Neurogastroenterol Motil (2008) 20 (Suppl.

1), 114120

REVIEW ARTICLE

Psychosocial factors in functional gastrointestinal

disorders: an evolving phenomenon
K. W. OLDEN

Division of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, AR, USA

development of psychoanalytic thinking. Heavily

dependent on psychoanalytic thought, it enjoyed great
success and tremendous interest in the years from
around 1940 until the 1970s. The psychoanalytic
school of thought fell victim to two fatal errors. The
first was that the adherents to this line of thinking
forgot that all science is provisional and did not revise
their thinking as biomedical science advanced. Secondly, these investigators relied too heavily on observational studies and did not adjust their methodology
to new techniques which were developing in the
behavioural sciences. These factors ultimately heralded the decline of psychoanalytically based psychosomatic medicine. Take for instance this excerpt
written by Franz Alexander, the father of psychosomatic medicine writing about peptic ulcer in 1950.
While the significance of emotional factors in the
ideology of peptic ulcer is accepted universally today,
there is divergence of opinion regarding the specificity
of the emotions involved. Those who approach the
problem from a clinical side thenare impressed by
the pronounced oral-receptive trend, manifesting itself
either in overt dependence or in its denial.1
Oh, if they only knew about Helicobacter pylori!
Psychoanalytic perspectives on peptic ulcer disease,
inflammatory bowel disease, asthma, eczema, thyrotoxicosis and rheumatoid arthritis all had their psychoanalytic underpinnings devastated by advances in
biomedical science. The second half of the 20th
century was characterized an increasing contempt for
any psychosomatic perspectives on any disease. This
dark age of psychosomatic medicine had substrates.
The extraordinary advances in biochemistry, genetics,
cell biology and immunology subsequently lead to
advances in pharmacology which in turn lead to the
previous psychosomatic theories being perceived as
being a little more than quaint. The second factor

Abstract The psychosocial aspect of functional gastrointestinal disorders have a long and complicated
investigative history. Emerging from the 1930s when
the observations of individual investigators and clinicians was the norm we have evolved in the last
25 years to an increasingly sophisticated era of scientific observation using standardized nosology, validated psychometric instruments and have made use of
emerging technology such as brain imaging, barostat
testing and other technologies. The application of the
scientific method to help improve out understanding
of the relationship of psychosocial factors as they relate to gastrointestinal illnesses is slowly but surely
revolutionizing gastroenterology practice. It is the
purpose of this paper to review the history of
Psychosomatic Gastroenterology to review the
dimensions of psychosocial factors as they relate to
gastroenterology and to review the emerging technologies which are helping us to develop this knowledge.
Finally we will attempt to speculate on where the field
will be going in the future.
Keywords biopsychosocial model, functional gastrointestinal disorders, psychosomatic gastroenterology.

HISTORICAL PERSPECTIVE
Modern psychosomatic medicine began in the early to
mid-20th century and was closely linked to the

Address for correspondence

Kevin W. Olden MD, Division of Gastroenterology, University of Arkansas for Medical Sciences, 4301 West Markham
#567, Little Rock, AR 72205, USA.
Tel: +1 501 686 5177; fax: +1 501 686 6248;
e-mail: kwolden@uams.edu
Received: 23 January 2008
Accepted for publication: 27 January 2008

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Psychosocial factors in functional GI disorders

