Natasha A. Koloski

Development and validation of the Geriatric Anxiety Inventory

BACKGROUND Anxiety symptoms and anxiety disorders are highly prevalent among elderly people, although infrequently the subject of systematic research in this age group. One important limitation is the lack of a widely accepted instrument to measure dimensional anxiety in both normal old people and old people with mental health problems seen in various settings. Accordingly, we developed and tested of a short scale to measure anxiety in older people. METHODS We generated a large number of potential items de novo and by reference to existing anxiety scales, and then reduced the number of items to 60 through consultation with a reference group consisting of psychologists, psychiatrists and normal elderly people. We then tested the psychometric properties of these 60 items in 452 normal old people and 46 patients attending a psychogeriatric service. We were able to reduce the number of items to 20. We chose a 1-week perspective and a dichotomous response scale. RESULTS Cronbachs alpha for the 20-item Geriatric Anxiety Inventory (GAI) was 0.91 among normal elderly people and 0.93 in the psychogeriatric sample. Concurrent validity with a variety of other measures was demonstrated in both the normal sample and the psychogeriatric sample. Inter-rater and test-retest reliability were found to be excellent. Receiver operating characteristic analysis indicated a cut-point of 10/11 for the detection of DSM-IV Generalized Anxiety Disorder (GAD) in the psychogeriatric sample, with 83% of patients correctly classified with a specificity of 84% and a sensitivity of 75%. CONCLUSIONS The GAI is a new 20-item self-report or nurse-administered scale that measures dimensional anxiety in elderly people. It has sound psychometric properties. Initial clinical testing indicates that it is able to discriminate between those with and without any anxiety disorder and between those with and without DSM-IV GAD.

Epidemiology and Health Care Seeking in the Functional GI Disorders: A Population-Based Study

OBJECTIVES:Functional GI disorders (FGIDs) are common in clinical practice, but little is known about the epidemiology of these disorders in the general population. We aimed to determine the prevalence, association with psychological morbidity, and health care seeking behavior of FGIDs in the population.METHODS:A random sample of subjects (n = 4500) aged ≥18 yr and representative of the Australian population were mailed a validated questionnaire. For these subjects we measured all Rome I GI symptoms and physician visits over the past 12 months, as well as neuroticism, anxiety, depression, and somatic distress.RESULTS:The response rate for the study was 72%. The prevalence of any FGID was 34.6%, and 62.1% of these subjects had consulted a physician. There was considerable overlap of the FGIDs (19.2% had more than two disorders). Independent predictors for an FGID diagnosis were neuroticism, somatic distress, anxiety, bowel habit disturbance, abdominal pain frequency, and increasing age. However, psychological morbidity did not independently discriminate between consulters and nonconsulters with an FGID.CONCLUSIONS:More than one third of the general population have one or more FGIDs. There seems to be a modest link between psychological morbidity and FGIDs, although other unknown factors seem to be more important in explaining health care seeking for these disorders.

The brain–gut pathway in functional gastrointestinal disorders is bidirectional: a 12-year prospective population-based study

Objective Psychological factors are known to be associated with functional gastrointestinal disorders (FGIDs) including irritable bowel syndrome (IBS) and functional dyspepsia (FD). No prospective studies have evaluated whether it is the brain (eg, via anxiety) that drives gut symptoms, or whether gut dysfunction precipitates the central nervous system features such as anxiety. In a 12-year longitudinal, prospective, population-based study, we aimed to determine the directionality of the brain–gut mechanism in FGIDs. Design Participants (n=1775) were a random population sample from Australia who responded to a survey on FGIDs in 1997 and agreed to be contacted for future research; 1002 completed the 12-year follow-up survey (response rate =60%), with 217, 82 and 45 people meeting Rome II for new onset FGIDs, IBS and FD, respectively. Anxiety and depression were measured using the Delusions Symptom States Inventory at baseline and follow-up. Results Among people free of a FGID at baseline, higher levels of anxiety (OR 1.11; 95% CI 1.03 to 1.19, p=0.006) but not depression at baseline was a significant independent predictor of developing new onset FGIDs 12 years later. Among people who did not have elevated levels of anxiety and depression at baseline, those with a FGID at baseline had significantly higher levels of anxiety and depression at follow-up (mean difference coefficient 0.76, p<0.001 and 0.30, p=0.01 for anxiety and depression, respectively). In IBS higher levels of anxiety and depression at baseline were predictive of IBS at follow-up, while only depression was predictive of FD at follow-up. Conclusions The central nervous system and gut interact bidirectionally in FGIDs.

