevant aspects of their life because of dyspepsia, and their enjoyment of these aspects; in addition, the individual importance of areas was assessed. It was subsequently shortened to 25 items, yielding five sub-scales.

AIM

To test the Nepean Dyspepsia Index's responsiveness and develop a responsive, very short form.

METHODS

A randomized, double-blind controlled trial was performed in 589 patients with documented functional dyspepsia. Symptoms and quality of life were measured at baseline, 2 and 4 weeks. Responsiveness of the Nepean Dyspepsia Index quality-of-life section was evaluated by correlation with symptom scores and calculation of standardized changes in scores. Two items from each sub-scale which best represented the area of life (by factor loadings) were selected to create the 10-item short form (SF; short form-Nepean Dyspepsia Index). Internal consistency was assessed by Cronbach's alpha and responsiveness was assessed as above.

RESULTS

The Nepean Dyspepsia Index quality-of-life scales demonstrated excellent responsiveness to change in both the active and placebo arms (standardized response means all > 1.0). The Nepean Dyspepsia Index accounted for only 8% of the variance in percentage change in symptoms (by visual analogue scales), indicating that it was evaluating areas of life not covered by symptoms. The 10-item short form had adequate internal consistency (all scales > or = 0.70) and all strongly (and significantly) correlated with the long form sub-scales; it was also highly responsive.

CONCLUSION

The Nepean Dyspepsia Index is a responsive disease-specific quality-of-life measure; the 10-item short form can be applied in clinical trials of functional dyspepsia.

A comparative trial of paper-and-pencil versus computer administration of the Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire

BACKGROUND

Although most health-related quality of life questionnaires are self-administered by means of paper and pencil, new technologies for automated computer administration are becoming more readily available. Novel methods of instrument administration must be assessed for score equivalence in addition to consistency in reliability and validity.

OBJECTIVES

The present study compared the psychometric characteristics (score equivalence and structure, internal consistency, and reproducibility reliability and construct validity) of the Quality of Life in Reflux And Dyspepsia (QOLRAD) questionnaire when self-administered by means of paper and pencil versus touch-screen computer. The influence of age, education, and prior experience with computers on score equivalence was also examined.

RESEARCH DESIGN

This crossover trial randomized 134 patients with gastroesophageal reflux disease to 1 of 2 groups: paper-and-pencil questionnaire administration followed by computer administration or computer administration followed by use of paper and pencil. To minimize learning effects and respondent fatigue, administrations were scheduled 3 days apart. A random sample of 32 patients participated in a 1-week reproducibility evaluation of the computer-administered QOLRAD.

RESULTS

QOLRAD scores were equivalent across the 2 methods of administration regardless of subject age, education, and prior computer use. Internal consistency levels were very high (alpha = 0.93-0.99). Interscale correlations were strong and generally consistent across methods (r = 0.7-0.87). Correlations between the QOLRAD and Short Form 36 (SF-36) were high, with no significant differences by method. Test-retest reliability of the computer-administered QOLRAD was also very high (ICC = 0.93-0.96).

CONCLUSIONS

Results of the present study suggest that the QOLRAD is reliable and valid when self-administered by means of computer touch-screen or paper and pencil.

Quality of life measurement in gastroenterology: what is available?

Monitoring and enhancement of a patient's health-related quality of life (HRQL) is an important element of research and medical care. In a previous article, we provided an overview of HRQL measurement. Now we will review the structure and properties of the most commonly used generic and digestive disease-specific HRQL instruments and illustrates their use in the gastroenterology and hepatology literature. Generic measures have been used to study specific diseases as well as to compare HRQL in GI and nongastrointestinal disease. Disease specific instruments have been developed for inflammatory bowel disease, irritable bowel syndrome, dyspepsia, gastroesophageal reflux disease, liver disease, and GI malignancy. Further work is needed to compare disease-specific instruments and to define the most appropriate uses of HRQL measurement in clinical trial and community practice settings.