disorder and somatization disorder predominant. This

narrow psychiatric differential diagnosis certainly raises
the possible hypothesis of a common pathophysiological mechanism for both the patients bowel symptoms
and their CNS dysfunction. Psychiatric research in the
last 20 years has demonstrated quite clearly a strong
correlation between serotonergic dysfunction in panic
disorder, major depressive disorder, anxiety disorders
and perhaps even somatoform disorder.10 Response to
serotonergically active medication such as tricyclic
antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs)11 further support this line of
thinking. Similar findings have been found using these
drugs for the treatment of functional GI disorders.
Functional chest pain, IBS, functional dyspepsia as well
as cyclic and functional vomiting have all been found to
respond well to TCAs and/or SSRIs.12
However, drug development for functional GI disorders is exploring a number of drugs which exploit a
variety of other CNS neurotransmitter system mechanisms. These include NK-1 antagonists, substance P
antagonists and third generation serotoninergic drugs.13
Clearly, the neurochemical correlates between the
enteric nervous system (ENS) and the central nervous
system (CNS) need to be much better defined. Research
in this area of drug development has been quite fruitful
to date and certainly offers promise for achieving a
much better understanding of gut function via the ENS
and its relationship to the CNS and behaviour.

promoting the psychosomatic dark age was that from

the 1930s right through the mid-1980s the dominant
force in American psychiatric teaching was psychoanalytic thought. When this writer was a psychiatric
resident in the late 1970s and early 1980s there was an
increasingly spirited struggle between the emerging
concepts of biologically based psychiatry and the
psychoanalysts who relied almost exclusively on
behavioural interpretation. It is only in the last
20 years that the biological model has become the
predominant force driving the field of psychiatry.
Advances in neurophysiology, brain imagining,
descriptive nosology and the incorporation of the
concept of the randomized control trial into psychiatric
research have revolutionized and rationalized the
scientific underpinnings for the treatment of psychiatric disorders. With the emergence of scientifically
based psychiatry, the scientific gap between biomedicine and psychosocial medicine has rapidly narrowed.
However, psychosomatic medicine is only now beginning to emerge from this Dark Age.
It will be the purpose of this paper to review briefly
the epidemiological evidence supporting the validity of
psychiatric comorbidity as it applies to functional
gastrointestinal (GI) disorders; to review mechanistic
theories about how these variables may interact to
produce symptoms, disease coping and healthcare
seeking behaviour and to discuss the implications for
treatment. Finally, recommendations for future study
and potentially promising areas of investigation will be
discussed.

CLINICAL IMPLICATIONS OF
PSYCHOLOGICAL DYSFUNCTION IN
GASTROINTESTINAL DISORDERS

PSYCHIATRIC COMORBIDITY AND

GASTROINTESTINAL DISORDERS

The clinical implications of psychological dysfunction

in patients with GI disorders can have number of
dimensions. These include: symptom perception; the
presence or absence of extraintestinal symptoms of
functional GI disorders; GI transit; coping ability and
clinical outcomes.

The first concept one needs to understand when

discussing psychiatric comorbidities as they relate to
GI disorders is that psychiatric comorbidity is not
limited to the functional GI disorders. A number of
studies have demonstrated higher levels of depression
and anxiety disorders in chronic liver disease2 inflammatory bowel disease.3 Likewise, psychiatric abnormalities have been noted with functional abnormalities of
the oesophagus;4 functional and cyclic vomiting;5 dyspepsia6 irritable bowel syndrome (IBS);7 functional
constipation8 and sphincter of oddi dysfunction.9
Although the prevalence of comorbid psychiatric
disorders is high in GI disorders, both functional
organic, compared to normal controls the differential
diagnosis of these psychiatric disorders is actually quite
narrow. Most studies have demonstrated that anxiety
disorders particularly panic disorder, major depressive
disorder and somatoform disorders particularly pain
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Symptom perception
One interesting study regarding symptom perception
involved a study of perceived vulnerability to illness in
individuals with IBS. In this study, the investigators
surveyed 124 university employees after a highly
publicized media scare regarding deep vein thrombosis
(DVT). The study subjects were surveyed regarding the
presence or absence of IBS using the ROME I diagnostic
criteria for IBS. There were also queried regarding other
conditions such as arthritis, asthma, chronic fatigue
syndrome, diabetes, eczema, fibromyalgia and insom-

