Psychological factors in irritable bowel syndrome: a population-based study of patients, non-patients and controls.

BACKGROUND: It has been suggested that psychopathology in irritable bowel syndrome (IBS) patients is a function of patient status rather than of the disease. Although there are many studies comparing IBS patients, IBS non-patients, and controls with each other, no previous study has recruited all three groups from a representative community sample and had all subjects diagnosed by a physician. In the present study we aimed to compare psychological factors in IBS patients, IBS non-patients, and normal controls in a sample recruited from the population. METHODS: Subjects aged 18-45 years were recruited from a random sample of the normal population. Seventeen (2 M and 15 F) IBS patients were matched by sex and age with IBS non-patients and normals. Measures of personality traits, interpersonal distress, and temporary psychological distress were used. A physician diagnosed all 51 subjects in order to exclude possible gastrointestinal diagnoses other than IBS. RESULTS: Controls often differed from IBS non-patients and patients on the personality, interpersonal, and psychological distress measures, while IBS non-patients and patients very rarely differed from each other. All three groups were non-alexithymic. CONCLUSIONS: The results indicate that there are psychopathological differences between normals and IBS persons (patients and non-patients), but they could not confirm that psychopathology was a function of patient status. Whether this psychopathology is a vulnerability factor for IBS, or a consequence of it, remains to be studied.

Psychological Factors in Irritable Bowel Syndrome: a Population-based Study of Patients, Non-patients and Controls.

BACKGROUND: It has been suggested that psychopathology in irritable bowel syndrome (IBS) patients is a function of patient status rather than of the disease. Although there are many studies comparing IBS patients, IBS non-patients, and controls with each other, no previous study has recruited all three groups from a representative community sample and had all subjects diagnosed by a physician. In the present study we aimed to compare psychological factors in IBS patients, IBS non-patients, and normal controls in a sample recruited from the population. METHODS: Subjects aged 18-45 years were recruited from a random sample of the normal population. Seventeen (2 M and 15 F) IBS patients were matched by sex and age with IBS non-patients and normals. Measures of personality traits, interpersonal distress, and temporary psychological distress were used. A physician diagnosed all 51 subjects in order to exclude possible gastrointestinal diagnoses other than IBS. RESULTS: Controls often differed from IBS non-patients and patients on the personality, interpersonal, and psychological distress measures, while IBS non-patients and patients very rarely differed from each other. All three groups were non-alexithymic. CONCLUSIONS: The results indicate that there are psychopathological differences between normals and IBS persons (patients and non-patients), but they could not confirm that psychopathology was a function of patient status. Whether this psychopathology is a vulnerability factor for IBS, or a consequence of it, remains to be studied.

The central relationship questionnaire (CRQ): psychometric properties in a Swedish sample and cross-cultural studies.

The Core Conflictual Relationship Theme (CCRT) method is one of the most widely used and tested instruments developed within a psychoanalytic context for assessing central relationship patterns or characteristic patterns of relating to others. The Swedish version of the Central Relationship Questionnaire (CRQ), a recently developed self-report instrument based on the CCRT, was tested in a sample of Swedish psychology students (31 men, 60 women) and compared with responses of Swedish outpatients (15 men, 15 women) and North American students (49 men, 49 women). The subscales of the Swedish CRQ showed acceptable internal consistency and correlated with each other in a predictable fashion, displaying a pattern of intercorrelations similar to the English version. The CRQ showed meaningful patterns of correspondence with self-reported interpersonal problems as well as meaningful differences between the Swedish students and Swedish outpatients, indicating preliminary convergent and divergent validity.

A population study on irritable bowel syndrome and mental health.

