Brenda B. Toner

Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders

BACKGROUND & AIMS Studies of antidepressants and psychological treatments in functional bowel disorders (FBD) are methodologically limited. The aim of this study was to assess the clinical efficacy and safety of cognitive-behavioral therapy (CBT) against education (EDU) and desipramine (DES) against placebo (PLA) in female patients with moderate to severe FBD (irritable bowel syndrome, functional abdominal pain, painful constipation, and unspecified FBD). We also evaluated the amenability of clinically meaningful subgroups to these treatments. METHODS This randomized, comparator-controlled, multicenter trial enrolled 431 adults from the University of North Carolina and the University of Toronto with moderate to severe symptoms of FBD. Participants received psychological (CBT vs. EDU) or antidepressant (DES vs. PLA) treatment for 12 weeks. Clinical, physiologic, and psychosocial assessments were performed before and at the end of treatment. RESULTS The intention-to-treat analysis showed CBT as significantly more effective than EDU (P = 0.0001; responder rate, 70% CBT vs. 37% EDU; number needed to treat [NNT ], 3.1). DES did not show significant benefit over PLA in the intention-to-treat analysis (P = 0.16; responder rate, 60% DES vs. 47% PLA; NNT, 8.1) but did show a statistically significant benefit in the per-protocol analysis (P = 0.01; responder rate, 73% DES vs. 49% PLA; NNT, 5.2), especially when participants with nondetectable blood levels of DES were excluded (P = 0.002). Improvement was best gauged by satisfaction with treatment. Subgroup analyses showed that DES was beneficial over PLA for moderate more than severe symptoms, abuse history, no depression, and diarrhea-predominant symptoms; CBT was beneficial over EDU for all subgroups except for depression. CONCLUSIONS For female patients with moderate to severe FBD, CBT is effective and DES may be effective when taken adequately. Certain clinical subgroups are more or less amenable to these treatments.

Further validation of the IBS-QOL: a disease-specific quality-of-life questionnaire

Abstract OBJECTIVE: There has been growing interest in the investigation of health-related quality of life (HRQOL) among patients with gastrointestinal (GI) disorders. We recently reported on the development and preliminary validation of the IBS-QOL, a specific quality-of-life measure for irritable bowel syndrome (IBS). The aim of this study was to determine the longitudinal construct validity (responsiveness) of the IBS-QOL. METHODS: Female patients enrolled in a multicenter treatment trial for functional bowel disorders were studied pre- and posttreatment with the IBS-QOL and other health status measures. Based on the response to treatment for several variables (pain/14-day score, daily function, and days in bed/3 months), patients were stratified into Responders, Partial Responders, and Nonresponders. Change scores in the IBS-QOL were then statistically compared with changes in the other variables to determine their correlation and whether Responders were significantly different from non- and Partial Responders on the IBS-QOL. RESULTS: There was a significant correlation between change scores on the IBS-QOL and the other measures of treatment effect (Pain/14 days, r = 0.25, p CONCLUSION: The IBS-QOL is responsive to treatment in a referral-based clinical population of patients with functional bowel disorders.

The effects of the ideal of female beauty on mood and body satisfaction

OBJECTIVE The present study examined changes in womens mood states resulting from their viewing pictures in fashion magazines of models who represent a thin ideal. METHOD Female university students completed the Profile of Mood States (POMS), the Body Parts Satisfaction Scale (BPSS), and the Eating Disorder Inventory (EDI). They were then exposed to 20 slides; the experimental group (N = 51) viewed images of female fashion models and a control group (N = 67) viewed slides containing no human figures. All subjects then completed the POMS and the BPSS again. RESULTS Women were more depressed (R2 = 0.745, p < .05) and more angry (R2 = 0.73, p < .01) following exposure to slides of female fashion models. DISCUSSION Viewing images of female fashion models had an immediate negative effect on womens mood. This study, therefore, supports the hypothesis that media images do play a role in disordered eating.

What determines severity among patients with painful functional bowel disorders

OBJECTIVE: For patients with painful functional bowel disorders (FBD), physicians frequently make diagnostic and treatment decisions based on the severity of the pain reported; patients with severe painful complaints may receive extensive diagnostic tests and treatments. Therefore, it would be important to determine what clinical factors contribute to the judgment of severity among patients with FBD. The aim of this study was to identify the psychosocial, behavioral, and physiological (visceral sensitivity) factors that predicted severity in patients with moderate to severe FBD. METHODS: Two hundred eleven female patients with moderate or severe FBD, as determined by the Functional Bowel Disorder Severity Index, entered a multicenter treatment trial at the University of North Carolina and the University of Toronto. Patients filled out diary cards and were given questionnaires and physiological testing (rectal sensitivity using barostat). Analysis of covariance and logistic regression adjusting for demographic factors were performed to determine which factors distinguished patients at study entry with moderate from those with severe FBD. RESULTS: Patients with severe FBD were characterized by greater depression and psychological distress, poorer physical functioning and health-related quality of life, more maladaptive coping strategies, and greater health care utilization. There was a trend for patients with severe FBD to have lower rectal sensation thresholds. Regression analysis indicated that severity was best predicted by behavioral features: poorer daily physical function, difficulties related to eating, more phone calls to the physician, and more days in bed for GI symptoms. CONCLUSIONS: We conclude that patient illness behaviors are best correlated with severity in FBD. The use of psychopharmacological agents (e.g., antidepressants) and psychological treatments to treat psychiatric comorbidity and to improve behavioral coping styles is recommended. Training to help medical physicians identify and respond to psychosocial and behavioral features of these conditions is likely to improve patient satisfaction with their care and the clinical outcome.

Long-term follow-up of anorexia nervosa.

