Functional dyspepsia

Functional dyspepsia is defined as persistent or recurrent upper abdominal pain or discomfort not explained by structural or biochemical abnormalities. In about half of the patients who present to their practitioner with chronic dyspepsia, no underlying disease is established after clinical investigation. Many clinical trials have been performed to demonstrate a certain relationship between functional dyspepsia and several pathogenic mechanisms like dysmotility, Helicobacter pylori infection, acid output and hypersensitivity to distension. Unfortunately, the conclusions of those studies are conflicting. Short-term follow-up, lack of consensus about diagnostic criteria for functional dyspepsia and unvalidated symptom measures make it difficult to interpret their results.

Impact of functional dyspepsia on quality of life

Little information on functional status and well-being is available in patients with functional gastrointestinal disease. We aimed to evaluate whether quality of life is poorer in patients with functional dyspepsia. A consecutive sample of 73 patients with functional dyspepsia completed a validated questionnaire prior to endoscopy. Organic disease controls comprised 658 outpatients attending endoscopy. Quality of life was measured using the validated Medical Outcomes Survey (which assessed physical, role, and social functioning; mental health; health perception; and any bodily pain) and the Brief Symptom Inventory (for current anxiety and depression); additional specific gastrointestinal items were also included. A stepwise logistic regression analysis was used to assess the association between diagnostic group and the quality of life measures, adjusting for potential confounders. Patients who reported more interruptions in their daily activities due to abdominal pain and who had fewer limitations of physical functioning were more likely to have functional dyspepsia (vs other disease, P < 0.01). Mental health, social functioning, and health perception also tended to be poorer in functional dyspepsia. We conclude that quality of life may be more impaired in patients with functional dyspepsia than in patients with other conditions who present for upper endoscopy.

Neuroticism and stressful life events in patients with non-ulcer dyspepsia

Hindi adaptation of the Middlesex Hospital Questionnaire (MHQ), Brief Psychiatric Rating Scale and Presumptive Stressful Life Events Scale were used to measure neuroticism, psychiatric morbidity and stressful life events in 35 patients with non-ulcer dyspepsia (NUD), 22 cass of peptic ulcer disease (PUD), 65 irritable bowel syndrome (IBS) and 45 age and sex matched healthy controls. NUD subjects had significantly higher total MHQ scores (28.8 +/- 11.3; p < 0.001) and scores in subscales of somatization (7.8 +/- 3.4; p < 0.001) and hysterical personality traits (5.5 +/- 2.8; p < 0.01) compared to healthy controls. MHQ scores in IBS subjects was significantly higher than in NUD, but in PUD subjects it was in-between NUD and healthy controls. Psychiatric morbidity, as assessed by Brief Psychiatric Rating Scale, was significantly higher in patients with NUD and IBS than in normal controls. Stressful Life event score was statistically similar in all the groups.

What are the real problems for patients with functional dyspepsia?

BACKGROUND

Patients with functional dyspepsia (FD) have more complaints than just the dyspepsia.

METHOD

One hundred FD patients were assessed with regard to psychologic, medical, and social factors, before randomization, in a study of cognitive therapy. They were asked to list their main problem areas or 'target complaints'.

RESULTS

Dyspepsia was the third most frequent target complaint (26 patients), and anxiety was the most frequent one (65 patients). Patients identifying dyspepsia as a target complaint differed from the other FD patients in several aspects. They had significantly more dyspeptic symptoms (p < 0.05) and scored significantly higher on multiple somatic complaints (p = 0.001), depression (p = 0.025), general psychopathology (p = 0.043), the global assessment scale (p = 0.001), and the General Health Questionnaire (p = 0.040). However, they did not have more somatic predisposing factors like consumption of alcohol and coffee or infection with Helicobacter pylori than the patients with other target complaints.

CONCLUSIONS

Anxiety and not dyspepsia was the most frequent target complaint, and patients who identified dyspepsia as a target complaint did not have more somatic predisposing factors.

Quality of life in upper gastrointestinal disorders

BACKGROUND

There is increased interest in the concept 'quality of life'. Available instruments are defined and discussed, with special emphasis on reliability and validity. Research on quality of life in patients with upper gastrointestinal disorders is reviewed, and our own results presented.

METHODS

The Psychosocial Adjustment to Illness Scale was used to compare 100 patients with functional dyspepsia and 100 patients with duodenal ulcer in a cross-sectional study, and to monitor the quality of life of 74 duodenal ulcer patients in a longitudinal phase.