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socialize and overall level of energy was associated

with somatization (P < 0.001) and a diagnosis of IBS
(P < 0.05). The tendency to report seasonal changes in
pain and disturbed defecation associated with IBS were
specifically associated with somatization but not with
other psychological variables.21

nia. Subjects were asked to rate their symptoms on a

5-point Likert scale. Subjects were also administered
the illness attitude scale (IAS), a measure of illness
concerns. The investigators found that IBS positive
respondents reported higher perceived risk of DVT
than healthy controls or respondents with known
asthma. This difference could not entirely be explained
by the presence of concurrent physical symptoms,
exposure to information about DVT or scores on the
IAS. The investigators concluded that IBS was associated with an enhanced perception of personal vulnerability to illness that was related to higher levels of
negative affect in the IBS group.14 The investigators
further concluded that individuals who seek treatment
for IBS tend to have more extraintestinal symptoms
than non-treatment seekers perhaps based on the same
mechanism.15 Along this line of thinking, it has also
been shown that parents with IBS made more primary
care visits for their children than healthy parents for all
causes.16 Finally, treatment studies have shown that
when patients with refractory IBS with psychological
comorbidity have overall outcomes which are poorer
than IBS patients with psychological distress.17
The role of chronic life stress in patients with
functional GI disorders has also been studied. These
findings seem to be true not just for IBS but also for
functional dyspepsia.18 Studies have shown that increased life stressors as measured by the life event
survey (LES), a measure of self reported stress, could
differentiate subjects with higher mean levels of GI
symptoms based on life stressors alone.19
In a classic study, Drossman et al. studied 72
subjects with IBS. In addition two other populations
were studied: the first included 82 persons with IBS
who had not sought medical treatment and the second
included 80 normal controls. Using a variety of
psychological measures they found that individuals
with IBS who chose to be patients had a higher
proportion of abnormal personality patterns, greater
illness behaviours and lower life events scores than
IBS non-patients (P < 0.001). In this same study, the IBS
non-patients who, scored psychologically between
IBS patients and normal controls, had no significant
differences of psychometric measures from normal
control patients.20 There is also some suggestion that
seasonality of functional bowel symptoms can also be
determined by psychological variables. Tally et al.
studied 163 volunteers who were administered psychometric instruments for somatization, depression
and neuroticism. In addition, the seasonal patterns of
their symptoms were also measured. The investigators
found that seasonal variation and a variety of symptoms including sleep, eating behaviours, ability to

Psychological variables and gastrointestinal

transit
Psychological variables also seem to be able to influence GI transit time. Gorard et al. studied 21 psychiatric outpatients who carried a diagnosis of generalized
anxiety disorder and/or major depression. They compared these subjects to normal controls. Orocecal
transit time (OCTT) and whole gut transit time
(WGTT) were measured using standardized techniques. They found that median WGTT was shorter
in patients with anxiety as well as the patients with
depression (P < 0.001) vs controls (P < 0.001). In
patients with anxiety, OCTT was also significantly
shorter than in patients with depression (P < 0.01) and
also vs controls (P < 0.05). It was noted that WGTT
correlated with a standard measure of depression the
Beck depression inventory (BDI); (P < 0.01) and the
hospital anxiety depression scale (HADS); (P < 0.001).22
This interesting ability of psychiatric disorders to
affect gut transit time and to affect selectively it by
psychiatric diagnosis has implications both for the
pathophysiological understanding of functional bowel
disorders as well as the impact of psychological
disorders on GI symptom generation.

Extraintestinal manifestations
The well-established relationship between IBS and
other extraintestinal syndromes particularly fibromyalgia syndrome (FMS) may also be influenced by
psychological variables. Sperber et al. compared 79 IBS
patients with 72 match controls and 100 patients with
FMS. They found that 25 of their 79 IBS patients and
only three of their 72 controls had FMS (P < 0.001). In
patients with a combined IBS/FMS diagnosis, there was
a statistically significant difference in global well being
(P < 0.001); sleep disturbance (P < 0.001); number of
physician visits (P = 0.003); pain scores (P < 0.001);
anxiety (P < 0.001) and global severity as measured by
the global severity index of the SCL-90-R (P < 0.001).
This study demonstrates the interaction between
psychological variables particularly depression and
anxiety and the presence of additional non-GI physical
symptoms (i.e. IBS and FMS) which in turn leads to
lower levels of health and well being.23