Quality of life measurement clarifies the cost-effectiveness of Helicobacter pylori eradication in peptic ulcer disease and uninvestigated dyspepsia

OBJECTIVES

Previous economic studies of Helicobacter pylori eradication in dyspepsia and peptic ulcer disease have not measured quality of life using utilities (preference probabilities), which are needed to compare the cost-effectiveness of such treatment to other health care interventions. The goals of this study were to measure quality of life in patients with dyspepsia or peptic ulcer and apply these measurements to published models of disease management to determine cost-effectiveness in dollars per quality-adjusted life year (QALY) gained.

METHODS

Utilities for dyspepsia and peptic ulcer disease were measured in adult patients (n = 73) on chronic acid suppression for peptic ulcer or ulcer-like dyspepsia. Median utility values were applied to the results of published cost-effectiveness analyses and a previously validated dyspepsia model. Cost-utility ratios for early H. pylori eradication in uninvestigated dyspepsia and peptic ulcer disease were then computed.

RESULTS

The total disutility, or lost quality of life, for an ulcer was 0.11 QALY, of which 0.09 QALY was attributed to dyspeptic symptoms. After these results were incorporated into published studies, cost-utility ratios for ulcer treatment varied from $3,100 to $12,500 per QALY gained, whereas estimates for uninvestigated dyspepsia management ranged from $26,800 to $59,400 per QALY. Sensitivity analyses indicated a range of $1,300 to $27,300 per QALY for management of duodenal ulcer and $15,000 to $129,700 per QALY for dyspepsia.

CONCLUSIONS

Strategies that emphasize early H. pylori eradication were cost-effective for patients with peptic ulcer and possibly cost-effective for patients with uninvestigated dyspepsia, relative to other medical interventions. Dyspeptic symptoms cause significant disutility that should be incorporated in future cost-effectiveness analyses of treatment strategies.

Psychological interventions for non-ulcer dyspepsia

BACKGROUND

Studies have also shown that NUD patients have higher scores of anxiety, depression, neurotism, chronic tension, hostility, hypochondriasis, and tendency to be more pessimistic when compared with the community controls.

OBJECTIVES

This review aims to determine the effectiveness of psychological interventions including psychotherapy, psychodrama, cognitive behavioral therapy, relaxation therapy, guided imagery or hypnosis in the improvement of either individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia (NUD).

SEARCH STRATEGY

Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and PsycLIT, using appropriate subject headings and text words and searching bibliographies of retrieved articles.

SELECTION CRITERIA

All randomised controlled trials (RCTs) or quasi-randomised studies assessing the effectiveness of psychological interventions (including psychotherapy, psychodrama, cognitive behavioural therapy, relaxation therapy, guided imagery or hypnosis) for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Data were collected on individual, global dyspepsia symptom scores, as well as measures of quality of life (QoL) scores and adverse effects.

MAIN RESULTS

The three trials identified showed that there was improvement in the dyspepsia symptom scores at the end of treatment and one trial showed improvement in the psychological parameters. However, meta-analysis was not possible as these trials used different psychological interventions and two of the trials only reported mean change in symptoms and did not give standard deviations of this change.

REVIEWER'S CONCLUSIONS

Psychological intervention in the form of psychodynamic psychotherapy and cognitive behavioral therapy may be useful in the treatment of NUD. However, we need more trials to assess dyspepsia symptom scores and also psychological intervention in order to give us a clearer picture of the role of psychological intervention in NUD.

Seeking medical consultation: perceptual and behavioral characteristics distinguishing consulters and nonconsulters with functional dyspepsia

OBJECTIVE

Subjects with functional dyspepsia (FD) in most previous studies have been confined to those who sought medical consultation. The generalizability of results from these studies to individuals with FD who do not seek medical consultation is limited. This study examined 1) differences in perceptual and behavioral characteristics between "nonconsulters" and "consulters" with FD and 2) the influence of these characteristics on dyspeptic and psychological symptoms.

METHODS

A matched case-control design was used to compare differences among 43 nonconsulters with FD, 43 consulters with FD, and 43 healthy individuals. Subjects' monitoring perceptual style, confrontative coping behaviors, dyspeptic symptoms, anxiety, and depression were assessed by using well-validated questionnaires.

