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Hypochondriasis describes a persistent preoccupation with the possibility of having one or more serious and progressive physical disorders. There is a continuum between normal health anxiety and persistent, disabling hypochondriasis. Interviews and self-administered questionnaires used to diagnose hypochondriasis are described and the question whether it is best considered a somatoform or an anxiety disorder is discussed. The best documented treatment is cognitive-behavioral therapy, and how this is performed, including mindfulness techniques, is described. Health anxiety is still underrecognized, and with the advent of focused, time-limited and effective therapy it deserves increased attention even in primary care settings.

Whiplash injuries show a variable prognosis which is difficult to predict. Most individuals experiencing whiplash injuries rapidly recover but a significant proportion develop chronic symptoms and ongoing disability. By employing longitudinal data, we investigated how psychological and physical symptoms, self-rated health, use of health services and medications, health behavior and demographic factors predict recovery from whiplash. Data from two waves of a large, Norwegian, population-based study (The Nord-Trondelag Health Study: HUNT2 and HUNT3) were used. Individuals reporting whiplash in HUNT2 (baseline) were identified in HUNT3 11 years later. The characteristics of individuals still suffering from whiplash in HUNT3 were compared with the characteristics of individuals who had recovered using Pearson’s chi-squared test, independent sample t-tests and logistic regression. At follow-up, 31.6 % of those reporting whiplash at baseline had not recovered. These individuals (n = 199) reported worse health at baseline than recovered individuals (n = 431); they reported poorer self-rated health (odds ratio [OR] = 3.12; 95 % confidence interval [CI], 2.20–4.43), more symptoms of anxiety (OR = 1.70; 95 % CI, 1.15–2.50), more diffuse somatic symptoms (OR = 2.38; 95 % CI, 1.61–3.51) and more musculoskeletal symptoms (OR = 1.21; 95 % CI, 1.13–1.29). Individuals still suffering from whiplash also visited more health practitioners at baseline (OR = 1.18; 95 % CI, 1.06–1.32) and used more medications (OR = 1.24; 95 % CI, 1.09–1.40). Poor self-rated health seems to be a strong risk factor for whiplash injuries becoming chronic. Diffuse somatic symptoms, musculoskeletal symptoms and symptoms of anxiety at baseline are important prognostic risk factors. Knowledge of these maintaining risk factors enables identification of individuals at risk of non-recovery, facilitating adequate treatment for this vulnerable group.

Objective Most individuals experiencing whiplash accidents recover rapidly. A considerable proportion, however, develop chronic symptoms. Psychological factors may slow recovery, possibly by increasing the likelihood of other symptoms being misattributed to, and amplified by the whiplash injury. We aimed to investigate how pre-injury mental and somatic symptoms, self-rated health, use of health-services and medications, health-behavior and socio-demographics predict the development of chronic whiplash. Methods Data from two waves of a large, population based study (HUNT2 (baseline) and HUNT3) were used. Individuals reporting no whiplash at baseline were identified in HUNT3. Characteristics reported at baseline were compared between those who had developed chronic whiplash in HUNT3 (n = 199) and those who had not (n = 20,600), using Pearson's chi-squared tests, independent sample t-tests and logistic regression analyses. Results Individuals developing chronic whiplash reported worse baseline health than those reporting no chronic whiplash. Poor self-rated health was a strong risk factor for subsequent chronic whiplash (OR = 2.26, 95%CI: 1.68–3.04). Musculoskeletal pain also increased the risk (OR = 1.21, 95%CI: 1.15–1.26), as did diffuse somatic symptoms (OR = 2.09, 95%CI: 1.47–2.96), use of different health services (OR = 1.31, 95%CI: 1.19–1.45), high use of medications (OR = 1.28, 95%CI: 1.14–1.43) and symptoms of anxiety (OR = 1.93, 95%CI: 1.39–2.68). Physical activity was protective (OR = 0.67, 95%CI: 0.49–0.91). Most socio-demographic variables were not significantly associated with chronic whiplash. Conclusion Poor somatic and mental pre-injury health increased the risk of subsequent chronic whiplash. This suggests that chronic whiplash is not merely an organic disorder, and highlights the importance of individual expectations, symptom reattribution and amplification in development of chronic whiplash.

Background: The risk of ischaemic heart disease (IHD) is largely influenced by lifestyle. Interestingly, cohort studies show that anxiety in general is associated with increased risk of IHD, independent of established risk factors for cardiovascular disease. Health anxiety is a specific type of anxiety characterised by preoccupation of having, acquiring or possibly avoiding illness, yet little is known about lifestyle and risk of disease development in this group. Aim: Investigate whether health anxiety is prospectively associated with IHD, and whether a potential association can be explained by the presence or absence of established risk factors for cardiovascular diseases. Methods: Incident IHD was studied among 7052 participants in the community-based Hordaland Health Study (HUSK) during 12 years follow-up by linkage to the Cardiovascular Diseases in Norway (CVDNOR) project. Scores above 90th centile of the Whiteley Index defined health anxiety cases. Associations were examined with the Cox proportional regression models. Results: During follow-up, 6.1% of health anxiety cases developed IHD compared with 3.0% of noncases, yielding a gender-adjusted HR of 2.12 (95% CI 1.52 to 2.95). After adjustments for established cardiovascular risk factors, about 70% increased risk of IHD was found among cases with health anxiety (HR: 1.73 (95% CI 1.21 to 2.48)). The association followed a dose–response pattern. Conclusions: This finding corroborates and extends the understanding of anxiety in various forms as a risk factor for IHD. New evidence of negative consequences over time underlines the importance of proper diagnosis and treatment for health anxiety. publishedVersion

The aim of the research described here is to provide knowledge of adolescents and their coping strategies through the construct of mindful coping. Little is known about the contributions of mindfulness to the enhancement of mental health in adolescents. Inspired by dialectical behaviour therapy (Linehan, 1993a, b), we discuss the mindful coping process and investigate how different aspects of this process are related to mental health in a non-clinical adolescent sample. The empirical approach consisted of a cross-sectional study of 652 high-school students from two high schools, covering all streams. The relations between the four proposed mindful coping aspectsawareness, distraction, preventing negative emotions and constructive self-assertionwith psychological symptoms (PS), as well as how these four aspects moderated the relationship of perceived life strains (LS) with PS, were studied. The results show that coping by preventing negative emotions and constructive self-assertion were associated with few...

