Qual Life Res

DOI 10.1007/s11136-015-0932-8

Illness perceptions mediate the relationship between bowel

symptom severity and health-related quality of life in IBS patients
Veronique De Gucht

Accepted: 27 January 2015

 The Author(s) 2015. This article is published with open access at Springerlink.com

Abstract
Purpose Irritable bowel syndrome (IBS) is a functional
bowel disorder with a large negative impact on HRQOL.
The present study examines whether severity of bowel
symptoms is directly related to HRQOL, and/or indirectly,
mediated by the patients illness perceptions.
Methods Patients were recruited from an IBS support
group (N = 123), and data were collected online. HRQOL
was measured with the Quality of Life Measure for Persons
with IBS and illness perceptions with the brief Illness
Perception Questionnaire. Mediation models were tested
using the bootstrapping procedure developed by Hayes.
Results Irritable bowel syndrome symptom severity is
directly related to total HRQOL and its subscales; after
entering the mediator variables (i.e. the patients illness
perceptions) into the model, this direct association remained only significant for total HRQOL. The relationship
between bowel symptom severity and total HRQOL was
partially mediated by illness perceptions, and its relationship with each of the HRQOL subscales was fully mediated
by the patients illness perceptions. Perceived consequences were a mediator of the relationship between bowel
symptom severity, total HRQOL as well as its subscales,
with the exception of Sexuality.
Conclusions Bowel symptom severity not only has a direct relationship with HRQOL, but also an indirect relationship via the patients cognitive and emotional
representations of their illness. In order to better understand
this relationship, future research should not only include

V. De Gucht (&)
Health Psychology Unit, Faculty of Social Sciences, Institute of
Psychology, Leiden University, Wassenaarseweg 52,
PO BOX 9555, 2300 RB Leiden, The Netherlands
e-mail: degucht@fsw.leidenuniv.nl

illness perceptions but also assess cognitive and behavioural coping responses. Clinicians wanting to improve
patients HRQOL should not only focus on the patients
symptoms, but also on their illness beliefs and coping
responses.
Keywords Irritable bowel syndrome
Illness
perceptions
Disease-specific health-related quality of life

Symptom severity

Introduction
Irritable bowel syndrome (IBS) is a functional disorder of
the bowel, meaning that it is not characterized by any
structural abnormality, but rather by unexplained pain and
bowel dysfunction [1]. It is diagnosed by the Rome III
criteria [2]: abdominal discomfort or pain which is (a) relieved by defecation and is (b) associated with a change in
stool frequency and/or consistency and/or (c) associated
with a change in the form or appearance of stool. For a
patient to meet these diagnostic criteria, the symptoms and
associations must have been present at least 3 days per
month for the past 3 months, with the initial onset of
symptoms 3 months or more in the past.
The prevalence of IBS in the general population is high,
ranging, depending upon the study, from 3 to 32 %, with
most studies reporting a prevalence of between 5 and 15 %
[3]. The overall prevalence found in a large survey of
40,000 subjects from different European countries was
11.5 % [4]. A population study conducted in the USA revealed an overall prevalence of 14.1 % [5]. With respect to
gender differences, there is a higher ratio of women who
develop IBS compared to men, ranging from 2:1 to 3:1 [6,
7]. The prevalence of IBS decreases slightly with age [3].

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Qual Life Res

The socio-economic impact of IBS, based on direct medical costs, decreased work productivity and increased work
absenteeism, is substantial [7, 8]. A recently published
review reported that the direct medical costs associated
with IBS range, depending upon the study, from 1,562$ to
7,547$ per patient per year [9].
Next to a socio-economic impact, IBS also has a considerable impact upon the patients personal lives and more
in particular upon their health-related quality of life
(HRQOL). HRQOL encompasses the appraisal of a patient
regarding his or her physical or mental health. This appraisal
depends upon whether patients experience limitations due to
their disease and/or the extent to which their disease interferes with their life and overall functioning [10]. Despite the
fact that IBS is not a life-threatening disease, the syndrome
has a large negative impact on HRQOL, when compared to
healthy controls [7, 8, 1113]. Several studies have also
shown that HRQOL in IBS is equal to or lower than QOL in
patients suffering from other chronic diseases and conditions
including inflammatory bowel diseases, asthma, migraine,
gastro-esophagal reflux disease, diabetes, dialysis-dependent
end-stage renal disease, breast cancer, heart disease and
severe obesity [10, 1418].
With respect to the factors influencing HRQOL in IBS,
empirical studies point at severity of bowel symptoms and
psychological factors as the main determinants [8, 14, 1921].
A study by Naliboff et al. [22] showed that psychological
factors had even a stronger direct effect on HRQOL than
bowel symptoms. In addition, bowel symptoms were found to
also exert an indirect effect on HRQOL, mediated by psychological distress. With respect to the physical and the mental
components of HRQOL, there seems to be a differential pattern of association: severity of bowel symptoms was found to
be a stronger predictor of physical functioning, whereas psychological factors such as anxiety and depression were found
to be stronger predictors of psychological functioning measured by the SF-12 and SF-36 [23, 24]. This does not come as
a surprise as the psychological functioning dimension of
HRQOL scales such as the SF-12 and SF-36 include items that
could also be part of anxiety and depression scales. It is
therefore important to look at possible psychological sources
of anxiety, depression and HRQOL in IBS patients.
From this perspective, the beliefs that patients hold
about their illness and treatment are potentially important
determinants. Leventhal et al. [25] developed the common
sense model (CSM) classifying these beliefs or illness
perceptions as follows: identity (the label given to and the
symptoms associated with the illness); timeline (beliefs
about duration and course of the illness); consequences
(perception of the illnesss effects on the patients daily life
and functioning); causes (the patients belief about the
likely cause(s) of the disease) and control (the amount of
control the patient feels he/she has over the illness and the

