Psychological Characteristics and Quality of Life of Patients With Functional Dyspepsia
Article information
Abstract
Objective
The objective of this study is to compare the psychosocial characteristics of functional dyspepsia (FD) with its subgroups, epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS), against a healthy control group, and to investigate the quality of life (QoL).
Methods
All of the subjects were 210 adults, 131 patients with FD were diagnosed by gastroenterologist and 79 adults with no observable symptoms of FD were selected as the normal control group. Demographic factors were investigated. The Korean-Beck Depression Inventory-II, Korean-Beck Anxiety Inventory, Korean-Childhood Trauma Questionnaire, Multidimensional Scale of Perceived Social Support, Connor-Davidson Resilience Scale, and WHO Quality of Life Assessment Instrument Brief Form were used to assess psychological factors. A one-way analysis of variance was used to compare differences among the groups. Further, a stepwise regression analysis was conducted to determine factors affecting the QoL of the FD group.
Results
Between-group differences in demographic characteristics were not significant. Depression (F=37.166, p<0.001), anxiety (F=30.261, p<0.001), and childhood trauma (F=6.591, p<0.01) were all significantly higher in FD group compared to the normal control. Among FD subgroups, EPS exhibited higher levels of both depression and anxiety than PDS. Social support (F=17.673, p<0.001) and resilience (F=8.425, p<0.001) were significantly lower in FD group than in other groups, and the values were higher in PDS than in EPS. Resilience (β=0.328, p<0.001) was the most important explanatory variable. The explained variance was 46.6%.
Conclusion
Significantly more symptoms of depression, anxiety, childhood trauma was observed for both FD sub-group. These groups also had less social support, resilience, and QoL than the control groups.
INTRODUCTION
Functional dyspepsia (FD) is one of the most common functional gastrointestinal disorders (FGIDs) and comprises various symptoms that appear in the upper abdomen, including epigastric pain, epigastric bloating, early fullness, fullness, nausea, vomiting, and burping. Particularly, FD is a group of heterogenous symptoms involving various pathophysiologies, and the reported prevalence to date is 5%–15% [1]. In terms of diagnosis, it is defined as a syndrome, in which gastrointestinal symptoms appear repeatedly in the absence of organic abnormalities in endoscopic, radiological, and pathological examinations. Especially, since the diagnosis is based on “symptoms,” the ambiguity of the scope has been pointed out [2].
Since the pathophysiology of FD has not been identified to date, the diagnostic criteria for the group with a relatively uniform pathophysiology have been revised several times. Based on the evidence-based guidelines, the 1988 Rome criteria were enacted and have been amended to Rome IV criteria in 2016. To establish a systematic foundation for the diagnosis and treatment of FD, the Rome III criteria has classified FD into two sub-types, postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS), depending on the primary symptoms. This was maintained in Rome IV criteria [3].
As the sub-types of FD, PDS, and EPS are assumed to have different pathophysiologies and mechanisms according to different symptoms, there may be differences in the therapeutic approach. Their pathophysiologies have been studied in terms of dysaccommodation, delayed gastric emptying, and visceral hypersensitivity but these studies failed to identify the pathophysiological mechanisms. Therefore, a multifactorial model, which states that emotional, cognitive, and behavioral factors influence in addition to physiological factors, has garnered considerable attention [4]. Consequently, the theory based on brain-gut interaction has been highlighted in recent years, and the Rome IV criteria also underscores the importance of the biopsychosocial model.
According to the brain-gut interaction, environmental stress factors, changes in cognition following changes in the mood, and the descending brain signal generated by the changing moods may cause gastrointestinal symptoms through the 5-hydroxytryptamine (5-HT)3 and 5-HT4 receptors. Thus, several studies have been conducted on the association between FD and psychological symptoms [5]. In the systemic literature review conducted by Esterita et al. [6], patients with FD demonstrated a significantly higher level of depression and anxiety compared to those in the control group, and a lower response to treatment was associated with a higher severity of psychological symptoms. Childhood traumas, such as sexual and physical abuse, have been known to be negatively correlated with the symptoms in patients with FGID including FD [7], whereas social support and resilience are known to have a positive correlation with FD. Lackner et al. [8] argued that those with a higher level of social support exhibited improved gastrointestinal symptoms, such as abdominal discomfort, while a lower level of social support was associated with worsening symptoms.
