Cognitive Appraisal and Psychological Distress Among Patients with Irritable Bowel Syndrome

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Isr J Psychiatry Relat Sci - Vol. 52 - No 1 (2015) Cognitive Appraisal and Psychological Distress Among Patients with Irritable Bowel Syndrome

Menachem Ben-Ezra, PhD,1 Yaira Hamama-Raz, PhD,1 Sharon Palgi, MA,2 and Yuval Palgi, PhD3

1 School of Social Work, Ariel University, Ariel, Israel 2 Department of Psychology, University of Haifa, Haifa, Israel 3 Department of Gerontology, University of Haifa, Haifa, Israel

in reducing their helplessness appraisal and increasing Abstract the appraisal of their ability to cope with the symptoms Background: Irritable Bowel Syndrome (IBS) is a debilitating of their illness. condition that affects mainly the patient’s mental health and quality of life. There is a gap in the literature regarding the relationship between cognitive appraisals and adjustment to physical and psychological aspects resulting from IBS. The aim of the current study was to Introduction explore the psycho-social factors that are associated Irritable bowel syndrome (IBS) is considered a significant with psychological distress among IBS patients and the functional gastrointestinal disorder, with prevalence contribution of cognitive appraisal to their adjustment. ranging from 10% to 15% (1). It occurs more often in women than in men, and it begins before the age of 35 in Methods: One hundred and three patients diagnosed with about 50% of people (2). IBS is also regarded as a chronic Irritable Bowel Syndrome participated in the study. Each illness that can dramatically affect the quality of life (3). participant filled a battery of questionnaires targeting Psychiatric disorders, especially depression and anxiety, demographic and psycho-social factors. The study occur in up to 94% of IBS patients (2). Psycho-social variables were analyzed via hierarchical regression along factors may play an important role in the development with supplementary analyses of multiple mediation tests as well as in the outcome and prognosis of the disorder of indirect effects. (4). The aim of the present study was to explore the Results: The findings showed that psychological psycho-social factors that are associated with psychologi- distress and depressive symptoms among IBS patients cal distress among IBS patients and the contribution of are better predicted by their global positive illness cognitive appraisal to their adjustment. cognition appraisal, specific illness cognition appraisal The study is based on the theoretical framework of of helplessness, resilience and to a lesser extent by social Lazarus and Folkman’s model of adjustment to stress (5-8). support, perceived optimism, illness cognitions appraisals This theory proclaims that cognitive appraisal, personal of acceptance and perceived benefit. Global positive resources and social resources might alleviate or exacerbate illness cognition appraisal gives us a sum of positive and the perceived stress experienced by an individual. negative appraisals into one unified appraisal. Cognitive appraisal has been defined as a “process through which the person evaluates whether a particular Conclusions: Our findings highlight the salience of encounter with the environment is relevant to his or cognitive appraisal and resilience in IBS psychological her well being, and if so, in what ways” (9). This pro- adjustment. It seems that IBS patients might benefit from cess involves both primary and secondary appraisals psycho-educational interventions designed to assist them that occur at the same time and interact in order to determine the significance and meaning of the event

Address for Correspondence: Prof. Menachem Ben-Ezra, School of Social Work, Ariel University, Ariel 40700, Israel [email protected]

