Psychiatric Illness and Irritable Bowel Syndrome: A Comparison With Inflammatory Bowel Disease
Edward A. Walker, M.D., Peter Lawrence Li, M.D., Deborah
P. Roy-Byrne, Amos, M.A.,
Structured psychiatric interviews and psychological self-report measures were administered to 28 patients with irritable inflammatory
bowel bowel
patients
irritable
with
diagnoses
of major
syndrome disease.
bowel
and 1 9 patients Significantly more
syndrome
depression,
had
somatization
with of the
lifetime disorder,
generalized anxiety disorder, panic disorder, and phobic disorder. They had significantly more medically unexplained somatic symptoms, and most had suffered from psychiatric disorders, particularly anxiety disorders, before the onset of their irritable bowel symptoms. (Am Psychiatry 1990; 147:1656-1661) J
I
rritable bowel syndrome accounts for 13%-S2% of new referrals to gastroenterology clinics (1, 2) and is a common presenting problem in primary care settings. Investigations of coexisting gastrointestinal and psychiatric symptoms in patients with irritable bowel syndrome have demonstrated that S4%-100% of these patients have mood or anxiety disorders (3-9). However, some studies did not use structured psychiatric interviewing (3, 6, 7), operationalized diagnostic criteria (3), or comparison groups (3, 4, 8), and some compared irritable bowel syndrome patients to patients without gastrointestinal illness (3, 7). The studies that did use structured interviewing (4-9) used the Research Diagnostic Criteria (RDC) (10), which prevent the diagnosis of an anxiety disorder if a primary mood disorder is discovered, so these studies underestimated the prevalence of anxiety disorders. Some
Received Feb. 28, 1990; revision received May 22, 1990; accepted June 1, 1990. From the Department of Psychiatry and Behavioral Sciences, Division of Consultation-Liaison, and the Department of Medicine, Division of Gastroenterology, University of Washington School of Medicine. Address reprint requests to Dr. Walker, Department of Psychiatry and Behavioral Sciences, Division of Consultation-Liaison,
University
of Washington
School
of Medicine,
Seattle,
WA 98195. The authors thank David Saunders, M.D., Charles Bedard, M.D., Anthony Bohorfoush, M.D., Brian Reid, M.D., Michael Kimmey, M.D., Fred Silverstein, M.D., Patricia Blount, M.D., Douglas Levine, M.D., and Patricia Schaan, R.N., for their assistance in this study. Copyright
1656
© 1990
American
Psychiatric
Association.
M.D., Wayne and Geoffrey
J. Katon, M.D., Jiranek, M.D.
studies did not reliably investigate the relative timing of gastrointestinal and psychiatric symptoms (3, 6-8), thus preventing determination of whether the psychiatnic symptoms developed as a result of the medical illness, developed simultaneously with the medical illness, or were present before the appearance of gastrointestinal symptoms. Our pilot study was an attempt to address these methodologic limitations and add to the existing knowledge about the relationship of irritable bowel syndrome and psychiatric disorders.
METHOD We recruited subjects from our university gastroentenology clinic and family medicine clinic and from two urban private-practice gastroenterologists. The subjects were a sequential sample of patients diagnosed as having irritable bowel syndrome by a gastroenterologist after appropriate exclusion of other medical disease according to the criteria of Manning et al. (11) as modified by Thompson et al. (12). For our comparison group we selected a sequential sample of patients with inflammatory bowel disease. Of the 63 patients in the initial sample, 47 (75%) agreed to participate, 11 (17%) refused, and five (8%) were excluded because of recent steroid use. Of the 39 patients with irritable bowel syndrome who were tially selected, most came from the university gastroenterology clinic (62%, N=24) or the private-practice gastroenterologists (31%, N= 12); a small number (8%, N=3) were from the primary cane clinic. A similar pattern was found in the 24 initial patients with inflammatory bowel disease: gastroenterology clinic, 54% (N= 13); private practice, 25% (N6); primary care clinic, 21% (NS). The final sample of 47 subjects included 28 with irritable bowel syndrome and 19 with inflammatory bowel disease; the latter group comprised 13 patients with Cnohn’s disease and six with ulcerative colitis. Chi-square tests with Yates’ correction and two-tailed t tests indicated that the groups did not differ significantly in age (mean±SD: 37.1±14.2 versus 35.3±12.5 years; t=0.44, df4S), marital status (57% versus 47% married; 2=0.71, df=1), social class (Hollingshead score: 3.2±0.9 yen-
mi-
Am
J
Psychiatry
147:12,
December
1990
WALKER,
TABLE
1. Psychiatric
Diagnoses
of 28 Subjects
With Irritable
Bowel Syndrome
Irritable Bow el Syndrome
DIS Diagnosis Depression Lifetime Current Panic disorder Lifetime Current Generalized anxiety Lifetime
and 19 Subjects
ROY-BYRNE,
With Inflammatory
KATON,
ET AL.