123

extent to which he/she considers the medical treatment to

help). A meta-analysis [26] demonstrated a link between
illness perceptions measured according to Leventhals
CSM and HRQOL as well as psychological well-being
across a range of different illnesses. More specifically,
perceptions that the illness was controllable were positively
related to psychological well-being, social functioning and
vitality and negatively related to psychological distress.
Perceived consequences, timeline and identity on the other
hand were negatively related to psychological well-being,
social functioning and vitality.
Only a few studies have investigated the relationship
between illness perceptions and HRQOL in IBS. In their
study, Rutter and Rutter [27] found that members of an IBS
patient support network that perceived a lot of consequences of IBS and attributed their symptoms to a psychological rather than a physical cause reported lower
HRQOL and higher anxiety and depression scores. Perceiving little control over the illness and thinking that IBS
would be difficult to cure was associated with both lower
HRQOL and higher depression scores. In another study,
adopting a longitudinal perspective, Rutter and Rutter [28]
found that strong consequence beliefs at baseline predicted
higher anxiety and depression scores at 12-month followup in a population of IBS patients consulting their primary
care physician. A study by Riedl et al. [29] demonstrated
that IBS patients with mainly somatic illness attributions
reported worse physical HRQOL, whereas patients with
mainly internal psychological attributions reported better
physical but worse mental HRQOL.
While the aforementioned studies pointed at a relationship between illness perceptions and HRQOL in IBS, in
each of these studies HRQOL was measured by means of a
generic rather than a disease-specific questionnaire. Generic
measures typically assess HRQOL independent of the
specific characteristics of a particular disease, making them
suitable for comparing HRQOL across diseases. The disadvantage of a generic measure is, however, that it is not
condition-specific, and as a consequence, important aspects
related to the impact of a particular disease on HRQOL may
be neglected. For the purpose of the present study, a diseasespecific HRQOL measure was used. This allows us to capture the patients subjective evaluation of HRQOL more
adequately as it specifically addresses the patients concerns
and experiences associated with the symptoms of IBS [30].
Previous studies on the relationship between illness
cognitions and HRQOL have not taken the severity of IBS
symptoms into account. A review article on HRQOL in IBS
concluded, however, that the severity of the bowel symptoms in IBS patients is associated with a corresponding
impact on HRQOL [14, p. 118]. It is therefore important,
when studying the relationship between patients cognitions
about their condition and HRQOL, to also include the

Qual Life Res

severity of bowel symptoms as a potential determinant of

HRQOL. The study by Naliboff et al. [22], pointing at the
fact that bowel symptom severity has not only a direct effect
on HRQOL, but also an indirect effect, mediated by psychological factors, suggests that a mediation model is an
adequate way to study the association between symptom
severity, cognitive factors (i.e. illness perceptions) and
HRQOL in IBS patients.
For the purpose of the present study, it was hypothesized
that patients illness perceptions mediate the impact of
bowel symptom severity on HRQOL. The direction of the
pathways was based upon the core principle/basic tenet of
cognitive behavioural theory, namely that an event or
trigger (i.e. bowel symptoms/pain) sets in motion cognitive
processes (i.e. negative beliefs/illness perceptions), leading
to negative emotional or behavioural consequences (i.e.
poor HRQOL) [31]. This core principle has also been integrated in explanatory models for medically unexplained
symptoms and syndromes [32].
Research question
The present study examines to what extent severity of
bowel symptoms is directly related to disease-specific
HRQOL in IBS patients, and/or indirectly, mediated by the
patients illness perceptions. It is also examined whether
there is a differential pattern of associations between
severity of bowel symptoms, illness perceptions and
HRQOL depending upon the specific (physical, emotional
or social) dimension of HRQOL that is looked at.

Methods
Study design and procedure
Data were collected with an online self-report measure.
Respondents were recruited from an IBS patient support
group by placing an advertisement and an invitation to
participate on the Internet forum and newsletter of the
support group. If patients were interested in participating in
the study, they could log on to the website anonymously.
On the website, a letter containing information on the study
was provided, accompanied by a statement emphasizing
the confidentiality of data collection. Respondents gave
their informed consent by ticking a box before they got
access to the study questionnaire. The study was approved
by the ethical committee of Leiden University.
Participants
One hundred and forty-four subjects filled in the questionnaire (126 women and 18 men). Subsequently, 21

subjects were excluded from the study because they did not
qualify for an IBS diagnosis according to the Rome III
criteria [2]. The final sample consisted of 123 subjects (108
women and 15 men). Ages ranged from 16 to 61, with a
mean age of 32.43 (SD = 11.82). The female-to-male ratio
in the present study (88 vs. 12 %) is not in accordance with
existing epidemiological data [6, 7]. It is, however, comparable to the ratio reported by Rutter and Rutter [27], a
study that also recruited respondents from an IBS network.
Measures
A self-report questionnaire based upon the Rome III
criteria for IBS was administered to determine whether the
respondents qualified for an IBS diagnosis. The questionnaire contained 16 items, measuring different IBS symptoms such as bowel pain, stool frequency and stool
consistency, based upon the Rome II Modular Questionnaire [33] and adapted to fit the newer Rome III criteria.
Irritable bowel syndrome symptom severity was measured with three questions from the irritable bowel severity
scoring system (IBSSS) [34], measuring (a) severity of
abdominal pain (0 = no pain, , 100 = severe pain),
(b) severity of abdominal distension or bloating (0 = no
distension, , 100 = severe distension) and (c) number of
days patients experienced pain in the last 10 days. A total
severity score was calculated by adding up the score on (a),
the score on (b) and the number of days (c) multiplied by
10, leading to a possible total score of 300. Francis et al.
[34] examined the reliability and validity of the IBSSS.
The testretest reliability of the IBSS was good as scores
repeated within 24 h were highly reproducible. The IBSSS
was also found to distinguish well between healthy controls
and patients suffering from IBS, and between patients
clinically diagnosed with mild, moderate and severe IBS,
indicating that the criterion validity of the IBSSS was
good. Finally, the responsiveness (sensitivity) to change
was found to be very good; in patients who became considerably better, the severity score showed a highly significant improvement.
Illness perceptions were measured using the Dutch
Language Version of the Brief Illness Perception Questionnaire (Brief IPQ-DLV) [35] which has been shown to
have acceptable reliability and validity. The Brief IPQ was
shown to have good testretest reliability over a period of 3
and 6 weeks. The questionnaire also demonstrated to have
good concurrent validity with similar measures and to
adequately predict a number of relevant disease outcomes
such as return to work and HRQOL across different patient
groups [36, 37]. The (single-item) dimensions consequences, timeline, identity, personal control, treatment
control and coherence, and the (two-item) dimension
emotional representation were administered. One open-

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Qual Life Res

ended question measures the perceived cause of the illness.

