Irritable bowel syndrome (IBS) is a highly prevalent chronic gastrointestinal disorder designated by abdominal pain or discomfort and associated bowel habit changes [1
]. The symptoms, hardships, and impairments characterize IBS rather than organic abnormalities. Dilemmas concerning diagnosis and the variability of symptoms combined with the complex interaction of factors that impact biological, psychological, and social aspects for an individual with IBS contribute to treatment challenges [2
]. The biopsychosocial model presents the relationships between psychosocial factors (life stress, psychological state, social support, and coping), physiological factors (motility, sensation, inflammation, and microbiome), symptoms and behaviors, and clinical outcomes (quality of life, doctor visits, functioning, and medical treatments).
Impairment of quality of life and maladaptive coping have been found in those who suffer from irritable bowel syndrome [3
]. Additionally, Rutter and Rutter [3
] found that adaptive coping can enhance outcomes such as quality of life and satisfaction with health. Likewise, coping was found to mediate the relationship between illness representations and outcomes. Maladaptive coping, such as catastrophizing, has been found to be endorsed by individuals with IBS [5
]. The construct catastrophizing is broadly perceived as an exaggerated negative “mental set” that comes to be when an individual is experiencing pain or is anticipating a pain experience [6
]. It is a “method of cognitively coping that is characterized by negative self-statements and overly negative thoughts and ideas about the future” [7
]. Catastrophizing has been associated with increased pain severity, disability and functional limitations, decreased quality of life, and worsening disease activity as measured by physiologic indices in those with rheumatoid diseases [8
]. Specific to IBS, van Tilburg et al. [5
] observed a direct association between catastrophizing and IBS severity; in addition, catastrophizing was found to mediate the relationship between anxiety and IBS severity. Individuals with IBS often experience comorbid psychiatric disorders such as anxiety, depression, and somatization [9
]. These psychological comorbidities have been reported to have a negative impact on IBS symptom severity [5
] and health-related quality of life [11
] and are strong predictors of psychological functioning [12
]. Accordingly, the intrinsic perceptions or illness representations of individuals are important roots to their IBS.
The common sense model (CSM) of illness representations was developed by Leventhal and colleagues [14
] and expanded to include parallel emotional representations [15
]. Illness representations are classified into the following categories: identity (the label and symptoms associated with an illness), timeline (beliefs regarding the time of development and duration), consequences (the ramification of the illness on the psychological, social, and physical functioning), cause (the individual’s belief about potential cause(s) of their illness), control (the belief regarding the amount of control the individual has regarding their ability to control symptoms and the belief in the provider to intercede and influence symptoms), and emotional representation (the negative impact of their illness on their emotional well-being). According to the CSM, illness representations and coping influence outcomes.
Research examining the role of catastrophizing and illness representations in IBS is limited. Therefore, the aim of the present study was to investigate the relevance of catastrophizing to patient-reported illness representations, psychological distress, and health-related quality of life. Specifically, the main focus of the study was to investigate whether there were reporting differences between catastrophizers and non-catastrophizers.
The main focus of this study was to examine whether the use of catastrophizing coping impacted the health-related quality of life, psychological distress, and illness perceptions of adults who suffer from IBS. Catastrophizing, an important psychological concept with limited previous research in IBS, was found to be significantly endorsed in this sample. Furthermore, individuals who catastrophized reported worse health-related quality of life, higher psychological distress, and perceived more somatic symptoms, worse consequences, and more severe emotional impact as compared to those participants who did not catastrophize.
Catastrophizing was positively associated with consequences, emotional, identity, and timeline representations and negatively associated with health-related quality of life, control, and coherence representations. These findings indicate that individuals who catastrophized associated a greater number of symptoms with their IBS and categorized their IBS as more chronic in nature and perceived worse consequences and a worse emotional impact. Alternatively, those reporting greater personal and treatment control and greater understanding of IBS were associated with a better health-related quality of life.