Irritable bowel syndrome (IBS) is associated with unexplained medical symptoms, and the degree of somatic comorbidity may indicate whether the aetiology of IBS is predominantly psychological or biological in origin. The purpose of this study was to examine the comorbidity and quality of life of patients with IBS following infection with Giardia lamblia.Sixty-seven consecutive patients with persistent abdominal symptoms, initiated by an acute infection with G. lamblia, completed questionnaires for scoring of subjective health complaints (SHC) and quality of life (Short-form Nepean Dyspepsia Index (SF-NDI)). The scores were compared with corresponding scores in persons from the general population (n=70).Compared with controls, each of the two groups of patients, those with present (n=17) and those with cured (n=50) G. lamblia infection, had significantly higher scores (p0.0001) on SHC. However, subscores on somatic comorbidity (musculoskeletal pain) were low and similar to those in the general population (OR 1.2 (0.51-2.73)). Quality of life was substantially impaired in the patients; sum scores 30.0+/-8.0 (mean+/-SD) and 31.7+/-9.3 in the patient groups and 13.5+/-6.8 in the general population (p0.0001).Patients with post-giardiasis IBS suffer very little somatic comorbidity, suggesting that the aetiology of this form of postinfective IBS is predominantly biological in origin and may thus differ from the more common, non-postinfective forms of IBS. The combination of persisting abdominal symptoms and psychological distress might be a perpetuating factor contributing to low quality of life.

OBJECTIVE: To assess the role of personality as a predictor of Short form-36 (SF-36) in distressed patients (perceived stress questionnaire, PSQ) with ulcerative colitis (UC) and Crohn's disease (CD). MATERIAL AND METHODS: Fifty-four patients with CD and 55 with UC (age 18-60 years) who had relapsed in the previous 18 months, i.e. with an activity index (AI) for UC or CD> or =4, PSQ> or =60, and without severe mental or other major medical conditions, completed the Buss-Perry Aggression Questionnaire (BPA), the Neuroticism and Lie scales of the Eysenck Personality Questionnaire (EPQ-N and -L), the Multidimensional Health Locus of Control Scale (LOC) (Internal (I), Powerful Other (PO), Chance (C)), the Toronto Alexithymia Scale (TAS) and the SF-36. RESULTS: Multiple linear regression analyses controlling for gender, age and clinical disease activity (AI) in separate analyses for UC and CD showed that the mental and vitality subscales were predicted by neuroticism in both UC and CD. The highest explained variance was 43.8% on the "mental" subscale in UC. The social function subscale was related to alexithymia only in UC, while the role limitation and pain subscales were related to personality in CD only. The physical function subscale related differently to personality in UC and CD. CONCLUSIONS: While mental and vitality subscales were predicted by neuroticism in both UC and CD, other subscales had different relationships to personality, suggesting different psychobiological interactions in UC and CD.

Zu den chronisch entzundlichen Darmerkrankungen (CED) gehoren die Colitis ulcerosa (UC) und der Morbus Crohn (CD). Kennzeichen dieser entzundlichen Erkrankungen des Intestinaltraktes bisher unbekannter Ursache ist ein chronischer, meist rezidivierender Verlauf. Zu den Symptomen gehoren Bauchschmerzen und -krampfe, Durchfalle, Gewichtsabnahme und Blutverlust aus dem Darm. Beim Morbus Crohn, der alle Abschnitte des Gastrointestinaltraktes befallen kann, finden sich haufig Ulzera am Ubergang zwischen Dunn- und Dickdarm. Bei einigen Patienten entstehen Fisteln zwischen Darmabschnitten, zu nahe liegenden Organen oder zur Haut. Bei der Colitis ulcerosa, die meist im Rektum beginnt und sich variierend nach proximal ausbreitet, entstehen diffuse und kontinuierliche Schleimhautulzerationen. Die somatische Behandlung ist abhangig von der Krankheitsaktivitat und beinhaltet 5-Aminosalicylate (5-ASA), Kortikosteroide und Immunsuppressiva (Azathioprin, Methotrexat, Ciclosporin, Infliximab). Sowohl die Glukokortikoide als auch Tumornekrosefaktor-Alpha-Antikorper (Infliximab) konnen zu psychischen und psychiatrischen Nebenwirkungen fuhren, am haufigsten Angst und Depressionen bzw. Manie. Auser der Erhohung der Lithiumkonzentration durch Methotrexat sind ernsthafte Interaktionen mit Psychopharmaka selten. Es gibt Anhaltspunkte fur eine negative Auswirkung auf den Krankheitsverlauf durch subjektiv erlebten Stress und fur ein etwas haufigeres Vorkommen psychischer Storungen als in der Normalbevolkerung. Gesicherte Nachweise fur die Zuordnung der chronisch entzundlichen Darmerkrankungen zu psychosomatischen Erkrankungen im traditionellen Verstandnis sind nicht gegeben. Unter Experten besteht Konsens, Patienten mit diesen Erkrankungen bei Vorhandensein chronischer Stressbelastungen oder eventuellen psychischen Storungen eine Behandlung anzubieten. Die Therapie erfolgt nach den ublichen Behandlungsleitlinien. Alle Psychopharmaka konnen eingesetzt werden. Eine Lithiumbehandlung ist schwer zu kontrollieren. Demgegenuber gibt es keine ausreichenden Hinweise, routinemasig den betroffenen Patienten eine psychodynamische oder andere Form von Psychotherapie anzubieten.