54 Menachem Ben-Ezra et al. in regard to well being (7). Primary appraisal considers individual’s ability to use familial, social, and external the perceived implications of the stressor for well being support in order to cope better with stressful events (26, through interpretation of stressful situation in one of 27). In light of this, we aim to explore the contribution three possible outcomes: irrelevant, challenge or threat. of social support to the IBS patients’ health. Secondary appraisal refers to a cognitive-evaluative pro- The relationship between social support and health, cess that focuses on minimizing harm or maximizing functioning, and quality of life is well established in the gains through coping responses. It involves purposeful literature (28-30). Two types of mechanisms have been evaluations of cognitive, affective and behavioral efforts described when studying this relationship: The direct to manage the perceived stress (7-9). Empirical studies positive path that relates to support and the buffering show that cognitive appraisal affects adjustment to ill- effect, by which social support moderates the impact of ness, including HIV (10), cardio-vascular disease (11), acute and chronic stressors on health (31). In the general and cancer (12). However, there is a gap in the literature population, social support buffers against stressful life regarding the relationship between cognitive appraisal events, increases adherence to medical treatments, and and adjustment to physical and psychological aspects improves recovery from medical illness, among other among IBS patients. The main difference between IBS health-promoting effects (28, 32-35). A recent study (4) has patients and the aforementioned medical conditions is found that among IBS patients, feelings of social isolation the existence of life threatening conditions in comparison existed regardless of the efforts of the family, friends and to IBS which is a debilitating condition that affects qual- some physicians to be supportive. The reasons were lack ity of life without the component of threat for one’s life. of understanding relating to the complexity and severity Other factors mentioned in Lazarus and Folkman’s of the disorder. Additive strain from relative and friends model are personal resources which may contribute telling the patients to ignore or minimize their experience, to the cognitive appraisal component and to adjust- telling them to ‘‘relax’’ or ‘‘do something else.” These actions ment. We chose two coping resources – optimism and have facilitated the creation of a social barrier impeding resilience, which may be especially relevant in the case normal functioning. of IBS patients due to the association between physical The goal of the current study was to further explore the condition and mental condition. psycho-social factors that are associated with psychological Optimism is described as a relatively stable, general distress among IBS patients and to gain more information tendency of individuals to expect positive outcomes (13). on psychiatric symptoms and cognitive attitudes, which can Individuals high in optimism typically have better psy- be further utilized in the development of psychotherapeutic chological adjustment to negative life events, report less treatment strategies. More specifically, we assessed the distress across a broad range of stressful situations, have relationships between psychological distress and depressive more positive social networks, and enjoy better physical symptoms among IBS patients and their socio-demographic health (14-16). Optimistic individuals are prone to show and medical variables, personal resources – resilience and higher self efficacy, and adapt to stressors more effectively perceived optimism, interpersonal resource - social sup- during time of crisis (17). Studies with various ethnicities port and cognitive appraisal. Based on the aforementioned have demonstrated that higher levels of optimism predict studies, we hypothesize that IBS patients with higher resil- lower levels of depression and stress (18-20). Optimism ience, perceived optimism, and perceived social support also may serve as a protective factor that promotes resilient will exhibited less psychological distress and depressive adaptation, as found among individuals with cancer (21), symptoms. Our second hypothesis predicted that partici- and coronary heart disease (22, 23). pants with the highest combination of positive cognitions Resilience is defined as the ability to resist, cope with, regarding their illness will have lower psychological distress recover from, and succeed in the face of adverse life expe- and depressive symptoms in comparison to those with riences (24). Resilience represents “the ability of adults lower positive cognitions. in otherwise normal circumstances who are exposed to an isolated and potential highly disruptive event to maintain relatively stable, healthy levels of psychological Method and physical functioning as well as the capacity for genera- Participants tive experiences and positive emotions” (25). Resilience One hundred and three patients diagnosed with Irritable also refers to important psychological skills and to the Bowel Syndrome participated in the study. The sample