BACKGROUND: Irritable bowel syndrome (IBS) is commonly thought to be associated with psychologic distress. However, in some studies only persons who had sought medical care for IBS (IBS patients) showed an increased frequency of psychiatric symptoms, and nonpatients did not differ significantly from normal subjects. Our aims were 1) to estimate the prevalence of IBS in the population aged 18-45 years, 2) to find the proportion seeking medical care for IBS, and 3) to compare IBS subjects with normals, and IBS patients with IBS nonpatients with regard to mental health. METHODS: Questionnaires on IBS symptoms and the General Health Questionnaire (GHQ) were mailed to 5000 randomly sampled persons aged 18-45 years. The response rate was 58%. RESULTS: IBS was found in 7.4% of the men and 13.3% of the women. Those who had sought medical attention had more severe symptoms. The Likert mean score on the GHQ was 4.7 (95% confidence interval, 4.4-5.0) points higher for the IBS group than for normals (P < 0.001). There was no difference in GHQ scores between IBS patients and nonpatients. CONCLUSIONS: The results indicate that IBS per se is associated with more psychiatric distress, regardless of medical care-seeking. Seeking medical care is associated with more severe IBS symptoms.

What patient characteristics make therapists recommend psychodynamic psychotherapy or other treatment forms?

In order to study factors that psychodynamic therapists considered to be important for recommendation of treatment, psychiatric diagnoses (DSM-III-R Axes I and II and the GAF) as well as character traits assessed by the Karolinska Psychodynamic Profile (KAPP) were retrospectively assessed in interview case-notes of patients applying for psychodynamic psychotherapy. Recommendation of psychotherapy was predicted by the absence of a personality disorder and high GAF scores, but not by the presence of a psychiatric syndrome. The KAPP differentiated between patients with and without disorders on Axis II, but not on Axis I. Patients who were recommended psychodynamic psychotherapy were healthier on all central KAPP variables compared to those who were recommended other treatments, and they were also characterized by predominantly neurotic personality organization, with inhibition as the most prominent defence.

Reliability of the Karolinska Psychodynamic Profile (KAPP) among patients with and without psychoactive substance abuse disorders.

BACKGROUND: The Karolinska Psychodynamic Profile (KAPP) is a rating instrument, based on psychoanalytic theory, that assesses different aspects of character from clinical interviews. The aim of the present study was to examine interrater reliability of the KAPP in a sample of patients with and without psychoactive substance abuse disorders, using interviewers and a reliability judge who had not been trained by the developers of the instrument. METHODS: The sample comprised 47 consecutive patients with and without psychoactive substance abuse disorders, who were referred to an outpatient psychotherapy unit specializing in the treatment of substance abuse and dependence. The two interviewers and the reliability judge had not been trained by the developers of the KAPP, and they worked outside the setting where it was constructed. RESULTS: The intraclass correlations were satisfactory for the total sample (mean 0.84, median 0.89, range 0.62-0.95), as well as for various sub-samples, such as males and females, and patients with and without substance abuse disorders. CONCLUSIONS: The results show that interviewers and a reliability judge who had not been trained by the developers of the KAPP can attain high interrater reliability in a sample of patients with substance abuse disorders. Some recommendations for conducting KAPP interviews are given.

A prospective study of personality as a predictor of quality of life after pelvic pouch surgery.

BACKGROUND: Surgeons often "know" preoperatively which patients will achieve good postoperative quality of life (QOL). This intuition is probably based on impressions of the patient's personality. The present aim was to examine whether preoperative personality traits predict postoperative QOL. METHODS: In 53 patients undergoing pelvic pouch surgery for ulcerative colitis the relationship between preoperative personality traits, and surgical functional outcome and QOL was examined at a median of 17 months postoperatively. Personality assessment instruments (KAPP and KSP), and specific measures of alexithymia were used. Postoperatively, the Psychosocial Adjustment to Illness Scale (PAIS), and surgical functional outcome scales were used. RESULTS: Using multiple correlation/regression, analysis lack of alexithymia, poor frustration tolerance, anxiety proneness, and poor socialization (resentment over childhood and present life situation) were found to predict poor postoperative QOL. CONCLUSIONS: The findings suggest personality traits, in addition to surgical functional outcome, to be important for the patient's postoperative QOL.

Symptoms and character traits in patients selected for long-term psychodynamic psychotherapy.