RESULTS

The quality of life of patients with functional dyspepsia was more negatively affected than that of patients with duodenal ulcer. After half of the patients had received short-term cognitive psychotherapy and all had received prophylactic H2-blocker treatment after ulcer relapse, quality of life improved in both the treatment group and the control group. Seventy-four patients with recurrent duodenal ulcers reported higher satisfaction with the health care system, improved sexual relationship, and less psychological distress one year after cure of the ulcer disease by the eradication of Helicobacter pylori compared to before.

CONCLUSIONS

Reliable and valid instruments are available to measure quality of life, and will probably gain increased importance in future medical research. In patients with recurrent duodenal ulcer disease, quality of life improves with the eradication of Helicobacter pylori.

Symptoms and personality in patients with chronic functional dyspepsia

Twenty-five patients, 12 men and 13 women, aged 24-50 yr, who had consulted physicians and had received the diagnosis functional dyspepsia after extensive examination 6-8 years prior to this study, and were still suffering from this condition, were compared with community control subjects pair-wise matched for age and sex. Control subjects who had ever consulted a physician for gastrointestinal symptoms were excluded. Questionnaires measuring symptoms, job strain, social support and personality traits were used. Relatively few differences were found between groups. Compared to the community controls, however, the patients reported more gastrointestinal and nervous symptoms, and higher somatization, measured by Symptom Check List-90. The extent of reported overall distress was greater in patients than in control subjects. The detachment score (Karolinska Scales of Personality) was significantly lower in patients than in control subjects; this difference was also significant in separate analysis for men. Female patients had lower socialization and higher suspicion scores than female control subjects. Male patients reported more decision latitude (job control) than male control subjects.

Selective gastric hypersensitivity and reflex hyporeactivity in functional dyspepsia

BACKGROUND/AIMS

We have previously shown that patients with functional dyspepsia are hypersensitive to gastric distention. The aim of this study was to establish whether this sensory disturbance was confined to the stomach and whether it was associated with gut reflex dysfunction.

METHODS

In 10 selected patients with dyspepsia and 12 healthy controls, perception and gut reflex responses to gastric distention, duodenal distention, and somatic stimulation were measured. Standardized distentions at fixed pressures were performed by gastric and duodenal barostats. Perception was scored by a detailed symptom questionnaire; gut reflex responses were measured as isobaric volume changes by each barostat. Somatic transcutaneous electrical nerve stimulation was produced on the hand. Individual stimuli (2-minute duration) were randomly applied at 10-minute intervals in stepwise increments in search of the respective threshold for discomfort.

RESULTS

Patients with dyspepsia had gastric hypersensitivity to distention (discomfort threshold at 6.4 +/- 0.4 mm Hg vs. 8.3 +/- 0.6 mm Hg in controls; mean +/- SE; P < 0.05), whereas duodenal and somatic sensitivity was normal. Furthermore, patients with dyspepsia explicitly recognized their clinical symptoms in all gastric but only in 58% +/- 12% of the duodenal distention trials. In addition, patients with dyspepsia showed defective gastric relaxatory responses to duodenal distention (68 +/- 30 mL gastric expansion vs. 239 +/- 12 mL in controls; P < 0.05).

CONCLUSIONS

Patients with dyspepsia are selectively hypersensitive to gastric distention; this sensory dysfunction is associated with impaired reflex reactivity of the stomach.

Effect of short-term cognitive psychotherapy on recurrence of duodenal ulcer: a prospective randomized trial

The aim of this prospective, randomized trial was to assess whether short-term cognitive psychotherapy (10 sessions during 4 months) could reduce the 1-year recurrence rate of duodenal ulcer. One group received psychotherapy; one group was a control group. One hundred patients, aged 17 to 64 years, with duodenal ulcer were selected from March 1989 to May 1991. The main outcome measure was relapse of duodenal ulcer, which was verified by endoscopy. When psychotherapy started after cessation of antiulcer medication, the relapse-free time was significantly shorter in the therapy group than in the controls. When the protocol was modified so that psychotherapy and antiulcer medication were given concomitantly, there was no significant difference in recurrence rate between the groups at 1-year follow-up (84% in the therapy group and 92% in the control group). Symptoms of upper abdominal discomfort/pain, measured every second month, decreased significantly in the therapy group compared to the control group. Psychotherapy led to less neuroticism (Eysenck Personality Questionnaire) and less trait anxiety (Spielberger Trait Anxiety Scale) compared to controls at 4 months. At the 12-month follow-up, most of this gain was lost, but the psychotherapy group had lower scores on "concern about disapproval" on the Sociotropy-Autonomy Scale than the control group. There is no beneficial effect of short-term cognitive psychotherapy on the 1-year recurrence rate of duodenal ulcer.