The impact of functional gastrointestinal disorders on quality of life

OBJECTIVE:The impact of functional gastrointestinal disorders (FGIDs) on quality of life is unknown. We aimed to evaluate whether FGIDs impair quality of life in terms of mental and physical functioning in patients and nonpatients.METHODS:A random sample of 4500 subjects, representative of the Australian population, were mailed a questionnaire on gastrointestinal symptoms in the past 12 months. Quality of life was assessed using the valid SF-12, in which the lower the scores, the greater the impairment of quality of life. The response rate was 72%.RESULTS:Among those fulfilling Rome I criteria for a diagnosis of a FGID (n = 1006) versus those not having a FGID (n = 1904) (healthy controls), there was a significant association with impaired mental (43.9 vs 48.1) and physical (47.7 vs 51.6) functioning. Mental functioning (43.3 vs 44.9) and physical functioning (46.0 vs 50.5) was significantly more impaired in patients versus nonpatients with a FGID. Furthermore, nonpatients with a FGID had more impaired mental and physical functioning than healthy controls.CONCLUSION:FGIDs impair quality of life, particularly in those that consult for health care.

A randomized controlled trial of cognitive behavior therapy, relaxation training, and routine clinical care for the irritable bowel syndrome

OBJECTIVES:Psychological treatments are considered to be useful in the irritable bowel syndrome (IBS), although the evidence is based on small, often flawed trials. Although cognitive behavior therapy (CBT) and relaxation therapy have both been promising, we hypothesized that CBT would be superior to relaxation and standard care alone in IBS patients. The objective of this study was to test this assumption by comparing the effects of cognitive behavior therapy with relaxation therapy and routine clinical care alone in individuals with IBS.METHODS:Patients (n = 105) with Rome I criteria for IBS were recruited from advertisement (n = 51) and outpatient clinics (n = 54); those patients with resistant IBS were not included. A randomized controlled trial with three arms (standard care for all groups plus either CBT or relaxation) for 8 wk was conducted, which applied blinded outcome assessments using validated measures with 1 yr of follow-up. The primary outcome for this study was bowel symptom severity.RESULTS:Of 105 patients at the commencement of treatment, the mean bowel symptom frequency score for the whole sample was 21.1 and at the end of treatment had fallen to 18.1; this persisted at the 52-wk follow-up, with a significant linear trend for scores to change over time (F= 39.57 p < 0.001). However, there were no significant differences among the three treatment conditions. Significant changes over time were found for physical functioning (F= 4.37, p < 0.001), pain (F= 3.12, p < 0.05), general health (F= 2.71, p < 0.05), vitality (F= 2.94, p < 0.05), and the social functioning scales on the Medical Outcomes Study Short Form 36 (F= 4.08, p < 0.05); however, all three arms showed similar improvement. There were significant reductions in anxiety, depression, and locus of control scales, but no significant differences among the treatment groups were detected.CONCLUSION:Cognitive behavior and relaxation therapy seem not to be superior to standard care alone in IBS.

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.

Does psychological distress modulate functional gastrointestinal symptoms and health care seeking? A prospective, community Cohort study.