Respondents had to note down what they considered to be
the most important cause of their IBS. Subsequently, these
answers were recoded into a dichotomous variable where
1 = a psychological cause (e.g. stress or life events) and
2 = a somatic cause (e.g. heredity or immune deficiencies). For the subscales consequences, timeline, identity
and emotional representation, higher scores represent more
negative illness perceptions (e.g. more consequences or a
longer timeline). For the subscales personal control, treatment control and coherence, higher scores represent more
positive illness perceptions (e.g. more personal control or
more treatment control).
Health-related quality of life was assessed by means of
the Dutch version of the Quality of Life Measure for
Persons with IBS consisting of 34 items (IBS-QOL) [38,
39]. The psychometric properties of the IBS-QOL were
demonstrated to be good. The testretest reliability was
good after a 1-week interval. Internal consistency was
found to be high for overall QOL (a = 0.95), as well as
for all of the subscales (ranging from 0.74 to 0.93) with
the exception of the subscale relationships (a = 0.65).
Criterion validity was good as the questionnaire distinguished well between mild, moderate and severe IBS
patients. Convergent validity analyses pointed out that the
IBS-QOL was more closely related to overall well-being
than to physical functioning measures [38]. For the purpose of the present study, the score for the total scale
(a = 0.93) as well as the scores for the following subscales was used: dysphoria (a = 0.90; eight items; e.g. I
feel my life is less enjoyable because of my bowel
problems.); interference with activity (a = 0.85; seven
items; e.g. I feel I get less done because of my bowel
problems.); body image (a = 0.65; four items; e.g. I
feel fat because of my bowel problems.); health worry
(a = 0.37; three items; e.g. I feel vulnerable to other
illnesses because of my bowel problems.); food avoidance (a = 0.73; three items; e.g. I have to watch the
kind of food I eat because of my bowel problems.);
social reaction (a = 0.70; three items, e.g. I worry that
people think I exaggerate my bowel problems.); sexuality (a = 0.85; two items; e.g. My bowel problems
reduce my sexual desire.); and relationships (a = 0.62;
three items, e.g. My bowel problems are affecting my
closest relationships.). All items were scored on a
5-point Likert scale, indicating to what extent the respondents could relate to each of the statements: not at
all, slightly, moderately, quite a bit and extremely. Due to
the low Cronbach a scores, the subscales body image,
health worry and relationships were excluded from further
analysis. The summed total and subscale scores were
transformed to a 0100 scale ranging from 1 (poor
HRQOL) to 100 (excellent HRQOL).

123

Statistical analysis
Pearsons correlation coefficients examined univariate associations between severity of bowel symptoms (independent variable), illness perceptions (mediator variables) and
HRQOL (dependent variable), as well as possible multicollinearity between the independent variable and the
mediator variables. Independent t tests compared scores on
the different HRQOL subscales between men and women,
patients with a low versus high educational level and patients reporting a psychological versus somatic cause for
IBS symptoms. Subsequently, six multiple mediation
models were constructed and tested; each of these models
placed illness perceptions as potential mediators between
bowel symptom severity on the one hand and HRQOL
(total score as well as the five subscale scores) on the other.
Multiple mediation analysis was considered to be the most
appropriate analytic strategy as it allows for multiple
indirect effects to be tested simultaneously [40]. As such,
the relative magnitude of the specific indirect effects associated with each putative mediator (i.e. the illness perceptions) was determined. The mediation models were
tested using the bootstrapping procedure suggested by
Hayes [41]. This method produces an estimate of the
magnitude of each indirect effect, as well as a corresponding confidence interval. An indirect effect is assumed
to be significant at an alpha level of 0.05 if its 95 % confidence interval (CI) does not include zero. A bias-corrected bootstrap CI was calculated, as this is considered to
be the best test in terms of statistical power; on the basis of
a number of simulations, Hayes and Scharkow [42] have
demonstrated that the bias-corrected bootstrap CI is the
most trustworthy test when an indirect effect exists. SPSS
20.0 was used for the descriptive and univariate analyses.
The indirect.sps macro for SPSS [43] was used for all
mediation analyses.

Results
The descriptives for severity of bowel symptoms, the IPQ
dimensions and the HRQOL subscales are shown in
Table 1.
No significant differences were found between men and
women, patients with a higher versus lower educational
level and patients reporting a psychological cause versus a
somatic cause for IBS symptoms on any of the QOL
dimensions.
Age was not significantly related to QOL. Severity of
bowel symptoms was significantly related to both total
HRQOL and each of the subscales. With respect to illness
perceptions, only the Brief IPQ dimensions measuring
consequences, identity and emotional representation were

Qual Life Res

Table 1 Descriptives for
severity of bowel symptoms,
illness perceptions and healthrelated quality of life

Variable

Descriptivesa

Frequency and severity of bowel symptoms (0300)

168.02 68.67

IPQ consequences (010)

6.81 2.18

IPQ timeline (010)

9.08 1.30

IPQ identity (010)

7.73 1.61

IPQ personal control (010)

3.72 2.16

IPQ treatment control (010)

4.73 2.52

IPQ coherence (010)

Values are mean SD unless

otherwise indicated

6.03 2.33

IPQ emotional representation (020)

13.04 4.13

Total QOL (0100)

61.02 17.22

QOL dysphoria (0100)

57.04 22.92

QOL interference with activity (0100)

62.54 23.59

QOL food avoidance (0100)

47.90 25.13

QOL social reaction (0100)

61.86 24.33

QOL sexuality (0100)

70.33 27.09

significantly related to HRQOL. None of the Pearsons

correlations between the independent and the mediator
variables exceeded the 0.80 multicollinearity threshold
suggested by field [44]. The correlation coefficients are
reported in Table 2.
Based on the results of the univariate analyses, only the
Brief IPQ dimensions measuring consequences, identity
and emotional representation were entered as potential
mediators in the mediation models with severity of bowel
symptoms as the independent variable and HRQOL as the
dependent variable (Fig. 1).
Mediation analyses
To answer the question whether the severity of bowel symptoms is directly and/or an indirectly related to HRQOL, mediated by the patients illness perceptions, we first checked the
results for the direct association between symptom severity and
HRQOL. IBS symptom severity was directly related to total
HRQOL and each of the subscales, but after entering the mediator variables into the model, this direct relationship only
remained significant (p \ 0.05) for total HRQOL.
To explore the potential indirect association between
IBS symptom severity and QOL, we first examined the
relationships between the independent variable, severity of
bowel symptoms, and the mediating variables consequences, identity and emotional representation of the Brief
IPQ (a paths); the associations between the independent
variable and each of the mediating variables were significant at the 0.01 level (Table 3).
With respect to the association between the mediators and
the dependent variable HRQOL (b paths), a significant relationship was found between the IPQ dimension consequences and total HRQOL, as well as the HRQOL subscales
dysphoria, interference with activity, food avoidance and

