Академический Документы
Профессиональный Документы
Культура Документы
www.elsevier.com/locate/pain
a r t i c l e
i n f o
Article history:
Received 24 July 2008
Received in revised form 22 June 2009
Accepted 6 July 2009
Keywords:
Pain
Circumplex
Psychodynamic interpersonal psychotherapy
IBS
a b s t r a c t
The aim of the present study was to assess the relationship between change in interpersonal difculties
with change in chronic pain, health status and psychological state in 257 Irritable Bowel Syndrome (IBS)
patients in a randomized control trial comparing psychotherapy, antidepressant and usual care. We
assessed at three time points interpersonal problems (IIP-32), abdominal pain and bowel symptoms, psychological distress (SCL-90), and health status (SF-36). Analysis included repeated measures (ANOVA) to
assess change over time and multiple regressions to identify whether change in IIP was associated with
outcome after controlling for psychological status. The main ndings were: (1) difculties with social
inhibition and dependency were associated with longer disease duration; (2) change in mean IIP-32 over
15 months was signicantly correlated with changes in pain, but these relationships were mediated by
change in psychological distress; (3) change in IIP-32 was an independent predictor of improved health
status at 15 months only in the psychotherapy group. These results indicate that improvement in interpersonal problems in IBS patients appear to be primarily associated with reduced psychological distress
but, in addition, the association with improved health status following psychotherapy suggests that specic help with interpersonal problems may play a role in improving health status of patients with chronic
painful IBS.
2009 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
1. Introduction
Irritable bowel syndrome (IBS) is a common chronic pain disorder which forms a majority of patients in gastroenterology clinics
and often leads to high healthcare use and much time missed from
work [15]. In common with other chronic pain patients, those with
IBS have difculties in interpersonal relationships [26,31], which
relate to pain coping and outcome of treatment [37]. Several studies have found an association between insecure attachment and related interpersonal difculties with poor pain self efcacy, anxiety
and poor coping [4,29,30]. These have all been cross-sectional
studies, however, and all these authors suggested examining
whether improved personal relationships are associated with reduced pain and reduced disability [4,24], which is what we have
tested in this study.
Patients with IBS are said to have difculties with being assertive [26]. Such a submissive interpersonal style has been related
to pain catastrophising [25], which is associated with soliciting
0304-3959/$36.00 2009 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2009.07.005
197
abdominal pain and its severity today [13]. In addition, each participant completed a daily diary recording the severity of their bowel symptoms for 14 days prior to each assessment. Psychological
distress was measured using the Global Severity Index (GSI) of
the SCL-90 [12]. Health status was measured using the Short
Form-36 (SF-36) [39], which corresponds closely to patients rating
of the disruption their daily lives [20,40]. We used the physical
component summary (SF-36-PCS) score as the main outcome variable; a low score indicates poor health status [38]. This is a composite score of the scales: physical function, role limitation
physical, bodily pain and health perception.
For the assessment of interpersonal problems, the Inventory of
Interpersonal Problems-32 (IIP-32) [2] was used. The IIP-32 is a
self-report measure developed as a shortened version of the original 127-item Inventory of Interpersonal problems [22], aiming to
assess the difculties people experience in their interpersonal relationships and comprises eight subscales which have shown high
internal consistency and conrmatory factor analysis has replicated the eight-factor structure [2]. We present results for baseline,
3 and 15 months later.
At the initial assessment only, a trained psychiatrist, who
worked independent of treating clinicians and was blind to treatment group, assessed psychiatric diagnosis using the Schedules for
Clinical Assessment in Neuropsychiatry (SCAN) [41]. The details
of the IBS symptom pattern (diarrhoea- or constipation-predominant) and IBS duration were ascertained using the questionnaire
of Drossman [36]. Diarrhoea-predominant IBS refers to patients
who had more than three bowel movements a day or watery stools
or urgency or having to rush to have a bowel movement whereas
constipation-predominant IBS refers to patients who had fewer
than three bowel movements a week or lumpy stools or straining
during a bowel movement.
A history of sexual abuse was documented using the Sexual and
Physical Abuse Questionnaire [14,28]. In this report sexual abuse
refers to either forced touching or forced penetration (rape),
against ones will either as a child or adult.
2.1. Statistical analysis
All the statistical analyses were performed using the Statistical
Package for the Social Sciences (SPSS) 15.0 (SPSS Inc., Chicago, IL,
USA) for Windows and Stata Statistical Software: Release 9 (College Station, TX: Statacorp LP. 2005). Summary statistics for all
variables were calculated. Normality was tested by the KolmogorovSmirnov test [1].