Psychosocial Adjustment to Illness Scale (PAIS-SR) in a Norwegian material of patients with functional dyspepsia, duodenal ulcer, and urinary bladder dysfunction. Clinical validation of the instrument

BACKGROUND

There is an increasing interest in the psychosocial impact of a disease, but few instruments available to measure it.

METHODS

The internal consistency and construct validity of the Norwegian translation of the Psychosocial Adjustment to Illness Scale (PAIS-SR) was examined in a total of 557 patients.

RESULTS

The seven dimensions of the psychosocial adjustment to medical illness from the original test were represented in the Norwegian translation. Psychologic distress, social environment, and vocational environment explained most of the variance. The instrument had high internal consistency with Cronbach's alpha coefficients of > 0.75 on six of seven subscales. The PAIS-SR differentiated between groups of patients with urologic and upper gastrointestinal disease and seemed to give meaningful and useful clinical data. Patients with functional dyspepsia (n = 97) had higher score on psychologic distress than the other groups, whereas patients with duodenal ulcer (n = 97) were significantly less affected in their social life than the other patients.

CONCLUSIONS

The Norwegian translation of the PAIS-SR had high internal consistency, acceptable construct validity, and good discriminating validity.

The personality patterns in patients with duodenal ulcer and ulcer-like dyspepsia and their relationship to the course of the diseases. Hvidovre Ulcer Project Group

OBJECTIVES

To compare personality characteristics in duodenal ulcer patients and patients with ulcer-like dyspepsia from the primary health sector with duodenal ulcer patients from a hospital and to evaluate the relationship of the personality characteristics to the course of the diseases.

DESIGN

A prospective study using the Minnesota Multiphasic Personality Inventory (MMPI) with retesting of a subgroup of patients after a median observation period of 14 months.

SETTING

Departments of Medical and Surgical Gastroenterology, Hvidovre University Hospital, and the primary health sector in Roskilde County, Denmark.

SUBJECTS

Sixty hospital patients with duodenal ulceration and 17 patients with duodenal ulceration plus 25 patients with ulcer-like dyspepsia from the primary health sector.

MAIN OUTCOME MEASURES

MMPI scores.

RESULTS

The hospital patients differed from the two other groups of patients by having higher scores of depression and anxiety (P < 0.05). Twenty-eight of the patients were retested with MMPI. Contrary to the patients with persisting complaints, abnormal personality characteristics disappeared in patients without complaints (P < 0.05-0.001).

CONCLUSIONS

The results indicate that abnormal personality characteristics in patients with functional and organic upper dyspepsia are consequential rather than causal factors.

Helicobacter pylori in functional dyspepsia and normal controls

BACKGROUND

The aim of this study was to examine whether Helicobacter pylori status can identify a specific subset of patients with functional dyspepsia (FD) and erosive prepyloric changes (EPC).

METHODS

Anamnestic, somatic, and psychologic data were collected from 87 patients with functional dyspepsia and 77 normal control persons. Presence of H. pylori infection was assessed by the 14C-urea breath test.

RESULTS

H. pylori infection increased with age. Thirty-four per cent of the patients were H. pylori-positive, compared with 36% of the control persons. The patients had higher scores than the normal control persons on psychologic measures regardless of H. pylori status. Of 27 variables analyzed, age was the only factor that discriminated between H. pylori-positive and -negative patients.

CONCLUSIONS

For most patients with FD and EPC the presence of H. pylori infection is probably a consequence of age, and it does not seem to help us in the search for factors that can identify a subset of patients within our group of FD patients.

Psychological factors and somatic symptoms in functional dyspepsia. A comparison with duodenal ulcer and healthy controls

One hundred patients with functional dyspepsia, 100 patients with duodenal ulcer and 100 healthy controls were assessed on anamnestic factors, somatic symptoms and psychological measures. Patients with functional dyspepsia had significantly higher levels of state-trait anxiety, general psychopathology, depression, a lower general level of functioning and more somatic complaints from different organ systems, especially the musculo-skeletal system, compared to patients with duodenal ulcer and healthy controls. Patients with functional dyspepsia had more frequent dyspepsia symptoms and a longer disease history than duodenal ulcer patients. Discriminant analyses using a model of fifteen psychological and anamnestic variables, classified correctly 71.5% of the subjects due to diagnoses. The test for multiple somatic complaints (Giessener Beschwerdebogen) was the most important discriminating factor (Eigenvalue 0.78). Seventy-five per cent of the patients were correctly classified, 71% by diagnosis with respect to diagnoses of duodenal ulcer and functional dyspepsia using frequency of dyspeptic symptoms as discriminating factor (Eigenvalue 0.40). Functional dyspepsia seems to be a disease entity of its own, distinct from duodenal ulcer and strongly associated with psychological factors.