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type 2 channel activator); and Linaclotide (a guanyase

cyclase agonist). Only a partial sampling of drugs
which are undergoing development for the treatment
of functional GI disorders. However, despite these
significant advances in medical management, there is
still a significant group of patients who do not achieve
adequate relief of their distress. There is good reason to
suspect that this lack of response is due to psychological as opposed to purely biological issues.25

Finally, a number of studies have demonstrated that

at the presence of anxiety and depression can predict
poor clinical outcomes particularly in IBS including a
poor response to treatment.17

Coping
The ability of IBS patients to cope also seems to be
influence mainly by psychological variables. In one
study, 30 patients with IBS were compared to 30
normal controls. Stressful life events and mechanisms
of coping were measured using standardized psychometric instruments. An IBS subgroup of patients with
measurable levels of anxiety and depression was
extracted from the non-anxious and non-depressed
subgroups using the hospital anxiety and depression scale (HADS). Positive and negative coping
mechanisms were then measured between these subgroups. The investigators found that 50% of the IBS
sample had clinically significant anxiety and/or depression. Furthermore, they found that IBS patients with
higher levels of either depression or anxiety tended to
use negative coping styles as it compared to IBS
patients without anxiety or depression.24
These factors taken together suggest that the presence of psychiatric comorbidity presents special issues
in the approach to patients with functional disorders
and indeed quite possibly all GI disorders with regard
to coping, healthcare seeking, prognosis and most
importantly the need for special interventions. These
will be discussed in the next section.

Behavioural intervention for gastrointestinal

disorders
The literature on behavioural intervention for the
treatment of GI illness, particular chronic liver disease
and functional bowel disorders has expanded considerably in the last few years and has produced some
extremely encouraging results. It is standard practice
for liver transplant programmes to have a dedicated
psychiatrist on staff to treat the significant psychiatric
side effects associated with chronic viral hepatitis,
particularly hepatitis C, and the psychological sequelae
of immunosuppressant therapy. Likewise, the literature regarding the behavioural treatment of functional
GI disorders is rapidly expanding. Numerous studies
have demonstrated the efficacy of behavioural therapy,
group therapy, psychodynamic therapy, relaxation
therapy and so called collaborative model (where
patients see both a gastroenterologist and a behavioural
specialist as part of their visit) for the treatment of
functional GI disorders.26 In this regard, two studies
stand out for a number of reasons. Both of these studies
compared behavioural interventions to treatment with
antidepressants which helps put the role of medication
in perspective relative to behavioural intervention.
Secondly, both of these studies have true placebos as
opposed to using wait list controls which can introduce bias regarding a patients motivation to benefit
from behavioural intervention. And finally in one
study a spectrum of functional GI disorders and not
IBS was included and in the second patients with
severe refractory IBS were included. The details of
these studies can be found elsewhere. It would suffice
to say that in the Drossman et al.s27 study cognitive
behavioural therapy benefited patients more than an
educational module control or antidepressants using
an intention to treat (ITT) analysis. In the second
study, Creed et al. major outcome measure was the
reduction in the healthcare costs, their subjects experienced in the 1 year follow-up after the intervention.
Comparing interpersonal dynamic psychotherapy vs
paroxetine vs usual medical treatment with the
attending gastroenterologist, the group that received