SUMMARY Background: Spiramycin (Rovamycin) is a well-established macrolide antibiotic with good anti-Helicobacter pylori activity in vitro. It is acid-stable and found in high concentration in various body fluids and cells after oral administration. Its anti-H. pylori activity in vivo has not yet been tested. Methods: Twenty-five consecutive patients with endoscopically verified peptic ulcer and a positive biopsy urease test were given spiramycin tables 1.5 MIU instead of oxytetracycline 500 mg q.d.s. in our triple therapy regimen with bismuth subnitrate suspension 10 mL (150 mg bismuth subnitrate) q.d.s. and metronidazole 400 mg t.d.s. for 10 days. Bismuth was taken between meals and spiramycin and metronidazole with meals. Re-endoscopy and 14C-urea breath test were performed 4 weeks after completion of therapy. Those who were H. pylori negative according to the breath test returned for 1-year follow-up. Results: Per protocol analysis at 4 weeks showed that 21 out of 23 patients were H. pylori negative and had healed ulcers. These 21 patients were persistingly H. pylori negative and had no ulcers at 1-year follow-up. H. pylori eradication and ulcer healing rates were thus 91.3%; 95 % confidence interval from 72.0% to 98.9%. Side-effects limiting daily activity were significantly less frequent than we have experienced previously using oxytetracycline in triple therapy. Conclusions: Spiramycin appears to be an alternative to tetracycline in the triple therapy of H. pylori infection. Further studies to position spiramycin as an anti-H. pylori drug are warranted.

Objective Health anxiety is associated with distress and disability, and overutilization of health services, but it is not known whether high levels of health anxiety may lead to increased detection of severe diseases such as cancer. By linking a large population based health study with the national cancer registry, the aim of the study was to investigate a potential prospective association between health anxiety in men and women and later cancer detection and tumour metastasis at the time of diagnosis. Method A longitudinal study with a 13.2 year follow-up linking the population-based Hordaland Health Study (HUSK) and the Cancer Registry of Norway (CRN) was conducted. Health anxiety was measured with the Whiteley Index. Associations were examined through gender stratified Cox regression analyses adjusted for relevant covariates. Results No association was found between baseline health anxiety and cancer detection for women (adjusted HR: 1.21, 95% CI: 0.42–3.50), but a positive association was found between health anxiety at baseline and cancer detection for men (adjusted HR: 1.76, 95% CI: 1.06–2.91). No statistically significant association was demonstrated between health anxiety and cancer metastasis for either gender. Conclusion An increased level of health anxiety in men may be advantageous, as it may motivate to self-examination and healthcare seeking when disturbing symptoms arise. Research is needed to investigate whether health anxiety has a protective effect on cancer metastasis at the time of detection, or whether health anxiety increases the risk of over-diagnosis and overtreatment.

Comorbidity of irritable bowel syndrome in general practice: a striking feature with clinical implications

The aim of this study was to elucidate the relationship between duodenal ulcer (DU) disease and psychological symptoms.Sixty-four Helicobacter pylori-positive patients with frequently relapsing DUs (patient group 1) were compared with 78 control subjects without dyspepsia, starting 2 years before and ending 10 years after eradication of H. pylori. Seven non-relapsing and untreated patients (patient group 2) were also followed-up.The relapse rate was reduced from 100% per year in the two years before anti-H. pylori treatment to 0.3% per year after treatment in patient group 1. The reinfection rate was 0.7% per year. Anxiety and neuroticism were high at inclusion, but had normalized at the 10-year follow-up in relapse-free patients. There was no increase of gastro-oesophageal reflux symptoms during the 10 years after H. pylori eradication.Normalization of anxiety and neuroticism following cure of DU disease supports the view that the increased anxiety and neuroticism are consequences, and not causes, of the disease.

Functional dysepsia (FD) is defined as persistent or recurrent pain or discomfort centered in the upper abdomen without evidence of organic disease likely to explain the symptoms. Visceral hypersensitivity, motor dysfunction, and impaired gastric accommodation are found in some patients with FD, and psychological factors like chronic stress, attention and perception bias are also likely to play a part in the symptom formation. There is considerable overlap of non-specific symptoms like fatigue, headache, abdominal discomfort, muscle pain, and sleep disturbance in patients with different functional disorders, in this article exemplified by FD, fibromyalgia, and chronic fatigue syndrome. This overlap of symptoms indicates a common underlying sensitization process, leading to somatization.

Objective The Whiteley Index (WI) is a widely used screening instrument for health anxiety/hypochondriasis. Several studies have previously explored the psychometric properties of the WI, but with mixed findings concerning both item composition and factor structure. The main aim of the current study was to examine different factor structures as identified from previous studies using data from a large general population based study. We also wanted to provide gender specific norms. Methods Data were taken from a large population-based study in Norway, the Hordaland Health Study (HUSK N = 7274). Confirmatory factor analysis (CFA) of several models of the WI was conducted. Item response theory (IRT) analysis was performed on the model with the best goodness-of-fit. Results CFA of all previously proposed factor models of the WI revealed clearly inadequate model fits. The IRT analysis suggested that a six-item model best described the data, and CFA confirmed an adequate goodness-of-fit across indices. Conclusion The current study found evidence for a six-item, single-factor model of the WI. Our findings suggest that this abbreviated version has the best factor structure compared to previously proposed factor models. We recommend that the factor structure identified in this study should be investigated further in independent samples.