[A depressive disorder in patients with irritable bowel syndrome and non-ulcer dyspepsia]

The relationships between psychiatric disorders and the symptoms of both irritable bowel syndrome (IBS) and non-ulcer dyspepsia (NUD) are herein investigated and discussed. Functional disorders of the small and large intestine induce irritable bowel syndrome. NUD is a syndrome that displays symptoms that might originate in the upper digestive system despite the absence of any organic disorder. In addition, it has also been suggested that the occurrence of NUD is based on a functional disorder of the upper digestive systems. Based on our studies of serious cases with both NUD and IBS, in approximately 50% of the NUD patients as well as about 50% of the IBS cases, a depressive disorder was found to be most closely related to the onset and continuance of the symptoms of either NUD or IBS. According to the evaluations of NUD and IBS as functional disorders and psychiatric disorders, the patients underwent treatment and all demonstrated a good response to the various treatment regimens. It is thus considered that NUD and IBS should be evaluated as both functional digestive disorders and psychiatric disorders.

Low vagal activity as mediating mechanism for the relationship between personality factors and gastric symptoms in functional dyspepsia

Low vagal tone may represent a mediating mechanism for relationships between personality and symptoms of functional dyspepsia (FD) through a mechanism of antral hypomotility. Twenty-one patients with FD and seventeen healthy controls completed a series of personality tests before vagal and sympathetic activity, antral motility, and abdominal symptoms were assessed in response to a laboratory task. Functional dyspepsia patients had lower scores on vagal tone (p = .054) and motility index (p = .011) in addition to the expected higher scores on epigastric discomfort (p = .002). Psychological factors explained a substantial amount of the variance in vagal activity, antral motility, and reported symptoms. Symptoms were predicted by trait anxiety (STAI-TR), depression (BDI), and neuroticism (EPQ-N). Poor vagal tone was related to neuroticism (EPQ-N). Poor motility was best explained by task-related state dysphoria (SACL-STR).

Dyspepsia in general practice: psychological findings in relation to Helicobacter pylori serum antibodies

Questionnaire data based on traditional concepts for measuring hypochondriasis and depression were related to serological data on Helicobacter pylori antibodies in 110 of 130 consecutive patients, aged 18-65 yr, consulting for dyspeptic symptoms in general practice. Of the patients thirty-seven (33.6%) and seventy-three (66.4%) were classified as H. pylori positives and H. pylori negatives, respectively, the H. pylori positive patients being significantly older than H. pylori negative patients. Factor analyses of the questionnaire data indicated the heterogeneity of each of the traditional concepts for measuring hypochondriasis and depression but succeeded in differentiating orthogonally between two hypochondriasis factors and three depression factors. Hierarchical regression analyses of factor scores, controlling for the influence of age and sex, indicated higher H. pylori antibody activity to be associated with less hypochondriacal signs of anxiety and uneasiness. It is hypothesized, that in dyspepsia without signs of H. pylori infection, somatization may account to a substantial extent for the illness.

[Functional dyspepsia. Old wine in new bottles?]

Functional dyspepsia covers various symptoms associated by the physician with the upper gastrointestinal tract without an identifiable organic cause. The existence of dyspepsia subgroups according to different symptom complexes, e.g. so-called "ulcer-like dyspepsia", has not been proved. Gastro-esophageal reflux disease is a distinguishable independent entity. Little is known about the pathogenesis of this common syndrome. Disturbances of gastric motility, especially postprandial antral hypomotility, are found in 50% of these patients but offer no explanation of the dyspeptic symptoms. Neither abnormal gastric acid secretion nor abnormal acid sensitivity has been proved in these patients. Furthermore, no relation between the symptoms and a Helicobacter pylori infection or a functional disturbance of the biliary tract has been established. In some cases fatty foods can provoke dyspeptic symptoms. Unfavorable psychosocial factors can influence the decision to consult a physician for dyspepsia. Recently, a lowered threshold of perception of stomach and small intestine distension in dyspepsia has been demonstrated. This disturbance of perception offers a new basis for further understanding and for possible treatment. Prokinetic agents can be of help in the treatment of functional dyspepsia. H2-receptor antagonists are most effective in patients presenting symptoms of gastro-esophageal reflux disease. Empiric therapeutic trials in this disease entity, which shows a high placebo response rate (between 30% and 60%), are not of proven value.