55 Isr J PsychiatryCognitive Relat Appraisa Sci - Vol. 52l and - No 1P (2015)sychological Distress Among Patients with Irritable Bowel Syndrome consisted of 69 men and 34 women, aged 18-50. The aver- “Do you perceived yourself as reviewing enough social age age was 24.53 (S.D. =6.243), 79.6% of the sample were support.” This item was coded as 0 = no, 1 = yes. unmarried (n=82). No history of previous medical condi- • Depressive symptoms were measured by the Short Center tions or psychiatric illnesses was reported by the subjects. for Epidemiologic Studies Depression Scale (SCES-D) which is a 10-item scale intended to measure the severity Measures of depressive symptoms an individual experiences (38). Demographic and medical information: Digestive disease The items are rated by frequency on a 4-point scale, report derived from the questions: Were you diagnosed where higher scores reflect higher risk for depression. with IBS by a gastroenterologist? Did you suffer from it The reliability of this scale was very good (Cronbach’s for at least one year? Only participants who answered alpha = 0.85). “yes” to those questions were enrolled into the study. • Psychological distress was measured by the General The respondents provided demographical data: age, Health Questionnaire (GHQ-12) (39), which contains gender coded as 0 = men, 1 = women, marital status 12 items (e.g., “felt you couldn’t overcome your diffi- coded as 0 = unmarried, 1 = married. culties,” “been losing confidence in yourself”) for 12 specific psychological symptoms such as anhedonia The following self-report questionnaires were used in and personal competence. Each item is rated by its this study: frequency over the past few weeks on a 4-point scale. • Subscales of Cognitive appraisal were measured by the Higher scores indicate poorer mental health. Cronbach’s Illness Cognition Questionnaire (ICQ) (36), which is alpha coefficient for this sample was 0.86. an 18-item scale intended to measure the personal perception of one’s own illness and his ability to function. Procedure The ICQ has three subscales: Acceptance, perceived The participants were recruited from the largest internet benefit and helplessness. High score in the acceptance forum in Israel dealing with gastroenterology. The initial scale reflects positive cognitions regarding one’s illness, message stated the inclusion criteria: (a) a Gastroenterologist while perceived benefit and helplessness reflect nega- diagnosis of IBS, (b) 18-50 years of age. The rationale to tive cognitions regarding one’s illness. The reliability of impose age limitation was in order to prevent sample bias. these scales were very good (Acceptance: Cronbach’s Participants received the questionnaires via e-mail. Along alpha = 0.804; Perceived benefit: Cronbach’s alpha = with the questionnaires, participants received instructions 0.851; Helplessness: Cronbach’s alpha = 0.892). and a short explanation as to the purpose of the study. After • Global positive illness cognition was measured by the the completed questionnaires were sent back by e-mail, a ICQ subscales using the median score of each sub- verification process was begun by the research assistant (DA) scale. In order to create the positive appraisal groups who asked the participants for their permission to contact we selected participants who had scored the following: them via phone in order to verify relevant details while guar- above the median in the acceptance sub-scale, under anteeing complete anonymity and to thank them personally the median in the perceived benefit and helplessness for their contribution to the study. Only participants who sub-scales). This led to four groups: high global positive were willing to participate in the verification process were appraisal and low global positive appraisal groups with enrolled in the study, in order to prevent potential biases two intermediate groups. that are known in internet studies (40). All the participants • Perceived optimism was measured by the single item were given the opportunity to request further information. statement: “given you current situation, do you con- The study was approved by the Institutional Review Board sider yourself optimistic about the future?” This item committee at the Open University. was coded as 0 = no, 1 = yes. • Resilience was measured by the Connor-Davidson Statistical methods Resilience Scale (CD-RISC) (37), which is a 25-item Four sets of hierarchical multiple regression were con- scale intended to measure the personal resilience, ducted, each one corresponding respectively to an outcome tolerance for negative affect and social support. High variable (psychological distress, depressive symptoms) in scores reflect higher resilience. The reliability of this order to test hypotheses 1 and 2. The hierarchical regression scale was very good (Cronbach’s alpha = 0.91). had four steps. The first step consisted of socio-demographic • Perceived social support was measure by a single item variables (age, gender, marital status). The second step con-