In this naturalistic study of 55 outpatients selected for long-term psychodynamic psychotherapy, two Swedish assessment instruments are presented (the Karolinska Psychodynamic Profile and the Karolinska Scales of Personality), and the significance of psychodynamic criteria for the selection of patients is discussed. Thirty patients (55%) fulfilled criteria for a DSM-III-R diagnosis. The most prominent psychodynamically defined character pathology was found in the areas of coping with aggressive affects; dependency and separation; frustration tolerance; and impulse control. Some psychodynamically defined character traits, particularly poor frustration tolerance, were related to symptomatic suffering.

Personality predictors of dimensions of psychosocial adjustment after surgery.

OBJECTIVE: Although many studies have examined the relationship between personality factors and adjustment after surgery, most of them have had very short follow-up periods. The present prospective study examines whether preoperative psychodynamic assessment of personality traits enhances prediction of various areas of psychosocial adjustment assessed at least 1 year after surgery. METHODS: In 53 patients undergoing pelvic pouch surgery for ulcerative colitis, we examined the relationship between personality traits measured before surgery, and postoperative psychosocial adjustment assessed at a median of 17 months postoperatively, controlling for the effect of surgical functional outcome. Personality traits were assessed with the Karolinska Psychodynamic Profile (KAPP). Surgical functional outcome scales and the Psychosocial Adjustment to Illness Scale (PAIS) were used. RESULTS: Problems with sexual satisfaction, perfectionistic body ideals, lack of alexithymia, and poor frustration tolerance predicted poor postoperative adjustment in various areas, beyond what was predicted by surgical functional outcome alone. Moreover, moderate preoperative levels of alexithymia were beneficial to postoperative adjustment in the area of psychological distress. CONCLUSIONS: The findings suggest that the preoperative assessment of the patient's long-term sexual functioning and satisfaction, the importance attached to his or her appearance, level of alexithymia, and general capacity to tolerate frustration and set-backs in life, might alert both the surgeon and the patient to potential risk factors for poor postsurgical adjustment.

A prospective study of the quality of life after pelvic pouch operation.

BACKGROUND: For surgeons familiar with pelvic pouch operation, it is disappointing that the patients, although very satisfied to have a pouch instead of an ileostomy, often have difficulty in specifying exactly how their quality of life really has improved. The present study is an attempt to examine this situation. STUDY DESIGN: In 48 patients with ulcerative colitis undergoing pelvic pouch operation, quality of life (QOL) was studied prospectively when the patients had an ileostomy, and at follow-up evaluation at least one year after restitution of anal defecation. The surgeons' evaluation of functional outcome was compared with those of three independent evaluators (the patient, a psychiatrist, and a psychologist). The Psychosocial Adjustment to Illness Scale, the Well-being Profile, the Global Assessment of Function Scale, and surgical evaluation scales were used. RESULTS: As assessed by surgeons using the surgical evaluation scales, functional outcome correlated significantly with most of the assessments of QOL done by the three independent evaluators (the patient, a psychiatrist, and a psychologist). Quality of life did not improve with increasing time, either with an ileostomy or with a functioning pelvic pouch. On most evaluations, there was no further significant improvement in QOL after restitution of anal defecation. CONCLUSIONS: The findings suggest that QOL is already satisfactory after "cure" of the disease, and restitution of normal defecation does not yield much further improvement.

Relationship between components of alexithymia as measured with psychodynamic ratings and subjective lack of well-being.

Two alexithymia-related characterological patterns, identified by means of psychodynamic assessments in a study of patients with ulcerative colitis, were further investigated regarding subjective lack of well-being. The multidisturbed group (with disturbances in interpersonal relations) was symptomatically characterized by more sadness and by less initiative, but manifested less anxiety, enjoyed sex and slept well at night. The inhibited group was characterized by the opposite. The groups could not be discriminated on the basis of their general adaptive level of functioning. Our results suggest that alexithymia may have several dimensions, associated with different characterological disturbances and symptoms.

Stability over time of character assessment using a psychodynamic instrument and personality inventories.