[The psychological characteristics of dyspepsia. A controlled study with gastroscopic follow-up]

It's known that some psychologic factors could be implicated in dyspepsia. Therefore, the psychologic aspects of 38 dyspeptic patients (17 males, 21 females, aged 18-65 years), who underwent digestive endoscopy, were evaluated by means of Rorschach and MMPI test. Patients with previous peptic ulcer history, with chronic ethanol or NSAID intake, operated on digestive tract and patients with behavioural problems were excluded. The results of psychological tests enhanced two main groups: anxiety patterns (17 patients--49%) and normal patterns (21 patients--55%). Endoscopic and histological findings moreover showed: "anxious" group--12 patients with chronic gastritis (HP+ 50%), 5 patients with normal endoscopy; "normal" group--16 patients with chronic gastritis (HP+ 87.5%), 5 patients with normal endoscopy. This study suggests that in about 50% of dyspeptic patients anxious pattern is present. Moreover chronic gastritis is more frequently associated to Helicobacter pylori in non-anxious patients.

The validity of Eysenck's neuroticism dimension within the Minnesota Multiphasic Personality Inventory in patients with duodenal ulcer. The Hvidovre Ulcer Project Group

A psychometric analysis on patients with duodenal ulcer using latent structure coefficients (Loevinger and Mokken) showed that the MMPI subscales of depression, psychasthenia, hypochondriasis, hysteria, schizophrenia and social introversion all could be considered as indicators of Eysenck's dimension of neuroticism. Both a MMPI neuroticism scale of 15 items (MMPI/N-15) and of 21 items (MMPI/N-21) were psychometrically valid, i.e. the total score was a sufficient statistic. Patients with duodenal ulcer who improved during treatment also had a significant decrease in their neuroticism scores, whereas patients who did not improve had unchanged neuroticism scores. In other words, neuroticism is secondary to the clinical symptoms of duodenal ulcer (a psychological adjustment to illness) and not an etiological factor.

[Physiopathologic aspects of non-ulcerous dyspepsia. Considerations of a new diagnostic method]

The above study is an analysis of different dyspeptic syndromes outlining their pathophysiology and clinical features. On this basis, the authors suggest a diagnostic strategy, stressing the importance of certain elements such as age at onset, duration and variability of symptoms. This allows to evaluate the indications for endoscopy or biopsy, or to decide that it is sufficient to continue observation while reassuring the patient that the dyspeptic condition is benign.

Quality of life in patients with upper gastrointestinal symptoms. An improved evaluation of treatment regimens?

There is growing interest in measuring quality of life (QoL) in medicine. Together with objective variables such as healing rate, as recorded with endoscopy, this is believed to give a better basis for evaluation of treatment regimens in patients with upper gastrointestinal diseases. A strategy for the assessment of QoL in patients with upper gastrointestinal symptoms is presented here. The QoL evaluation was based on a battery of questionnaires, covering both general and specific aspects of life. General well-being was evaluated with the Psychological General Well-being Index (PGWB), and subjective symptoms with two specific questionnaires, the Gastrointestinal Symptom Rating Scale (GSRS) and the Ulcus Esophagitis Subjective Symptoms Scale (UESS). This new strategy was applied clinically in a study including 146 outpatients with suspected peptic ulcer. Initially, the patients reported a low degree of general well-being as evaluated with the PGWB, but the values returned to those found in normal populations within 4 weeks. Evaluation of the GSRS and UESS with regard to internal consistency, construct validity, and the ability to detect changes showed them to be satisfactory. The psychometric documentation of the measures indicates that they may give reliable and clinically valid information when used for evaluation of medical treatments in upper gastrointestinal disease. Further documentation of the methods is, however, needed to establish a generally acceptable QoL assessment in gastroenterology.