56 Menachem Ben-Ezra et al. sisted of personal variables (resilience, perceived optimism). tion appraisal (β = -2.039; t = -4.701; p <.001) and perceived The third step consisted of a cognitive appraisal variable social support (β = 1.763; t = 2.191; p <.05). This model (global positive illness cognition) which reflects one global explained about 36% of the variance (R2 = .405; adjusted illness appraisal. The fourth step consisted of an interper- R2 = .361; p < .001). For more information, see Table 2. sonal variable (social support). A preliminary analysis The results of the multiple mediation tests of indirect was conducted for potential multicollinearity. Applying effects showed that the following mediators were sig- the rules used in the literature stating that tolerance of nificant when psychological distress was the dependent less than 0.20 and/or variance inflation factor (VIF) of 5 variable: resilience (β = -.13; t = -4.000; p <.001), global and above indicate a multicollinearity problem (41). The positive illness cognition appraisal (β = -2.975; t = -6.375; preliminary analysis of the regressions yielded tolerance p <.001) and perceived social support (β = 2.090; t = ranging from 0.486-0.972 and VIF of 1.029-2.058. These 2.415; p <.05). This model explained about 45% of the results have indicated that there was no multicollinearity variance (R2 = .492; adjusted R2 = .454; p < .001). For problem. Finally, additional supplementary analyses of more information, see Table 3. multiple mediation tests of indirect effects were conducted based on the after mentioned hierarchical regressions (42). Discussion The results have shown that psychological distress and Results depressive symptoms among IBS patients are associated with For basic information and correlation matrix, see Table 1. global positive illness cognition, specific illness cognition In line with hypothesis 1 and 2, as seen in Table 2 and of helplessness appraisal, resilience and to lesser extent by 3, higher depressive symptoms were associated with lower social support, perceived optimism, illness cognitions of level of global positive illness cognition appraisal (β = -.409; acceptance and perceived benefit appraisals. These find- t = -4.803; p>.001) in step 3 and step 4 (β = -.394; t = -4.701; ing are in line with our hypotheses to some extent. While p>.001). In addition, higher psychological distress was asso- showing that resilience, illness cognition of helplessness ciated with lower global positive illness cognition appraisal appraisal add to the ample evidence that personal resources (β = -.509; t = -6.435; p>.001) in step 3 and step 4 (β = -.494; help persons to cope with stressful or traumatic events t = -6.375; p <.001). For more information, see Table 2 and 3. (7, 43) and account for at least some of the variability in The results of the multiple mediation tests of indirect individuals’ adjustment to stressors (44, 45). The results effects showed that the following mediators were significant also provide further support for Lazarus and Folkman’s when depressive symptoms were the dependent variable: (7-9) claim that persons’ appraisals of stressful events are resilience (β = -.11; t = -3.69; p <.001), perceived optimism more important to their psychological adjustment than (β = -1.708; t = -2.027; p <.05), global positive illness cogni- the “objective” stress of the events. Furthermore, our find-

Table 1. Baseline Characteristics of the Study Variables (n=103) Predictors Mean (SD) % 1 2 3 4 5 6 7 8 9 Age 24.5 (6.2) -.130 .519** -.115 .093 -.045 -.079 -.010 -.045 Gender (Men) 67.0 -.201* .043 -.068 -.031 .224* .078 .063 Marital status (Not Married) 79.6 -.065 -.007 -.047 -.084 -.091 -.171 Resilience 93.2 (13.8) -.130 .314** .005 -444** -.405** Optimism 1.34 (.48) -.045 .085 -.045 -.083 Positive appraisal 1.66 (.96) -.083 -596** -.490** Social support 1.37 (.50) .222* .206* Psychological distress 24.3 (5.8) .749** Depressive symptoms 19.6 (4.9) Gender was coded as 0 = men; 1 = women Marital status was coded as 0 = married/cohabitation; 1 = not married/cohabitation Psychological Distress was measured by the GHQ-12. Depressive symptoms were measured by the Short CES-D. * p< .05; ** p<.01; ***p<.001

57 Isr J PsychiatryCognitive Relat Appraisa Sci - Vol. 52l and - No 1P (2015)sychological Distress Among Patients with Irritable Bowel Syndrome

Table 2. Hierarchical Multiple Regression Predicting Increased Risk of Depression (CES-D) (n=103) Step 1: Model R = .181; Step 2: Model R = .474; Model Step 3: Model R = .612; Model Step 4: Model R = .636; Model Model R2 = .033 R2 = .224; R2 change = .191*** R2 = .375; R2 change = .150*** R2 = .405; R2 change = .030* Predictors Standardized β t Standardized β t Standardized β t Standardized β t Age .060 .523 .031 .295 .034 .353 .043 .463 Gendera .031 .308 .033 .366 .012 .144 -.027 -.328 Marital statusb -.196 -1.675 -.210 -1.974 -.226* -2.360 -.224* -2.380 Resilience -.435*** -4.792 -.307*** -3.562 -.312*** -3.691 Optimism -.141 -1.555 -.145 -1.769 -.164* -2.027 Positive appraisal -.409*** -4.803 -.394*** -4.701 Social support .180* 2.191 aGender was coded as 0 = men; 1 = women bMarital status was coded as 0 = married/cohabitation; 1 = not married/cohabitation * p< .05; ** p<.01; ***p<.001