The role of catastrophizing in illness perceptions has not previously been reported in an IBS population. Previous research has confirmed the association between catastrophizing and depression, and pain severity [6
]. In addition, catastrophizing has been found to be a mediator between psychological distress and pain [26
] and attachment style and symptom severity [27
]. Our findings further highlight the importance of this cognitive coping style frequently associated with IBS.
Additionally, it is important to mention that we found psychological distress (anxiety, depression, and somatization) was significantly associated with impairment of HRQOL. The main effects and interaction between anxiety and depression explained a third of the variation that catastrophizing or pain explained. Of the psychological distress variables, anxiety was the greatest predictor of HRQOL impairment. The literature has established that individuals with IBS often experience comorbid psychological distress [5
] and psychological distress is consistently found to negatively impact patient’s quality of life as measured by physical and mental functioning [12
]. In addition, van Tilburg et al. (2013) have found that psychological distress (anxiety) relation to IBS symptom severity was mediated by catastrophizing [5
]. It is important to keep in mind the impact psychological factors have on individuals who suffer from IBS, especially with regard to their HRQOL. However, given the results of this study, it may be prudent to also consider the maladaptive coping skills, in particular catastrophizing coping, as the findings of our study suggest that maladaptive coping in addition to psychological distress may play an important role in IBS outcomes.
Medical treatment modalities in IBS have had limited success [31
]. The influence catastrophizing has on the well-being of individuals with IBS suggests directions for the design of psychosocial interventions targeted toward catastrophizing as a possible means to positively impact behavior and functioning. Influencing outcomes positively with Cognitive Behavior Therapy (CBT) has been reported in the pain literature [33
], as well as in IBS [35
]. However, varying duration, intervention methods, effect sizes, and diversity of CBT formats contribute to treatment inconsistencies and varying benefits. Thorn and colleagues [33
] have developed a CBT program that centers on the diminishment of catastrophizing. The authors report a clinical observation that those with chronic pain respond to adaptive coping training only after they become aware of their catastrophizing. Research to assess and direct treatment specifically focused at reducing catastrophizing resulting in positive outcomes is needed. Such research would provide healthcare providers with greater insight into the mechanisms of change.
In addition to focusing treatment regimens on catastrophizing, addressing illness representations also appears to be a pertinent variable on which to focus. Illness representations have been noted to impact outcomes in such disorders as heart disease [36
], rheumatoid arthritis [37
], cancer [38
], and limited reports in IBS [3
]. There is persistent evidence for the theoretical predictable relations between illness perceptions, coping, and outcomes across these studies. Assessment and integration of both catastrophizing and illness perceptions into the management of individuals who suffer with IBS may maximize health outcomes.
There are limitations to this study that need to be acknowledged. First, this study relied on patient-reported measures. Self-reported responses have been noted as potential limitation to studies [40
]. There is a risk that a participant may be unable to remember information, such as description of personal views, feelings, distress level, and way of thinking. However, specific to this study it is important to note that these are the participant-reported perceptions and in contrast may actually have strengthened this study by further validating the experience of IBS. Second, the sample was relatively small and composed primarily of women from specialty gastrointestinal practices. Women are disproportionately affected with IBS [41
]. The high distribution of women in our sample may be due in part to this disproportion in prevalence. The results may not generalize to males and/or non-gastrointestinal specialty practice patients. Given the sample size, results can only favor a trend that necessitates confirmation in larger sample size studies. In addition, the sample consisted of a significant number of participants that catastrophized compared to non-catastrophizers. As noted in the past research of individuals who suffer from IBS, there is a tendency to catastrophize [5
]. It is unclear if this sample is representative of this tendency as there is no current literature quantifying catastrophizing frequency in an IBS population. A final limitation is that our data were cross-sectional in nature and as a result cannot speak to the direction, if any, of causal effects.
The authors would like to acknowledge Dr. Vicki Conn, PhD, RN, FAAN and Dr. Todd Ruppar, PhD, RN for their valuable input during preparations of this manuscript.
This study was financially supported by Grand Teton Gastroenterology, ID, and The Gastroenterology Center of Connecticut, CT, to LeeAnne B. Sherwin.