Örebro University
School of Medical Sciences Degree Project, 30 ECTS 3th of January 2018
Psychological Profile in Patients with Pathologic Gastroscopic Findings and
Functional Dyspepsia:
A Pilot Study
Version 2
Author: Otilia Siversten, Bachelor of Medicine Supervisor: Michiel van Nieuwenhoven, Consultant, Associate Professor in Medicine and
Abstract
Introduction: Quality of life (QoL) has been reported to be lower in patients with functional dyspepsia (FD). Psychological and psychiatric factors have been shown important, however, on the contribution of personality factors, little research has been performed.
Aim: To compare symptom burden, features of anxiety/depression and personality traits between patients with FD and patients with pathologic gastroscopic findings, in order to increase our understanding of FD.
Material and Methods: This pilot study was conducted at Örebro University Hospital, Sweden, in September to December 2017. Questionnaires on symptoms and QoL, personality traits and features of anxiety and depression were given to patients undergoing gastroscopy.
Results: The functional group (n=31) experienced nausea, belching, discomfort and pain in the upper abdomen more frequently, as well as QoL being lower than the organic group (n=60). The functional group also had significantly elevated levels of depression and anxiety, and significantly higher scores on neuroticism as well as lower scores on conscientiousness.
Conclusion: The functional group had a higher frequency of dyspeptic symptoms and lower QoL, as well as higher levels of anxiety, depression and neuroticism. These factors affect health care seeking and patient outcome. This study can contribute to understanding dyspepsia pathology and to reduce the burden on patients, as well as society, via a better way of managing these patients in the future. This pilot study is also an important contribution for designing larger studies yet to come in this field.
Key words:
Dyspepsia, Functional Dyspepsia, Depression, Anxiety, Personality Traits, Neuroticism,Abbreviations
ASA BFI DSM FD FGIDs Acetylsalicylic acid Big Five InventoryDiagnostic and Statistical Manual of Mental Disorders Functional dyspepsia
Functional gastrointestinal disorders GERD
GI
Gastroesophageal reflux disease Gastrointestinal
HADS HCs
Hospital Anxiety and Depression Scale Healthy controls NSAID OG PHQ-9 PPI PUD
Non-steroidal anti-inflammatory drugs Organic group
Patient Health Questionnaire-9 Proton pump inhibitor
Peptic ulcer disease QoL Quality of life SERT protein
SSRI SF-NDI TCAs
Serotonin plasma membrane transport protein Selective serotonin reuptake inhibitor
Short Form Nepean Dyspepsia Index Tricyclic antidepressants
Introduction
Dyspepsia is defined as symptoms originating from the upper abdomen, such as pain/discomfort, a burning sensation, postprandial fullness or early satiety [1]. Dyspepsia is common and the incidence in Sweden has been observed being 15.3 per 1000 and the prevalence 25% [2–9]. It can have organic causes, such as esophagitis or peptic ulcer, or the cause can be functional, which means that standard
investigations cannot identify an organic cause [1–5,8–15]. The prevalence of functional dyspepsia (FD) is approximately 5-25% [6,7,9,10,16–18].
The aetiology of FD and other functional gastrointestinal disorders (FGIDs) such as Irritable Bowel Syndrome comprises disturbances in the brain-gut-axis [4,11]. This represents a bidirectional communication between the brain and the enteric nervous system [4]. Studies on brain function in FD observed differences mainly around the limbic system and homeostatic afferent processing network, showing correlations with dyspeptic symptoms and quality of life (QoL) [19–23]. On the gut level, studies on FD have shown a few microscopical changes, such as neural aberrations [24].
Because of the brain-gut-axis, underlying mood- and anxiety disorders can affect visceral perception from the gastrointestinal (GI) tract, as well as GI symptoms can affect mood and behaviour [11]. Psychological factors are therefore considered important regarding symptom severity, i.e. stress worsens symptoms in FD patients and 46% of subjects with FD were reported to be treated for
psychological or psychiatric disorders [3,4,7]. In longitudinal studies, anxiety and depression has been shown to be higher in FD-patients, but is also associated with the development of FD [16,18]. However, little research has been performed to investigate the relationship between personality traits and dyspepsia, but one study by Filipović et al revealed higher levels of neuroticism among FD-patients in comparison to patients with peptic ulcer disease (PUD) and healthy controls (HCs) [25].
FD is often recurrent and pharmacotherapy is ineffective [1–3,9,10,19]. It is associated with work absenteeism, higher rates of unemployment and functional impairment [15,26,27]. QoL has also been shown to be lower in persons suffering from dyspepsia, FD in particular. Disease duration is not related to symptoms, QoL, or anxiety/depression [19,28]. Lower QoL, worries for illness and other psychological factors, as well as psychiatric illness are factors that affect health care seeking [4,9,12]. FD implies a high burden on health care resources [26]. In Sweden, costs related to dyspepsia have been calculated to be 4 billions Swedish crowns/year [4].