PSYCHOLOGICAL TREATMENT OF
GASTROINTESTINAL DISORDERS
The treatment of GI disorders has undergone tremendous advances in the last 20 years. The development of
second and third generation 5-ASA compounds, the use
of biologics and advanced immunosuppressants such
as methotrexate and cyclosporine in inflammatory
bowel disease, the use of interferon and ribavirin for
chronic hepatitis and the development of proton pump
inhibitors have revolutionized our treatment of GI
disorders. Part of this revolution has also included
significant advances in the medical management of
functional GI disorders. The development of serotonergic agents such as alosetron and tegaserod has
been followed by a number of other agents that are
currently in development. These include DDP225
(5-HT3 antagonist) Dextofisopam a non-sedation
GABA antagonist; DDP773 (another 5HT3); Renzapride
(5HT3 antagonist and 5HT4 agonist) as well as nonserotonergic drugs such as Lubiprostone (a chloride
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tion, clinical outcomes and overall patient satisfaction

can all be improved by adopting a behavioural dimension
to GI practice irrespective of the GI diagnosis.

psychotherapy had lower healthcare cost compared

either to the subjects that received antidepressants or
to the subjects receiving usual medical treatment.28
Also of note was the fact that in both of these studies
the dropout rates for the psychotherapy groups were
significantly lower than the dropout rates for the
medication groups, the latter averaging approximately
50% of the subjects treated with antidepressants.
These studies teach us a number of things. The first
is that psychotherapy seems to be extremely efficacious and seems to be better received, better tolerated
and has better results than the use of antidepressant
medications. Secondly, as demonstrated in the Creed
study, behavioural intervention can reduce healthcare
costs significantly compared to medication or usual
medical treatment.

Brain imaging and other emerging technologies

Psychiatry has been using brain imaging to identify
changes in brain function as they apply to various
psychiatric disorders for approximately the last
30 years.31 Only recently has gastroenterology begun
to follow in kind.32 Greater collaboration needs to
occur between these two disciplines with regard to
brain imaging. Collaborative efforts which identify
specific areas of the brain involved in patients with
combined psychiatric and gut dysfunction need to be
carried out to better localize areas of CNS dysfunction
and how they relate both to behaviour and to the ENS.
A second area of mutual interest between psychiatry
and gastroenterology is the issue of pharmacogenetics.
Psychiatry has become intensely interested in the area of
pharmacogenetics both from the perspective of improving specific drug response by individual patients, but
also in an attempt to predict and prevent medication
adverse events. This has become a major area of investigation within Psychiatry. This research has gained
interest specifically in the area polymorphisms of the
catechol-O-methyltransferase (COMT) gene.33 It is
interesting that these polymorphisms may also play a
role in a generation of extraintestinal manifestations of
IBS including fibromyalgia and temporomandibular
dysfunction and possibly GI-related anxiety disorders.34
Clearly, further investigation in this area is warranted,
not just in terms of mechanistic studies with regard to
aetiology and comorbidity but also to be able to predict
drug response and drug side effects. The potential for
improvements in drug treatment particularly for
functional and other painful GI disorders is promising
based on the preliminary data to date.

FUTURE DIRECTIONS
From the perspective of this physician, the future
directions that we should take in the area of psychological dimensions to GI practice should be divided
into four general areas. These are: (i) improvements in
clinical practice; (ii) additional collaborative research
in the area of brain imaging; neurochemistry and
pharmacogenitics; (iii) improvements in training in
the area of psychological dimensions of GI practice;
and (iv) improvements in the quality and quantity of
randomized controlled trials of both psychopharmacological and psychotherapeutic interventions for functional GI disorders.

Future directions for gastroenterology practice

Medicine is clearly moving in the direction of incorporating behavioural and psychopharmacological treatments into gastroenterology practice. This goes beyond
the functional GI disorders and includes other diseases
such as inflammatory bowel disease, chronic liver
disease, organ transplantation and even GI cancers.29
However, a significant lag remains between clinical
practice and literature based biopsychosocial practice.
The work of Gerson and Gerson26 has demonstrated the
effectiveness of incorporating behavioural practioners as
part of the GI practice setting. Improved outcomes,
symptom relief and normal patient satisfaction can all
be improved using this model of practice. In Europe, it is
standard to have Departments of Pyschosomatic Medicine. The USA has approached such endeavours cautiously, if at all. This is despite the fact that the literature
supports this approach and indeed is recommended by
the Rome working teams for functional GI disorders.30
There is no doubt that recidivism, healthcare utiliza-