social reaction. The second mediator, identity, was only

significantly related to the HRQOL subscale sexuality,
whereas the third mediator variable, emotional representation, was significantly related to total HRQOL, and the
dysphoria and social reaction subscales.
Finally, the analysis of the indirect relationship between IBS symptom severity and HRQOL revealed that
bowel symptom severity was indirectly related to total
HRQOL as well as the subscales dysphoria and social
reaction (a 9 b paths), mediated by the IPQ dimensions
consequences and emotional representation. A significant
indirect relationship was found between symptom severity
and the subscales interference with activity and food
avoidance, mediated only by the IPQ dimension consequences. The relationship between symptom severity and
the subscale sexuality was only mediated by identity. The
results of the mediation analyses are presented in Table 3
and Fig. 2.
As a whole, each of the models was significant, explaining 60 % of the variance in total HRQOL (Adj.
R2 = 0.59, p \ 0.001), 64 % of the variance in the subscale dysphoria (Adj. R2 = 0.63, p \ 0.001), 36 % of the
variance in the subscale interference with activity (Adj.
R2 = 0.34, p \ 0.001), 16 % of the variance in the subscale food avoidance (Adj. R2 = 0.13, p = 0.001), 33 %
of the variance in the subscale social reaction (Adj.
R2 = 0.31, p \ 0.001) and 21 % of the variance in the
subscale sexuality (Adj. R2 = 0.18, p \ 0.001).

Discussion
In this study, we examined to what extent severity of bowel
symptoms is directly related to HRQOL and/or indirectly,
mediated by the patients illness perceptions.

123

123

IBSS

IPQ-C

IPQ-T

IPQ-I

IPQ-PC

IPQ-TC

IPQ-CO
IPQ-ER

QOL-T

QOL-D

QOL-IA

QOL-FA

QOL-SR

QOL-S

8
9

10

11

12

13

14

15

-0.08

0.09

-0.00

0.04

-0.10

0.02

0.10
0.04

0.02

0.00

0.07

0.12

0.18*

-0.04

0.46***

0.07

0.27**

-0.19*

-0.30***

-0.18*

-0.26**

-0.37***

-0.42***

-0.01
0.38***

0.04

-0.13

0.60***

0.07

-0.39***

-0.51***

-0.38***

-0.58***

-0.69***

-0.68***

0.09
0.50***

0.07

-0.01

0.11

-0.09

0.004

-0.01

-0.07

-0.16

-0.10

0.02
0.05

-0.04

-0.17

-0.42***

-0.35***

-0.24**

-0.40***

-0.56***

-0.56***

0.01
0.51***

0.14

-0.19*

0.39***

0.11

0.09

-0.04

0.10

0.16

0.13

0.30***
-0.04

0.02

0.12

0.09

0.04

0.02

0.04

0.23**
0.01

-0.14

-0.01

-0.08

-0.08

0.15

0.00

-0.20*

-0.28**

-0.45***

-0.30***

-0.40***

-0.68***

-0.63***

0.45***

0.75***

0.61***

0.86***

0.87***

10

0.34***

0.59***

0.43***

0.65***

11

0.38***

0.59***

0.54***

12

0.15

0.36***

13

0.27***

14

15

* p \ 0.05, ** p \ 0.01, *** p \ 0.001

IBSS irritable bowel symptom severity, IPQ brief illness perception questionnaire, IPQ-C IPQ consequences, IPQ-T IPQ timeline, IPQ-I IPQ identity, IPQ-PC IPQ personal control, IPQ-TC
IPQ treatment control, IPQ-CO IPQ coherence, IPQ-ER IPQ emotional representation, QOL quality of life measure for persons with irritable bowel syndrome, QOL-T total QOL, QOL-D QOL
dysphoria, QOL-IA QOL interference with activity, QOL-FA QOL food avoidance, QOL-SR QOL social reaction, QOL-S QOL sexuality

Age

Table 2 Pearsons correlations between age, severity of bowel symptoms, illness perceptions and quality of life (N = 123)

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Fig. 1 Mediation models that
were tested. Note a13 effect of
independent variable on
mediators, b13 effect of
mediators on dependent
variables, IBSS irritable bowel
symptom severity, HRQol
health-related quality of life

Consequences
a1

IBSS

a2

b1

Emotional
representation

b3

a3

Identity

Our main findings were: (1) severity of bowel symptoms

is directly related to total HRQOL and its dimensions; (2)
the relationship between bowel symptom severity and total
HRQOL is partially mediated by illness perceptions,
whereas its relationship with each of the separate dimensions of HRQOL is fully mediated by illness perceptions;
(3) the total model, including both the independent variable
disease severity and the mediators explained a very high
percentage (60 %) of the variance in total HRQOL; (4)
perceived consequences of IBS are a mediator of the relationship between bowel symptom severity and total
HRQOL as well as all of its subscales, except one (the
subscale sexuality); (5) neither perceived cause nor the
control-related dimensions of the brief Illness Perception
Questionnaire are significantly related to bowel symptom
severity or HRQOL.
The existence of a direct relationship between bowel
symptom severity and HRQOL is in accordance with previous studies [2224]. The correlation coefficients, however, also indicate that this direct relationship is not as
strong as the relationship between the psychological factors
(in this case the patients illness perceptions) and HRQOL,
which was also found by Naliboff et al. [22]. The mediation analyses that we conducted demonstrated that the
relationship between bowel symptom severity and HRQOL
is partially (in the case of total HRQOL) to fully (in the
case of each of the dimensions of HRQOL) mediated by
illness perceptions. This result somewhat fits the findings
of Naliboff et al. [22], who demonstrated in a population of
IBS patients that symptom severity was not only directly,
but also indirectly related to HRQOL, mediated by psychological factors. The major difference between Naliboffs study and ours is that we looked into the patients
illness perceptions as a mediator, whereas Naliboff considered psychological distress as the potential mediating
factor.
Previous studies pointed at the existence of a differential
relationship between symptom severity, psychological
factors and HRQOL [23, 24]. In particular, these studies
demonstrated that IBS symptoms and pain were more
strongly related to the physical dimension of HRQOL,
whereas depression, somatic distress and anxiety were

b2

1.
2.
3.
4.
5.
6.