RESULTS

FD consulters exhibited higher levels of monitoring, confrontative coping, anxiety, and depression than FD nonconsulters and healthy subjects (p values < .01). Results from discriminant analysis revealed that all these variables reliably predicted the membership of the three groups. Significant Monitoring by Confrontative Coping interaction effects were also found, indicating the conjoint influences of these variables on dyspeptic and psychological symptoms.

CONCLUSIONS

These results show that FD nonconsulters are distinguishable from FD consulters by their perceptual style, coping behaviors, and psychological symptoms. Both monitoring perceptual style and confrontative coping behaviors may magnify dyspeptic and psychological symptoms in individuals with FD, especially those who seek medical consultation.

Motilin- and neuropeptide Y-like immunoreactivity in a psychophysiological stress experiment on patients with functional dyspepsia

BACKGROUND

The aim of the study was to compare plasma motilin-like immunoreactivity (MOT-LI) and neuropeptide Y (NPY)-like immunoreactivity (NPY-LI) in patients with functional dyspepsia (FD) during a controlled psychophysiological experiment.

METHOD

25 patients (12 men, 13 women), age 24-50, with recurrent FD, and 25 pair-wise sex- and age-matched community control subjects were studied. In an experiment, after a rest period, subjects were studied during a 15-min stress interview. The aim of the interview was to elicit anxiety. Before and during the intervention blood samples were drawn for peptide analyses. Outcome measures were the Gastrointestinal Symptom Rating Scale, fasting blood glucose, heart rate and blood pressure as well as the subjects' self-ratings on visual analogue scales. The plasma concentrations of MOT-LI and NPY-LI are given as anti-logarithms.

RESULTS

Mean plasma MOT-LI concentration was 7.3 (CI: 5.7-9.4) pmol/L in the patient group, and 7.9 (CI: 6.1-10.2) pmol/L in the control group. Mean plasma NPY-LI concentration was 14.2 (CI: 12.3-16.4) pmol/L in the patient group, and 13.4 (Cl: 11.8-15.3) pmol/L in the control group. Using ANCOVA (covariates: group, gender, age, body mass index and smoking) MOT-LI was related to lower indigestion symptomatology (p<0.04) and positive change in joyfulness during the interview (p<0.03). In the patient group delta motilin correlated with increased joyfulness (p<0.03) and decreased sadness (p<0.03). The NPY-LI increase during the interview was related to higher fasting blood glucose before the interview (p<0.01) and a stronger increase in systolic blood pressure during the test (p<0.05).

CONCLUSION

During a stress interview plasma MOT-LI is positively related to less indigestion symptomatology and joyfulness, while changes in plasma NPY-LI were positively related to sympathetic nervous system activity, but not to gastrointestinal symptoms.

A randomized controlled trial of psychotherapy in patients with chronic functional dyspepsia

BACKGROUND & AIMS

This study aimed to determine whether brief psychodynamic-interpersonal (PI) psychotherapy is more efficacious than a psychological control for patients with chronic, intractable functional dyspepsia (FD), and whether patients with abnormal gastric function respond differently than those with normal gastric function.

METHODS

Ninety-five consecutive patients with chronic symptoms of FD who had failed to respond to conventional pharmacologic treatments were approached. Thirty-seven received PI psychotherapy, and 36 the control condition (supportive therapy). Patients completed self-report questionnaires before and after treatment and 12 months later. The patients' gastroenterologists, who were blind to the study groups, conducted independent ratings before and after treatment. Forty-nine patients also underwent a radioisotope gastric emptying study. An intention-to-treat analysis was used with baseline scores as covariates.

RESULTS

At the end of treatment, there were significant advantages for PI psychotherapy compared with controls for the gastroenterologists' (P = 0.002) and patients' total symptom score (P = 0.015). One year after treatment, the symptomatic scores were similar. However, a subanalysis showed that PI therapy was superior to the control condition at 1 year, when patients with severe heartburn were excluded. There was no difference in outcome between patients with normal and abnormal gastric emptying.