Quality of life (QoL) refers to the state of physical health, functioning, psychological state and well-being, social interaction, economic and occupational status, or religious or spiritual state as perceived by the individual in their life concerning their goals, expectations, standards, and interests amid the culture and value system to which the individual belongs [9]. Previous reports have stated that the QoL in patients with FGIDs, including FD, is lower in comparison to that of healthy individuals [10]. It is well established that psychosocial factors, such as depression and anxiety, significantly influence the symptoms of FD and the QoL of patients with FD [11,12].
Although psychosocial factors are critical in understanding FD, only a few studies have examined them in association with FD. To the best of our knowledge, no study to date compared the psychosocial characteristics of the two subgroups, EPS and PDS. Therefore, we aim to examine the psychosocial characteristics of patients with FD by classifying them into two subgroups, EPS and PDS, as well as identify the factors that influence the QoL in these patients. We would like to see an overall hypothesis about the relationship between higher depression and anxiety in FD patients (and the differences, if any, between subgroups) and variables such as childhood trauma history, social support, resilience, and QoL.
METHODS
Participants
This study was conducted from May 2020 to December 2022 and included patients who visited the brain-gut mental health clinic at a university hospital who had been diagnosed with FD by a gastroenterologist. A total of 131 patients with FD (EPS, n=72; PDS, n=59) were studied. The control group included 79 public officers from an arbitrary city who did not have FD symptoms according to the Rome IV criteria. The objectives of the study were explained to the participants and they were asked to provide informed consent to participate in the study. This study was approved by the Institutional Review Board (IRB) of the Wonkwang University Hospital (IRB number: WKUH 2020-04-006).
Depression
Depression was diagnosed using the Korean Version of the Beck Depression Inventory Second Edition (K-BDI-II). K-BDI-II is a self-reported scale consisting of 21 questions on the psychological, cognitive, and physiological symptoms of depression. Each question is rated on a 4-point scale ranging from 0 to 3 points. Scores of <9, 10–15, 16–23, and 24–63 points indicate normal condition, mild depression, moderate depression, and severe depression, respectively. The K-BDI-II was translated into Korean by Sung et al. [13] and evaluated for validity and reliability.
Anxiety
As a tool for measuring anxiety, the Korean Version of the Beck Anxiety Inventory (K-BAI) was used. K-BAI comprises 21 questions on the cognitive, behavioral, and physical domains of anxiety. In this scale, each participant rates the level of each symptom of anxiety he/she experienced in the past week on a 4-point scale ranging from 0 to 3 points. The reliability of the K-BAI has been evaluated by Yook et al. [14] An anxiety scale score of 22–26, 27–31, and ≥32 points indicates anxiety, severe anxiety, and extreme anxiety, respectively.
Childhood trauma
Childhood trauma was assessed using the Korean version of the Childhood Trauma Questionnaire (K-CTQ). The K-CTQ comprises 28 questions under the validity scale and five sub-scales for emotional neglect (failure to provide basic emotional needs), physical neglect (failure to meet basic physical needs, such as food and safety), emotional abuse involving threats using words or actions, physical abuse involving an attack on the body resulting in injury, and sexual abuse involving forced sexual activity. Each question is rated on a 0–4-point scale, with higher scores indicating severe traumatic experiences in childhood. The study on the validity of K-CTQ was conducted by Kim et al. [15].
Social support
To measure the extent of social support as perceived by an individual, the Multi-dimensional Scale of Perceived Social Support (MSPSS) developed by Zimet et al. [16] was used after validation of the Korean version by Shin et al. [17] MSPSS is a self-reported scale comprising 12 questions developed to measure the perceived level of social support from human resources, such as family, friends, and significant others. Each question is measured on a 1–5-point scale, with higher scores indicating a higher level of social support.