Background : In patients with low-grade reflux oesophagitis adequate symptom control is the aim of treatment. Effervescent tablets alleviate heartburn more rapidly than ordinary tablets. Aim : To investigate symptom control, patient satisfaction, health-related quality of life and disease progress when ranitidine 150 mg effervescent tablets were offered as on demand treatment. We also wanted to investigate whether any biological or psycho-social factor could predict patient satisfaction. Method : Consecutive patients with endoscopically verified reflux oesophagitis grade I–II were followed up for 12 months. 24 h pH-metry, disease history, symptoms and several psycho-social factors were registered at baseline and 12 months follow-up. Results : Eighty-one patients were included. Mean age was 50.7 years (range 21–82), 63% were men. Mean tablet consumption was 1.21 per day (range 7–1016 tablets/year). At the 1-year follow-up discomfort resulting from reflux symptoms was significantly reduced (P

Participation in screening programs for malignant disease may have negative psychologic health effects that could outweigh the beneficial effects of the screening itself. The present study was designed to investigate the psychologic effect of attending a screening program for detection and removal of colorectal adenomas, which are precursors to colorectal cancer.In 1983 a prospective. controlled screening study using flexible sigmoidoscopy to detect adenomas was started in Telemark County, Norway. Four hundred individuals were enrolled as a screening group and 399 as a control group. In 1996 survivors in both groups were invited to have a colonoscopic screening examination for detection and removal of polyps. Four hundred and fifty-one individuals (71%) attended; their mean age was 67.2 years (range, 63-72 years), and 48% were women. Fourteen days and 3 and 17 months after the examination the attendees received by mail a questionnaire composed of Goldberg's General Health Questionnaire (GHQ-28) and the Hospital Anxiety and Depression Scale (HADS). The questionnaire was also mailed to an age- and sex-matched group not enrolled in the endoscopic screening study. Four hundred and nine (95%), 395 (92%), and 389 (91%), respectively, returned the questionnaire. Of the controls 314 (70%) returned filled-in questionnaires.The scores for both GHQ-28 and HADS were lower, indicating a lower level of psychiatric morbidity among those attending the examination in 1996 than among the controls. There was a trend towards higher scores with increasing time after the examination in the screened group.During the first 17 months after screening the attendees, as a group, did not appear to have developed untoward psychologic effects as judged by HADS and GHQ questionnaires.

Measures of disability pensions, sickness certification and long-term health related benefits are often self-reported in epidemiological studies. Few studies have examined these measures, and the validity is yet to be established. We aimed to estimate the validity of self-reported disability pension, rehabilitation benefit and retirement pension and to explore the benefit status and basic characteristics of those not responding to these items. A large health survey (HUNT2) containing self-reported questionnaire data on sickness benefits and pensions was linked to a national registry of pensions and benefits, used as “gold standard” for the analysis. We investigated two main sources of bias in self-reported data; misclassification - due to participants answering questions incorrectly, and systematic missing/selection bias - when participants do not respond to the questions. Sensitivity, specificity, positive (PPV) and negative (NPV) predicative value, agreement and Cohen’s Kappa were calculated for each benefit. Co-variables were compared between non-responders and responders. Results: In the study-population of 40,633, 9.2% reported receiving disability pension, 1.4% rehabilitation benefits and 6.1% retirement pension. According to the registry, the corresponding numbers were 9.0%, 1.7% and 5.4%. Excluding non-responders, specificity, NPV and agreement were above 98% for all benefits. Sensitivity and PPV were lower. When including non-responders as non-receivers, specificity got higher, sensitivity dropped while the other measures changed less. Between 17.7% and 24.1% did not answer the questions on benefits. Non-responders were older and more likely to be female. They reported more anxiety, more depression, a higher number of somatic diagnoses, less physical activity and lower consumption of alcohol (p < 0.001 for all variables). For disability pension and retirement pension, non-responders were less likely to receive benefits than responders (p < 0.001). For each benefit 2.1% or less of non-responders were receivers. False positive responses were more prevalent than false negative responses. Conclusions: The validity of self-reported data on disability pension, rehabilitation benefits and retirement pension is high – it seems that participants’ responses can be trusted. Compared to responders, non-responders are less likely to be receivers. If necessary, power and validity can be kept high by imputing non-responders as non-receivers. © Myrtveit et al.; licensee BioMed Central Ltd. 2013. This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background Gastrointestinal complaints are very common in the general population and very often co-occur with common mental disorders. We aimed to study the prospective impact of gastrointestinal complaints on long term sickness absence, and address the contribution from co-occurring common mental disorders and other somatic symptoms. Method Health data on 13 880 40-45 year olds from the Hordaland Health Study (1997-99) were linked to national registries on sickness absence. As part of a wider health screening, gastrointestinal complaints were ascertained. Participant's anxiety and depression, and the presence of other somatic symptoms were evaluated. In Cox regression models, we predicted sickness absences over an average 5.4 years follow-up, with adjustment for confounders, anxiety and depression and other somatic symptoms. Results After adjusting for gender, level of education and smoking, those reporting GI complaints had higher risk for later sickness absence (HR = 1.42, 95% CI 1.34-1.51). GI complaints were associated with both anxiety (OR = 3.66, 95% CI 3.31-4.04) and depression (OR = 3.28, 95% CI 2.89-3.72), and a high level of other somatic symptoms (OR = 8.50, 95% CI 7.69-9.40). The association of GI complaints was still independently associated with future sickness absence (HR = 1.17, 95% CI 1.10-1.16) adjusting for mental illness and other somatic symptoms. Discussion Sickness absence is a complex behavioural outcome, but our results suggest GI complaints contribute by increasing the risk of long term sickness absence independently of comorbid mental illness and presence of other somatic symptoms. Occupational consequences of illness are important, and should also be addressed clinically with patients presenting with GI complaints.

