Interpersonal problems in patients
who somatise
Else Guthrie: Professor of Psychological
Medicine and Medical Psychotherapy
University of Manchester, UK
Introduction
• Chronic functional bowel disorders are common conditions
• High rates of psychological distress
• High health care utilisation and costs
• Pathogenesis unclear
• Most likely to be biopsychosocial
A biopsychosocial model for FBD (Drossman et al, Gut 1999: 45
(Suppl) II25-II30
Functional bowel disorders-interpersonal
relationships
• Two seminal papers both reported evidence of relationship
difficulties in FBD (Chaudhury and Truelove, 1963; McDonald and Bouchier,
1972)
• High rates of sexual abuse and physical abuse (Drossman et al,
1995)
• Problems with sexual functioning (Guthrie et al, 1987)
Interpersonal relationships
• Women with FBD report higher rates of emotional abuse, self blame and
self silencing than controls (Ali et al,2000)
• Previous research on somatisers suggests that they invest much of their
own personal resources in nurturing others at the expense of themselves
(Barsky et al 1988)
• Suggested link between communal feminity and disease conviction
(Toner and colleagues, 2000)
Aim
• To assess interpersonal function of patients with chronic and severe
functional gastrointestinal disorders in comparison with a) psychiatric
patients b) non-distressed controls
• Hypothesised that FGID group would report significantly higher scores on
the “nurturing subscales” of the IIP than controls and would be less
assertive than controls.
Population groups-FGID
• Consecutive patients with chronic and severe irritable bowel
syndrome and functional dyspepsia attending GI clinics in the
NW.
• Patients recruited in the context of two RCTs, (Hamilton et al,
2000; Creed et al, 2003)
Psychiatric patients
• Two groups:
– Consecutive patients presenting following self poisoning to an A&E
department
– Consecutive patients attending a psychiatric outpatient department with
anxiety and depression, who had not responded to treatment (Guthrie et
al, 1999)
Non-distressed controls
• Consecutive patients attending A&E for a reason other than self
harm
• “Normal volunteers” recruited from university/health service
setting.
Measures
• Inventory of interpersonal problems (IIP-32: Barkham et al,
1996)
– 19 item “It is hard for me to….”
– 13 items “The following are things I do too much”
Subscales
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Hard to be supportive
Hard to be assertive
Hard to be involved
Hard to be sociable
Too dependent
Too aggressive
Too caring
Too open
Subscales
• Before conducting comparative analyses the discriminant
function of the IIP-32 for the pooled sample of subjects was
examined
• Factor structure held up well with good replication of the 8
subscales
Groups-recruitment
• FGIDs
257/317 IBS (81%)
•
73/95 FD (77%)
• Psych
108/166 SP (65%)
•
110/144 PsychOPD (76%)
• Non-dis 108
A&E
•
108
A&E
Groups
• 297 FGID
• 218 psychiatric patients
• 208 non-distressed
Age and Gender
IIP-32 subscales
IIP-32 subscales
Summary
• Too aggressive: Psych>FGID>non-dis
• Too caring: Psych> FGID> non-dis
• Hard to be supp: Psych>non-dis>FGID
Comparison with normal population
• Using normative data from Barkham and colleagues
Summary of results for males and females in comparison with normal
population
• Males
• Too caring
• Hard to be assertive
• Females
• Too aggressive
• Hard to be support
• Not open
Hypotheses
• Partially upheld
• Some evidence of problems with “nurturance”
• But psych patients report more problems than FGID
Summary
• Patients with psychiatric problems score highly on all subscales
of IIP-32
• FGID patients differ in following manner:
• Too caring than non-distressed controls
• Lowest scores on “hard to be supportive”
• “Too aggressive” than non-distressed controls
Summary
• IIP-32 not a very good measure for discriminating FGID from other
groups
• In general: psychiatric patients report global distress
• FGID patients may problems re nurturance
• Maybe very different IIP profiles between males and females with FGID,
which differ from usual patterns seen in general population.
Summary
• Caution re interpretation of these results in highly select population samples
• Two new projects to study interpersonal relationships using RAPFA (Hill) semistructured interview based measure which assesses the following domains:
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Romantic/sexual relationships
Friendships
Social contact
Work relationships
Negotiation
Self harm versus non-self harm psychiatric patients
FGID vs organic GI (CECA)