Gastrointestinal Disorders Francis Creed, M.D., FR.C.P, ER.C.Psych., FMed.Sci. Kevin W. Olden, M.D. THE CLOSE RELATIONSHIP between the gut and the psyche means that there are many examples of biopsychosocial rela- tionships in the patient population seen by gastroenterologists. The consulting psy- chiatrist can expect to see a large number of patients with functional gastroentero- logical disorders, which comprise approxi- mately half of all patients seen by gastro- enterologists (Thompson et al. 2000). Psychiatrists in medical settings can also expect to see patients with organic diseases, such as liver disease and inflammatory bowel disease, where psychiatric disorders can influence management and outcome. Some patients are seen routinely by psy- chiatrists prior to liver transplant (see Chapter 14, “Organ Transplantation”) or before the start of interferon treatment for chronic hepatitis C. Functional Gastrointestinal Disorders ‘The broad categorization of disorders into {functional and organic (or structural) has helped to facilitate research into the psy- chological factors that are important in the functional disorders. It has also helped with the adaptation of the biopsychosocial model in gastroenterology (Drossman 1998; Drossman et al. 1999). The functional and organic termin- ology may, however, reinforce dualistic thinking—the separation of mind and body. Furthermore, some gastroenterologists falsely equate functional with psychiatric, which leads them to ignore psychiatric disorders in patients with organic disease In clinical practice, the identification and treatment of psychiatric disorders in patients with gastrointestinal (GI) disorders can be very rewarding. Many patients with functional GI disorders may experience considerable improvement in their symp- toms when a concurrent psychiatric disor- der is successfully identified and treated. In structural (organic) disorders, the GI symp- toms may not change as dramatically when coexisting depression or anxiety is treated, but patients may experience substantial im~ provement in their health-related quality of life—that is, they can cope with their symp-ESSENTIALS OF PSYCHOSOMATIC MEDiciye toms, treatment, and lifestyle changes much more successfully. The Relationship Between tric Disorders and Gastrointestinal Diseases (Our understanding of the relationship be~ tween psychiatric and GI disorders has developed considerably over the last ovo decades. The Diagnostic and Statistical Manual of Mental Disorders (DSM; Ameri can Psychiatric Association 2000) has been mirrored by a similar symptom-based clas- sification of the functional GI disorders, the so-called Rome criteria (Drossman et al. 2000a). Such a classification has caused much discussion among gastroenterolo- gists, who are used to making diagnoses on the basis of observable structural abnor- malities. This has implications for clinical practice because some gastroenterologists may give the impression to patients that complaints based on structural abnormali- ties of the gut are “real,” whereas com- plaints without any abnormalities seen on endoscopy or imaging studies may be dis- missed as they turn out to be “only” fanc~ tional. When this occurs, the psychiatrist must first deal with patients feeling angry or devalued before a full clinical appraisal of symptoms is commenced (Creed and Guthrie 1993; Guthrie and Creed 1996). Peptic Ulcer Ithas been estimated that approximately 10% of individuals in Western countries will develop a peptic ulcer sometime dur- ing their lifetime (Rosenstock and Jor- gensen 1995). The two major risk factors associated with the development of both gastric and duodenal ulcers are the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and the presence of infection with Heliobacter pylori (Kurata et al. 1997), However, despite the importance of py, Iori in the etiology of peptic ulcer, signe. cant psychosocial dimensions remain yj, considered with this disorder. Prevalence of Psychiatric Disorders Although the prevalence of anxiety and de. pressive disorders appears increased in pa. tients with peptic ulcer disease (Table 4-1), this is not a firm conclusion because of methodological weaknesses with man studies (Lewin and Lewis 1995). One of the most comprehensive studies included patients with peptic ulcer and inflamma. tory bowel diseases of recent onset (Craig 1989); 16% of patients had definite psychi- atric disorders, and a further 32% had bor- derline (“subthreshold”) psychiatric disor- ders. Subthreshold disorders may impair health-related quality of life and lead to a worse prognosis, so psychiatric