Aim
The aim of this study is to compare symptom burden, features of anxiety/depression and personality traits between FD patients and patients with pathological findings on gastroscopy, in order to increase our understanding of FD. This may lead to a better treatment of FD patients.
Material and Methods
Study design: This pilot study was conducted at the Department of Gastroenterology at the Örebro University Hospital, Sweden. Data were collected from September to December 2017. Standardized and validated questionnaires, a medication record form and an informational letter with inquiry of
participation were sent to patients who were planned for a gastroscopy, as well as handed out at the endoscopy registration office. Exclusion criteria comprised: not filling out the forms correctly, previous surgery affecting the stomach, adenomatous polyposis, pregnancy or a symptom free patient without pathological findings (i.e. investigation of anemia). Endoscopic outcomes were screened for gastroscopic findings. Sex, age and current use of medications were recorded as well. Based on gastroscopy findings, patients were divided into two groups; 1: the Organic Group (OG) if they had pathologic findings, or 2: the FD group if no pathology could be found with gastroscopy.
Questionnaires: The Short Form Nepean Dyspepsia Index (SF-NDI) is a validated dyspepsia-specific symptom- and QoL instrument [13]. It consists of a self-reported Symptom Checklist, covering 15 symptoms over the past 2 weeks, as well as 10 items in 5 subscales of QoL; tension, interference of daily activities, disruption to regular eating/drinking, knowledge/control over disease symptoms and
interference with work/study. The answers are rated on a Likert scale, with higher scores indicating more impact.
The 14-item Hospital Anxiety and Depression Scale (HADS) is a validated and widely used self-report questionnaire, investigating states and severity of anxiety and depression during the last week [29]. There are 7 questions in each subscale (anxiety and depression), with the possibility of scoring 0-21 points on each of them. In comparison to other psychological measures, HADS does not include questions that can be signs of physical illness (i.e dizziness or headache), which makes it suitable in this setting [16,29]. In this study, a cut-off score of 11 or more was used to denote elevated levels of anxiety [29].
The Patient Health Questionnaire-9 (PHQ-9) is a reliable and validated, widely used, self-administered instrument of 9 items that evaluates depression severity [30]. It comprises how often the individual suffered from depressive symptoms in the prior 2 weeks, including information on impairment of normal life due to symptom manifestation, with respect to the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria for depression disorders. Scoring can range from 0 to 27, where a score of 5-9 represents mild depression, 10-14 moderate, 15-19 moderately severe, and 20 or more severe depression [30].
The Big Five Inventory (BFI) is a self-report instrument investigating personality traits [31]. It consists of 44 items covering the five dimensions of personality (extraversion, agreeableness,
Gastroscopy: Gastroscopy was performed by an experienced endoscopist using a Pentax gastroscope. The endoscopists were not aware of questionnaire results. If biopsies were taken, those were incorporated in the assessment. In some cases, however, the PAD did not arrive in time so that we could not consider them. In the OG, endoscopic findings were classified into: gastritis, esophagitis, portal hypertension, hiatal hernia, ulcus ventriculi, ulcus duodeni, stomach cancer, duodenal cancer, achalasia, duodenitis, peptic stenosis/stricture, Barrett changes, duodenal polyps, villous atrophy or intestinal bleeding.
Statistical analysis: The data were processed using Microsoft Excelâ and IBM SPSS Statistics for Windows, version 23. Descriptive statistics were used, and since Kolmogorov-Smirnov test showed that the data were not normally distributed, the non-parametric Mann-Whitney test was used to compare the differences between the two groups. A p-value of <0.05 was considered significant.
Ethical considerations: According to the Helsinki declaration [32], all information was solely handled by the research group and data were presented anonymously. Written informed consent was obtained in most cases, in others we referred to quality examination.
Results
In total, 91 patients were included in the study; 31 FD-patients (females 61.3%) and 60 patients in the OG (females 60.0%). Median age in the FD group was 44 (range 18-88), and 62 (range 25-86) in the OG, with the difference being statistically significant (p=0.005). The most common diagnosis in the OG was hiatal hernia (43.3%), followed by gastritis (38.3%), esophagitis (23.3%) and ulcus ventriculi (13.3%), see Figure 1. Use of medications in both groups are displayed in table 1.
Figure 1. Pathological findings on gastroscopy in the OG (in percent). Other include intestinal bleeding,
cancer in ventricle or duodenum, Barrett changes, esophageal stricture/Schatzki ring, duodenal polyp and achalasia.
OG, organic group.
Table 1. Use of medications in the FD group and OG.