Advances in gastrointestinal fellowship training

Advances in treatment are useless unless practitioners
are trained and are comfortable using them. Gastroenterology to its tremendous benefit has been driven for
the last 50 years by a strong biomedical model. The
advances in the care of patients with GI disorders
which have resulted as a result of this focus are
remarkable. However, we are beginning to learn that
there are other dimensions to illness which impact
outcomes which do not respond well to a straight
biomedical approach. The biopsychosocial model as
postulated by Engel35 has much more relevance now
than it did 20 years ago because of advances in

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Psychosocial factors in functional GI disorders

treatment for functional GI disorders, this literature

clearly needs to improve. To date, the only functional
GI disorder that has been studied relative to these
modalities in depth is IBS. With exception of a few
treatment trials of behavioural intervention and
psychopharmacological intervention for functional
dyspepsia and non-cardiac functional chest pain, the
study of other GI disorders remains fairly barren. We
clearly need further multicentre, randomized controlled trials of behavioural interventions, collaborative and the use of psychopharmacological agents,
including anxyolytics and anticonvulsants as well as
antidepressants to treat a variety of functional GI
disorders. Inflammatory bowel disease, chronic liver
disease and non-functional GI motility disorders such
as diabetic gastroparesis would be fertile ground for
these studies. The Rome working teams have given
excellent guidance regarding the design of treatment
trials for functional GI disorders.37 It is our task as
investigators and clinicians to take this guidance to the
next step and intensify our study of these disorders
using a biopsychosocial and a biomedical approach.

psychometric assessment, psychopharmacological and

psychotherapy treatment and an increasing body of
evidence to support the relevance of these approaches.
However, the appropriate psychometric assessment of
the GI patient, knowledge of psychopharmacology as it
relates to gastroenterological practice and an understanding of the basic concepts of psychotherapy at least
to where a physician can make an intelligent referral
are critical to implementing this treatment approach.
Clearly, we as gastroenterologists are not currently
equipped to do this. The simple answer is to incorporate behavioural medicine specialists into our training
programmes and clinical practices. This can be accomplished in a number of ways. For years, Family
Medicine has required a behavioural specialist in
residence for their residency programme.36 There is
no reason why this approach is not applicable to
gastroenterological practice. In the GI fellowship
programme at our institution, we have a half time
psychologist who attends all of our gastroenterology
clinics, all our conferences and makes ward rounds on
specific patients where there are relevant behavioural
issues. We have found this to be highly effective in
promoting an understanding of psychometrics, psychodiagnostics and teaching our fellows to be more
effective in referring more patients for formal mental
health treatment. We have a Challenging Patient
Conference as part of our programme, where patients
who have significant behavioural issues related to their
GI disorder (irrespective of GI diagnosis) are presented
and discussed by the entire faculty and trainee group
with the discussion led by our Psychologist or by a
consulting Psychiatrist who participates in our conferences. This conference has gained the notice of the
ACGME during a recent site visit. We have been asked
to share the elements of our programme on their
website. Clearly, there is support from the accreditation infrastructure to this line of education. It is our job
as educators to implement, evaluate and improve this
dimension to GI education. This is not difficult, not
terribly expensive and pays huge educational and
clinical dividends for both our trainees and our
patients. It is the opinion of this educator that in the
years to come this will become a standard component
of gastroenterology training programmes.

SUMMARY
The last 20 years have seen an amazing explosion in
our knowledge regarding psychological aspects of GI
disorders, and functional GI disorders in particular. We
have gained much in terms of our therapeutic armamentarium to intervene with these disorders using
psychotherapeutic and psychopharmacological tools.
However, all knowledge is provisional. We need to
intensify our investigation of the efficacy of these
interventions and to use the technologies available to
us, including brain imaging, pharmacogenetics and
neurochemistry to further develop our understanding
of the mechanism of functional GI disorders, how they
interact with psychological dysfunction and specifically, to look for common mechanisms. This, in turn,
will lead us as a specialty to develop ever more
effective interventions for our long suffering patients.

