Suppression of Anger and Gastric Emptying in Patients with Functional Dyspepsia E. J . BENNETT, J. E. KELLOW, H. COWAN, A. M. SCOTT, B . SHUTER, P. M. LANCELUDDECKE, R. HOSCHL, M. P. JONES & C . C. TENNANT Depts. of Medicine, Nuclear Medicine, Academic Psychiatry, and Health Information Systems, Royal North Shore Hospital, Sydney, Australia

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Bennett EJ, Kellow JE, Cowan H, Scott AM, Shuter B, Langeluddecke PM, Hoschl R, Jones MP, Tennant CC. Suppression of anger and gastric emptying in patients with functional dyspepsia. Scand J Gastroenterol 1992;27:869-874. 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. Key words: Anger; coping behaviour; emotional stress; functional dyspepsia; gastric emptying; unhappiness

Dr. J . E. Kellow, Dept. of Medicine, Royal North Shore Hospital, St Leonards NSW 2065, Australia

Psychologic factors have long been implicated in the pathogenesis of functional (non-ulcer)dyspepsia (FD) ( 1 4 ) . However, the psychophysiologic mechanisms involved are poorly understood (5), as there is little research linking specific psychologic factors with measures of gut function. Laboratory studies consistently indicate that both acute and sustained psychologic stressors produce transient alterations in upper gastrointestinal motor activity in healthy subjects (69). The changes observed are similar to the gastric antral hypomotility and delayed gastric emptying observed in a significant proportion (3WO%) of FD patients in the basal state (8). Patients with gastric dysmotility, or suspected dysmotility, seem to respond to acute stress with a generalized suppression of gastric motor (8) and autonomic (10) activity. Although it is possible that chronic distress associated with life strain (10) or exposure to a chronic life stressor (1 1-13) may link acute responses and intermittent gastric motor dysfunction with more sustained gastric motor dysfunction, this remains to be demonstrated. Research relating psychologic factors other than stress to gut function is scant. One study reported indices of personality derived from the MMPI and psychiatric evaluation to be unrelated to gastric motor dysfunction in FD (8). Various other factors implicated in the aetiology of functional gut disorders remain to be studied in relation to gastric motor dysfunction. These include specific personality traits (such as neuroticism, trait anxiety, aggression, and irritability), maladaptive methods of coping with stress, anxious

or dysthymic states, somatic anxiety, social dependence, and affect expression (14-16). Anger is an emotion or affect that appears to be of particular relevance to gut motility. It has been demonstrated to have potent effects on colonic motility, usually increasing activity (17-20). Also relevant is research indicating negative affect and its expression or suppression to be related to various adverse psychophysiologic states (21-24). A tendency to suppress anger, for instance, may be even more important to motility disturbance than the experience of anger per se. It is commonly believed that unexpressed anger (anger suppressed or held in) increases autonomic arousal and, in turn, heightens the risk of somatic dysfunction (for example, gastric dysmotility). Of note is a recent study reporting that many patients with upper abdominal pain admitted to ‘bottling up their anger’, and some stated that they ‘never became angry’ (10). At odds with this are findings that FD patients as a group d o not seem to suppress anger, anxiety, or a depressed mood any more than patients with duodenal ulcer or community controls (25). The aim of the present study was to assess the relationship of various psychologic factors to gastric stasis in FD sufferers and assess their relative importance. The psychologic assessment included measures of affect expression/suppression (including anger), coping methods, personality, mood states, and other responses to stress. Dual-isotope scintigraphy and power exponential analysis were utilized to assess gastric emptying of both solids and liquids.