Immunoreactive-somatostatin concentrations of the human stomach and mood state in patients with functional dyspepsia: a preliminary case-control study

Immunoreactive-somatostatin (ir-SS) concentrations of the gastric mucosa and mood state in patients with functional dyspepsia were examined. The subjects were 12 patients with upper abdominal discomfort, nausea and/or vomiting (motility disorder group) and 14 patients complaining of upper abdominal pain (ulcer-like disorder group) for more than a month without any organic upper-gastrointestinal tract disease proven by endoscopy. These patients were compared with either an age- and sex-matched group of asymptomatic outpatients without any organic disease (control group: n = 26) or to a group of patients with peptic ulcer (n = 19). Somatostatin concentrations of the stomach were measured by radio-immunoassay, and the mood state of each subject was assessed by Manifest Anxiety Scale (MAS) and Self-rating Depression Scale test. Immunoreactive-somatostatin concentrations of the gastric mucosa were significantly higher in the ulcer-like disorder group than in the peptic ulcer, motility disorder or control group, and gastric juice levels were higher in the ulcer-like disorder group. The psychometric tests showed that the motility disorder group was more depressive than the ulcer-like disorder group, but there were no differences between the motility disorder, ulcer-like disorder and peptic ulcer group in MAS scores or environmental factors. These results indicate that there may be two different subgroups in functional dyspepsia influenced by both ir-SS concentration of the stomach and/or mood state.

Role of anxiety and personality in non-ulcer dyspepsia: a comparative study with duodenal ulcer

BACKGROUND

Though emotional factors are known to influence gut functions, studies evaluating the role of anxiety and personality in non-ulcer dyspepsia (NUD) are few and have not yielded consistent results.

AIMS

To find out whether anxiety and abnormal personality pattern are specifically associated with NUD.

METHODS

33 patients with NUD and 30 patients with duodenal ulcer, who were randomly selected from among those attending a gastroenterology out-patient clinic, were administered a) the Eyesenck Personality Inventory, to measure neuroticism and extroversion; and b) a short self-rating scale for anxiety, to measure state and trait anxiety.

RESULTS

There were no significant differences between the two groups in state anxiety, neuroticism and extroversion. Trait anxiety, however, was significantly higher in the NUD group (p = 0.05).

CONCLUSIONS

Though the difference in trait anxiety score between the two groups attained significance, this finding needs further support to indicate a causal role for anxiety in NUD. There is need for further studies about the role of anxiety in various subgroups of NUD.

[Is there a typical conflict in dyspepsia? An epidemiologic psychoanalytic contribution to the topic of a specific conflict in psychosomatic medicine]

The question whether a dependency-independency-conflict is specific for subjects with gastric complaints was investigated by means of a representative, psychoanalytic-epidemiologic field study (Mannheimer Kohortenprojekt). Out of a population of 600 adults probands with dyspepsia were compared with individuals with musculoskeletal symptoms and "healthy" subjects. Using interview protocols of these individuals two "blinded" raters judged whether the conflict under consideration was present in different aspects of life. It could be confirmed that subjects with gastric complaints showed the conflict significantly more often than either control group. However, the conflict was also found among individuals of either control group. It can be concluded that the dependency-independency-conflict is typical, but not specific for subjects suffering from dyspepsia.

Nonulcer dyspepsia associated with psychiatric disorder

Studies of dyspepsia show a 1% to 2% prevalence in adults, and 25% to 40% of these patients do not have a physical reason for their symptoms. These findings prompted us to do a retrospective follow-up study of 390 patients having motility studies for chest pain and gastrointestinal (GI) symptoms; 278 (71%) responded. Patients were asked to complete a self-rating symptom questionnaire regarding current GI symptoms and current symptoms of anxiety, panic, and depression; they were also asked to complete the Brief Symptom Inventory. Two groups were compared--those with known heart disease and those without heart disease. Substantial numbers of patients in both groups satisfied criteria for generalized anxiety disorders (> 70%), panic disorder (> 30%), and major depression (> 35%). GI symptoms compatible with nonulcer dyspepsia were strongly associated with a psychiatric diagnosis. Our data suggest that anxiety and depressive states are strongly associated with dyspepsia and other GI symptoms not caused by ulcer disease.

[Dyspepsia and life style]

Information on eating habits, life situation and perceived stress was collected from 100 patients who consulted general practitioner because of dyspeptic complaints. This information was compared with information from a control group with no dyspeptic symptoms. The patients reported a higher degree of stress in connection with occupation and family, and more economic worries, than the control group. Patients with ulcus also tended to have a higher consumption of tobacco. There were no significant differences in eating habits or alcohol consumption between the groups.