Abstract Objective Little is known about the natural history of functional GI symptoms, including what factors influence GI symptom patterns and health care seeking for them over the long term. We aimed to determine whether psychological factors play a role in the development and long-term course of these symptoms. Methods A random sample of community subjects (n = 361) who reported having unexplained abdominal pain for ≥1 month in a previous population survey were included in the study. Controls (n = 120) were defined as not having abdominal pain for ≥1 month from this initial survey. Subjects were prospectively followed up via a questionnaire every 4 months over a 12-month period. The questionnaire asked about the presence of GI symptoms over the past week and psychological distress over the past 3 wk (psychological caseness being defined as a score of ≥2 of 12 on the General Health Questionnaire). The number of visits made to a physician or medical specialist over the past 4 months was evaluated. Results GI symptoms were common among community controls and subjects with abdominal pain. Similar onset and disappearance rates were observed for the majority of GI symptom categories, accounting for the stability of the prevalence rates over a 1-yr period. Changes in a state measure of psychological distress were not significantly associated with changes in GI symptom status between the 4- and 8-month (r = 0.14, p = 0.08) and 8- and 12-month (r = 0.02, p = 0.77) follow-ups. Baseline psychological distress, however, was an independent predictor of having persistent GI symptoms, including abdominal pain, bloating, and constipation, and frequently seeking health care for GI symptoms over 1 yr. Conclusions Psychological distress levels do not seem to be important in explaining GI symptom change over a 1-yr period. Psychological distress, however, is linked to having persistent GI symptoms and frequently seeking health care for them over time. Clinicians should consider psychological factors in the treatment of this subset of irritable bowel syndrome patients.

Epidemiology of the functional gastrointestinal disorders diagnosed according to Rome II criteria: an Australian population‐based study

Background: Population‐based studies of the prevalence of all functional gastrointestinal disorders (FGID) using the Rome II criteria are lacking. It is also not certain whether subjects who meet the Rome II criteria for an FGID are different in terms of demographic and psychological characteristics from those subjects meeting exclusively the more restrictive Rome I criteria.

A History of Abuse in Community Subjects with Irritable Bowel Syndrome and Functional Dyspepsia: The Role of Other Psychosocial Variables

Background/Aims: Why abuse is associated with irritable bowel syndrome and functional dyspepsia remains unclear but other psychosocial factors may be important. We hypothesized that other psychosocial variables may confound the association. Methods: 207 subjects identified from a previous population survey who also met Rome I criteria for IBS (n = 156) or functional dyspepsia (n = 51) were included in the study. Controls (n = 100) did not report having any abdominal pain in a previous population survey. Sexual, physical, emotional/verbal abuse as a child (≤13 years) and adult (≧14 years) was assessed using validated self-report questions. Other psychological variables were assessed via validated self-report. Results: Adulthood abuse was significantly more common in IBS and/or functional dyspepsia (40%) compared with healthy controls (25%). Abuse was not an independent predictor for IBS or functional dyspepsia when psychological and buffering factors were controlled for in the analyses. Having a diagnosis of depression and using a self-controlling coping style were significantly associated with having a history of abuse. Conclusions: Abuse occurring as an adult was significantly associated with IBS and/or functional dyspepsia, but it was not an important factor when psychosocial factors were controlled for in these disorders.

Impact of Persistent Constipation on Health-Related Quality of Life and Mortality in Older Community-Dwelling Women

OBJECTIVES:Very little is known about whether the reported health-related impact of constipation is worse in people who experience constipation over a long period of time vs. those with more transient symptoms. We aimed to determine the impact of persistent vs. transient constipation on health-related quality of life (QOL), depression, and mortality.METHODS:We analyzed data from 5,107 women (aged 70–75 years in 1996) who answered “Have you had constipation in the past 12 months?” in all five surveys sent out every 3 years of the Australian Longitudinal Study on Women’s Health.RESULTS:Of the 5,107 women, 20.9, 54.1, and 24.7% reported having persistent constipation on at least 4 out of 5 surveys, transient constipation reported on 1–3 surveys, or none reported over the 15-year time frame, respectively. Women who reported persistent constipation had significantly lower scores for all domains of QOL on the SF-36 except role-emotional, and had higher levels of self-reported depression, even after adjusting for number of chronic illnesses and fluid intake. Mortality rates were increased when comparing women with no reported constipation with persistently reported constipation (8.2% vs. 11%, odds ratio = 1.32, 95% confidence interval 1.0, 1.74, P = 0.05) controlling for specific chronic illnesses.CONCLUSIONS:Persistent constipation among older women is associated with poor health outcomes.