Summary Background Psychodermatology has focused primarily on depression and anxiety in eczema. Skin symptoms are listed among many others for the ICD-10 diagnosis of somatization disorder. Somatization (unexplained somatic symptoms) is highly prevalent in the general population, but its association with eczema is yet to be empirically investigated. Objectives We therefore explored the association between somatization and eczema by examining the extent of somatization in eczema compared with allergic rhinitis, and by examining if eczema was more strongly associated with somatization than with anxiety and depression. Finally, we aimed to examine the relationship between the site of eczema and somatization for individual somatic symptoms and for somatic symptoms as a whole. Methods For this population-based cross-sectional study we employed data from the Hordaland Health Study (HUSK) with 15 225 participants aged 41–48 years. Information on nonspecific eczema, allergic rhinitis, somatization, anxiety, depression and other covariates was obtained by self-report. Results The association between nonspecific eczema and somatization was strong and followed a dose–response pattern, as did all somatic symptoms in our index of somatization when analysed separately. The association between nonspecific eczema and somatization was stronger than that between rhinitis and somatization, and also the association between nonspecific eczema and anxiety and depression. In multivariate models, somatization accounted for most of the association between nonspecific eczema and anxiety/depression. In contrast, the association between nonspecific eczema and somatization was robust for adjustment for anxiety/depression. Conclusions Somatization was strongly associated with nonspecific eczema. This applies to a whole range of somatic symptoms constituting the construct of somatization. There is hardly any mention of somatization in leading dermatological journals, in contrast to anxiety and depression which are frequently reported in eczema. We speculate that this under-recognition of somatization in the dermatological literature may correspond to under-recognition of this factor also in clinical practice.

Effects of acute mental stress on gastric antral motility were investigated in 23 healthy persons and 25 patients with functional dyspepsia (FD). Real-time ultrasonography of gastric antrum was recorded, after ingestion of 500 ml meat soup, during a 4-min resting period, 2.5 min of mental stress, and a 4-min recovery period. Amplitude of antral contractions was scored as a fraction of relaxed area. Motility-index was calculated as the amplitude multiplied by frequency. Measurement of skin conductance reflected sympathetic tone, and respiratory sinus arrhythmia (RSA) was calculated to index vagal tone. Antral motility was reduced by mental stress in the healthy persons, but not in FD patients. Group differences were significant for amplitude (p < 0.002) and motility-index scores (p < 0.02). Sympathetic tone increased during stress in both groups. Vagal tone was lower in the FD patients than in the healthy controls (p < 0.001). The lack of stress-related reduction of motility among patients with FD may, therefore, be a consequence of poor vagal tone.

Background: The use of stress management psychotherapy is hypothesized to produce greater improvement in disease course and disease-specific quality of life (IBDQ) compared to usual medical care alone in patients with ulcerative colitis (UC) or Crohn's disease (CD) showing high levels of stress (based on the Perceived Stress Questionnaire [PSQ]). Methods: Fifty-eight patients with UC and 56 patients with CD who had experienced continuous disease activity or had relapsed over the previous 18 months, with an activity index for UC or CD ≥4, a PSQ ≥60, and without serious psychiatric disorders or other serious medical conditions were randomized to receive either treatment as usual (TAU) or TAU plus stress management psychotherapy. Psychotherapy consisted of three group sessions (psychoeducation, problem-solving, relaxation) and 6–9 individual sessions based on cognitive behavior therapy-related methods with 1–3 booster sessions at 6 and 12 months follow-up. Gastroenterologists blinded to intervention group assessed disease activity and course at baseline and at 3, 6, 12, and 18 months. Patients completed the IBDQ at baseline, 6, 12, and 18 months. Results: The intervention did not improve disease or reduce relapse; however, it increased the IBDQ score (P = 0.009, mean differences 16.3 [SD 6.1]). On analysis of UC and CD separately, improvement of IBDQ was only found in the UC group. Conclusions: Stress management psychotherapy does not appear to improve disease course or reduce relapse in patients with IBD. It might improve quality of life, particularly in patients with UC. (Inflamm Bowel Dis 2011;)

Objective: To examine the hypothesized effect of health anxiety on subsequent disability pension award. Mental disorders are consistently underrecognized in general health care, leading to underestimation of its effects on related social security expenditures. According to medicolegal diagnoses for disability pension award, there are almost no awards of disability benefits for health anxiety or hypochondriasis. There are no empirical longitudinal population-based studies on occupational disability in health anxiety or the extreme of hypochondriasis. Methods: Using a historical cohort design, we utilized a unique link between a large epidemiological cohort study (n = 6819) and a comprehensive national database of disability benefits to examine the effect of health anxiety on subsequent disability pension award (n = 277) during 1.0 to 6.6 years of follow-up. The data sources were merged after informed consent, using the national personal identification number. Results: Health anxiety was a strong predictor of disability pension award, exceeding the effect of general anxiety, and comparable to the effect of depression. This effect was partly accounted for by adjustment for income and level of education, and comorbid mental, psychosomatic, or physical conditions. The effect was not limited to high symptom levels, but followed a dose-response association. Despite the robust effect in this prospective study, health anxiety or hypochondriasis was not recognized as medicolegal diagnosis for any awards of disability pension, and was not accounted for by other mental disorders. Conclusions: Health anxiety is a strong, independent, and yet underrecognized risk factor for disability pension award.

The connection between psychologic factors and somatic diseases is still unknown. The activation theory, a fairly new theory for psychosomatic diseases, is presented. Duodenal ulcer is traditionally known as a psychosomatic disease, and psychotherapy can influence the symptoms. Duodenal ulcer is effectively treated with H2 blockers, but the relapse rate is high: 50-80% have a relapse within the first year after healing. In this project patients with duodenal ulcer are treated with cognitive therapy to influence the relapse rate. There is a strong relationship between non-ulcer dyspepsia and psychosocial factors. In this project patients with non-ulcer dyspepsia are treated with cognitive therapy to influence the symptoms. The design of the project and some preliminary results are presented.