Since we used the 32-item version of the IIP for the rst time in
IBS patients, a conrmatory principal component factor analysis
was performed to conrm that the factorial structure of this version in IBS patients is comparable to that of the original version
of the IIP-32 [2].
Univariate analyses to asses the independent associations between demographic, clinical or psychopathology variables and IIP
scores used one-way analyses of variance, two-tailed t-tests, and
Pearsons or Spearmans correlations as appropriate [1].
Repeated measures (ANOVA) for IIP mean score adjusted for
baseline score was performed to test for a signicant change of
IIP over time (baseline, 3 months, and 15 months), and the relationship of this with treatment.
To test hypothesis 1, we assessed change in IIP with change in
abdominal pain severity, bowel symptoms, psychological distress
and health status between baseline and 15 months, adjusting for
baseline scores with ANCOVA.
Multiple regression analyses were performed to assess whether
SCL-90 global severity index score mediated the association of
change in pain and bowel symptoms with change in interpersonal
difculties between trial entry and follow-up. These analyses used
198
3. Results
3.1. Patient characteristics
The demographic and clinical characteristics of the participants
in our trial have been reported previously [6]. Briey, a total of 257
subjects (81% of eligible patients) were recruited to the study.
There were no differences in demographic and diagnostic variables
between those patients who agreed and those who declined to enter the trial (N = 60). Ages ranged from 19 to 65 years, with a median of 39 years. The majority of the patients were women (79.8%),
married (65.8%), and 54.5% had 12 or more years of education.
The IBS was chronic (median duration, 8 years; interquartile
range, 9 years) and led to restricted activities on a mean of 12.1
(SD, 11.8) days per month before baseline assessment, while sev-
enty patients (27.2%) were unemployed through illness. Mean typical pain score was 67.4 of 100. Fifty-nine patients (22.9%) reported
that they had experienced sexual abuse. Seventy four patients
(28.8%) had diarrhoea-predominant IBS, 59 (23.0%) had constipation-predominant IBS, and 124 (48.2%) had the general form of
the disorder.
Of the 85 patients randomized to psychotherapy, 59 (69.4%)
completed all eight sessions, and 43 of the 86 patients (50%) randomized to paroxetine completed the 12-week course (x2, 5.91;
df, 1; p = 0.013).
The main ndings of the study were that patients treated with
psychotherapy or antidepressants compared with those receiving
usual care showed a signicant improvement in health status
12 months post treatment [6]. In the present study we examine
whether reduction in IIP score is associated with such improvement in health status.
3.2. Preliminary (factor) analysis of IIP-32
Of the 257 IBS patients, 225 (87.5%) completed all 32 items of
IIP and these were used in analysis. Principal component analysis
showed a Kaiser-Mayer-Olkin statistic of 0.86, an average communality of 0.679 and a signicant Bartletts test for sphericity (x2,
4290; df, 496; p < 0.0005), all supporting the factorability of the
correlation matrix. An inspection of the scree plot revealed a large
rst component and a number of elbows resulting in a very small
eigenvalue after eight components. An eight component extraction
was rotated with both Varimax and Oblimax rotations. Both rotated solutions revealed the presence of a coherent multidimensional structure with eight components. Table 1 presents the
results of the Oblimax rotation, since this rotation showed the
clearer loadings. The eight components explain a cumulative
70.75% of the variance. As shown in Table 1, all items have their
strongest loadings exactly as suggested by Barckam et al. [2] with
only four of the possible 224 non-design loadings being above of
the criterion of 0.3 and all but one are below 0.4, the remaining
being 0.45. These results indicate that IIP-32 responses of the IBS
patients conform very well to the design of the instrument.
3.3. Interpersonal difculties, demographic, clinical and
psychopathology variables at baseline
Table 2 shows that socio-demographic variables and symptom
pattern (diarrhoea-predominant, constipation-predominant and
general) were not signicantly associated with IIP mean score
but depressive, generalized anxiety and panic disorders were signicantly associated. Further analysis (not shown) found that these
results held when each of the eight IIP subscales were examined
individually.
Table 3 shows that IIP mean score was associated with SCL-90
global severity index but not with bodily pain, bowel symptoms
or duration of IBS. Further analysis with the eight IIP subscales
showed that no subscale score was associated with bowel symptom pattern (data not shown). The two subscales concerning difculties with social inhibition and dependency (hard to be
sociable and too dependent) were associated with the duration
of IBS after adjustment for age, sex, marital status and psychological distress (partial correlation coefcients r = 0.166, p < 0.009 and
r = 0.125, p < 0.05, respectively).