CONFLICTS OF INTEREST
KWO has received speakers fees and research funding
from Takeda Pharmaceuticals, and has acted as a
consultant to Microbia and to Dynogen Pharmaceuticals.

THE NEED FOR MORE RANDOMIZED

CONTROLLED TRIALS OF BEHAVIOURAL
AND PSYCHOPHARMACOLOGICAL
TREATMENT

REFERENCES
1 Alexander F. Psychosomatic Medicine. New York: W. W.
Norton and Company, 1950: 149 pp.

Despite the advances in the literature regarding the

efficacy of behavioural and psychopharmacological
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Journal compilation  2008 Blackwell Publishing Ltd

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20 Drossman DA, McKee D, Sandler R et al. Psychosocial

factors in the irritable bowel syndrome. A multivariate
study of patients and nonpatients with irritable bowel
syndrome. Gastroenterology 1988; 95: 7018.
21 Talley NJ, Boyce PM, Bronwen KO. Psychological distress
and seasonal symptom changes in irritable bowel syndrome. Am J Gastroenterol 1995; 90: 21159.
22 Gorard DA, Gomborone JE, Libby GW, Farthing MJG.
Intestinal transit in anxiety and depression. Gut 1996; 39:
5515.
23 Sperber AD, Atzmon Y, Neumann L et al. Fibromyalgia in
the irritable bowel syndrome: studies of prevalence and
clinical implications. Am J Gastroenterol 1999; 94: 12.
24 Pinto C, Lele MV, Joglekar AS, Panwar VS, Dhavale HS.
Stressful life-events, anxiety, depression and coping in
patients of irritable bowel syndrome. JAPI 2000; 48: 6.
25 Hiller W, Cuntz U, Rief W, Fichter M. Searching for a
Gastrointestinal Subgroup Within the Somatoform Disorders. Psychosomatics 2001; 42: 1.
26 Gerson CD, Gerson MJ. A collaborative health care model
for the treatment of irritable bowel syndrome. Clin Gastroenterol Hepatol 2003; 1: 44652.
27 Drossman DA, Toner BB, Whitehead WE et al. Cognitivebehavioral therapy versus education and desipramine
versus placebo for moderate to severe functional bowel
disorders. Gastroenterology 2003; 125: 1931.
28 Creed FH, Fernandes L, Guthrie EA et al. The cost-effectiveness of psychotherapy and paroxetine for severe
irritable bowel syndrome. Gastroenterology 2003; 124:
30317.
29 Kathol RG, Stoudemire A. Strategic integration of inpatient
and outpatient medical-psychiatry services. In: Wise MG,
Rundell JR, eds. The American Psychiatric Publishing
Textbook of Conulstation-Liaison Psychiatry. Washington, DC: American Psychiatric Publishing, 2002: 87188.
30 Creed F, Levy RL et al. Psychosocial aspects of functional
gastrointestinal disorders. In: Drossman DA, Corazziari E
et al., eds. Rome III The Functional Gastrointestinal
Disorder, 3rd edn. McLean, 2006: 296368.
31 Innis RB, Malison R. Principles of neuroimaging. In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry/VI, Vol. 1, 6th edn. Baltimore, MD: Williams &
Wilkins, 1995: 89103.
32 Drossman DA, Ringle Y, Vogt B et al. Alterations of brain
activity associated with resolution of emotional distress
and pain in a case of severe IBS. Gastroenterology 2003;
124: 761766.
33 Zubieta JK, Heitzeg MM, Smith YR et al. COMT val158met genotype affects mu-opioid neurotransmitter
responses to a pain stressor. Science 2003; 299: 12403.
34 Diatchenko L, Slade GD, Nackley AG et al. Genetic basis
for individual variations in pain perception and the
development of a chronic pain condition. Hum Mol Genet
2005; 14: 13443.
35 Engel GL. The need for a new medical model: a challenge
for biomedicine. Science 1977; 196: 12936.
36 American Medical Association. Graduate Medical
Education Directory. Chicago, IL: American Medical
Association, 2007.
37 Irvine EJ, Whitehead WE et al. Design of treatment trials for
functional gastrointestinal disorders. In: Drossman DA,
Corazziari E et al., eds. Rome III The Functional Gastrointestinal Disorders, 3rd edn. VA: McLean, 2006: 779834.