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SUBJECTS A N D METHODS

Patients Twenty-eight consecative functional (non-ulcer) dyspepsia patients (9 men, 19 women; aged 21-72 (mean, 49 2 15) years) referred by their general practitioner for gastroenterologic assessment were recruited from a specialist endoscopy clinic. Diagnosis of FD was based on clinical evaluation of symptoms by a standard form, supported by normal findings at endoscopic, ultrasonic, and other appropriate investigations (26). All patients had upper abdominal pain or discomfort together with two or more of the following: (a) nausea and/or vomiting; (b) early satiety and/or anorexia; (c) abdominal bloating and/or a feeling of distension; and (d) cxcessive belching (26). N o patient was taking psychopharmacologic medication or medication known to affect gastric emptying, and all were free of organic gut disease. Patients were otherwise unselected. Procedure Potential subjects were invited (initially by mail and subsequcntly by telephone) to participate in a study to assess the relationship between psychologic factors and gastric emptying. Compliance was l00%. The gastric emptying studies were performed by a nuclear medicine physician who was blind to the psychologic data. Precautions were taken to ensure that the setting of the testing was stress-free so that the findings reflcct gastric emptying in a basal state. Psychologic data were obtained in a blind and independent manner within 1-2 weeks of the endoscopic and gastric emptying procedures. Informed consent was obtained from all subjects, and the study was approved by the Medical Research Ethics Committee of the Royal North Shore Hospital. Psyc,hologic,assessment The psychologic questionnaires and outcome measures were as follows: A . Affect expression The Anger Exprcwion ( A X ) Scale (27). This assesses Anger-Out: anger expressed towards other people and the environment-for example, ‘I . . . slam doors’, ‘I argue with others’, ‘I lose my temper’. Anger-In: anger held in/suppressed-for example, ‘I keep things in’, ‘I a m angrier than I am willing to admit’, ‘I boil inside, but I don’t show it’. Anger-Control: control and/or resistance to becoming angry-for example, ‘I control my angry feelings’, ‘I keep my cool’, ‘I am patient with others’, ‘I try to be tolerant and understanding’. Anger-Out and Anger-In are independent, orthogonal dimensions that have demonstrated validity and reliability (28-30); the psychometric properties of the Anger-Control scale are not as well-researched, particularly since the addition of new items (30).

The Courtauld Emotional Control Scale (CECS) (31). Higher scores on each subscale indicate greater control/ suppression over negative affects of Suppression of anger: for example, ‘I hide my annoyance’, ‘I bottle it up’. Suppression of anxiety: for example, ‘I refuse to say anything about it’. Suppression of depressed mnodlunhtippiness: for example, ‘I hide my unhappiness’. The reliability and validity of the CECS are well established (31,32). B. Coping style The Defense Style Questionnaire (DSQ) (DSM-III-R-labelled version) ( 3 3 ) . This assesses neurotic, mature, and immature coping styles. Locus of Control of Behaviour (34). This assesses internality-externality . C. Personality The Brief Eysenck Personulity Inventory (EPI) ( 3 5 ) . This assesses neuroticism and extraversion. The Spielherger State and Trait Anxiety Inventory (STAI) (36). This assesses trait anxiety.

D. Mood state STAI (36) assesses state anxiety. The Centre for Epidemiological Studies Depression Scale (CES-D) (37) measures depression.

E. Stress response The Stress Scale. Developed by Folkman & Lazarus (38), this scale assesses the extent to which the following four types of emotions were experienced during exposure to a recent ’natural’ stressor: threat, challenge. harm, and benefit. The Mental Adjustment to Cancer (MAC) Scale (M. Watson, S. Greer. Personal communication). This scale was adapted to determine the extent to which the subject’s mental adjustment to a recent ‘natural’ stressor was characterized by a fighting spirit (the tendency to respond to life stressors in a positive and optimistic manner) and/or helpless-hopelessness (the tendency to become engulfed by the difficulty, to be wholly pessimistic). Gastric emptying assessments Patients ingested a standard test meal of a scrambled egg (to which had been added 20 mBq ‘9”1Tc-labelled sulphur colloid), two slices of toast, and a slice of ham (total weight of meal,48 g), followed by 150 ml water (with 20 mBq 1131111n-, labelled diethylenetriamine-pentaacetic acid (DTPA). The total caloric content of the meal was 422 Kcal (carbohydrate, 30%; protein, 17%; fat, 53%). The in-vitro stability of these solid and liquid phase markers was 92% of the solid marker adherent to the solid phase at 2.5 h and less than 10% of the

Anger and Gastric Emptying in Dyspepsia Table I. Models of solid gastric emptying factors in terms of combinations of psychosocial factors with independent statistically significant effects

GE factor

Predictors in the model

Anger-in Manifest unhaooiness Fighting spirit Solid delay Anger-Con trol Rate of emptying Anger-In at 45 min Rate of emptying Anger-In at 70 min Solid T,,,

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, L

Variance explained

P

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 ...
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