Antacids PPI NSAID ASA Antidepres-sants Anxiolytics None of the previous FD n=31 2 (6.5%) 13 (41.9%) 2 (6.5%) 6 (19.4%) 2 (6.5%) 3 (9.7%) 11 (35.5%) OG n=60 3 (5.0%) 21 (35.0%) 6 (10.0%) 8 (13.3%) 8 (13.3%) 2 (3.3%) 21 (35.0%)
PPI, protonpumpinhibitor; NSAID, non-steroidal anti-inflammatory drugs; ASA, acetylsalicylic acid; FD, functional dyspepsia; OG, organic group.
Symptoms that differed significantly were frequency of nausea (p=0.020), belching (p=0.038), discomfort (p=0.032) and pain (p=0.031) in the upper abdomen; the FD-group experienced these symptoms more frequently. Regarding QoL, the subscales of tension (p=0.015), knowledge/control over disease
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pe rc ent age
Pathological findings on gastroscopy
symptoms (p=0.032), interference of daily activities (p=0.002) and work/studies (p=0.006), as well as the subscale mean (p=0.009) were higher in the FD group.
The distribution of depression severity is displayed in table 2. The median scores on symptoms as well as impairment caused by symptoms was higher on PHQ-9 in the FD group, and this was statistically significant (p=0.033 and p=0.002, respectively). Elevated levels of depression on HADS were seen in 13.8% in the FD group and 3.4% in the OG, the median score was significantly higher in the FD group (p=0.024). Elevated levels of anxiety were seen in 37.9% in the FD group and 15.8% in the OG. Median score on anxiety was significantly higher in the FD group (p=0.006).
Table 2. Severity of depression across the FD group and OG according to the PHQ-9 results.
No depression
Mild Moderate Moderately severe Severe FD n=29 7 (24.1%) 10 (34.5%) 7 (24.2%) 3 (10.3%) 2 (6.9%) OG n=53 23 (43.3%) 17 (32.1%) 9 (17.0%) 4 (7.5%) 0 (0%) FD, functional dyspepsia; OG, organic group.
FD patients had significantly higher scores on neuroticism (p=0.021) and lower scores on conscientiousness (p=0.018). In the FD group, 70.4% had scores above the 50th
percentile for neuroticism, compared to 49.1% in the organic group. The differences for scores on extraversion, agreeableness and openness were not statistically significant.
Discussion
Our patients characteristics are in line with similar studies, showing women having a higher prevalence of dyspepsia and FD, as well as FD being more common in younger adults compared to organic dyspepsia [3–6,9,13,15,24,26,27,33,34]. Mean age in other studies was approximately 36-56 years in dyspepsia in general, 65 years in organic dyspepsia and 40-43 years in FD patients [13,15,24,26,27,33–35]. In our population, the age differences can also be attributed to the fact that gastroscopy is offered more liberally to older patients because of the higher risk for organic pathology, according to current guidelines [36].
Dyspepsia was shown to have an organic cause in approximately 15-25% of gastroscopies in Sweden, and in studies from other countries this number has varied from 22 to 43% [9,13–15,35]. In our study, 66% had pathological findings on gastroscopy. This high number is probably because of the fact that we, in contrast to other studies, regarded hiatal hernia (our most prevalent finding) as organic pathology because this can contribute to dyspeptic symptoms. Since the organic group did not entirely
consist of patients with dyspeptic symptoms, but also other diseases that required a gastroscopy, previous numbers may not be entirely translatable to our results.
The OG had demonstrated anxiety- and depression levels which were comparable to the general population [37,38], and the increase in FD patients was significant. Previous studies have demonstrated varied associations between dyspepsia and anxiety/depression. Some have not shown an association between lifestyle and psychosocial factors and dyspepsia, (with the exception of smoking being a risk factor for ulcers [1,3]). However, most studies demonstrated higher depression- and anxiety scores in FD-patients, not only compared to HCs but also to organic diseases such as PUD [19–
23,25,27,28,39,40]. Dyspepsia symptoms were positively correlated with depression scores and associated with anxiety and sleep disorder [12,34].
The SF-NDI demonstrated FD patients to have not only more frequent dyspeptic symptoms, but also a lower QoL than the OG. Several studies showed that FD-patients have a lower QoL compared to HCs and organic dyspepsia [13,19,20,22,27]. Shetty et al showed a lower self-rated health in the domains of pain, usual activities and anxiety/depression in FD [15]. Filipović et al showed that FD-patients had more problems with emotional distress but not with psychosocial functioning or vitality, compared to HCs and PUD patients [25]. Ebling et al reported a dependence between dyspeptic symptoms and the feeling of tension and pain interfering with normal activities, as well as with the feeling of hopelessness, miserableness and being suicidal [7].