Low vagal tone and antral dysmotility in patients with functional dyspepsia

Effects of acute mental stress on gastric antral motility were investigated in 23 healthy persons and 25 patients with functional dyspepsia (FD). Real-time ultrasonography of gastric antrum was recorded, after ingestion of 500 ml meat soup, during a 4-min resting period, 2.5 min of mental stress, and a 4-min recovery period. Amplitude of antral contractions was scored as a fraction of relaxed area. Motility-index was calculated as the amplitude multiplied by frequency. Measurement of skin conductance reflected sympathetic tone, and respiratory sinus arrhythmia (RSA) was calculated to index vagal tone. Antral motility was reduced by mental stress in the healthy persons, but not in FD patients. Group differences were significant for amplitude (p < 0.002) and motility-index scores (p < 0.02). Sympathetic tone increased during stress in both groups. Vagal tone was lower in the FD patients than in the healthy controls (p < 0.001). The lack of stress-related reduction of motility among patients with FD may, therefore, be a consequence of poor vagal tone.

Is there a typical conflict in gastric complaints? An epidemiologic-psychoanalytic contribution to the question of conflict specificity in psychosomatic medicine

The question of conflict specificity for subjects with gastric complaints was investigated in the context of a representative, epidemiologic-psychoanalytic field study. Out of a population of 600 adults probands with dyspepsia were compared with individuals with musculoskeletal symptoms and 'healthy' subjects. Using interview protocols 2 'blinded' raters judged whether a dependency-independency conflict was present in different aspects of life. Findings supported the higher prevalence of the conflict among subjects with dyspepsia. Therefore, the conflict was considered typical, but not specific for the experimental group.

Effect of cisapride therapy for severe dyspepsia on gastrointestinal symptoms and quality of life

Quality of life measures have received little attention in evaluation of therapy for dyspepsia. To examine the effect of cisapride on gastrointestinal symptoms and quality of life measures, we studied eight patients with chronic, severe dyspepsia, before and after therapy with cisapride (20 mg three times daily) for 12 months. Gastrointestinal (GI) Total Symptom Score (TSS), Overall Patient Assessment (OPA), and quality of life by both trait (Minnesota Multiphasic Personality Inventory (MMPI)) and physical function (Sickness Impact Profile (SIP)) were measured at base line and at month 12 of cisapride therapy. Results showed significant improvement in TSS, OPA, and the MMPI Depression and Anxiety scales (all, p < 0.05). Improvement in the SIP physical dimension score approached significance (p = 0.065). We conclude that, in this group of patients with severe dyspepsia, both GI symptoms and quality of life measures improved with 12 months of cisapride therapy. These quality of life measures may prove useful in evaluating the efficacy of drug treatment for dyspepsia.

The outcome of unexplained dyspepsia. A questionnaire follow-up study of patients after endoscopy

Ninety-three consecutive patients referred to a gastroenterology unit with unexplained dyspeptic symptoms were sent a postal questionnaire 6-12 months after endoscopy. It inquired into their current physical symptoms and subjective improvement since investigation, satisfaction with treatment, past history and current psychological well-being. A comparison group of 47 patients with peptic disease were similarly surveyed. Those with unexplained dyspepsia reported more current physical symptoms, more dissatisfaction with their treatment and less subjective improvement than those with peptic disease. The two groups were similar in terms of psychological distress but previous consultation for abdominal and other somatic complaints were more common in those with unexplained dyspepsia. The implications for management of dyspeptic patients are discussed.

Suppression of anger and gastric emptying in patients with functional dyspepsia

Psychologic distress and gastric motor dysfunction have both been implicated in the pathogenesis of functional (non-ulcer) dyspepsia (FD). This study assesses the association between psychologic factors and gastric emptying in 28 FD patients. Subjects completed an extensive range of psychologic questionnaires and underwent dual-isotope scintigraphic assessment of solid and liquid gastric emptying. Attempts to resist, control, suppress, and hold in anger, to adopt a fighting spirit whilst dealing with chronic stressors, and manifest unhappiness were predictors of prolonged gastric emptying. These findings suggest that psychologic factors may be important in the aetiology of gastric stasis and subsequent upper gastrointestinal symptoms in patients with functional dyspepsia.

[Psychological factors of non-ulcer dyspepsia]

Given the absence of any demonstrable organic reason for non-ulcer dyspepsia, and the well known fact, that the psyche influences stomach function, it is widely held, that psychological factors cause NUD. To now, studies are concerned with the psychopathology and personality of NUD-patients, their illness behaviour, and with the relation between stress and abdominal pain. A critical review of these studies revealed, that among the psychological variables mainly anxiety and illness behaviour seems to play a central role in NUD. However, future studies should focus more on the distinction towards other functional disorders and on the differentiation within the heterogeneous group of NUD-patients (especially with regard to physiological variables). Besides this, it seems rewarding to examine the so far scientifically neglected group of subjects with abdominal pain, who do not contact a physician.