Total HRQoL
Dysphoria
Interference with activity
Food avoidance
Social reaction
Sexuality

more strongly related to the psychological dimension of

HRQOL. These findings are partially supported by the
present study. Our results indicate that the emotional representation of illness mediates the relationship of symptom
severity with the HRQOL subscale dysphoria, a diseasespecific measure of depression, and, as such, a psychological dimension of HRQOL. In addition, emotional representation also mediates the association between symptom
severity and the subscale social reaction, a social dimension of HRQOL that was not considered in the studies by
Rey et al. [23] and Koloski et al. [24]. Consequences,
one of the illness perceptions that underlies the cognitive
representation of illness, however, mediates the relationship between symptom severity and the subscales dysphoria, interference with activity, food avoidance and
social reaction, or in other words, psychological, physical
as well as social aspects of HRQOL. This latter finding
does not support the idea that there is a distinct pattern of
associations between symptom severity, illness perceptions
and HRQOL depending upon the specific dimension of
HRQOL that is looked at. It rather points at the central role
of the cognitive illness representation consequences. As
consequences have been measured with a single item in
the present study, it remains unclear which perceived
consequences contribute to this finding. A number of
(qualitative) studies, evaluating (the impact of) IBS
through the patients eyes, [4547] point at the fact that
IBS causes multiple aspects of life to be disrupted: physical
functioning, social functioning/activities/relationships/
roles as well as psychological well-being. With respect to
psychological well-being, patients mention feeling stigmatized by the presence of a condition for which no clear
somatic cause can be found and feeling embarrassed because of the symptoms (e.g. abdominal bloating or diarrhoea). In addition, a number of misconceptions regarding
the consequences of IBS are reported (e.g. the belief that
IBS could lead to colitis or cancer), causing anxiety and
fear in patients. Next to that, the impact IBS has on physical functioning and social activities constitutes a threat to
patients identity and self-image and may ultimately be
responsible for feelings of depression. Uncertainty about
the course/chronicity of the disease and about the factors

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Table 3 Summary of Mediation Analyses
Independent variable (IV)

a paths
an: IV ? M

Mediators
(M)

b paths
bn: M ? DV

Dependent
variables
(DV)

Indirect effect an 9 bn

95 % Bootstrap
CI of indirect effect

IBS symptom severity

a1 = 0.008**

IPQ-C

b1 = -3.539***

QOL-T

a1 9 b1 = -0.030**

-0.054, -0.008a

IBS symptom severity

a2 = 0.011***

IPQ-ER

b2 = -2.667***

QOL-T

a2 9 b2 = -0.030***

-0.052, -0.015a

IBS symptom severity

IBS symptom severity

a3 = 0.011***
a1 = 0.008**

IPQ-I
IPQ-C

b3 = -0.575
b1 = -4.635***

QOL-T
QOL-D

a3 9 b3 = -0.006
a1 9 b1 = -0.039**

-0.024, 0.010
-0.074, -0.010a

IBS symptom severity

a2 = 0.011***

IPQ-ER

b2 = -4.558***

QOL-D

a2 9 b2 = -0.052***

-0.084, -0.026a

IBS symptom severity

a3 = 0.011***

IPQ-I

b3 = -0.709

QOL-D

a3 9 b3 = -0.008

-0.033, 0.014

IBS symptom severity

a1 = 0.008**

IPQ-C

b1 = -5.442***

QOL-IA

a1 9 b1 = -0.046**

-0.088, -0.013a

IBS symptom severity

a2 = 0.011***

IPQ-ER

b2 = -1.327

QOL-IA

a2 9 b2 = -0.015

-0.042, 0.005

IBS symptom severity

a3 = 0.011***

IPQ-I

b3 = -0.032

QOL-IA

a3 9 b3 = -0.000

-0.032, 0.028

IBS symptom severity

a1 = 0.008**

IPQ-C

b1 = -3.695**

QOL-FA

a1 9 b1 = -0.031*

-0.072, -0.007a

IBS symptom severity

a2 = 0.011***

IPQ-ER

b2 = -1.705

QOL-FA

a2 9 b2 = -0.019

-0.057, 0.006

IBS symptom severity

a3 = 0.011***

IPQ-I

b3 = 0.730

QOL-FA

a3 9 b3 = 0.008

-0.025, 0.045

IBS symptom severity

a1 = 0.008**

IPQ-C

b1 = -4.495***

QOL-SR

a1 9 b1 = -0.038*

-0.080, -0.010a

IBS symptom severity

a2 = 0.011***

IPQ-ER

b2 = -2.876**

QOL-SR

a2 9 b2 = -0.033*

-0.063, -0.010a

IBS symptom severity

a3 = 0.011***

IPQ-I

b3 = 1.177

QOL-SR

a3 9 b3 = 0.013

-0.022, 0.049

IBS symptom severity

a1 = 0.008**

IPQ-C

b1 = -2.557

QOL-S

a1 9 b1 = -0.022

-0.059, -0.001a

IBS symptom severity

a2 = 0.011***

IPQ-ER

b2 = -0.504

QOL-S

a2 9 b2 = -0.006

-0.039, 0.024

IBS symptom severity

a3 = 0.011***

IPQ-I

b3 = -4.692*

QOL-S

a3 9 b3 = -0.050*

-0.102, -0.013a

Confidence intervals (CI) presented are bias corrected and accelerated, and based on 5,000 bootstrap re-samples
IPQ brief illness perception questionnaire, IPQ-C IPQ consequences, IPQ-T IPQ timeline, IPQ-I IPQ identity, IPQ-PC CIPQ personal control,
IPQ-TC IPQ treatment control, IPQ-CO IPQ coherence, IPQ-ER IPQ emotional representation, QOL quality of life measure for persons with
irritable bowel syndrome, QOL-T total QOL, QOL-D QOL dysphoria, QOL-IA QOL interference with activity, QOL-FA QOL food avoidance,
QOL-SR QOL social reaction, QOL-S QOL sexuality
a

95 % CI does not include zero

*p \ 0.05; **p \ 0.01; ***p \ 0.001

triggering symptom flare-ups and the unpredictability of

symptoms may be factors underlying the disruption of
patients lives.
The study by Rutter and Rutter [27] reported a similar
relation between consequences and HRQOL but also found
that attributing IBS to a psychological rather than a physical cause was associated with poorer HRQOL. Riedl et al.
[29] reported that psychological illness attributions were
associated with worse mental QOL, but better physical
QOL, whereas somatic illness attributions were related to
worse physical QOL. In our study, patients who favoured a
psychological cause of IBS did not differ from patients
who favoured a somatic cause on any of the dimensions of
HRQOL. Differences in the way perceived cause of
IBS was measured may be responsible for this. In their
study, Riedl et al. [29] measured the patients illness attributions making use of two different questionnaires, one
questionnaire to measure the dimensions intrapsychic
causes, social causes and interpersonal causes, and
one questionnaire to measure physiological causes; for
each of these dimensions, total scores were calculated.
Rutter and Rutter [27] used the cause item of the illness