or psycho- logical treatments should not be confined to people who meet the DSM criteria for a psychiatric disorder (Creed et al. 2002). The onset, perpetuation, and recur- rence of peptic ulcers are associated with stressful life events. This has been demon- strated after earthquakes, where stress and the presence of H. pylori interacted (Mat- sushima et al. 1999). Onset or relapse of peptic ulcer disease is associated with chronic stressors involving goal frustra- tion, in which the individual is repeatedly prevented from reaching a much-treasured goal (Craig 1989; Ellard et al. 1990). Such frustration may reflect a personality type associated with continuing to strive toward a goal even when success is unlikely. ‘The personality traits of social with- drawal, suspiciousness, hostility, and de- pendency may be associated with increased Cigarette and alcohol consumption, which contributes to development of peptic ul- cers (Levenstein 2000), Psychosomatic medicine specialists should be prepared to discuss these finding with patients as part ofa strategy to prevent59 Gastrointestinal Disorders seep nog Asonrurrep = pgescave npeps woven anoueiq este FOS wossexdac sIpRas aBo.owPHEE 20} 2H)" C-SI MN 15 woreda pur ferry ‘dnos¥ jonvo> oN, 1% 8 asa sciooa8 cig wo2s99 200009419 ON ov a Savi sdnoa8 qT woamteq au92aH1P ON, a $00 a-sao ‘sdnoaB qq] wong 29U922H1P ON, st oF sia (qussms) 29 ssoo(qns jonoo wr wen 2:07y (ounay) 22 0s Tose BW (eonsasdep) or Coed) st ssoa(qns jonoo ur wexp aousyesoid 210245) aur) 92 ts mewsasia 1361 2 seu, sdnox8 sayeo aaron por aseanp gujoxr u29s309 25H? ON ff wr TIEWsa 861-182 s825pay (cog) suoned 1 sera somyfiog, Ayeoxpoue soxpo wr req o1 sens 2013]8490 9 0s protsonut senenpésd porparpumis za6t 1829 27H quewuioy —_soplosip une yPksd “ou ‘eunseaus 49ps051P ems yyya auodi0d reren ounenphsd ‘syuajyed aseosip 5,U4O1) ‘pue spijo> eanes92in, aseosip jomoq Goveunueyjul wim siuapied ul Jopsosip 2unenpAed yo e>ucjeneid “Z-P 31EVE60 ESSENTIALS OF PSYCHOSOMATIC MEDICINE 20 EERE Se cae Se TABLE 4-3. Rome ll criteria for irritable bowel syndrome ‘Atleast 12 weeks or more, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has two out of the following three features: + Relieved with defecation © Onset associated with a change in frequency of stool + Onsetassociated with a change in form (appearance) of stool Symptoms that cumulatively support the diagnosis of irritable bowel syndrome: + Abnormal stool frequency (for research purposes, “abnormal” may be defined as ‘more than three bowel movements per day or less than three bowel movements per week) ‘+ Abnormal stool form (lumpy/hard or loose/watery stool) * Abnormal stool passage (strai urgency, or feeling of incomplete evacuation) + Passage of mucus * Bloating or feeling of abdominal distension compasses the functional esophageal disor- ders, such as noncardiac chest pain and functional dysphagia; functional dyspepsia (previously called nonulcer dyspepsia); IBS; and functional constipation, func- tional diarrhea, and functional abdominal pain, The sine qua non of a functional GI disorder is the lack of structural or bio- chemical abnormalities that could explain the patient’s symptoms, which requires that the diagnosis of functional GI disor- ders be symptom based. ‘The most common functional GI dis- order is IBS, which comes in three general clinical forms: with constipation, with di- arthea, and with an alternating pattern of diarrhea and constipation. The diagnostic criteria for IBS are outlined in Table 4-3 Prevalence of Psychiatric Disorders “The prevalence of anxiety, panic, and mood disorders in patients attending gastroenter- ology clinics with functional bowel disor. ders (50%-60%) is approximately twice that of IBD (Drossman et al. 2000a, 2002), “The prevalence is similar across diagnostic groups such as patients with IBS, functional dyspepsia, functional abdominal pain, and noncardiac chest pain (Biggs 2004; Dime- nas et al. 1995), Anxiety is more prominent in first-time attenders, but depression seems more prominent in those who have chronic symptoms and who have been at- tending the clinic over a long period with- out remission (Guthrie et al. 1992). Panic disorder is frequent in some specialist settings (Lydiard et al. 1993). High levels of psychological distress are found in peo- ple who have numerous bodily symptoms outside of the GI tract (so-called extrain- testinal symptoms), including fibromyal- gia (Sperber et al. 2000; Whitehead et al. 2002). The onset of anxiety or mood disorder precedes or coincides with the onset of the bowel disorder in approximately two- thirds of