All of the above-mentioned factors are likely to be complexly intertwined. For example, Nan et al showed that dyspeptic symptom scores were correlated to scores of QoL, anxiety and depression [19,21], and Dibaise et al reported that FD symptom severity was negatively affecting QoL, including a significant influence of psychosocial variables (such as depression) on this relationship [12].
We found that FD-patients had significantly higher scores on neuroticism while scores on agreeableness and extraversion did not differ, similar to previous research [25]. This previous study also found neuroticism to have mutual concordance with anxiety [25]. Interestingly, conscientiousness was lower in FD-patients in our study. Since we did not adjust for age, this might be a confounder that needs to be investigated further.
Serotonin (5-HT) is involved in the regulation of mood and psychological states, as well as in the sensorimotor function of the GI tract [39]. The serotonin plasma membrane transport protein (SERT protein) is located on the presynaptic membrane and terminates the serotonergic
neurotransmission by the process of reuptake of 5-HT. Tominaga et al showed an increased density of SERT in the midbrain and thalamus in FD-patients compared to HCs, and this showed a positive correlation with GI symptom scoring [39]. The SERT-density in hippocampus did also correlate to GI symptom- and anxiety scoring in all subjects, and there was a tendency towards significance between SERT-density in the thalamus and depression scores [39]. This might be a part of visceral sensory/pain
processing, and Tominaga et al suggest a relation between central SERT disorders and both dyspeptic- and psychological symptoms in FD-patients, and discuss that anxiety can amplify pain [39].
In this respect, it is interesting that the selective serotonin reuptake inhibitor (SSRI) escitalopram has no effect on FD symptoms [1], which is remarkable because the mechanism of actions of SSRIs’ is to block the effect of SERT. In contrast, tricyclic antidepressants (TCAs) also block SERT, as well as the noradrenalin transporter (NET), which results in an elevation of the synaptic concentrations of these neurotransmitters, and therefore an enhancement of neurotransmission. TCAs have been shown to have significant effects on both pain and motor activity in the GI-tract, and they are used to treat FD [1,2,4,9]. Psycho- and hypnotherapy has also shown positive effects on FD [4].
It might not be surprising that FD-patients have lower QoL and more symptoms of anxiety and depression, since these patients are more often not responding to treatment, have protracting and recurrent symptoms and work absenteeism, which of course can lead to worrying, anxiousness or feeling hopelessness, as well as an increased vigilance tosymptoms, affectingQoL. It may be suggested that neuroticism contributes to these tendencies. Neuroticism may lead to more care-seeking behaviour, and dissatisfaction regarding the information that is provided to the patient. Worrying may lead to stress, which can lead to an increase in symptom burden.
The Rome criteria for FD comprise criteria for symptom duration, which we did not consider in this study. In Örebro, patients can book a gastroscopy themselves, hence the duration of symptoms plays a less important role in this clinical setting. However, Dibaise et al showed patients that FD patients not fulfilling the duration criterion had equal or results closer to normal than FD-patients fulfilling this, both regarding QoL, GI symptoms and psychological ones [12]. In Dibaises’ study, patient characteristics such as sex, age and sociodemographics were similar between those two groups as well [12].
Because most patients are candidate for a patient-booked gastroscopy, we acknowledge that this study includes potential confounders, such as comorbidities, sociodemographics etc., but we decided not to adjust for such factors in this pilot study. However, studies have shown that sociodemographic factors are not significantly associated with FD, and no differences in sociodemographic factors were seen between FD patients and patients who underwent a gastroscopy for iron deficiency and suspected celiac disease [17,41]. Furthermore, because of the small study sample, further statistics (i.e. subanalysis) were not applicable. We did not perform a Bonferroni correction, but are aware of the fact that
performing multiple analyses could lead to false positive results.
Prevalence of medication was self-reported and if not so, chart information was used, with a risk of being outdated and missing non-prescription drugs. Medication can bias findings; i.e. anxiolytics and antidepressants can decrease symptoms of anxiety and depression, and PPIs are not recommended immediately before gastroscopy [1,9].
It has been shown that up to 10% of ulcers are overlooked by endoscopists [1,3,10], making this a random error. Important to note is also that not all OG patients had dyspeptic symptoms, and could be asymptomatic. Future studies may match FD-patients with patients with organic pathology of same symptom burden. At the same time, ulcus disease, gastroesophageal reflux disease (GERD) or gastritis do not necessarily have to be the cause of symptoms [4,11,42], and caution should be taken because FGIDs can coexist with organic disease. For example, reflux and dyspepsia can coexist and be hard to
differentiate [1,2,4,14,18]. Future studies may implement the use of pH-measurements, since patients may suffer from non-erosive gastroesophageal reflux which does not result in macroscopically visible findings on endoscopy.