Background: To explore the relationship between personality and disease-specific quality of life [Inflammatory Bowel Disease Questionnaire (IBDQ)] in distressed [Perceived Stress Questionnaire (PSQ)] patients with ulcerative colitis (UC) and Crohn's disease (CD). Methods: Included in the study were 56 patients with UC and 54 patients with CD ranging in age from 18 to 60 years with a relapse in the previous 18 months, a UC or CD activity index ≥ 4, a PSQ ≥ 60, and without serious mental or other serious medical condition. The patients completed the Buss-Perry Aggression Questionnaire, the Neuroticism and Lie (social conformity/desirability) scales of the Eysenck Personality Questionnaire, the Multidimensional Health Locus of Control (LOC) Scale [Internal (I), Powerful Other (PO), Chance (C)], the Toronto Alexithymia Scale, and the IBDQ. Results: In linear regression controlling for sex, education (years), and clinical disease activity (AI) in separate analyses of UC and CD patients, higher IBDQ score was related to less social conformity in CD and less neuroticism in UC; higher emotional function score was related to less neuroticism in both CD and UC and less PO-LOC in UC. Higher social function score was related to less social conformity in CD and lower I-LOC and PO-LOC in UC. Bowel function and systemic symptoms were unrelated to personality in either UC or CD. Conclusions: Although the emotional function subscale was related to neuroticism in both UC and CD, the social function subscale and total IBDQ were related to different personality traits in UC and CD. Personality traits should be taken into account when using IBDQ in studies. (Inflamm Bowel Dis 2007)

The aim of this observational, population-based study was to compare subjective health complaints (SHC) in Norwegians, living in a Western welfare society, and Maasai people, living in rural Kenya under primitive conditions. An interview-based version of SHC inventory was used. Data from 320 Maasais were compared to data from 1243 Norwegians. The Maasais had significantly higher score than the Norwegians on 23 of 28 items, involving musculoskeletal, “pseudo-neurological” and gastrointestinal complaints. The Maasais, living under primitive conditions, close to nature, seems to have more SHC than Norwegians, living in a modern, highly developed and industrialized country.

Background: It has convincingly been shown that relapses of duodenal ulcers are significantly reduced after eradication of Helicobacter pylori. The aim of this study was to examine the long-term effect of bacteria eradication on Quality of Life (QOL) and subjective somatic symptoms. Methods: Seventy-four Helicobacter pylori-positive patients with recurrent duodenal ulcer disease were treated with triple treatment. Relapses, H. pylori status, QOL and subjective somatic symptoms were registered at yearly intervals for 4 years. Results: Preliminary results show that the patients were more satisfied with the healthcare system, had better sexual relationships and less psychological distress up to 3 years after eradication of the bacteria. They also had fewer symptoms of exhaustion and less stomach discomfort than before triple treatment. Conclusion: Long-term follow-up of patients after eradication of H. pylori shows that QOL is improved and feeling of exhaustion and stomach discomfort reduced.

Subjective health complaints without known physical pathology are common and might develop into somatoform disorders. Normalization of neuroticism and anxiety in patients with duodenal ulcer disease after a relapse-free state is acquired and maintained is an indication that biological factors influence psychological factors. Recent research has shown that psychological and behavioural changes, on the other hand, have the capacity to change the brain. Visceral hyperalgesia is an example of biological sensitisation, but the abnormal sensory perception can be normalised by hypnotherapy. The dual-etiology hypothesis of functional somatic syndromes implies that in some patients with somatoform disorders there is a predominant biological etiology, whereas in others there is a predominant psychological etiology. The theory is supported by recent research, and may result in better handling of patients. Cognitive factors like catastrofising amplifies subjective physical symptoms and emotions effect the perception of them. In preventive health care the following slogans are proposed as antidotes preventing subjective health complaints form developing into somatoform disorders: Do not listen to your body's signals! Do not trust your feelings! Do not trust your thoughts!

Medical students and other people with knowledge about health and disease are often thought to have more anxiety about their health than others.80 medical students and 100 law students were asked to fill in a questionnaire designed to identify higher disease anxiety (Whiteley Index). A high total score on the Whiteley Index indicates high disease anxiety. 62 medical students (78%) and 70 law students (70%) returned the questionnaire in an anonymous form.Medical students had lower total score compared with law students (p0.01). One medical student and six law students had a total score susceptible of hypochondriasis. Male students had a non-significantly higher mean total score than female students. Those with depressive mood (n = 5), had higher total score than the others (p0.01.) Those who had experienced disease in their family (n = 83) tended to have lower total score.Medical students have less disease anxiety than law students, contrary to what is often believed.

Hypochondriasis is an annoying disorder. Diagnostic criteria for primary and secondary hypochondriasis as well as comorbidity are explained.Some studies of prevalence, aetiology and treatment are reviewed. Special emphasis is given to the cognitive model.The prevalence of primary hypochondriasis in population studies is around 1%, while the prevalence in medical outpatient clinics is 3-4.5%. Several controlled, clinical studies have found positive effect of cognitive-behavioural therapy. Excessive health anxiety that is secondary to depression disappears when the primary disorder is treated. Controlled clinical trials of medication is lacking. Traditionally, hypochondriasis has been considered a difficult diagnosis to present to the patient and hard to treat. Research has increased our knowledge and understanding of the disease, and structured treatment protocols have led to a well founded optimism concerning prognosis. Central themes in the consultations are the question of life and death, interpretation of subjective somatic symptoms and the ability to make decisions when still in doubt.

In research we often apply hypothesis testing which assumes a linear, causal relationship between two or more factors. This is a valid way of testing fragments of a complicated chaos of known and unknown elements. However, I want us to reflect upon the thought that the answers we get are limited by the questions we ask. It is said that “If you have a hammer, the only thing you see are nails”. Western medical education and research has, for more than a century, been dominated by a dualistic view of human nature, and from the psychoanalytical tradition (based on Freud's work) we have learned to differentiate between biological (physical, organic, somatic) on one side and psychological (thoughts and emotions) on the other. This dualistic view, emphasising that psychological and biological are two entirely different aspects of human life, is mechanistic and reductionistic, and in today's world a non-scientific position to hold.1 In spite of many decades of research, there is no evidence that emotions can “pile up” somewhere in the body and that psychological conflicts, if unresolved, are converted to somatic symptoms or diseases. On the contrary, science is moving into a position of integration, and the cognitive science (such as neuroscience) has developed rapidly in recent years. You cannot experience an emotion or think a thought without biological correlates. Unresolved mental conflicts lead to activation of the central nervous system (CNS), and of the autonomic systems. Activation theories, such as the “cognitive activation theory of stress” states that the stress response is the same as activation—a general alarm system operating whenever the organism registers that there is a discrepancy between what is expected and what really exists.2 The brain-gut axis is a good example of a circular relationship between different factors, and illustrates that research on interrelationship …