IBS patients (Craig 1989; Ford et al, 1987). This suggests a close link be- tween the psychiatric disorder and gut symptoms. The presence of (untreated) psychiatric disorder predicts a poor out- come, and conversely, reduction of psychi- atric symptoms is associated with reduc- tion of bowel symptoms (Creed 1999). Stress precedes the onset of functional bowel disorders, whether there is concur- rent psychiatric disorder or not (Creed et al, 1988; Drossman et al. 1988). The most common stresses relate to difficult per- sonal relationships—marital separations, divorce, and other relationship breakups. Many patients tend to deny the impor- tance of such events and claim that any psychological or social difficulties are theGastrointestinal Disorders result of the bowel disorder rather than stress. Careful history taking with suf- ficient attention paid to time course of events will usually demonstrate the correct sequence. Social stress is also the single most im- portant predictor of outcome in patients with IBS who attend a gastroenterology clinic (Bennett et al. 1998). Failure to ad- dress the stressor(s) may therefore lead to persistent symptoms. Some patients are reluctant to discuss social stress, protest- ing that it is unrelated to the bowel disor- der (Creed and Guthrie 1993). For most patients, however, a clear explanation of, the purpose of doing so leads to a fruitful discussion. For example, a series of pa- tients with dyspepsia were asked to list their main complaints, and about two- thirds spontaneously mentioned “anxiety” before “dyspepsia”; therefore, an open question may enable the psychiatrist to rapidly elicit a person's concerns (Haug et 1.1995). Health-Related Quality of Life ‘Anxiety and mood disorders play a large part in the impairment of health-related ‘quality of life observed in IBS (Creed et al 2001; Walker et al. 1995; Whitehead etal 1996). As in other medical conditions, the effects of physical and psychological symptoms are approximately additive in terms of their effect on quality of life (Creed et al. 2001, 2002). In dyspepsia, psychological distress is a better predictor ofhealch-related quality of life than the se- verity of the dyspepsia (Quartero et al 1999), and the considerable impairment of health-related quality of life attributed to TBS may be the result of concurrent psy- chiatric disorders (Creed et al. 2005; Drossman et al. 2000b). In other words, there is a good prospect of improvement of health-related quality of life when the anxiety or mood disorder is satisfactorily 61 treated, as has been demonstrated with both antidepressants and psychotherapy (Creed et al. 2003; Drossman et al. 2003; Guthrie etal. 1991; Hamilton etal. 2000), Relationship Between Health Care Utilization and Psychological and Disease-Related Variables ‘Many people with functional dyspepsia or TBS do not consult a doctor (Drossman et al. 1988). Those who do so have more se- ‘vere abdominal pain than nonconsulters, but they also have more anxiety and de~ pression and, in particular, more worries about their health—especially fears of cancer (Creed 1999; Gomborone etl. 1995; Kettell et al. 1992; Koloski et al. 2003; Lydiard and Jones 1989). Adequately ad- dressing these worries in the gastroenter~ ology clinic may lead to fewer subsequent visits (van Dulmen et al. 1995). Psychia- trists should routinely ask about such fears and be prepared to deal with them directly, because they often persist even after diag nostic investigations have been normal (Lucock etal. 1997). ‘The sources of persistent health anxi~ ety are not fully understood, but lack of social support and early life experience, in- cluding illness in the family, abuse, or ne- lect, both may play a part (Biggs et al. 2003; Whitehead et al. 1982). It is crucial for the psychiatrist to fully explore con- cerns about serious illness with the pa- tient; such concerns are often related to illness in family members or remarks made to the individual by a physician that play oon the patient's mind. Sexual Abuse and Functional Gastrointestinal Disorders ‘There is an established literature demon- strating an association between IBS and a history of childhood sexual abuse (Delvaux et al. 1997; Drossman et al. 1990, 1995; Leserman et al. 1996, 1998; Walker et a.62 ESSENTIALS OF PSYCHOSOMATIC MEDICINE 1995), although there are some inconsis- tencies (Biggs 2004; Talley etal. 1995), in- cluding in population-based studies (Tal- ley et al. 1998). It appears that a history of sexual abuse might be a predictor of chro- nicity and severity of a disorder (Long- streth et al. 1993) and may not be