Today, FD-patients are provided with information [1–4,9–11] and ineffective
pharmacotherapy such as PPIs, TCAs’ and prokinetics. However, the impact of psychological factors affects QoL, health care utilization, work absenteeism, compliance, outcome of treatment and therefore lead to more burden for both the patient and the health care system. It is unclear whether psychological distress motivates or hinder patients to seek health care, but excessive health care utilisation should alert clinicians to risk for psychiatric comorbidity [6]. A large proportion of anxiety- and depression symptoms never catches the gastroenterologists attention [28]. Hence it is important to assess these patients
adequately with the right approach, and new insights may contribute to a more effective and holistic one, preferable in a multidisciplinary setting. Therapy focusing on psychological factors may be appropriate for at least a subset of patients, and by learning more we will hopefully be able to identify those patients that may benefit from this.
Conclusion
In this study, the functional dyspepsia group had a higher frequency of dyspeptic symptoms and lower QoL, as well as higher levels of anxiety, depression and neuroticism, compared to patients with
pathologic gastroscopic findings. These factors are likely to be complexly intertwined, affecting health care seeking and patient outcome. Our study contributes to understanding dyspepsia pathology, and can contribute to reduce the burden on patients, as well as society, via a better way of managing these patients in the future. This pilot study is also an important contribution for designing larger studies yet to come in this field.
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Appendix
Informational letter with inquiry of participation and medication record form
Förfrågan om deltagande i studie
Skriftlig information till deltagare
Personlighet och psykiskt mående har betydelse för vårt generella välbefinnande, inte minst gäller detta besvär i magtarmkanalen. Vi genomför just nu en studie vid Medicinska kliniken (avdelning
Gastroenterologi) på Universitetssjukhuset i Örebro och vid Örebro Universitet. Denna studie undersöker sambandet mellan symtom från magtarmkanalen (såsom smärta, obehag, brännande känsla, tidig
mättnadskänsla och ”uppkördhet” efter måltid) och personlighetstyp, psykiskt mående och fynd på gastroskopiundersökning.
Vi vänder oss till Dig för att tillfråga dig om deltagande i studien, då Du stått med på väntelista till gastroskopi på Medicinska kliniken. Studien innefattar 4 korta enkäter och ett blad där du får skriva ner vilka läkemedel du tar. Vi vill be dig att fylla i enkäterna och listan över läkemedel hemma och ta med dem ifyllda till Endoskopimottagningen. Gastroskopiundersökningen kommer att utföras på sedvanligt sätt och innebär inte något extra ingrepp.
Endast de personer som arbetar med studien kommer ha tillgång till Dina uppgifter och inga obehöriga kommer kunna ta del av dem. Alla Dina uppgifter hanteras enligt Personuppgiftslagen och
Patientdatalagen, och kommer presenteras utan namn eller personnummer så att de inte ska kunna knytas till Dig.
Deltagandet i studien är helt frivilligt. Om Du väljer att inte delta kommer detta inte påverka vilket omhändertagande du får i fortsättningen. Om Du är intresserad kan Du vid studiens slut ta del av dess resultat genom att kontakta ansvariga.
Tack på förhand för ditt samarbete
Om du har några frågor kan du höra av dig till:
Otilia Siversten, Läkarkandidat, mejl: otisiv131@studentmail.oru.se
Samtycke till deltagande i studie
Informerat samtycke
Jag har tagit del av information kring studien och fått svar på de eventuella frågor jag haft.
Jag samtycker härmed till deltagandet i studien och att mina uppgifter används i den: (Sätt kryss i rutan) --- Underskrift --- Namnförtydligande ---
Läkemedelslista
Var vänlig och skriv ner de läkemedel du tar, alternativt ta med en giltig läkemedelslista som innehåller alla de läkemedel du tar, både stående och tillfällig medicinering ska stå med.
PREPARATNAMN STYRKA DOSERING SEDAN HUR
LÄNGE HAR DU TAGIT LÄKEMEDLET?
Short Form Nepean Dyspepsia Index (Swedish)
NEPEAN DYSPEPSI FRÅGEFORMULÄR -
KORTVERSION
SF-NDI
â
Tack för att du hjälper oss med den här undersökningen. Det här frågeformuläret innehåller detaljerade frågor om dina magbesvär och hur de påverkar dig och ditt liv.
En del av frågorna är ganska personliga, men informationen som du lämnar kommer att behandlas med sekretess och känslighet.
SF-NDIÓ Nicholas J Talley, 1998
Detta är den ÖVRE DELEN AV BUKEN (magen)
Nepean dyspepsi frågeformulär - kortversion (SF-NDI)©
Var vänlig SKRIV SIFFROR i tabellen nedan för att ange hur ofta du har haft magbesvär under de senaste 14 DAGARNA och hur intensiva och besvärande de har varit.