In patients with functional dyspepsia, scanning by a novel ultrasonographic method was carried out to investigate postprandial accommodation of the proximal stomach. Twenty patients with functional dyspepsia and 20 controls were scanned fasting in a sitting position after drinking 500 ml meat soup. Images were recorded up to 25 min after the ingestion period using an ultrasound sector scanner with a 3.25-MHz transducer. The area in a sagittal section and the maximal diameter in a oblique frontal section were chosen as the main variables for calculating the emptying fraction of the proximal stomach, defined as: (aV2.5min - aVactual/aV2.5min. All subjects were asked to score total symptoms (1-9) provoked by the meal. From 7.5 to 25 min after the ingestion period the patients exhibited both smaller area in the sagittal section (P0.018) and shorter diameter in the frontal section (P0.046) compared with the healthy controls, and they suffered more symptoms in response to the meal (P = 0.002). Dyspeptic patients revealed higher emptying fractions (P = 0.0005, ANOVA), and H. pylori status did not influence the emptying fractions. Diagnostic sensitivity of the method at 20 min postprandially was 70% and the specificity was 65%. Patients with functional dyspepsia have impaired accommodation of the proximal stomach to a meal, temporarily related to symptom induction.

Background: Life events and stress may be important for functional dyspepsia and duodenal ulcer. Methods: The perception of life events in the preceding 6 months was recorded in 100 patients with functional dyspepsia, 100 patients with duodenal ulcer, and 100 healthy controls. In addition, psychologic and social factors were assessed. Results: Patients with functional dyspepsia experienced significantly more life events than patients with duodenal ulcer and healthy controls. The difference in life events between the groups was due to the difference in stressful life events. The patients with functional dyspepsia had higher levels of state-trait anxiety, general psychopathology, and depression than patients with duodenal ulcer and healthy controls. Conclusion: Patients with functional dyspepsia had higher scores on negative life events than patients with duodenal ulcer and healthy controls. This may be causally related to the higher levels of anxiety, depression, and general psychopathology in these patients.

Patients with duodenal ulcer or functional dyspepsia do not differ on dyspeptic symptoms. The aim of the present study was to test the hypothesis that functional dyspepsia and duodenal ulcer are two different diagnostic entities by examining the discriminating power of several anamnestic, biological, and psychosocial variables. Ninety-four patients with duodenal ulcer and 86 patients with functional dyspepsia were included. Anamnestic data, global assessment, Helicobacter pylori status, blood group, Lewisa+ phenotype, and several measures of psychological distress and somatic complaints were registered. Compared to patients with functional dyspepsia, the duodenal ulcer patients were more often infected by Helicobacter pylori and had their stomach discomfort more often relieved by eating. Compared to patients with duodenal ulcer, patients with functional dyspepsia had higher scores of depression, trait anxiety, general psychopathology and different somatic complaints (called somatization). They were also less satisfied with the health care system, their disorder had a greater negative impact on their quality of life, and their global assessment of own health was poorer. Discriminant analysis including age, smoking, Helicobacter pylori status, global assessment, and somatic complaint classified 86.1% of the patients correctly (77.9% of the patients with functional dyspepsia and 93.6% of the patients with duodenal ulcer). It is concluded that duodenal ulcer and functional dyspepsia are two separate diagnostic entities. Patients with duodenal ulcer are older, smoke more often, and almost all are infected with Helicobacter pylori, while patients with functional dyspepsia are characterized by somatization and a negative assessment of their own health.

Patients with functional dyspepsia (FD) have more complaints than just the dyspepsia.One hundred FD patients were assessed with regard to psychologic, medical, and social factors, before randomization, in a study of cognitive therapy. They were asked to list their main problem areas or 'target complaints'.Dyspepsia was the third most frequent target complaint (26 patients), and anxiety was the most frequent one (65 patients). Patients identifying dyspepsia as a target complaint differed from the other FD patients in several aspects. They had significantly more dyspeptic symptoms (p0.05) and scored significantly higher on multiple somatic complaints (p = 0.001), depression (p = 0.025), general psychopathology (p = 0.043), the global assessment scale (p = 0.001), and the General Health Questionnaire (p = 0.040). However, they did not have more somatic predisposing factors like consumption of alcohol and coffee or infection with Helicobacter pylori than the patients with other target complaints.Anxiety and not dyspepsia was the most frequent target complaint, and patients who identified dyspepsia as a target complaint did not have more somatic predisposing factors.

There is increased interest in the concept 'quality of life'. Available instruments are defined and discussed, with special emphasis on reliability and validity. Research on quality of life in patients with upper gastrointestinal disorders is reviewed, and our own results presented.The Psychosocial Adjustment to Illness Scale was used to compare 100 patients with functional dyspepsia and 100 patients with duodenal ulcer in a cross-sectional study, and to monitor the quality of life of 74 duodenal ulcer patients in a longitudinal phase.The quality of life of patients with functional dyspepsia was more negatively affected than that of patients with duodenal ulcer. After half of the patients had received short-term cognitive psychotherapy and all had received prophylactic H2-blocker treatment after ulcer relapse, quality of life improved in both the treatment group and the control group. Seventy-four patients with recurrent duodenal ulcers reported higher satisfaction with the health care system, improved sexual relationship, and less psychological distress one year after cure of the ulcer disease by the eradication of Helicobacter pylori compared to before.Reliable and valid instruments are available to measure quality of life, and will probably gain increased importance in future medical research. In patients with recurrent duodenal ulcer disease, quality of life improves with the eradication of Helicobacter pylori.