specific to IBS (Katon etal. 2001). Reported childhood sexual abuse or related trauma is associated with increased health care utilization in functional bowel disorders (Biggs et al. 2003; Guthrie and Creed 2003; Leserman et al. 1998). Self- reported abuse is associated with com- plaints in adulthood of a greater number of bodily symptoms; this may be associated with a lower pain threshold and a tendency to be hypervigilant about bodily symptoms (Galmon et al. 2003). Perhaps the mecha- nism most commonly involves mood, panic, and other anxiety disorders, which occur in those subjected to abuse during childhood (Blanchard et al. 2002). As we have seen, these psychiatric disorders are ‘more common in functional bowel disor- ders than organic GI diseases, and they are independently associated with higher health care utilization in IBS (Budavari and Olden 2003). In clinical practice, it is important for psychiatrists to routinely assess possible childhood abuse in patients with functional GI disorders, especially those who have not responded to treatment. Whatever the type of disorder, patients will usually not have had the opportunity to speak to their gastroenterologist about such intimate as- pects of their life (Drossman et al. 1990). Other Functional Gastrointestinal Disorders The other functional GI disorders, for ex- ample, gastroesophageal reflux, globus, functional abdominal pain, and cyclic vomiting, are described in the Rome book (Drossman et al. 20002). They often co- exist with other functional GI disorders, and their features are very similar to the two disorders described here; anxiety and depression are common. Clinical assess- ‘ment and treatment follow the general pattern described in this chapter, with the exception that speech therapy may be helpful for globus (Khalil et al. 2003). Liver Disease ‘A variety of liver diseases are important in psychosomatic medicine. We focus here primarily on hepatitis C virus (HCV) in- fection. Viral hepatitides are also discussed in Chapter 10, “Infectious Diseases.” In the developed nations, alcohol is the most common cause of liver disease. Most forms. of chronic liver disease can result in cirrho- sis, leading to hepatic encephalopathy, which may manifest with symptoms of psy- chosis, mania, depression, apathy, or con- fusion before becoming a frank delirium Wieperink et al. 2000) (see Chapter 14, “Organ Transplantation”). Wilson's disease (Chapter 15, “Neurology and Neurosur- gery”) and the porphyrias (Chapter 6, “En- docrine Disorders”) are rare diseases affect- ing the liver whose first symptoms may be psychiatric. Fatigue is a common symptom in liver disease and may be caused by the disease, its treatment, or a comorbid depression. In one study of patients with primary biliary cirrhosis, fatigue was more closely associ- ated with depression than with liver dis- ease (Cauch-Dudek et al. 1998). Depres- sion is also common in people undergoing liver transplantation, and there is some ev- idence that the depression may improve following transplantation (see Chapter 14, “Organ Transplantation”), Chronic liver disease leads to signifi- cantly impaired health-related quality of life; successful treatment, either by tans- plant or by antiviral treatment, may lead to improvement (De Bona et al. 2000; Diep-Gastrointestinal Disorders rink et al. 2000). Depression also predicts impaired health-related quality of life (Fontana et al. 2001). Thus, treatment of depression in patients with chronic liver disease is important for three reasons: in its own right, to improve health-related quality of life, and to facilitate treatment of liver disease. Chronic Hepatitis C Virus Infection Chronic HCV (previously known as non-A, non-B hepatitis) has become the major cause of chronic liver disease in the United State, swith a prevalence of 1.8% ofthe population. eis estimated that 4 million Americans are infected with HCV (Alter 1997) HCV infection is acquired through in- travenous drug abuse, a strong risk factor for other psychiatric disorders (Dwight et al 2000). Individuals with HCV infection are more likely to have major depressive disorder, posttraumatic stress disorder (PTSD), and anxiety disorders as well as alcohol- and drug-use disorders (El-Serag et al. 2002). Studies of war veterans with HCV have recorded a very high preva- lence of alcohol and drug abuse (80%) combined with current depression and PTSD, which occurred in 60% ofthe sam- ple (Nguyen et al. 2002). In contrast to HCY, hepatitis B virus (ABV) is acquired mainly through sexual contact and through maternal-fetal trans- mission. It is much less likely