&NA; This study compared the long‐term outcome of restricting and bulimic anorexic women using standardized psychometric instruments in addition to global clinical ratings. Results indicated that, in general, restricting and bulimic anorexic subtypes did not differ in their long‐term outcome according to clinical ratings and standardized assessments of anorexic symptoms, psychiatric diagnoses, and psychosocial functioning. The only exception to this pattern was that the bulimic group had a higher incidence of substance use disorders during the last year compared with the restricting group. Findings also indicated that relative to a matched comparison group of women of average weight, a significant percentage of anorexics from both subtypes met DSM‐III criteria for an affective or anxiety disorder at some point in their lives as well as at long‐term follow‐up. Results are discussed in terms of theoretical and methodologic issues involved in the long‐term follow‐up of anorexia nervosa.

Cross-cultural variation in disease-related concerns among patients with inflammatory bowel disease

Abstract OBJECTIVE: The aim of this work was to study cross-cultural variations in the impact of inflammatory bowel disease (IBD) on health-related quality of life by an international comparison of disease-related concerns. METHODS: Item and factor scores on the Rating Form of Inflammatory Bowel Disease Patient Concerns and overall mean concern levels were compared by analysis of variance among 2002 IBD patients in eight countries. RESULTS: The overall level of concern varied from 51 out of 100 in Portugal to 19 in Sweden, with intermediate scores for Italy (43), Canada (40), United States (39), France (39), Austria (33), and Israel (25). Having surgery, an ostomy, the uncertain nature of the disease, and medication side effects were each rated among the first five in importance in six countries. Other items varied considerably. For example, concern regarding pain and suffering was high in Israel and low in Portugal, whereas concern over developing cancer was low in Italy. Concern over financial issues and access to high-quality health care were inversely associated with measures of national economic prosperity. CONCLUSIONS: 1) Cross-cultural comparisons of patient concerns related to IBD are feasible using translated scales. 2) Reporting tendencies vary greatly; within Europe, patients from southern countries report greater overall concern. 3) The complications and the variable evolution of disease elicit general concern, but the importance of specific issues varies among countries. 4) The reasons for national differences may have social, cultural, and/or economic determinants with relevance to the patient-physician relationship, patient education, and therapeutic decision making.

Gender role and irritable bowel syndrome: literature review and hypothesis

Studies examining the prevalence of irritable bowel syndrome (IBS) consistently show that women outnumber men in both patient and nonpatient populations. However, because IBS does affect both women and men, it is important to examine and to understand gender similarities and differences in the expression of this complex disorder. Studies that have explored gender differences have focused their investigations on prevalence and health seeking behavior, physical and psychological symptomotology, and abuse history. This article reviews and summarizes the findings from those studies. As well, whereas the literature examining differences between men and women with IBS has focused on distinctions based on the biological sex of study participants, this article offers an alternate approach to the exploration of gender differences. The concept of gender role, defined as generalizations about appropriate male and female traits that are associated with masculinity and femininity, may further our understanding of IBS in both women and men.

Development, use, and factor analysis of a self-report inventory for mania

This report describes the development and initial psychometric evaluation of a 47-item self-report inventory for mania developed by the authors. Twenty-five subjects with a diagnosis of mania and 82 subjects with other diagnoses were tested during a hospital admission. The manic group scored significantly higher than the nonmanic group. The questionnaire correctly classified 71% of subjects. Manic patients who lacked insight endorsed as many items as manic patients with insight. A reliability analysis indicated that the items comprising the questionnaire are homogeneous. Test-retest reliability was high. A rotated factor analysis produced two factors, energized dysphoria and hedonistic euphoria. The authors discuss diagnostic, research, and clinical implications and applications of the Self-Report Manic Inventory.

Concerns of patients with inflammatory bowel disease: results from a clinical population.

OBJECTIVE:The impact of chronic illness is influenced not just by physical symptoms but also by psychosocial factors. The aim of this study was to determine the concerns of inflammatory bowel disease (IBD) patients in a clinical sample, if concerns differ between patients from varied clinical and demographic variables, and if concerns influence well-being beyond the influence of physical symptoms.METHODS:Subjects (n = 259) completed a validated measure of concerns specific to IBD and provided demographic and disease-related information.RESULTS:The most intense concerns involved both physical (e.g., energy level) and psychosocial issues (e.g., achieving full potential). There were numerous differences in disease concerns based on ability to work but none based on disease duration. Factor analysis yielded three indices: body image and interpersonal concerns, general physical impact, and disease stigma. Age and education only affected certain concern indices in subgroups of patients. Greater concerns negatively influenced well-being beyond the influence of physical symptoms.CONCLUSION:Psychosocial factors, in addition to physical symptoms, play an important role on the impact of illness in patients with IBD.

Emotional abuse, self-blame, and self-silencing in women with irritable bowel syndrome.

Objective: The purpose of this study was to investigate the presence of emotional abuse and two psychosocial constructs (self-blame and self-silencing) in a sample of women diagnosed with irritable bowel syndrome (IBS) relative to a comparison sample of women diagnosed with inflammatory bowel disease (IBD). Methods: Women diagnosed with IBS (N = 25) were compared with women diagnosed with IBD (N = 25) on measures of history of abuse, self-blame, and self-silencing. Results: It was found that women in the IBS sample scored significantly higher on emotional abuse, self-blame, and self-silencing than did women in the IBD sample. These three variables were also found to be significantly intercorrelated in both the IBS and IBD samples. Finally, emotional abuse was significantly higher in IBS patients than in IBD patients beyond the differences accounted for by physical and/or sexual abuse history. Conclusions: These findings empirically demonstrate an association between IBS and emotional abuse, as well as a possible connection with psychosocial variables, that may mediate the connection between emotional abuse and functional bowel symptoms. We suggest that these variables be further evaluated in the context of clinically relevant research on IBS.