Illustrationen på framsidan visar den ”ÖVRE DELEN AV BUKEN” – var vänlig titta på illustrationen när du svarar på frågor om besvär i den ”ÖVRE DELEN AV BUKEN”.
Under de senaste 14 dagarna, hade du något av
följande MAGBESVÄR?
Hur MÅNGA DAGAR hade du
det?
0 = Inga alls 1 = En till fyra dagar 2 = Fem till åtta dagar 3 = Nio till tolv dagar 4 = Varje dag/nästan
varje dag
Om du upplevde detta symptom, hur INTENSIVT var
det vanligtvis? 0 = Inte alls 1 = Väldig svagt 2 = Svagt 3 = Måttligt 4 = Kraftigt 5 = Väldigt kraftigt Om du upplevde detta symptom, hur BESVÄRANDE var det? 0 = Inte alls 1 = Lite grann 2 = Måttligt 3 = Mycket 4 = Extremt mycket
Smärta eller värk i den övre delen av buken
(magen)
Obehag i den övre delen av buken (magen) Brännande känsla i den övre delen av buken
(magen)
Brännande känsla i bröstet (halsbränna) Kramper i den övre delen av buken (magen) Smärta eller värk i bröstet, ovanför magen Oförmåga att avsluta en vanlig måltid Bitter/sur vätska som kommer upp i din
mun eller hals
Tidig mättnadskänsla vid måltid eller
långsam matsmältning
Tryck i den övre delen av buken (magen) Känsla av uppsvälldhet i magen
Illamående
Rapningar
Kräkningar
Spänningar
1. Har ditt ALLMÄNNA KÄNSLOMÄSSIGA VÄLBEFINNANDE blivit stört av dina
magbesvär under de senaste 14 dagarna?
1
Inte alls 2
Lite grann 3
Måttligt 4
Mycket 5
Extremt mycket
2. Har du varit LÄTTRETLIG, SPÄND eller FRUSTRERAD under de senaste
14 dagarna på grund av dina magbesvär?
1
Inte alls 2
Lite grann 3
Måttligt 4
Mycket 5
Extremt mycket
Störning av dagliga aktiviteter
3. Har din FÖRMÅGA att engagera dig i saker som du vanligtvis gör som
FRITIDSAKTIVITET (som rekreation, uteliv, hobbies, sport mm) blivit störd av dina magbesvär under de senaste 14 dagarna?
1
Inte alls 2
Lite grann 3
Måttligt 4
Mycket 5
Extremt mycket
4. Har din GLÄDJE av det du vanligtvis gör som FRITIDSAKTIVITET (som rekreation,
uteliv, hobbies, sport mm) blivit störd av dina magbesvär under de senaste 14
dagarna? 1
Inte alls 2
Lite grann 3
Måttligt 4
Mycket 5
Extremt mycket
6
Ej tillämpligt (Jag har inte kunnat göra någon av dessa saker under de
Att äta/dricka
5. Har din FÖRMÅGA att ÄTA eller DRICKA (inklusive när, vad och hur mycket) blivit
störd av dina magbesvär under de senaste 14 dagarna?
1
Inte alls 2
Lite grann 3
Måttligt 4
Mycket 5
Extremt mycket
6. Har din GLÄDJE av att ÄTA och/eller DRICKA störts av dina magbesvär under de
senaste 14 dagarna? (Inkludera din aptit och hur du mår efter mat eller dryck).
1
Inte alls 2
Lite grann 3
Måttligt 4
Mycket 5
Extremt mycket
Kunskap om/kontroll över magbesvären
7. Under de senaste 14 dagarna, har du UNDRAT om du ALLTID kommer att ha de
här magbesvären? 1
Nästan aldrig 2
Ibland 3
Ofta 4
Väldigt ofta 5
Ständigt
8. Under de senaste 14 dagarna, har du UNDRAT om dina magbesvär kan bero på en
mycket ALLVARLIG sjukdom (såsom cancer eller hjärtproblem)?
1
Nästan aldrig 2
Ibland 3
Ofta 4
Väldigt ofta 5
Ständigt
Arbete/hushållsarbete/studier
9. Har din FÖRMÅGA att ARBETA, STUDERA eller göra HUSHÅLLSARBETE störts av
dina magbesvär under de senaste 14 dagarna?
1 Inte alls 2 Lite grann 3 Måttligt 4 Mycket 5 Extremt mycket
6 Ej tillämpligt (Jag har inte arbetat, studerat eller gjort hushållsarbete
under de senaste 14 dagarna, på grund av mina magbesvär)
10. Har din GLÄDJE av att ARBETA, STUDERA eller göra HUSHÅLLSARBETE störts av
dina magbesvär under de senaste 14 dagarna?