to induce de- pression or other psychiatric symptoms as compared with HCV, and thus HBV is less of an issue for the consultation psychiatrist. ‘A major concern now lies in the in- creased chance of developing significant depression with interferon (antiviral) treat- ment of hepatitis C. Interferon treatment has significant side effects, including fa- tigue, neurological and cognitive symp- toms, and depression (fulfilling the criteria for major depression in approximately one- third of people) Bonaccorso et al. 2002; 63 Horikawa et al. 2003; Kraus et al. 2003). Suicidal ideation occurs frequently and has Jed to cessation of treatment. In one study, 58% of individuals receiving interferon had a diagnosable psychiatric illness after initia- tion of therapy (Kraus et al. 2003). In patients with chronic HCV infee- tion, severity of depressive symptoms is highly correlated with fatigue severity, but measures of hepatic disease severity, inter- feron dosage, and severity of comorbid medical illnesses are not (Dwight et al- 2000). Patients’ symptoms of listlessness, anhedonia, fatigue, and physical pain may bbe mistaken as manifestations oftheir liver disease; however, it is much more likely that these symptoms are the result of a co- morbid psychiatric disorder, most likely iajor depressive disorder (Poreelli et al. 1996; Wessely and Pariante 2002). Antidepressants, most often selective serotonin reuptake inhibitors (SSRIs), are useful in the treatment of depressive disor- der during interferon-alfa treatment. Par- oxetine (Kraus et al. 2001, 2002), sertra- line (Schramrn et al. 2000), and citalopram (Gleason et al. 2002) have all been ef- fective in clinical trials for the treatment of interferon-induced depression in patients infected with HCV. gnostic Issues ‘The diagnosis of psychiatric disorders in gastroenterology patients does not usually present great difficulties. Some GI symp- toms, such as pain, anorexia, or constipa- tion, may be ambiguous (ie., resulting from either psychiatric or GI disorders), but there are usually a host of other so- matic and psychological symptoms that enable the psychiatrist to diagnose anxiety or depressive disorders. Somatization and somatoform pain disorders may be more difficult to distinguish from GI disorders,64 ESSENTIALS OF PSYCHOSOMATIC MEDIC ie because both present with physical symp- toms; but the diagnosis will usually be- come apparent after a careful history and physical and psychiatric examinations. Acommon problem lies in persuading gastroenterologists and primary care doc- tors to recognize anxiety or depressive dis- orders early in their management of GI diseases. The search for possible organic causes of symptoms such as abdominal pain and diarrhea can become very exten- sive, increasing health anxiety. The doc~ tor's attention can be drawn to the possi- bility of a psychiatric disorder by the use ofa simple screening questionnaire such as the Beck Depression Inventory (BD!) Beck et al. 1961) or the Hospital Anxiety and Depression Scale (HADS) (Drossman ‘etal, 20003; Zigmond and Snaith 1983). Rarely, but especially in older people, an undiagnosed depressive illness can lead to marked diarrhea (as a manifestation of, accompanying anxiety), abdominal pain, and weight loss. These symptoms may lead to the suspicion of an underlying GI ‘malignancy and numerous investigations. Psychiatrists should be prepared to treat such a person energetically with anti- depressants and monitor closely both the depressive and GI symptoms. If two dis- orders are present—a malignancy and de- pression—sleep, pain, mood, and hope- lessness might improve, but weight and diarrhea might not. Patients with carcinoma of the pan- reas have a reputation for presenting first with depression (Passik and Breitbart 1996) (see Chapter 7, “Oncology”). Gas- troenterologists may encounter patients with unsuspected anorexia nervosa with chronic diarrhea, generalized weakness, and hypokalemia from laxative abuse, or chronic vomiting éither self-induced or from ipecac abuse. Psychiatric symptoms in patients with ostomies are discussed in Chapter 13, “Surgery.” Treatment Clinical Assessment ‘The clinical psychiatric assessment ofp, tients with GI disorders i similar to shy in other medical disorders (sce Chapter “Psychiatric Assessment and Consul.” ‘on’) In this section, we emphasize peings relevant to patints seen by psychiatrists ferred from gastroenterologiss, Accurate Dating of Symptom Onset Careful history taking should establish several dates: the date of onset and exacey. bation of the GI symptoms and the date of onset of depressive or