In a group of patients with a preoperative diagnosis of ulcerative colitis, the stability of character traits and modes of mental functioning were studied after a major life event, major abdominal surgery, using the Karolinska Psychodynamic Profile (KAPP), an interview-based assessment instrument founded upon psychoanalytic theory. In addition, different personality and temperamental variables were assessed with 2 self-report instruments. The patients were assessed before surgery, and follow-up was made at least 1 year after their final scheduled surgery. Although the patients had undergone major abdominal surgery and convalescence between the assessments, the correlations between the scores before and after surgery were very high, and the levels of the scores were very similar. This was true for all the instruments, indicating that they assessed stable characteristics in the patients. The changes that did occur were mainly in the predicted direction. The results of this study suggest that the KAPP can assess modes of mental functioning and character traits that are relatively stable and only slowly variable.

The concept of alexithymia: an empirical study using psychodynamic ratings and self-reports.

In patients with ulcerative colitis, alexithymia and related traits were studied using the Karolinska Psychodynamic Profile (KAPP), a recently constructed psychodynamic assessment instrument, and other measures of alexithymia (the Schalling-Sifneos Personality Scale (SSPS) and the Beth Israel Questionnaire (BIQ)), and other personality traits using the Karolinska Scales of Personality (KSP). The results of these measures were analyzed for correlation. The prevalence of mental disorder as defined by DSM-III was not above normal, and the KSP T-scores were within normal limits. As rated with the KAPP, alexithymia was uncorrelated with age or level of education, but was inversely correlated with proximity to a major life event (abdominal surgery), suggesting that alexithymia may have a defensive function. Cluster analysis, with Regression in the service of the ego (R), Alexithymia (A) and Normopathy (N) as clustering variables, yielded 3 groups: normal, multidisturbed (problems with R, A and N) and inhibited (problems with R and N). SSPS failed to distinguish between the multidisturbed and the inhibited groups, and BIQ between any groups. In the multidisturbed group, correlations were found with detachment and with disturbances in interpersonal relations. The results suggest that disturbances in object relations are of major importance in alexithymia.

The Karolinska Psychodynamic Profile. I. Validity and dimensionality.

The Karolinska Psychodynamic Profile (KAPP) is a new rating instrument based on psychoanalytical theory that is intended to assess relatively stable modes of mental functioning, as they appear in self-perception and in interpersonal relations. The 18 subscales of the KAPP and their scale steps are described in detail. The information needed for assessment is obtained through a structural interview procedure. The KAPP can discriminate between patients with and without a DSM-III diagnosis. It does not appear to be sensitive to the strain of a major life event. Comparison between interview-based ratings and projective test-based ratings shows satisfactory agreement and similarities in factor structure. The KAPP appears to possess both discriminative and construct validity.

The Karolinska Psychodynamic Profile. II. Interdisciplinary and cross-cultural reliability.

The Karolinska Psychodynamic Profile (KAPP) is a rating instrument based on psychoanalytical theory, that is intended to assess relatively stable modes of mental functioning, as they appear in self-perception and in interpersonal relations. The 18 subscales of the KAPP and their scale steps are described in detail and kept close to clinically observable phenomena. The information needed for assessment is obtained through a structural interview procedure. The interrater reliability was tested with different Swedish raters with varying psychodynamic training and experience. It was also tested with a non-Swedish rater with psychoanalytic training. The interrater correlations were generally high, suggesting that the KAPP has interdisciplinary and cross-cultural reliability.

Karolinska Psychodynamic Profile. KAPP.

The Karolinska Psychodynamic Profile, KAPP, is a rating instrument founded upon psychoanalytic theory. Its validity is satisfactory, and high interrater reliability can be attained with modest training of the raters in using the instrument. It enables relatively stable and only slowly variable modes of mental functioning and character traits to be assessed psychodynamically. The profile is based upon eighteen subscales, by means of which these modes of mental functioning and character traits can be represented. The subscales have been chosen with a view to obtaining a comprehensive assessment of modes of mental functioning and character traits, as reflected in the patient's self-image and relationships with others. The subscales and their scale steps have been provided with relatively detailed descriptions which are kept close to clinically observable phenomena. The information needed for making the assessments is obtained through a structural interview procedure. The manual, the subscales and their scale steps, and the assessment procedure is presented.