Resilience
Resilience was measured using the Korean Version of the Connor-Davidson Resilience Scale developed by Conner and Davidson [18] and validated by Baek et al. [19] It comprises 25 questions under five factors, including hardiness, persistence/tolerance, optimism, support, and spirituality. Each question is rated on a 5-point scale ranging from 0 (strongly disagree) to 5 (strongly agree), with higher scores indicating a higher resilience.
QoL
QoL was measured using the Korean Version of the World Health Organization Quality of Life Assessment Instrument Brief Form, which was developed by the World Health Organization Quality of Life Group and validated by Min et al. [20] This tool comprises 24 questions covering four domains, including physical, psychological, and social health, and living environment. Each question is rated on a 1–5-point scale, with higher scores indicating a higher QoL.
Statistical analysis
The demographic and psychosocial characteristics were compared between the groups. Continuous variables were reported in terms of means and standard deviations while categorical variables were reported in terms of frequencies and percentages. A one-way analysis of variance was used to compare intergroup differences. The stepwise regression analysis was conducted to examine the psychological factors that influence the QoL in patients with FD. The Statistical Package for the Social Sciences (Version 21; IBM Corp., Armonk, NY, USA) was used for data analysis.
RESULTS
Demographic and clinical characteristics of the participants
There were no significant intergroup differences in terms of age, sex, marital status, education, income, smoking, alcohol, and chronic diseases (Table 1).
Demographic and clinical characteristics of the participants
Comparison of depression among EPS, PDS, and healthy control
In the subdomains of depression, emotional depression showed significant intergroup differences among patients with EPS (10.11±5.74), PDS (7.02±4.39), and healthy controls (4.05±3.91) (F=30.802, p<0.001), with post-hoc results showing that the order was EPS, PDS, and healthy control. In the context of cognitive depression, there were significant intergroup differences among patients with EPS (5.24±4.38), PDS (3.32±3.48), and healthy controls (1.75±2.17) (F=19.642, p<0.001), with the post-hoc results indicating the order as EPS, PDS, and healthy control. Regarding somatic depression, a significant intergroup difference was found among patients with EPS (6.72±2.85), PDS (6.54±2.74), and healthy controls (3.38±2.33) (F=37.866, p<0.001), with the post-hoc analysis revealing that the results for patients with EPS and PDS were higher than those of healthy controls. There was a significant difference in the sum of depressive symptoms among patients with EPS (22.08±11.58), PDS (16.68±8.45), and healthy controls (9.18±7.23) (F=37.166, p<0.001), and the post-hoc results showed that the results were in the order of EPS, PDS, and healthy control (Table 2).
Comparison of depression among EPS, PDS, and healthy controls
Comparison of anxiety among EPS, PDS, and healthy control
Regarding the sub-domains of anxiety, reflecting subjective showed significant intergroup differences among patients with EPS (4.60±4.44), PDS (4.00±3.81), and healthy control (1.32±2.03) (F=18.523, p<0.001), and post-hoc results demonstrated that the results for patients with EPS and PDS were higher than those of healthy controls. In the neurophysiological domain, there was a significant intergroup difference among patients with EPS (5.38±4.49) and PDS (4.20±3.58), and healthy controls (1.51±1.85) (F=25.518, p<0.001), while the posthoc analysis results showed that the values of patients with EPS and PDS were higher than those of healthy controls. In the autonomic domain, there was a significant intergroup difference among patients with EPS (2.43±2.62) and PDS (2.03±1.95), and healthy controls (0.52±1.06) (F=19.923, p<0.001), as posthoc results showed that the values of patients with EPS and PDS were both higher than those of healthy controls. In the context of panic symptoms of anxiety, there was a significant intergroup difference among patients with EPS (3.68±2.56) and PDS (3.31±2.18), and healthy controls (1.06±1.57) (F=33.207, p<0.001), with the post-hoc analysis results showing that the values of patients with EPS and PDS were both higher than those of healthy controls. In the context of the sum of anxiety, there was a significant intergroup difference among the values of patients with EPS (16.08±12.52) and PDS (13.54±9.97), and healthy controls (4.41±5.67) (F=30.261, p<0.001), with posthoc analysis results showing that the values of patients with EPS and PDS were both higher than those of healthy controls (Table 3).