CONCLUSIONS

PI therapy may have both short- and long-term effects in patients with dyspepsia, but further evaluation is required. Its cost-effectiveness needs to be determined.

Personality traits predict treatment outcome with an antidepressant in patients with functional gastrointestinal disorder

BACKGROUND

We investigated the relationship between personality traits and response to treatment with the tetracyclic antidepressant mianserin or placebo in patients with functional gastrointestinal disorder (FGD) without psychopathology.

METHODS

Forty-eight patients completed the Buss-Durkee Hostility Inventory, Neuroticism Extroversion Openness -Personality Inventory (NEO-PI), and Eysenck Personality Questionnaire (EPQ), neuroticism + lie subscales, before they were consecutively allocated to a 7-week double-blind treatment study with mianserin or placebo. Treatment response to pain and target symptoms were recorded daily with the Visual Analogue Scale and Clinical Global Improvement Scale at every visit.

RESULTS

A low level of neuroticism and little concealed aggressiveness predicted treatment outcome with the antidepressant drug mianserin in non-psychiatric patients with FGD. Inversely, moderate to high neuroticism and marked concealed aggressiveness predicted poor response to treatment. These findings were most prominent in women. Personality traits were better predictors of treatment outcome than serotonergic sensitivity assessed with the fenfluramine test.

CONCLUSION

Assessment of the personality traits negativism, irritability, aggression, and neuroticism may predict response to drug treatment of FGD even when serotonergic sensitivity is controlled for. If confirmed in future studies, the findings point towards a more differential psychopharmacologic treatment of FGD.

Quality of life before and after laparoscopic fundoplication

BACKGROUND

Laparoscopic fundoplication is a well-established surgical option for the treatment of gastroesophageal reflux disease. The aim of this study was to assess the surgical outcomes from the patient's point of view by using a validated quality of life instrument.

METHODS

Fifty patients have been prospectively included. All patients underwent a standardized 270-degree posterior fundoplication. Quality of life was measured by the Gastrointestinal Quality of Life Index (GIQLI), a 36-item-questionnaire. The patients received the questionnaire before surgery, and 3 months and 1 year after surgery.

RESULTS

Preoperative score was 95.6+/-21 points. The score increased significantly (P <0.0005) at 3 months (103.6+/-16) and 1 year (111.4+/-22) after surgery. This improvement concerned the four domains of the questionnaire (symptoms, social functioning, physical status, and emotions). The score in patients at 1 year remained, however, significantly lower than that in healthy persons (126+/-18).

CONCLUSIONS

GIQLI is a sensitive tool to assess surgical outcomes after fundoplication. The quality of life after surgery did not reach the level of healthy population, not because of failure of surgery to treat GERD but probably because of functional dyspepsia that was present prior to surgery and did not change after fundoplication.

Stress, coping, and depression in non-ulcer dyspepsia patients

Thirty adults with upper gastrointestinal symptoms in the absence of structural organic disease diagnosed with non-ulcer dyspepsia (NUD) were compared to 30 healthy adults who had visited the hepatobiliary clinic for medical evaluation of non-organic complaints without NUD. Medical investigation in both groups were negative. Before independent gastrointestinal physicians conducted diagnostic evaluations, all subjects were evaluated for anxiety and depressive symptoms, stressful life events, coping style, and social support. The measures included Symptom Checklist 90-Revised (SCL-90-R), Beck Depression Inventory (BDI), Spielberger State-Trait Anxiety Inventory (STAI), Ways of Coping Checklist, and Interpersonal Support Evaluation List, and a self-report questionnaire, which measured the quantity of perceived stressful life events. The NUD patients reported significantly more symptoms of depression, more perceived stressful life events, less problem-focused coping, and less social support than the control subjects. Depressive symptoms were negatively correlated with interpersonal support, whereas, problem-focused coping was positively correlated with interpersonal support in the NUD patients. The two groups did not differ significantly in terms of anxiety and emotion-focused coping. The implications of these findings for the diagnosis and treatment of NUD are discussed.