3.4. Change in interpersonal difculties and change in pain, bowel
symptoms, psychological distress and health status
Repeated measures (ANOVA) analysis showed that IIP mean
score reduced with time (F = 11.84, p < 0.001) but there was no signicant treatment by time interaction (F = 0.79, p = 0.45). This
199
Table 1
Factor loadings of the IIP-32 in the IBS sample.
Factors
Items
Hard to be sociable
7
3
1
9
14
15
13
16
28
30
20
21
24
29
10
17
25
26
18
32
4
11
6
2
19
5
12
8
23
31
22
27
.901
.867
.737
.719
Hard to be supportive
Too aggressive
Too open
Too caring
Hard to be assertive
Hard to be involved
Too dependent
.879
.875
.786
.555
.923
.892
.827
.791
.839
.798
.463
.455
.327
.391
.865
.799
.656
.547
.842
.832
.774
.733
.758
.633
.457
.352
.458
.364
0.89
0.86
0.87
0.63
0.78
0.85
.717
.603
.600
.444
0.75
0.80
Note. Jblimin rotation with Kaiser normalization; loadings censored at 0.3; item loadings that correspond to the loadings of the original version are highlighted with bold characters.
Table 2
IIP-32 total mean score and demographic, clinical and psychiatric categorical
variables.
N
Mean
SD
Sex
Male
Female
50
197
1.16
1.06
0.04
0.09
t=
1.01
0.311
Education
Less than GCSE
GCSE or more
112
135
1.04
1.11
0.63
0.65
t=
0.86
0.391
1.07
1.11
0.63
0.68
t=
0.40
0.688
Marital status
Married
Singles
Div/Sep
1.15
1.11
0.86
0.74
0.62
0.57
Sexual abuse
No
Yes
159
50
38
188
59
1.05
1.18
0.64
0.63
1.07
1.17
0.99
0.63
0.66
0.63
Depressive disorder
No
Yes
174
73
0.93
1.43
212
35
Panic disorder
No
Yes
218
29
F2,244 = 2.78
t=
1.36
reduction of IIP mean score between baseline and 15 months follow-up was associated with the reduction of all measurements of
pain and with improvement of disability (Table 4).
Fig. 1a and b show the temporal sequence of changes. In the
psychotherapy and antidepressant groups improvement in pain
and psychological distress occur during the 3 months of treatment
before the reduction in IIP; the latter occurs predominantly during
the follow-up year. This means that change in IIP should not be regarded as the primary change with treatment as the other parameters (pain, psychological distress and health status) show change
before change in IIP.
A much greater change in IIP score is apparent at follow-up and
multiple regression analysis was used to identify the variables
most closely associated with this change; they are shown in
0.064
0.173
F2,244 = 1.29
0.277
0.58
0.64
t=
5.96
<0.0005
1.04
1.33
0.64
0.61
t=
2.48
0.014
1.01
1.61
0.61
0.61
t=
4.97
<0.0005
Table 3
Correlations of baseline IIP-32 total mean score with demographic, baseline clinical
and baseline psychiatric continuous variables.
Age
Age of onset
Duration of IBS
VAS typical pain
VAS pain today
Number of days with pain
SF-36 physical component
SF-36 pain
Diarrhoea
Constipation
SCL-90 Global severity index
a
b
ra
0.031
0.099
0.077
0.099
0.057
0.016b
0.022
0.037
0.002
0.034
0.676
0.623
0.122
0.229
0.122
0.375
0.826
0.731
0.558
0.998
0.780
<0.0005
200
Table 4
Associations of change in IIP mean score with change in psychological distress, pain,
diary measure diarrhoea and diary measure constipation scores between baseline and
follow-up, adjusted for baseline scores.
Change
Change
Change
Change
Change
Change
Change
Change
in
in
in
in
in
in
in
in
Correlation coefcient
p-value
0.201
0.208
0.301
0.200
0.236
0.355
0.281
0.567
0.003
0.003
<0.005
0.008
0.001
<0.0005
<0.0005
<0.0005
Table 5. Model 1 shows that the improvement of pain was a significant predictor of improvement in interpersonal difculties, but
this is not so in model 2, when the improvement in SCL-90 global
severity index was added to the linear regression equation.