1
Inte alls 2
Lite grann 3
Måttligt 4
Mycket 5
Extremt mycket
6
Ej tillämpligt (Jag har inte arbetat, studerat eller gjort hushållsarbete
under de senaste 14 dagarna, på grund av mina magbesvär)
Patient Health Questionnaire-9 (Swedish)
F O R M U L Ä R F Ö R P A T I E N T H Ä L S A - 9 ( P H Q - 9 )
Under de senaste 2 veckorna, hur ofta har du besvärats av något/några av följande problem?
(Sätt en bock “✔” bredvid ditt svar) Inte alls Flera dagar Mer än hälften av dagarna Nästan varje dag
1. Lite intresse eller glädje av att göra saker 0 1 2 3
2. Känt dig nedstämd, deprimerad eller upplevt känsla av
hopplöshet 0 1 2 3
3. Svårigheter att somna eller få en sammanhängande sömn,
eller sovit för mycket 0 1 2 3
4. Känt dig trött eller haft för lite energi 0 1 2 3
5. Dålig aptit eller ätit för mycket 0 1 2 3
6. Tycker illa om dig själv – eller att du känt dig misslyckad
eller att du svikit dig själv eller din familj 0 1 2 3
7. Svårigheter att koncentrera dig på saker, till exempel att
läsa tidningen eller att titta på TV 0 1 2 3
8. Att du rört dig eller talat så långsamt att andra människor
märkt det? Eller motsatsen – att du varit så nervös eller
rastlös att du rört dig mer än vanligt 0 1 2 3
9. Tankar att det skulle vara bättre om du var död eller att du
skulle skada dig på något sätt 0 1 2 3
FOR OFFICE CODING 0 + ______ + ______ + ______
=Total Score: ______
Om du svarat att du haft något av dessa problem, hur svårt har dessa problem gjort det för dig att utföra ditt arbete, ta hand om saker hemma, eller att komma överens med andra människor?
Inte alls
svårt svårt Lite Mycket svårt Extremt svårt
Framtagen av läkarna Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke och kollegor, med ett utvecklingsanslag från Pfizer Inc. Ingen tillåtelse krävs för att reproducera, översätta, visa eller distribuera.
Hospital Anxiety and Depression Scale (Swedish)
Hospital Acquired Depression Scale
Fyll i det alternativ som stämmer bäst in på Dig!
Jag känner mig spänd eller nervös: Allting känns trögt:
( ) Mestadels ( ) Nästan alltid
( ) Ofta ( ) Ofta
( ) Av och till ( ) Ibland
( ) Inte alls ( ) Aldrig
Jag uppskattar fortfarande saker jag Jag känner mig orolig, som om jag har
tidigare uppskattat: ”fjärilar” i magen:
( ) Definitivt lika mycket ( ) Aldrig
( ) Inte lika mycket ( ) Ibland
( ) Endast delvis ( ) Ganska ofta
( ) Nästan inte alls ( ) Väldigt ofta
Jag har en känsla av att något hemskt Jag har tappat intresset för hur jag ser
kommer att hända: ut:
( ) Mycket klart och obehagligt ( ) Fullständigt
( ) Inte så starkt nu ( ) Till stor del
( ) Betydligt svagare nu ( ) Delvis
( ) Inte alls ( ) Inte alls
Jag kan skratta och se det roliga i saker Jag känner mig rastlös:
och ting: ( ) Väldigt ofta
( ) Lika ofta som tidigare ( ) Ganska ofta
( ) Inte lika ofta nu ( ) Sällan
( ) Betydligt mer sällan nu ( ) Inte alls
( ) Aldrig
Jag ser med glädje fram emot saker och
Jag bekymrar mig över saker: ting:
( ) Mestadels ( ) Lika mycket som tidigare
( ) Ganska ofta ( ) Mindre än tidigare
( ) Av och till ( ) Mycket mindre än tidigare
( ) Någon enstaka gång ( ) Knappast alls
Jag känner mig på gott humör: Jag får plötsliga panikkänslor:
( ) Aldrig ( ) Väldigt ofta
( ) Sällan ( ) Ganska ofta
( ) Ibland ( ) Sällan
( ) Mestadels ( ) Aldrig
Jag kan sitta stilla och känna mig Jag kan uppskatta en god bok, eller ett
avslappnad: TV- eller radioprogram
( ) Definitivt ( ) Ofta
( ) Vanligtvis ( ) Ibland
( ) Sällan ( ) Sällan
COVER LETTER
Journal of xxxxx
2nd of January 2017 Dear Editor,
Please consider publishing the enclosed manuscript entitled “Psychological Profile in Patients with Pathologic Gastroscopic Findings and Functional Dyspepsia: A Pilot Study” in Your Journal. We think that this could be of interest to readers because of the following reasons:
• This is one of few studies investigating the association between functional dyspepsia and not only features of anxiety and depression, but also personality traits, compared to patients with pathologic gastroscopic findings.