2 Hilsabeck R, Hassanein T, Carlson M. Cognitive functioning and psychiatric symptomatology in patients with
chronic hepatitis C. J Int Neuropsychol Soc 2003; 9: 854
874.
3 North CS, Alpers DH. A review of studies of psychiatric
factors in Crohns disease: etiologic implications. Ann
Clin Psychiatry 1994; 6: 11724.
4 Olden KW. The psychological aspects of noncardiac chest
pain. Gastroenterol Clin North Am 2004; 33: 617.
5 Olden KW. Panic attack induced vomiting: clinical and
behavioral characterstics. Am J Gastroenterol 1999; 94:
2614.
6 Locke GR III, Weaver AL, Melton LJ III et al. Psychosocial
factors are linked to functional gastrointestinal disorders:
a population based nested case-control study. Am J
Gastroenterol 2004; 99: 3507.
7 Schwartz SP, Blanchard EB, Berreman CF et al. Psychological aspects of irritable bowel syndrome: comparisons
with inflammatory bowel disease and nonpatient controls.
Behav Res Ther 1993; 31: 297304.
8 Wald A, Hinds JP, Caruana BJ. Psychological and physiological characteristics of patients with severe idiopathic
constipation. Gastroenterology 1989; 97: 9327.
9 Drossman DA, Li Z, Andruzzi E et al. U.S. householder
survey of functional gastrointestinal disorders. Prevalence,
socio-demography, and health impact. Dig Dis Sci 1993;
38: 156980.
10 Briley M, Chopin P. Serotonin in anxiety: evidence from
animal models, in 5-hydroxytryptamine. In: Sandler M,
Coppen A, Harnett S, eds. Psychiatry: A Spectrum of
Ideas. Oxford, NY: Oxford Medical Publications, 1992:
177197.
11 Potter WZ, Manji HK, Rudorfer MV. Tricyclics and tetracyclics. In: Schatzberg AF, Nemeroff CB, eds. The American Psychiatric Press Textbook of Psychopharmacology,
2nd edn. London, England: American Psychiatric Press,
Inc, 1998: 199218.
12 Jackson JL, OMalley PG, Tomkins G et al. Treatment of
functional gastrointestinal disorders with antidepressant
medications: a meta-analysis. Am J Med 2000; 108: 6572.
13 Haddjeri N, Bier P. Sustained blockade of neurokinin-1
receptors enhances serotonin neurotransmission. Biol
Psychiatry 2001; 50: 1919.
14 Crane C, Martin M. Perceived vulnerability to illness in
individuals with irritable bowel syndrome. J Psychosom
Res 2002; 53: 111522.
15 Crane C, Martin M. Adult illness behaviour: the impact
of childhood experience. Pers Individ Dif 2002; 32: 785
98.
16 Levy R, Whitehead W, Von Korff M, Feld A. Intergenerational transmission of gastrointestinal illness behavious.
Am J Gastroenterol 2000; 95: 4516.
17 Creed F. The relationship between psychosical parameters
and outcome in irritable bowel syndrome. Am J Med 1999;
107: 74S80S.
18 Cheng C. Seeking medical consultation: perceptual and
behavioral characteristics distinguishing consulters and
concosulanters with functional dyspepsia. Psychosom
Med 2000; 62: 84452.
19 Levy R, Cain K, Jarrett M, Heitkemper M. The relationship
between daily life stress and gastrointestinal symptoms in
women with irritable bowel syndrome. J Behav Med 1997;
20: 2.

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