123

perception questionnaire [48], consisting of ten items; on

the basis of a principal component analysis, two components were retained, one measuring internal psychological
causes and one measuring external somatic causes. In
contrast, the patients participating in our study answered an
open-ended question, asking them to note down what they
considered to be the most important cause of their IBS. The
answers to this question were then recoded into a dichotomous variable (psychological vs. somatic causes).
These clearly distinct approaches may be responsible for
the difference in results.
Rutter and Rutter [27] concluded that weaker control
beliefs were associated with lower HRQOL. Contrary to
this finding, in our study, neither personal control nor
treatment control was related to any of the dimensions of
HRQOL. The way the control dimension was measured
may at least be partly responsible for the differences found.
In their study, Rutter and Rutter [27] used the cure/control
dimension of the original IPQ [48], consisting of six items
and resulting in a total score, ranging from 6 (min) to 30
(max). As such, no distinction is made between personal
and treatment control in the Rutter and Rutter study,

Qual Life Res

Consequences

-3.539*** (b1)

.008** (a1)
- 4.635*** (b1)

-.106*** (c) / -.040* (c)

IBSS

1.Total HRQoL
-5.442*** (b1)
0.011*** (a2)

2.Dysphoria

-2.667*** (b2)

Emotional
representation

-4.558*** (b2)
-3.695** (b1)

3.Interference with activity

0.011*** (a3)
-2.876** (b2)

-4.495*** (b1)

4.Food avoidance

5.Social reaction

Identity

-4.692* (b3)

6.Sexuality

Fig. 2 Direct and indirect effects of irritable bowel syndrome

symptom severity (IBSS) on health-related quality of life (HRQOL;
total and subscales) through the illness perceptions consequences,
emotional representation and identity. Note. a13 effect of
independent variable on mediators, b13 effect of mediators on

dependent variables, c total effect of independent variable on

dependent variable; c = direct effect of independent variable on
dependent variable after the effect of the mediators was taken into
account. Only statistically significant associations are depicted.
* p \ 0.05, ** p \ 0.01, *** p \ 0.001

whereas in our study, two separate one-item scores are

used, each of them ranging from 0 to 10.
This study has several strengths including the use of a
validated disease-specific measure, the IBS-QOL [38, 39],
to assess HRQOL. As symptom severity and illness perceptions are disease-specific constructs, it is important to
also measure the outcome on a disease-specific level. The
diagnosis of IBS was made using the Rome III criteria [2],
and validated measures were used to assess bowel symptom severity [34] as well as the patients cognitive and
emotional perceptions of the illness [36]. Furthermore, this
study is also the first one to examine whether the relationship between bowel symptom severity and HRQOL is
mediated by the patients illness perceptions. The study
has, however, also some limitations. First, the study has a
cross-sectional design and therefore does not allow for
clear-cut conclusions regarding the direction of the relationships that were found. Based upon the basic tenet of
cognitive behavioural theory, it was hypothesized that a
trigger (bowel symptoms) activates cognitive processes
(illness perceptions), which in turn has an impact upon
emotional and behavioural factors (HRQOL). It is, however, also feasible that poor functioning (HRQOL) leads to
more negative illness perceptions, which in turn influences
symptom severity. Future studies should therefore adopt a
longitudinal perspective to evaluate whether illness perceptions mediate the impact of IBS symptom severity on

HRQOL, measured at a later time point, or whether the

relationship is bidirectional. Second, in the present study,
mediation models were constructed and tested for each of
the six dependent variables separately. As the number of
subjects available for the analyses was rather small compared to the number of models and pathways tested, this
may have led to a type I error, and as such possibly to an
elevation of false positives. Based on the results of our
exploratory analyses into the mediators of the relationship
between bowel symptom severity and HRQOL, future research should focus on constructing more parsimonious
models, making use of SEM. Third, to limit participant
burden, illness perceptions were measured with the Brief
IPQ, consisting of six single-item scales and one two-item
scale. As a consequence, two of the putative mediators in
the mediation models are represented by a single-item
measure (i.e. consequences and identity). With respect to
this, Broadbent et al. [36] found that the correlation coefficients between the single-item scales of the Brief IPQ and
the multi-item scales of the IPQ-R were highly significant
(p \ 0.001), suggesting that the single-item scales sufficiently capture the conceptual domain of each of the illness
perceptions measured by the IPQ-R [49]. Nevertheless,
within the psychometric literature, single-item measures
have been criticized for their lack of precision, because
they tend to categorize people in a relatively small number
of groups [50]. Future research should therefore consider

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Qual Life Res

measuring illness perceptions by means of its multi-item

counterpart, the IPQ-R [49]. Fourth, due to their low internal consistency, three subscales of the IBS-QOL (body
image, health worry and relationships) have been excluded
from the statistical analyses. As a consequence, we did not
explore to what extent patients illness perceptions (partially) mediate the relationship between symptom severity
and these three HRQOL subscales. Fifth, no data on illness
duration, time since diagnosis or specific treatment followed by the patients were available to us. As these variables may have an impact on the way patients perceive
their condition, this dimension should be taken into account
in future research on the relationship between symptom
severity, illness perceptions and HRQOL. Finally, this
study was conducted in members of an IBS patient support
group, which may reduce the generalizability of the results.
The main finding of the present study is that, in addition
to a direct relationship, symptom severity also has an
indirect relationship with HRQOL, via the cognitive and
emotional representations patients have of their illness.
Perceived consequences, emotional representation and to a
lesser extent identity were found to be a mediator of total
HRQOL and some of its subscales. There is, however, an
important theoretical concern about this finding, a concern
that also applies to other studies that explored the relationship between disease severity, illness perceptions and
HRQOL. There is clearly a conceptual overlap between
specific illness perceptions such as (a) identity and disease
severity if the disease severity measure is based on patient
reports and (b) consequences and emotional representation
on the one hand and physical and psychological or emotional aspects of quality of life scales on the other hand.
Such overlap makes it difficult to identify a clear cause
effect relationship between these concepts, since the disease severity measure may be influenced by identity perceptions, while beliefs about consequences and emotional
representation may be a cause as well as a consequence of
poor HRQOL and functioning. For future research, it is
therefore advisable to also include measures that assess
possible cognitive and behavioural coping responses that
result from these perceptions but are conceptually less
contaminated such as catastrophizing, rumination, generalization (cognitive responses) or limiting behaviour and
symptom management (behavioural responses). This would
allow clinicians wanting to improve the patients quality of
life to focus not only on negative illness perceptions but
also on dysfunctional coping patterns. In their 2012 review,
Petrie and Weinman [51] discussed the central role of illness perceptions as a determinant of patient coping and
patient-related outcomes and pointed out that interventions,
that focus on changing patients illness perceptions, are an
emerging field within health psychology. With respect to
IBS, there is increasing evidence for the efficacy of