Bowel Disease
Inflammatory Bowel Disease
N
%
N
%
Significancea
17 6
61 21
3 1
16 5
8 2
29 7
0 0
0 0
54
2
11
2=7.32,
11
1
S
20.02,
17
61
2
11
2=9.8S,p
Edward A. Walker, M.D., Peter Lawrence Li, M.D., Deborah
P. Roy-Byrne, Amos, M.A.,
Structured psychiatric interviews and psychological self-report measures were administered to 28 patients with irritable inflammatory
bowel bowel
patients
irritable
with
diagnoses
of major
syndrome disease.
bowel
and 1 9 patients Significantly more
syndrome
depression,
had
somatization
with of the
lifetime disorder,
generalized anxiety disorder, panic disorder, and phobic disorder. They had significantly more medically unexplained somatic symptoms, and most had suffered from psychiatric disorders, particularly anxiety disorders, before the onset of their irritable bowel symptoms. (Am Psychiatry 1990; 147:1656-1661) J
I
rritable bowel syndrome accounts for 13%-S2% of new referrals to gastroenterology clinics (1, 2) and is a common presenting problem in primary care settings. Investigations of coexisting gastrointestinal and psychiatric symptoms in patients with irritable bowel syndrome have demonstrated that S4%-100% of these patients have mood or anxiety disorders (3-9). However, some studies did not use structured psychiatric interviewing (3, 6, 7), operationalized diagnostic criteria (3), or comparison groups (3, 4, 8), and some compared irritable bowel syndrome patients to patients without gastrointestinal illness (3, 7). The studies that did use structured interviewing (4-9) used the Research Diagnostic Criteria (RDC) (10), which prevent the diagnosis of an anxiety disorder if a primary mood disorder is discovered, so these studies underestimated the prevalence of anxiety disorders. Some
Received Feb. 28, 1990; revision received May 22, 1990; accepted June 1, 1990. From the Department of Psychiatry and Behavioral Sciences, Division of Consultation-Liaison, and the Department of Medicine, Division of Gastroenterology, University of Washington School of Medicine. Address reprint requests to Dr. Walker, Department of Psychiatry and Behavioral Sciences, Division of Consultation-Liaison,
University
of Washington
School
of Medicine,
Seattle,
WA 98195. The authors thank David Saunders, M.D., Charles Bedard, M.D., Anthony Bohorfoush, M.D., Brian Reid, M.D., Michael Kimmey, M.D., Fred Silverstein, M.D., Patricia Blount, M.D., Douglas Levine, M.D., and Patricia Schaan, R.N., for their assistance in this study. Copyright
1656
© 1990
American
Psychiatric
Association.
M.D., Wayne and Geoffrey
J. Katon, M.D., Jiranek, M.D.
studies did not reliably investigate the relative timing of gastrointestinal and psychiatric symptoms (3, 6-8), thus preventing determination of whether the psychiatnic symptoms developed as a result of the medical illness, developed simultaneously with the medical illness, or were present before the appearance of gastrointestinal symptoms. Our pilot study was an attempt to address these methodologic limitations and add to the existing knowledge about the relationship of irritable bowel syndrome and psychiatric disorders.
METHOD We recruited subjects from our university gastroentenology clinic and family medicine clinic and from two urban private-practice gastroenterologists. The subjects were a sequential sample of patients diagnosed as having irritable bowel syndrome by a gastroenterologist after appropriate exclusion of other medical disease according to the criteria of Manning et al. (11) as modified by Thompson et al. (12). For our comparison group we selected a sequential sample of patients with inflammatory bowel disease. Of the 63 patients in the initial sample, 47 (75%) agreed to participate, 11 (17%) refused, and five (8%) were excluded because of recent steroid use. Of the 39 patients with irritable bowel syndrome who were tially selected, most came from the university gastroenterology clinic (62%, N=24) or the private-practice gastroenterologists (31%, N= 12); a small number (8%, N=3) were from the primary cane clinic. A similar pattern was found in the 24 initial patients with inflammatory bowel disease: gastroenterology clinic, 54% (N= 13); private practice, 25% (N6); primary care clinic, 21% (NS). The final sample of 47 subjects included 28 with irritable bowel syndrome and 19 with inflammatory bowel disease; the latter group comprised 13 patients with Cnohn’s disease and six with ulcerative colitis. Chi-square tests with Yates’ correction and two-tailed t tests indicated that the groups did not differ significantly in age (mean±SD: 37.1±14.2 versus 35.3±12.5 years; t=0.44, df4S), marital status (57% versus 47% married; 2=0.71, df=1), social class (Hollingshead score: 3.2±0.9 yen-
mi-
Am
J
Psychiatry
147:12,
December
1990
WALKER,
TABLE
1. Psychiatric
Diagnoses
of 28 Subjects
With Irritable
Bowel Syndrome
Irritable Bow el Syndrome
DIS Diagnosis Depression Lifetime Current Panic disorder Lifetime Current Generalized anxiety Lifetime
and 19 Subjects
ROY-BYRNE,
With Inflammatory
KATON,
ET AL.
Bowel Disease
Inflammatory Bowel Disease
N
%
N
%
Significancea
17 6
61 21
3 1
16 5
8 2
29 7
0 0
0 0
54
2
11
2=7.32,
11
1
S
20.02,
17
61
2
11
2=9.8S,p