Sobel tests showed that the indirect effect of each one signicant independent variable (i.e. change in pain, change in diary diarrhoea and change in diary constipation) on the dependent variable
(i.e. change in interpersonal relationships) through the mediator
(i.e. change in SCL-90 global severity index) was signicant (Sobel
test statistics (Z): 4.59, p < 0.0005; 3.62, p < 0.0004 and 3.09,
p < 0.002, respectively). Sobel tests for the indirect effects of baseline values of the independent variables on the dependent variable
through change in SCL-90 global severity index values were not
Psychotherapy group
0.5
0.4
0.3
z-score
0.2
IIP
SF-36 pcs
SCL-90 global severity index
VAS pain today
0.1
0
-0.1
-0.2
-0.3
-0.4
baseline
3 months
15 months
Paroxetine group
0.5
0.4
0.3
z-score
0.2
0.1
IIP
SF-36 pcs
SCL-90 global severity index
Vas pain today
0
-0.1
-0.2
-0.3
-0.4
baseline
3 months
15 months
Fig. 1. Effect size for changes from baseline for IIP-32, SCL-90 global severity index
SF-36 physical component summary and VAS-pain today in psychotherapy (a) and
antidepressant group (b).
201
Table 5
Multiple regression analyses to predict change in IIP mean score between baseline and follow-up (N = 214).
Predictor variables
Beta
Age
Sex
Education
Widowed, divorced, separated
Baseline IIP-32 mean score
Baseline SF-36 pain
Baseline diary diarrhoea
Baseline diary constipation
SF-36 pain improvement between baseline and 15 months
Diary diarrhoea improvement between baseline and
15 months
Diary constipation improvement between baseline and
15 months
Psychotherapy
Antidepressant
Baseline SCL-90-R GSI
SCL-90-R GSI improvement between baseline and 15 months
Regression statistics
R square adjusted
F-values
0.006
0.001
0.034
0.022
0.521
0.158
0.188
0.026
0.149
0.201
0.925
0.992
0.549
0.705
<0.0005
0.014
0.004
0.684
0.033
0.003
0.002
0.024
0.001
0.003
0.775
0.037
0.089
0.037
0.028
0.100
0.968
0.579
0.974
0.951
<0.0005
0.469
0.073
0.447
0.607
0.059
0.133
0.041
0.038
0.014
0.004
0.829
0.953
0.008
0.005
0.626
0.603
0.343
F(13,200) = 9.53, p < 0.0005
0.453
0.868
0.915
<0.0005
<0.0005
0.632
F(15,198) = 25.4, p < 0.0005
Table 6
Multiple regression analyses to predict change in SF-36 physical component summary score between baseline and follow-up for psychotherapy and antidepressant groups.
Variables
Psychotherapy group
Severe sexual abuse
Age
Baseline SF-36 physical component score
Unemployed due to poor health
Baseline IIP-32 mean score
IIP-32 mean improvement between
baseline and 15 months
SCL-90-R GSI improvement between
baseline and 15 months
VAS pain today improvement between
baseline and 15 months
Adjusted R square
Antidepressant group
Severe sexual abuse
Age
Baseline SF-36 physical component score
Unemployed due to poor health
Baseline IIP-32 mean score
IIP-32 mean improvement between
baseline and 15 months
SCL-90-R GSI improvement between
baseline and 15 months
VAS pain today improvement between
baseline and 15 months
Adjusted R square
Unstandardized regression
coefcient (B)
Std. Error
Standardized regression
coefcient (beta)
10.317
0.152
0.512
5.427
3.299
4.59
3.502
0.092
0.114
2.262
1.761
2.34
0.324
0.192
0.495
0.267
0.244
0.276
0.005
0.104
<0.0005
0.02
0.067
0.05
3.992
2.376
0.198
0.099
0.003
0.034
0.010
0.933
4.510
0.172
0.375
2.845
1.913
0.554
2.451
0.082
0.094
2.411
1.656
2.209
0.185
0.221
0.488
0.146
0.136
0.041
0.070
0.041
<0.0005
0.242
0.252
0.803
4.689
2.238
0.328
0.040
0.040
0.032
0.136
0.214
0.428 (F = 6.43,
p < 0.0005)
202
There are some limitations of this study, which need to be recognized. First, this is a secondary analysis of a dataset that was collected for another purpose. Another limitation lies in the absence
of a healthy control group, which could allow us clearer conclusions with regard to IBS patients specic interpersonal difculties.