123

cognitive behaviour therapy (CBT), a psychological treatment that focusses both on identifying, challenging and
changing negative dysfunctional thoughts about IBS
(symptoms) and on behavioural coping strategies [52]. A
recent study [53] explored cognitive, emotional and behavioural mediators of treatment effects following a brief
CBT intervention for IBS. It was demonstrated that cognitive factors, i.e. illness perceptions (measured with the
Brief IPQ) mediated treatment effects. A limitation of this
study [53] is, however, that a sum score was calculated
from the Brief IPQ and entered into the mediation model.
As a consequence, it remains unclear which specific illness
perceptions are the most important mediators of treatment
effects. In addition, the relation between specific illness
perceptions (such as consequences and emotional representation) and behavioural responses was not explored.
Future cognitive-based intervention studies in IBS should
examine this further.
Open Access This article is distributed under the terms of the
Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original
author(s) and the source are credited.

References
1. Blanchard, E. B. (2001). Irritable bowel syndrome: Psychosocial
assessment and treatment. Washington, DC: American Psychological Association.
2. Drossman, D. A., Corazziari, E., Delvaux, M., Spiller, R. C.,
Talley, N. J., Thompson, W. G., et al. (2006). Rome III: The
functional gastrointestinal disorders (3rd ed.). McLean, VA:
Degnon and Associates.
3. Choung, R. S., & Locke, G. R, I. I. I. (2011). Epidemiology of
IBS. Gastroenterology Clinics of North America, 40, 110.
4. Hungin, A. P. S., Whorwell, P. J., Tack, J., & Mearin, F. (2003).
The prevalence, patterns and impact of irritable bowel syndrome:
An international survey of 40,000 subjects. Alimentary Pharmacology and Therapeutics, 17, 643650.
5. Hungin, A. P. S., Chang, L., Locke, G. R., Dennis, E. H., &
Barghout, V. (2005). Irritable bowel syndrome in the United
States: Prevalence, symptom patterns and impact. Alimentary
Pharmacology and Therapeutics, 21, 13651375.
6. Grundman, O., & Yoon, S. L. (2010). Irritable bowel syndrome:
Epidemiology, diagnosis and treatmentAn update for healthcare practitioners. Journal of Gastroenterology and Hepatology,
25, 691699.
7. Chang, L. (2004). Review article: Epidemiology and quality of
life in functional gastrointestinal disorders. Alimentary Pharmacology and Therapeutics, 20, 3139.
8. Creed, F., Ratcliffe, J., Fernandez, L., Tomenson, B., Palmer, S.,
Rigby, C., et al. (2001). Health-related quality of life and health
care costs in severe, refractory irritable bowel syndrome. Annals
of Internal Medicine, 134, 860868.
9. Nellesen, D., Yee, K., Chawla, A., Lewis, B. E., & Carson, R. T.
(2013). A systematic review of the economic and humanistic
burden of illness in irritable bowel syndrome and chronic constipation. Journal of Managed Care Pharmacy, 19, 755764.
10. Lackner, J. M., Gudleski, G. D., Zack, M. M., Katz, L. A.,
Powell, C., Krasner, et al. (2006). Measuring health-related

Qual Life Res

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

quality of life in patients with irritable bowel syndrome: Can less

be more? Psychosomatic Medicine, 68, 312320.
Halder, S. L. S., Locke, G. R, I. I. I., Talley, N. J., Fett, S. L., &
Zinsmeister, A. R. (2004). Impact of functional gastrointestinal
disorders on health-related quality of life: A population-based
casecontrol study. Alimentary Pharmacology and Therapeutics,
19, 233242.
Koloski, N. A., Talley, N. J., & Boyce, P. M. (2000). The impact
of functional gastrointestinal disorders on quality of life. The
American Journal of Gastroenterology, 95, 6771.
Kaji, M., Fujiwara, Y., Shiba, M., Kohata, Y., Yamagami, H.,
Tanigawa, T., et al. (2010). Prevalence of overlaps between
GERD, FD and IBS and impact on health-related quality of life.
Journal of Gastroenterology and Hepatology, 25, 11511156.
El-Serag, H. B., Olden, K., & Bjorkman, D. (2002). Health-related quality of life among persons with irritable bowel syndrome: A systematic review. Alimentary Pharmacology and
Therapeutics, 16, 11711185.
Frank, L., Kleinman, L., Rentz, A., Ciesla, G., Kim, J. J., &
Zacker, C. (2002). Health-related quality of life associated with
irritable bowel syndrome: Comparison with other chronic diseases. Clinical Therapeutics, 24, 675689.
Pace, F., Molteni, P., Bollani, S., Sarzi-Puttini, P., Stockbrugger,
R., Porro, B., et al. (2003). Inflammatory bowel disease versus
irritable bowel syndrome: A hospital-based, casecontrol study of
disease impact on quality of life. Scandinavian Journal of Gastroenterology, 10, 10311038.
Tkalcic, M., Hauser, G., & Stimac, D. (2010). Differences in the
health-related quality of life, affective status, and personality
between irritable bowel syndrome and inflammatory bowel disease patients. European Journal of Gastroenterology and Hepatology, 22, 862867.
Gralnek, I. M., Hays, R. D., Kilbourne, A., Naliboff, B., &
Mayer, E. A. (2000). The impact of irritable bowel syndrome on
health-related quality of life. Gastroenterology, 119, 654660.
Cho, H. S., Park, J. M., Lim, C. H., Cho, Y. K., Lee, I. S., Kim, S.
W., et al. (2011). Anxiety, depression and quality of life in patients with irritable bowel syndrome. Gut and Liver, 5, 2936.
Monnikes, H. (2011). Quality of life in patients with irritable
bowel syndrome. Journal of Clinical Gastroenterology, 45, S98
S101.
Thijssen, A. Y., Jonkers, D. M. A. E., Leue, C., Van der Veek, P.
P. J., Vidakovic-Vukic, M., Van Rood, Y. R., et al. (2010).
Dysfunctional cognitions, anxiety and depression in irritable
bowel syndrome. Journal of Clinical Gastroenterology, 44,
e236e241.
Naliboff, B. D., Kim, S. E., Bolus, R., Bernstein, C. N., Mayer, E.
A., & Chang, L. (2012). Gastrointestinal and psychological mediators of health-related quality of life in IBS and IBD: A
structural equation modeling analysis. American Journal of
Gastroenterology, 107, 451459.
Rey, E., Garcia-Alonso, M. O., Moreno-Ortega, M., AlvarezSanchez, A., & Diaz-Rubio, M. (2008). Determinants of quality
of life in irritable bowel syndrome. Journal of Clinical Gastroenterology, 42, 10031009.
Koloski, N. A., Boyce, P. M., Jones, M. P., & Talley, N. J.
(2012). What level of IBS symptoms drives impairment in healthrelated quality of life in community subjects with irritable bowel
syndrome? Quality of Life Research, 21, 829836.
Leventhal, H., Leventhal, E. A., & Contrada, R. J. (1998). Selfregulation, health, and behavior: A perceptual-cognitive approach. Psychology and Health, 13, 717733.
Hagger, M. S., & Orbell, S. (2003). A meta-analytic review of the
common-sense model of illness representations. Psychology and
Health, 18, 141184.