anxiety symptoms ‘These dates may be compared to the dates of any important life events to establish an accurate time course. Thus, for instance, discovery of a spouse’ extramarital affair ay be followed by onset of anxiety symp. toms, later marital separation, and subse. quent simultaneous onset of depressive symptoms, abdominal pain, and diarrhea, This sequence suggests that the bowel symptoms are related to stress, It does not, however, prove that the symptoms are caused by a functional, as opposed to an organic, disorder, because symptoms of IBD may also get worse with stress and precipitate anxiety or depression. The time sequence allows the psychiatrist to evaluate any suggestion from the patient that the depression is unrelated or is sim- ply a reaction to the bowel disturbance. It also allows a full exploration of the pa- tient’ feelings about the life events. Systems Review tis also important to perform a thorough review of symptoms in other bodily systems. By eliciting all of the patient’ bodily symp- toms, the psychiatrist makes the patient fe! understood, which is the frst stage of man- ‘agement ofa patient with medically unex- Plained symptoms (Morriss et al. 1999).Gastrointestinal Disorders Health Anxiety, Early Experiences, and Attitudes Icis important to elicit fears of cancer or other serious illness. Satisfactory consulta- tion with a gastroenterologist leads to re- duction in fears of cancer and to decreased preoccupation and helplessness in relation to the pain (van Dulmen et al. 1995), However, if these issues have not been ad- dressed previously, the psychiatrist should address them and explore possible reasons, such as serious illness in the family; de- pressive, panic, and other anxiety disor- ders; and hypochondriacal personality traits (Colgan et al. 19882). ‘As noted earlier in this chapter, sexual abuse in childhood and related traumatic experiences may be important in patients with functional GI disorders, especially those with high health care utilization. In their extreme forms, the illness atti- tudes and behaviors seen in patients with fanctional GI disorders may amount to a psychiatric diagnosis of a somatoform disorder or a factitious disorder or malin- gering. Measurement and Monitoring Nowadays, psychiatrists often use stan- dardized instruments to measure the se~ verity of depressive or anxiety disorders, particularly for screening and in research. ‘Many common psychiatric instruments include GI symptoms, so it may be wise to consider the total score with and without these symptoms included, especially in bor- derline cases. For example, the BDI has items concerning aches and pains, upset stomach, constipation, and changes in ap- petite (Beck et al. 1961), The HADS (Zig- mond and Snaith 1983) was designed for use in medical populations and may be particularly useful in GI patients because it specifically excludes items concerning bodily symptoms. The Rome committee has reviewed the instruments commonly used (Drossman et al. 1999, 2000a). 65 Pharmacological Treatment Functional Gastrointestinal Syndromes Pharmacological treatment of IBS has been recently reviewed (Talley 2003). ‘There is clear evidence of the effectiveness of tricyclic antidepressants (TCAs) in IBS (Clouse 2003; Jackson et al. 2000). Sys- tematic reviews of the existing literature show an odds ratio of 4.2 (95% CI: 2.3 to 7.9) for the efficacy of TCAs over placebo, mostly measured in terms of pain relief Gackson et al. 2000). The mechanism of the benefit derived from TCAs in func- tional bowel disorders is not entirely clear. They are effective in low doses with rapid onset, suggesting the benefits may be the result of analgesic and anticholinergic ef- fects. Imipramine was helpful in chest pain in one study (Cannon et al. 1994), but the mechanisms of action are also not clear. “Too few studies have examined the ef- fect of SSRI antidepressants to be clear about their efficacy, but they are active in doses that are effective in clinical depres- sion, and the onset of action is slower, sug- gesting that they act through a different mechanism from TCAs (Creed et al. 2003; Kirsch and Louie 2000, Masand et al. 2002). In larger studies, effectiveness of TCAs and SSRIs in improving abdominal pain is related to medication adherence (Creed et al, 2003; Drossman et al. 2003). Some pa~ tients with constipation-predominant IBS cannot tolerate TCAs, and some with di- arrhea may experience an increase in diar- shea with SSRIs. Dropout rates are high for either class of drug unless special effort is made to promote adherence (Clouse 2003; Creed et al. 2003). Newer