In addition, our results pertain to patients with severe IBS and may
not hold for people with less severe IBS. We used only a self-report
questionnaire to assess interpersonal difculties and it is not clear
whether such an instrument measures the discomfort in relationships that is associated with eliciting sympathetic response from
others [37]. Similarly we did not measure catastrophising which
means we cannot compare our results with those which found
an association between interpersonal problems and pain catastrophizing [4,2426].
This paper does overcome some of the limitations of the previous studies, however, notably the prospective design. Strengths of
our study include also the representative nature of our sample
(81% of the eligible patients were recruited), the detailed measures,
our ability to demonstrate the factorial structure of the main
instrument used (IIP-32) and the reasonably large sample size, at
least as compared to other studies using IIP.
The prospective design and response to treatment are the major
assets of this study. We found that interpersonal problems improved over time and this is, we believe, the rst study that shows
this in IBS patients. We found a clear association between improvement in IIP score and improvement in all our measures of pain and
disability and we also found that this was mediated by change in
psychological distress. This occurred irrespective of treatment
group and it is most plausible that improved mood leads to feeling
better about interpersonal relationships. The additional nding is
also new-improvement in IIP was associated directly with improved health status in the psychotherapy group but not in the
antidepressant group. This nding suggests, perhaps, that the
mode of action of antidepressants and psychotherapy may not be
identical. We interpret this nding as suggesting that a component
of the change following psychotherapy was some aspect of
improvement of interpersonal difculties (sexual abuse was also
a predictor of improved health status [7]) whereas following antidepressant treatment a reduction in the level of distress was the
primary change [6].
It has not been possible to identify a single major predictor of
outcome in this group of patients with severe IBS, unlike the study
of temporomandibular disorder patients reported by Rudy [32].
This probably results from our selection of a relatively homogenous group of patients with severe IBS. We have shown previously
that depressive and panic disorders, neurasthenia and marked
somatisation predict a poor outcome [8,9] and that a history of sexual abuse predicts a good response [7]. In this paper we aimed to
identify whether interpersonal difculties also predict outcome
and it seems that this is the case in the psychotherapy group,
though the effect was of borderline signicance, possibly reecting
small sample size. Since this analysis showed that a history of sexual abuse and interpersonal difculties are independent predictors
of outcome in the psychotherapy, even after controlling for the
reduction of distress, we conclude that specic interpersonal
change following our brief psychotherapy is an important aspect
of the long-term outcome following this type of treatment. This effect was not found in the antidepressant group suggesting that the
two treatments act differently in this respect. Both aspects of treatment could be utilised in the treatment of chronic pain patients, in
addition to cognitive behavioural treatment, which acts principally
on different aspects of the persons response to pain.
The main clinical implication of this study is that IBS patients
interpersonal difculties improved over time and that this
improvement was associated with improved health status in both
treatment groups. Therefore, the choice of treatment might be
203
[32] Rudy TE, Turk DC, Kubinski JA, Zaki HS. Differential treatment responses of
TMD patients as a function of psychological characteristics. Pain 1995;61:
10312.
[33] Shapiro DA, Firth JA. Exploratory therapy manual for the Shefeld
Psychotherapy Project (Memo No.733) [Available from University of Leeds,
Leeds, England].
[34] Silk DB. Impact of irritable bowel syndrome on personal relationships and
working practices. Eur J Gastroenterol Hepatol 2001;13:132732.
[35] Spanier JA, Howden CW, Jones MP. A systematic review of alternative
therapies in the irritable bowel syndrome. Arch Intern Med 2003;163:
26574.
[36] Thompson WG, Creed F, Drossman DA, Heaton KW, Mazzacca G. Functional
bowel disease and functional abdominal pain. Gastroenterol Int 1992;5:7591.
[37] Thorn BE, Keefe FJ, Anderson T. The communal coping model and interpersonal
context: problems or process? Pain 2004;110:5057.
[38] Ware JE, Kosinski M, Keller SD. SF-36 physical and mental health summary
scales: a users manual. Boston: The Health Institute, New Engl. Med. Centre;
1994.
[39] Ware JE, Sherbourne CD. The MOS 36-item short-form health survey
(SF-36): 1. Conceptual framework and item selection. Med Care 1992;30:
47383.
[40] Whitehead WE, Burnett CK, Cook III E, Taub E. Impact of irritable bowel
syndrome on quality of life. Digest Dis Sci 1996;41:224853.
[41] World Health Organization. Schedules for clinical assessment in
neuropsychiatry. Geneva, Switzerland: Division of Mental Health; 1994.