Table 3. Hierarchical Multiple Regression Predicting Increased Risk of Psychological Distress (GHQ-12) (n=103) Step 1: Model R = .119; Step 2: Model R = .477; Model Step 3: Model R = .679; Model Step 4: Model R = .701; Model Model R2 = .014 R2 = .228; R2 change = .213*** R2 = .460; R2 change = .233*** R2 = .492; R2 change = .031* Predictors Standardized β t Standardized β t Standardized β t Standardized β t Age .054 .463 .016 .154 .019 .219 .029 .338 Gendera .064 .628 .070 .766 .043 .560 .003 .041 Marital statusb -.106 -.901 -.117 -1.101 -.137 -1.542 -.135 -1.552 Resilience -.466*** -5.152 -.307*** -3.839 -.312*** -4.000 Optimism -.103 -1.134 -.108 -1.412 -.127 -1.695 Positive appraisal -.509*** -6.435 -.494*** -6.375 Social support .183* 2.415 aGender was coded as 0 = men; 1 = women bMarital status was coded as 0 = married/cohabitation; 1 = not married/cohabitation * p< .05; ** p<.01; ***p<.001 ings contribute to the view of coping as contextual, that The global positive illness appraisal was found to be dis- is, influenced by persons’ appraisal of the actual demands criminant predictor of psychological distress and depressive in the encounter and resources for managing them. The symptoms even more than resilience among IBS patients. emphasis on the context means that particular persons and More specifically, global perception of one’s illness gave situation variables shape together the coping efforts (46). us a sum of positive and negative appraisals into one uni- More specifically, the findings highlight the importance fied construct. This is somewhat similar to other known of resilience as an interpersonal resource that contributes to predictors of physical and mental health in the literature one’s ability to cope, function and adapt well to the stressful such as self-rated health (49) and subjective well-being (life situation. IBS patients who were less resilient were more satisfaction) (50). This may lead to a rather bold argument distressed and exhibited higher depressive symptoms. favoring the unified construct of illness perception over Thus, if an individual exhibits behaviors associated with its subscale. These subscales were less salient predictors of low resilience, then there is an increased likelihood that the psychological distress and depressive symptoms. individual will function poorly in stressful situations thus Perceived social support was another predictor of higher showing lesser adaptation (47). Our findings are consistent level of depressive symptoms among IBS patients. This finding with the ample literature showing that individuals who is somewhat surprising in view of the direct positive effect do not display a resilient adaptation exhibit difficulties of support and the buffering effect, by which social support in regulating negative emotions and higher sensitivity to moderates the impact of acute and chronic stressors on health stressful life events (48). (4). Another study (51) posits that social support is strongly

58 Menachem Ben-Ezra et al. correlated with the stress and coping process. Specifically, Clinical implication and future research social support is considered a moderator in the stress process. Our findings highlight the salience of cognitive appraisal Moderators are “the variety of appraisals, coping strategies, and resilience in IBS psychological adjustment. It seems resistance factors, and vulnerabilities that modify how stress that IBS patients might benefit from psycho- educational is experienced and what its effects may be” (52). Moderators interventions (CBT based) designed to assist them in are believed to reduce the appraisal of stress when functioning reducing their helplessness appraisal and increasing the in a positive manner. By reducing the appraisal it indirectly appraisal of their ability to cope with the symptoms of their facilitates the coping process. A possible explanation might illness. More specifically, a cognitive-behavioral treatment be that family and friends’ concerns add emotional burden approach may help clients reconceptualize their experience to the feelings of shame and embarrassment that the IBS with IBS from helplessness and hopelessness to resourceful- patients already experience. IBS patients sense that their life ness and optimism, may help clients identify relationships was interrupted while not grasping fully how their condition among thoughts, feelings, behaviors, the environment, and encompasses every domain of their lives. In this context, a IBS symptoms, and may empower clients to develop and study by Stansfeld (31) has found that among IBS patients, a implement increasingly more effective ways of coping with predominant theme was perceived social stigma when others IBS in order to improve their quality of life (55). Moreover, did not understand or accept their feelings (4). psycho-social professionals should present resilience-based interventions to IBS patients in order to help them to adapt better to adversity inherent in their illness. Further research Limitations is suggested to examine other factors that affect adjustment There are several study limitations to be noted. Firstly, we to IBS. A possible direction to explore is working with did not identify many differences in health status and illness families using psycho-educational techniques in order severity, as have been showed by other studies (53). Secondly, to make social support effective. Group therapy within our sample’s mean age and gender distribution are different a cognitive framing context in order to enhance positive to that of IBS subjects’ demographic characteristics found in appraisals and reduce negative appraisals thus reduces epidemiologic studies (54). 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