Comparison of anxiety among EPS, PDS, and healthy controls
Comparison of childhood trauma among patients with EPS, PDS, and healthy controls
Regarding the sub-domains of childhood trauma, there were no significant intergroup differences found for emotional neglect, physical abuse, sexual abuse, and emotional abuse. For physical neglect, significant intergroup difference was found among patients with EPS (10.74±2.61) and PDS (10.92±2.49), and healthy controls (8.75±3.40) (F=12.553, p<0.001), while post-hoc analysis results showed that the values of patients with EPS and PDS were both higher than those of healthy controls. In the sum of childhood trauma, significant intergroup differences were found among patients with EPS (43.01±10.78) and PDS (42.10±9.85), and healthy controls (37.41±9.77) (F=6.591, p<0.01), and post-hoc analysis results showed that the values of patients with EPS and PDS were both higher than those of healthy controls (Table 4).
Comparison of childhood trauma among EPS, PDS, and healthy controls
Comparison of resilience and social support among patients with EPS, PDS, and healthy controls
Regarding resilience, there were significant intergroup differences among patients with EPS (55.36±18.24) and PDS (62.97±20.46), and healthy controls (67.92±18.15) (F=8.425, p<0.001), and posthoc analysis results showed that the values of patients with EPS were higher than healthy control. In the context of social support, there were significant intergroup differences among patients with EPS (31.14±9.10) and PDS (34.10±8.56), and healthy controls (39.06±7.22) (F=17.673, p<0.001), and post-hoc analysis results showed that the values of patients with EPS and PDS were both lower than those of healthy controls (Table 5).
Comparison of resilience and social support among EPS, PDS, and healthy controls
Stepwise regression analysis of QoL among the patients with FD
In the stepwise regression model using QoL as the dependent variable of patients with FD, resilience (β=0.328, p<0.001), depressive symptoms (β=-0.330, p<0.001), and social support (β=0.244, p<0.001) were included to represent 46.6% (F=38.836, p<0.001) of the total explanatory variance (Table 6).
Stepwise regression analysis of QoL among the patients with FD (N=131)
DISCUSSION
In this study, we aimed to examine the differences in the psychosocial characteristics of FD by classifying the sub-types into EPS and PDS and identifying the effects of those psychosocial factors on the QoL in patients with FD.
Demographic factors did not show a significant difference between EPS and PDS. Previous studies have reported a higher prevalence of FGIDs in women, which may be interpreted as the differences in genetic, physiological, and biochemical responses, resulting in the corresponding differences in hormones, visceral hypersensitivity, cytokines, and brain functioning [21]. Porcelli et al. [22] reported that patients with FGIDs with high levels of education tend to accurately perceive and express emotions whereas those with low levels of education may exhibit maladaptive disease behavior. Regarding age, the incidences of functional esophageal disorders and dyspepsia decrease with increasing age, while reports are stating that the incidence of irritable bowel syndrome (IBS) also typically decreases with increasing age owing to the changes in pain perception, although some studies have reported an increase in incidence, from 8% for ages of 65 and 74 years to 12% in individuals aged ≥85 years [23-25]. Unfortunately, there have been no reports on the differences in the demographic characteristics of FD, specifically between patients with EPS and PDS. However, in the intervention for FD, it would be important to understand through this study that the effect of a single demographic factor on the sub-symptoms of FD is limited while understanding the psychological characteristics represented by these factors.