27. Rutter, C. L., & Rutter, D. R. (2002). Illness representation,

coping and outcome in irritable bowel syndrome (IBS). British
Journal of Health Psychology, 7, 377391.
28. Rutter, C. L., & Rutter, D. R. (2007). Longitudinal analysis of the
illness representation model in patients with irritable bowel
syndrome (IBS). Journal of Health Psychology, 12, 141148.
29. Riedl, A., Maass, J., Fliege, H., Stengel, A., Schmidtmann, M.,
Klapp, B. F., & Monnikes, H. (2009). Subjective theories of illness and clinical and psychological outcomes in patients with
irritable bowel syndrome. Journal of Psychosomatic Research,
67, 449455.
30. Wong, R. K. M., & Drossman, D. A. (2010). Quality of life
measures in irritable bowel syndrome. Expert Reviews in Gastroenterology and Hepatology, 4, 277284.
31. Wright, J. H., Basco, M. R., & Thase, M. E. (2006). Learning
cognitive-behaviour therapy. An illustrated guide. Arlington:
American Psychiatric Association.
32. Deary, V., Chalder, T., & Sharpe, M. (2007). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review, 27,
781797.
33. Ersryd, A., Posserud, I., Abrahamsson, H., & Simren, M. (2007).
Subtyping the irritable bowel syndrome by predominant bowel
habit: Rome II versus Rome III. Alimentary Pharmacology and
Therapeutics, 26, 953961.
34. Francis, C. Y., Morris, J., & Whorwell, P. J. (1997). The irritable
bowel severity scoring system: A simple method of monitoring
irritable bowel syndrome and its progress. Alimentary Pharmacology and Therapeutics, 11, 395402.
35. De Raaij, E. J., Schroder, C., Maissan, F. J., Pool, J. J., & Wittink,
H. (2012). Cross-cultural adaptation and measurement properties
of the brief illness perception questionnaire-Dutch language
version. Manual Therapy, 17, 330335.
36. Broadbent, E., Petrie, K. J., Main, J., & Weinman, J. (2006). The
brief illness perception questionnaire. Journal of Psychosomatic
Research, 60, 631637.
37. Hagger, M. S., & Orbell, S. (2005). A confirmatory factor analysis of the revised illness perception questionnaire (IPQ-R) in a
cervical screening context. Psychology and Health, 20, 161173.
38. Patrick, D. L., Drossman, D. A., & Frederick, I. O. (1997). A
quality of life measure for persons with irritable bowel syndrome.
Washington: University of Washington Seattle.
39. Drossman, D. A., Patrick, D. L., Whitehead, W. E., Toner, B. B.,
Diamant, N. E., Hu, Y., et al. (2000). Further validation of the
IBS-QOL: A disease-specific quality of life questionnaire. The
American Journal of Gastroenterology, 95, 9991007.
40. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling
strategies for assessing and comparing indirect effects in multiple
mediator models. Behaviour Research Methods, 40, 879891.
41. Hayes, A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Communication Monographs, 76, 408420.
42. Hayes, A. F., & Scharkow, M. (2013). The relative trustworthiness of inferential tests of the indirect effect in statistical mediation analysis. Does method really matter? Psychological
Science, 24, 19181927.
43. Hayes, A. F. (2011). SPSS INDIRECT macro syntax reference.
http://www.afhayes.com/public/indirect.pdf.
44. Field, A. (2005). Discovering statistics using SPSS (2nd ed.).
London: Sage.
45. Halpert, A., Dalton, C. B., Palsson, O., Morris, C., Hu, Y.,
Bangdiwala, S., et al. (2007). What patients know about irritable
bowel syndrome (IBS) and what they would like to know. National survey on patient educational needs in IBS and development and validation of the patient educational needs

123

Qual Life Res

46.

47.

48.

49.

questionnaire (PEQ). American Journal of Gastroenterology,

102, 19721982.
Kennedy, A., Robinson, A., & Rogers, A. (2003). Incorporating
patients views and experiences of life with IBS in the development of an evidence based self-help guidebook. Patient Education and Counselling, 50, 303310.
Farndale, R., & Roberts, L. (2011). Long-term impact of irritable
bowel syndrome: A qualitative study. Primary Health Care Research and Development, 12, 5267.
Weinman, J., Petrie, K. J., Moss-Morris, R., & Horne, R. (1996).
The illness perception questionnaire: A new method for assessing
the cognitive representation of illness. Psychology and Health,
11, 431445.
Moss-Morris, R., Weinman, J., Petrie, K. J., Horne, R., Cameron,
L. D., & Buick, D. (2002). The revised illness perception questionnaire. Psychology and Health, 17, 116.

123

50. Fuchs, C., & Diamantopoulos, A. (2009). Using single-item

measures for construct measurement in management research.
DBW, 69, 195210.
51. Petrie, K. J., & Weinman, J. (2012). Patients perceptions of their
illness: The dynamo of volition in health care. Current Directions
in Psychological Science, 21, 6065.
52. Tang, Q.-L., Lin, G.-Y., & Zhang, M.-Q. (2013). Cognitive-behavioral therapy for the management of irritable bowel syndrome.
World Journal of Gastroenterology, 19, 86058610.
53. Chilcot, J., & Moss-Morris, R. (2013). Changes in illness-related
cognitions rather than distress mediate improvements in irritable
bowel syndrome (IBS) symptoms and disability following a brief
cognitive behavioural therapy intervention. Behaviour Research
and Therapy, 51, 690695.