• To our knowledge, this is the first study on gastroscopy patients using the validated Big Five Inventory-Questionnaire to assess personality traits. This showed higher levels of neuroticism in functional dyspeptics.
• Comparing functional dyspeptics to patients with pathologic gastroscopic findings, the functional group had a higher frequency of dyspeptic symptoms, lower quality of life and higher levels of anxiety and depression (while the group with pathologic
gastroscopic findings were more in line with population norms).
• The study was done with respect to the common population in everyday clinical work, so results are generalizable to many clinics around the world.
• Our study contributes to understanding dyspepsia pathology, and can contribute to reduce the burden on patients, as well as society, via a better way of managing these patients in the future.
• This pilot study is an important contribution for designing larger studies yet to come in this field.
The authors declare no conflicts of interest. This manuscript has not been published, nor is it for consideration elsewhere.
Yours sincerely, Otilia Siversten Örebro Sweden POPULÄRVETENSKAPLIG SAMMANFATTNING
Dyspepsi innebär symtom från övre magen, såsom smärta, obehag, brännande känsla, uppkördhet och tidig mättnadskänsla. Dyspepsi är vanligt och kan bero på sjukdom i övre magen eller att man inte hittar någon orsak, så kallad funktionell dyspepsi. Det finns ingen bra behandling för funktionell dyspepsi, som ofta ger långdragna problem.
Forskning har visat att patienter med funktionell dyspepsi har lägre livskvalitet samt att sjukdomen har ett samband med psykologiska och psykiatriska faktorer, såsom ångest och depression. Detta ger lidande och hög sjukfrånvaro, och vidare höga kostnader för samhället. För att minska detta ville vi genomföra en studie som kunde bidra till förståelse för sjukdomen.
I forskningsstudien delades enkäter ut till patienter som skulle genomföra gastroskopi. Det visade sig att patienter med funktionell dyspepsi oftare hade
dyspepsisymtom samt lägre livskvalitet jämfört med gruppen med sjukdomsfynd (via gastroskopi). Patienterna med funktionell dyspepsi hade också mer symtom på ångest och depression, och mer neurotiska personlighetsdrag.
Alla ovanstående komponenter samspelar troligen i ett komplicerat samband mellan hjärna och mage. Med varje studie lär vi oss mer om hur detta fungerar och kan förhoppningsvis använda detta till bättre bemötande och behandling för patienterna.
Magsårssjukdom; ett exempel på sjukdom i övre
magen som kan ses med hjälp av gastroskopi.
ETISK REFLEKTION
Etik är en av grundstenarna för att modern forskning ska vara tillämpbar i vårt samhälle, något nuvarande regler/lagar och Helsingforsdeklarationen bidrar till. I forskning innefattande forskningspersoner är det till exempel viktigt med information om projektet (vem, vad, var, hur, varför) samt en otvingad förfrågan om deltagande (vilket ska vara frivilligt). Det är också av vikt att forskningspersonen vet att information behandlas med sekretess och presenteras avidentifierat, och att hen kan dra sig ur utan att detta påverkar framtida vård. Om personen i fråga har frågor måste det finnas utrymme för sådana. Transparens är oumbärlig för att forskningspersonen ska kunna ta ett välgrundat beslut om deltagande, och är en indikation på att forskningen sker på ett tillförlitligt och professionellt sätt.
För- och nackdelar är likaså viktiga för forskningspersonens beslut, och ska alltid vägas samman av forskare och etiknämnd för att avgöra om forskningsprojektet är genomförbart. I just vår studie var nackdelarna inte särskilt påtagliga,
gastroskopiundersökningen (som utfördes på sedvanligt sätt) utgjorde inte något extra ingrepp. Fördelarna var däremot ett bidrag till utvidgning av kunskapsbasen kring forskningsämnet, för att hitta ett bättre förhållningssätt och framtida behandling.
Forskning kring psykisk hälsa kan vara känsligt och det är därför extra viktigt med ovanstående punkter. Ett exempel är hur man hanterar forskningspersoner med
ångest/depression. Kanske ska man erbjuda hjälp, men samtidigt ska uppgifterna avidentifieras, och i vår studie fanns ingen psykiatrisk intervention. Man kan också
argumentera att uppsökande av vård sker när patienten känner sig redo för det, kanske bidrar till exempel enkäter till sjukdomsinsikt.
Gastroskopi:
Gastroskopi innebär att man tittar ner i magsäcken och första delen av
tunntarmen med en liten kamera, för att se om det finns någon sjukdom eller avvikelse där. Om man inte hittar någon sådan hos en patient med dyspepsi blir diagnosen