drugs de~ veloped for IBS have been agonists and antagonists of enteric serotonin receptors (eg., alosetron, tegaserod), but they do not seem to interact adversely with SSRIs. In clinical practice, it is important to decide why antidepressants are being used—for their analgesic properties inESSENTIALS OF PSYCHOSOMATIC MEDICINg 66 people who have severe pain or to treat 8 Eoncurrent depressive illness—and to carefully explain this to the patient. On doctors have prescribed many occasions, m E for patients low-dose antidepressants pain, only to be told later that these pa- tients did not take (or stopped taking) the medication because they learned that the drug is an antidepressant and they did not consider themselves depressed. “The Rome committee has reviewed in detail the use of psychotropic drugs in treating functional GI disorders (Dross- man et al. 2000a). Antidepressants have also been used with some degree of suc- cess for functional dyspepsia (Mertz et al. 1998). A number of other agents may also provide symptom relief (see Stanghellini etal. 2003). Depression in People With Organic Gastrointestinal Disorders Antidepressant treatment for interferon- induced depression was discussed earlier in this chapter (see subsection “Chronic Hepatitis C Virus Infection’. Psychological Treatment Functional Gastrointestinal Disorders There have been many studies of psycho- logical treatments of functional bowel dis- orders, but the sample sizes have been small in some studies, and different thera- pies and different measures have been used (Spanier et al. 2003). However, the overall evidence suggests that these treatments are helpful (Lackner etal. 2004). There seems to be no difference according to sp. treatment—dynamic interpersonal ther- ‘apy, cognitive-behavioral therapy, hypno- sis, and relaxation training all appeared to be successful. It is not clear whether these therapies have a specific effect on gut func tion or whether they act in a general way by reducing tension or improving inter- personal relationships and assertiveness. Because of their time-consuming nature and associated expense, psychological treat. ments tend to be reserved for the morg severe cases. In clinical practice, the choice between an antidepressant and psychotherapy may be made by patient preference. Often the latter is preferred. Because psychotherapy and pharmacotherapy probably have differ. ent modes of action, it is reasonable to as. ‘sume that they may have synergistic effects, so it is responsible to try a combination (Olden and Drossman 2000). A patient with depressive disorder and excessive con cern about serious illness might benefit from antidepressant treatment combined with cognitive-behavioral therapy. Peptic Ulcer and Inflammatory Bowel Disease ‘There is nearly always a need to provide proper education and support to patients with organic GI diseases (peptic ulcer and IBD). The provision of information can lead to decreasing patient anxiety, empowering patients to participate more fully in their care and to obviate unnecessary worries such asan undue fear of cancer and the like. Both dynamic interpersonal therapy and hypnosis have been studied in patients with peptic ulcer. These studies are inter~ esting because they employed the same treatment method for patients with peptic ulcer as they did for patients with IBS. One used dynamic psychotherapy (Sjodin etal. 1985), and the other used hypnother- apy (Colgan et al. 1988b). Both found a more pronounced positive result in IBS, but the psychological treatments had a clear beneficial effect on ulcer symptoms compared to the control condition. Thisis a reminder that psychological factors may play a part in the etiology or perpetuation of the symptoms of peptic ulcer disease Psychotherapy trials, both controlled and uncontrolled, have not shown a benefit in improving outcome in IBD (Jantschek et al. 1998; Maunder and Esplen 2001).gastrointestinal Disorders Conclusion — “The detection and treatment of psychiat- se disorders in patients presenting to gus- {roenterologists is an important aspect of inical practice. Whereas anxiety and de- pression have @ more prominent role in functional gastrointestinal disorders, they have important effects on treatment, out- ‘come, and quality of life in patients with organic” gastrointestinal disorders as well, Chronic hepatitis C infection is of particular concer, both because ofits fe- {quengy in patients with serious mental ill ness and substance abuse and because of the psychiatric side effects associated with its treatment. 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