[Functional dyspepsia--a stress disease]

Because non-ulcer dyspepsia is associated with stress and motility disturbances it is now called functional dyspepsia. Compared with healthy persons, patients with functional dyspepsia are characterized by poor vagal tone, wider gastric antrum both fasting and postprandially, lack of stress-related repression of antral motility and meal-induced dyspeptic symptoms. Postprandial discomfort is related to antral distension. Poor vagal tone may cause antral distension and dysmotility as well as symptoms in these patients. Treatment programmes or drugs which improve vagal tone may be beneficial.

Abnormal perception of visceral pain in response to gastric distension in chronic idiopathic dyspepsia. The irritable stomach syndrome

Sensory and pressure responses to gastric distension were evaluated in 24 consecutive patients suffering from chronic idiopathic dyspepsia and 20 healthy subjects. A latex balloon was placed in the proximal stomach and inflated by increments of 100 ml of air up to a maximal volume of 800 ml. Symptom response and intragastric pressure-volume curve were recorded during the gradual balloon distension. Thirteen of the 24 patients experienced pain at a distension volume less than or equal to 400 ml of air, but only one of the 20 controls (P less than 0.001). Intragastric pressure-volume curves were similar in patients and controls, and in patients with and without abnormal pain threshold, suggesting that a compliance defect was not the cause of the sensory anomaly. Gastric emptying of solids and liquids was measured in 20 of the 24 patients using a dual isotopic technique; psychological status was also evaluated in 18 patients using the Mini-Mult test. The frequency of the sensory anomaly was not different in patients with (7/14) or without (4/6) gastric stasis, but was lower in patients with (5/13) than in those without psychological disturbances (5/5, P less than 0.01). Thus, a primary visceral sensory anomaly, either alone or in conjunction with motility disturbances, can play an important role in chronic idiopathic dyspepsia and must be taken in account for further therapeutic research.

[Physiopathological approach to non-ulcerative dyspepsia: clinical consequences]

Non-ulcer like dyspepsia comprises different symptoms of the upper intestinal tract with no macroscopic lesion and no identifiable etiology. Motility disturbances are the best known alterations and resemble a delay in the emptying of the stomach. Gastroesophageal reflux may produce atypical symptoms. Mucosal lesions are sometimes found which may explain the transmucosal electric potential differences. However, chronic active Helicobacter associated gastritis is usually asymptomatic. There has been no proof of psychological factors up to now. In 50% of the patients the minimum pain threshold in response to distention of the stomach is lowered. No generally accepted therapy has been found. The therapeutic principles depend on the pathogenesis of the syndrome in every individual. Medication which may enhance as well as inhibit motility may be of help.

Psychological profiles of patients with upper gastrointestinal symptomatology induced by non-steroidal anti-inflammatory drugs

Eighty three patients with classical or definite rheumatoid arthritis taking non-steroidal anti-inflammatory drugs (NSAIDs) were studied in an attempt to determine whether a patient's personality and psychological profile might contribute to the development of NSAID induced gastrointestinal symptomatology. It was found that the personality profile of the group of 45 asymptomatic patients was similar to that of a previously reported control group. In contrast, the 37 patients with gastrointestinal symptoms attributed to NSAIDs had a significantly higher mean score for free floating anxiety, depression, and somatisation than controls, suggesting that a patient's personality may influence the development of NSAID induced gastric symptoms.

Non-ulcer dyspepsia

This paper discusses the definition of non-ulcer dyspepsia and its relationship to other functional bowel disorders. The research on the prevalence, outcome, aetiology and management of this condition is reviewed with particular emphasis on its multifactorial nature. Future research will need to concentrate on the inter-relationship of physical and psychosocial factors including the health beliefs of the individual patient.

Life stress and non-ulcer dyspepsia: a case-control study

Sixty-two patients with persistent NUD symptoms were compared with healthy persons of comparable age, sex and social status on a variety of life stress, personality, mood state and coping measures. Highly threatening chronic difficulties were significantly more evident in the NUD group than controls (98 and 2% respectively), as were acute life events which remained highly threatening one week after their onset. Other psychological variables significantly related to NUD were high levels of anxiety and depressive symptoms, personality traits indicating neurotic or anxious tendencies, a tendency to use less mature stress-coping mechanisms and to have less high-quality emotional support. Multivariate analysis revealed the presence of highly threatening stressors to be by far the most important predictor of NUD status. The implications of these findings in relation to the significance of stress and other psychological variables in the aetiology and treatment of NUD are discussed.