The aim of the study was to compare relapse rates and quality of life before and after eradication of Helicobacter pylori in a group of patients with documented recurrent duodenal ulcer disease.Seventy-four patients with three endoscopically verified duodenal ulcers during the past 2 years received triple treatment consisting of bismuth subnitrate, oxytetracycline, and metronidazole for 14 days. Quality of life was measured with the Psychosocial Adjustment to Illness Scale (PAIS-SR) and H. pylori status with the 14C-urea breath test.After triple treatment H. pylori was eradicated in 96%, and the ulcer was healed in all. Ulcer relapse was reduced from 100% before to 1.4% during a mean observation time of 111 weeks. The H. pylori reinfection rate was 2.4% during the 1st year. The patients were more satisfied with the health care system and had better sexual relationship and less psychologic distress 1 year after eradication of H. pylori than before.For patients with recurrent duodenal ulcer, eradication of H. pylori with triple treatment leads to a significantly reduced ulcer relapse rate and improved quality of life.

Patients with functional dyspepsia were assigned at random to cognitive psychotherapy (10 sessions of 50 min duration, n = 50) or to a control group (no treatment, n = 50). Before treatment all patients were assessed on psychological, somatic and lifestyle factors. If allocated to the therapy group all patients were also asked to define the main problems they wanted to discuss in therapy (‘target complaints’). The patients were evaluated at the end of therapy (after 4 months) and at 1 yr follow-up. Outcome measures were dyspeptic symptoms, scores on ‘target complaints’ and psychological parameters. Both groups showed improvement in dyspeptic and psychological parameters after 1 yr. The improvement in the control group was attributed to a non-specific effect of increased interest and attention. The therapy group showed greater reduction than the control group on dyspeptic symptoms [days of epigastric pain ( p = 0.050), nausea ( p = 0.024), heartburn ( p = 0.021), diarrhoea ( p = 0.002) and constipation ( p = 0.047)]; and on scores on ‘target complaints’ ( p = 0.001).

The aim of this prospective, randomized trial was to assess whether short-term cognitive psychotherapy (10 sessions during 4 months) could reduce the 1-year recurrence rate of duodenal ulcer. One group received psychotherapy; one group was a control group. One hundred patients, aged 17 to 64 years, with duodenal ulcer were selected from March 1989 to May 1991. The main outcome measure was relapse of duodenal ulcer, which was verified by endoscopy. When psychotherapy started after cessation of antiulcer medication, the relapse-free time was significantly shorter in the therapy group than in the controls. When the protocol was modified so that psychotherapy and antiulcer medication were given concomitantly, there was no significant difference in recurrence rate between the groups at 1-year follow-up (84% in the therapy group and 92% in the control group). Symptoms of upper abdominal discomfort/pain, measured every second month, decreased significantly in the therapy group compared to the control group. Psychotherapy led to less neuroticism (Eysenck Personality Questionnaire) and less trait anxiety (Spielberger Trait Anxiety Scale) compared to controls at 4 months. At the 12-month follow-up, most of this gain was lost, but the psychotherapy group had lower scores on "concern about disapproval" on the Sociotropy-Autonomy Scale than the control group. There is no beneficial effect of short-term cognitive psychotherapy on the 1-year recurrence rate of duodenal ulcer.

Wilhelmsen I, Tangen Haug T. Sipponen P, Berstad A. Helicobacter pylori in functional dyspepsia and normal controls. Scand J Gastroenterol 1994;29:522-527.Background: The aim of this study was to examine whether Helicobacter pylori status can identify a specific subset of patients with functional dyspepsia (FD) and erosive prepyloric changes (EPC).Methods: Anamnestic, somatic, and psychologic data were collected from 87 patients with functional dyspepsia and 77 normal control persons. Presence of H. pylori infection was assessed by the 14C-urea breath test.Results: H. pylori infection increased with age. Thirty-four per cent of the patients were H. pylori-positive, compared with 36% of the control persons. The patients had higher scores than the normal control persons on psychologic measures regardless of H. pylori status. Of 27 variables analyzed, age was the only factor that discriminated between H. pylon'-positive and -negative patients.Conclusions: For most patients with FD and EPC the presence of H. ...

Low vagal tone may represent a mediating mechanism for relationships between personality and symptoms of functional dyspepsia (FD) through a mechanism of antral hypomotility. Twenty-one patients with FD and seventeen healthy controls completed a series of personality tests before vagal and sympathetic activity, antral motility, and abdominal symptoms were assessed in response to a laboratory task. Functional dyspepsia patients had lower scores on vagal tone (p = .054) and motility index (p = .011) in addition to the expected higher scores on epigastric discomfort (p = .002). Psychological factors explained a substantial amount of the variance in vagal activity, antral motility, and reported symptoms. Symptoms were predicted by trait anxiety (STAI-TR), depression (BDI), and neuroticism (EPQ-N). Poor vagal tone was related to neuroticism (EPQ-N). Poor motility was best explained by task-related state dysphoria (SACL-STR).

One hundred patients with functional dyspepsia, 100 patients with duodenal ulcer and 100 healthy controls were assessed on anamnestic factors, somatic symptoms and psychological measures. Patients with functional dyspepsia had significantly higher levels of state-trait anxiety, general psychopathology, depression, a lower general level of functioning and more somatic complaints from different organ systems, especially the musculo-skeletal system, compared to patients with duodenal ulcer and healthy controls. Patients with functional dyspepsia had more frequent dyspepsia symptoms and a longer disease history than duodenal ulcer patients. Discriminant analyses using a model of fifteen psychological and anamnestic variables, classified correctly 71.5% of the subjects due to diagnoses. The test for multiple somatic complaints (Giessener Beschwerdebogen) was the most important discriminating factor (Eigenvalue 0.78). Seventy-five per cent of the patients were correctly classified, 71% by diagnosis with respect to diagnoses of duodenal ulcer and functional dyspepsia using frequency of dyspeptic symptoms as discriminating factor (Eigenvalue 0.40). Functional dyspepsia seems to be a disease entity of its own, distinct from duodenal ulcer and strongly associated with psychological factors.