In this study, both anxiety and depression were found to be high in patients with DPS and PDS compared to healthy controls. Many existing studies have reported the correlation between FD and depression and anxiety [26-29]. Such correlation can be explained by the fact that the cytokines secreted as a result of low-grade gut inflammation change the function of the central nervous system [30]. In addition, it can also be explained by the fact that the increase in the secretion of corticotropin-releasing hormone caused by anxiety results in FD by promoting eosinophils degranulation and increasing the amount of cytokines, such as tumor necrosis factor-alpha [31]. Specifically, in this study, among the sub-factors of depression, emotional and cognitive depression was higher in EPS compared to PDS. In general, depression is explained by cognitive-affective and somatic dimensions [32]. Cognitive-affective dimension includes negative mood and negative affect whereas the somatic dimension includes fatigue or loss of energy [33]. In this study, the differences in emotional and cognitive depression seem to have been caused by pain acting as the major factor. In the case of IBS, a representative FGID syndrome, repetitive pain is known to be the major cause of damaging functionality in the patient [34]. Emotional depression is important in understanding pain because emotional depression causes an individual to constantly reflect on the physical challenges faced in situations of external stress or internal conflict [35]. Consequently, the individual is more focused on the pain, leading to a persistent experience of pain [36]. Moreover, the catastrophizing effect shown in emotional and cognitive depression magnifies the negative aspects of pain, resulting in feelings of despair and difficulty in coping with pain [37]. In a study conducted on patients with fibromyalgia, the patients who tended to catastrophize showed neural activation in the affective regions as well as the secondary somatosensory cortex of the brain in response to a pain stimulus. This can be interpreted as a demonstration of the correlation between catastrophizing and negative affect [38]. Thus, the difference between EPS and PDS for emotional and depression unlike somatic depression may suggest a correlation with pain typically accompanied in EPS in comparison to PDS. In anxiety, there was no significant difference between PDS and EPS. In the tripartite model for depression and anxiety that includes positive affect (PA), negative affect (NA), and physiological hyperarousal (PH), depression has low PA and high NA whereas anxiety has high NA and high PH. Further, in terms of the psychopathological aspect, depression is a more severe type of psychopathology that is above the level of anxiety [39]. In a study by Lee et al. [40], the impact of anxiety was significant in the comparison of healthy controls and the FGIDs group (odds ratio [OR], 10.21; 95% confidence interval [CI], 2.49–41.76), but when the number of visits to the medical institutions was compared among those with FGIDs, the group that visited medical institutions (exhibiting severe symptoms) showed a high risk of depression (OR, 5.554; 95% CI, 2.06–14.97). As this study included patients who visited medical institutions with symptoms of FD, the effects of anxiety were relatively small and the difference between PDS and EPS may have not been significant because of this issue.
Psychological trauma such as abuse or neglect experienced during childhood affects the expression and worsening of FGID symptoms [41,42]. The known causes include the following points: 1) accompanying or experiencing severe psychological distress and complaints of frequent physical symptoms [43,44], 2) maladaptive coping mechanisms [45], 3) dysfunction in interpersonal relationships in adulthood [46], 4) reduction in the threshold of receiving afferent gastrointestinal signals from the central nerve, and 5) the increase in autonomic nervous system activity and gastrointestinal motility due to hyperarousal [47]. However, in this study, there was no difference in K-CTQ between PDS and EPS. In older adult individuals, assessment of retrospective self-reported childhood trauma can be easily influenced by recall and selection biases [48]. Considering that the subjects of this study were older adults, it is highly likely that the recall bias influenced the data on childhood trauma, which led to under-reporting. Thus, in the psychological approach for FD, it is important to focus on the current psychological symptoms based on past distress and develop suitable intervention strategies.
There was no difference between EPS and PDS in the context of social support. Patients with FGIDs are often overlooked by clinicians without receiving proper support or education on the disease despite the discomfort due to symptoms and functional decline [49]. Social support is defined as the resources or interaction provided by others who can help individuals cope with difficulties [50]. The role of social support can be divided into the following two categories: The first category represents the scenario in which the support helps the individuals concerned to continuously have positive experiences to create stable, socially rewarding roles [51]. Through this, it plays an instrumental role in encouraging the patients to maintain specific health-protective behaviors, such as adhering to medical recommendations, exercising, eating nutritional food, and quitting smoking. The second category represents social support that acts as a buffer or attenuates the effects of stress [52]. Previous studies have reported that when a member of a social network provides individuals with proper support, the individuals demonstrated improved health by responding to stressful life events [53]. Thus, adequate education and support on the disease provided by medical staff in a clinical setting would be particularly important in FD cases.
Resilience is the dynamic process of showing positive adaptive skills by an individual who experienced significant adversity or trauma and represents the ability to respond to stress [54]. Highly resilient, individuals not only show psychological and physical health states but also have the comprehensive ability to appropriately respond to various work and social situations [55]. In long-term FGID cases, patients ultimately experience psychological symptoms, such as depression and anxiety, and the important factor in overcoming these psychological symptoms is resilience [56]. In this study, there was no difference among EPS and PDS cases. However, it was significantly lower when compared to healthy controls. Thus, it is evident that meditation utilizing psychotherapy or mindfulness that can amplify the internal resilience of patients with FD would be effective in the treatment of FD.
QoL is a concept that encompasses overall physical, emotional, and spiritual well-being. While depression, anxiety, or distress are factors that reduce the QoL, social support or resilience are known to be the protective factors of QoL [9]. Patients with FGIDs report a QoL that is significantly lower than that of healthy individuals [10]. In a stepwise regression analysis conducted to identify the factors that affect QoL in patients with FD, significant factors included resilience (β=0.328, p<0.001), depression (β=-0.330, p<0.001), and social support (β=0.244, p<0.001), as they accounted for 46.6% of the total explanatory variance for QoL. Thus, attention is required for various psychosocial and psychological factors, including depression in clinical settings, to improve the symptoms of FD and QoL.
This study had several limitations. First, as a cross-sectional study, this study had a limitation in identifying the causal relationship between each variable. Second, the reliability of the study results was limited owing to the possibility of recall bias and under-reporting inherent in retrospective data collection based on self-reported questionnaires. Third, the effects of regional characteristics and treatment environment could not be ruled out as the population was restricted to patients who visited a university hospital in an arbitrary area. Fourth, there was a lack of collected information from young patients as the mean age of the participants was the late 50s. Fifth, covariate factors were not specified during the analysis. Further explanation is needed on this matter.
Despite these limitations, this study had high reliability and was scientifically designed as it assessed psychological symptoms since a psychiatrist conducted psychiatric interviews with patients who were diagnosed with FD after undergoing a physiological test by a gastroenterologist. Moreover, the effects of psychological factors were greater in patients with EPS than in PDS; such results suggest a theoretical basis for empirical understanding that tricyclic antidepressant that control symptoms by acting on pain pathway is mostly used for EPS in clinical settings, while selective serotonin reuptake inhibitor and psychological interventions, such as psychiatric treatment and cognitive-behavioral therapy, are effective for PDS. Therefore, various psychological approaches suitable for the symptoms of each patient should be incorporated into the treatment of patients with FD in the future.
Notes
Availability of Data and Material
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
Author Contributions
Conceptualization: Seung-Ho Jang, Sang-Yeol Lee. Data curation: Su-Woo Lee, Seung-Ho Jang. Formal analysis: Suck-Chei Choi, Han-Seung Ryu. Funding acquisition: Sang-Yeol Lee. Investigation: Su-Woo Lee, Seung-Ho Jang, Suck-Chei Choi, Han-Seung Ryu. Methodology: Seung-Ho Jang, Sang-Yeol Lee, Chan-Mo Yang. Software: Chan-Mo Yang. Validation: Su-Woo Lee. Writing—original draft: Su-Woo Lee, Seung-Ho Jang, Sang-Yeol Lee. Writing—review & editing: Seung-Ho Jang, Sang-Yeol Lee, Su-Woo Lee.
Funding Statement
This paper was supported by Wonkwang Institute of Clinical Medicine in 2020.
Acknowledgements
None