ORIGINAL PAPERS

Adv Clin Exp Med 2014, 23, 6, 987992

ISSN 18995276

Copyright by Wroclaw Medical University

Magdalena Grzesiak1, AD, F, Jan A. Beszej1, A, C, D, F, Agata Mulak2, A, B, D, F,

Marcin Szechiski1, B, E, F, Monika Szewczuk-Bogusawska1, B, E, F,
Ewa Waszczuk2, A, B, E, F, Monika Kantorska1, C, E, F, Dorota Frydecka1, C, EG

The Lifetime Prevalence of Anxiety Disorders

AmongPatients with Irritable Bowel Syndrome*
1
2

Department of Psychiatry, Wroclaw Medical University, Poland

Department of Gastroenterology and Hepatology, Wroclaw Medical University, Poland

Aresearch concept and design; Bcollection and/or assembly of data; Cdata analysis and interpretation;
Dwriting the article; Ecritical revision of the article; Ffinal approval of article; Gother

Abstract
Background. The prevalence of irritable bowel syndrome (IBS), the most common functional gastrointestinal
disorder, ranges from 10% to 20% in the general population. It is estimated that from 40% to 90% of persons with
adiagnosis of IBS suffer from mental disorders, mainly anxiety and depressive disorders.
Objectives. The aim of the study was to assess the lifetime prevalence of anxiety disorders in IBS patients and to
compare it with the prevalence of these disorders in acontrol group of patients with gastroesophageal reflux disease
(GERD).
Material and Methods. The study included 106patients with IBS and 53patients with GERD. IBS was diagnosed
according to the Rome II criteria after a basic evaluation to exclude an organic disease. Anxiety disorders were
diagnosed using the Composite International Diagnostic Interview (CIDI) in accordance with ICD-10 diagnostic
criteria.
Results. Anxiety disorders during the patients lifetime were diagnosed in 50 IBS patients (47%). Specific phobias
occurred in 23.5% of them, social phobias in 10.4 %, generalized anxiety disorder in 10.4%, panic disorder in 3.8%
and agoraphobia in 8.5%. In the control group with GERD, anxiety disorders during the subjects lifetime were
diagnosed in 30% of the group. The difference in the prevalence of anxiety disorders between patients with IBS and
GERD was statistically significant (p<0.05).
Conclusions. The lifetime prevalence of anxiety disorders in IBS patients was higher than in the control group with
GERD (47% vs. 30%). The prevalence rate of anxiety disorders in the control group with GERD was similar to the
prevalence rate in the general population (Adv Clin Exp Med 2014, 23, 6, 987992).
Key words: anxiety disorders, irritable bowel syndrome, CIDI.

Irritable bowel syndrome (IBS) is afunctional

gastrointestinal disorder characterized by chronic
abdominal pain, discomfort, bloating and alteration of bowel habits[13]. The prevalence of IBS
in the general population is estimated to be around
1020% [1, 4]. Depending on the predominant
symptoms, 3 types of IBS can be distinguished:
IBS with constipation, with diarrhea, or with alternating constipation and diarrhea. The highest
morbidity is observed between the ages of 20 and
50[35]. In western countries, IBS occurs twice as
* The study was supported by research grant 2 P05B 07230.

often among women as among men, and according to some studies performed in specialist centers,
IBS shows as much as 3 or 4times greater prevalence among women in comparison to men[69].
It has repeatedly been shown that among IBS
patients the prevalence of psychiatric disorders is
higher than in the general population. Psychiatric
disorders are diagnosed among around 4060% of
IBS patients, and according to some sources the
rate among IBS patients is as high as 90%[1013].
The most prevalent psychiatric disorders among

988

M.Grzesiak et al.

IBS patients are affective disorders (depression,

dysthymia) and anxiety disorders (mainly panic
attacks and general anxiety disorder).
There have been no studies in Poland so far
assessing the prevalence of psychiatric disorders
among patients with IBS. There have been only 2 studies discussing the issue of psychiatric comorbidity with IBS. In the first study depressive
symptoms were assessed using the Zung Self-Rating Depression Scale [14]; in the second study
the personality profile of patients with IBS was
described[15].
The aim of the present study was to assess the
lifetime prevalence of anxiety and depressive disorders among patients with IBS in comparison to
a control group patients with gastroesophageal
reflux disease (GERD). The study was approved
by the Ethics Committee of Wroclaw Medical
University.

Material and Methods

A total of 106 IBS patients admitted to the Department of Gastroenterology and Hepatology
were included in the study 90women (85%) and
16men (15%). The mean age was 49.214.6years,
ranging from 18 to 73years. There was no statistically significant difference between the ages of the
women and the men (=40.7, p=0.87). The control group comprised 53patients with adiagnosis
of GERD 43 women (81%) and 10 men (19%),
with amean age of 48.412.4years, ranging from
19 to 69years. There was no statistically significant
difference between the age of the IBS patients and
the age of the control group with GERD (=51,
p=0.48).
Written informed consent was obtained from
all participants after they were provided with full
information about the study.
IBS was diagnosed according to the Rome II
criteria [16], after excluding alarming symptoms
and risk factors for structural disease (such as loss
of weight, bleeding from the gastrointestinal tract,
anemia, fever, onset of symptoms after the age of
50 years, familial occurrence of inflammatory or
neoplastic diseases of intestines). All the patients
had gone through colonoscopic examinations in
the last 5 years in order to exclude other organic disorders of the large bowel. GERD was diagnosed according to clinical criteria and on the basis
of gastroscopic examinations. Patients who had severe cognitive impairment or serious somatic diseases were excluded from the study.
Depressive and anxiety disorders were diagnosed in accordance with the ICD-10 diagnostic criteria (The ICD-10 Classification of Mental

of Mental and Behavioral Disorders) [17], based

on the computer version of the Composite International Diagnostic Interview (CIDI). The CIDI
is a highly structured diagnostic instrument for
the diagnosis of mental disorders in accordance
with the ICD-10 and DSM-IV classification systems [1820]. It was developed by the World
Health Organization (WHO) for epidemiological
research purposes. It is widely used to assess the
prevalence of mental disorders in the general population, as well as among individuals with various
medical conditions. It has amodular structure and
consists of 16 parts that cover all mental disorders.
The modules can be used separately, depending on
the aim of the study. Moreover, the CIDI makes it
possible to exclude psychopathological symptoms
that may be areaction to medical condition, trauma, pharmacological treatment, or due to the use
of alcohol or other psychoactive substances.

Statistical Analysis
The statistical analysis was performed using
the STATISTICA software package (version 9.0,
StatSoft, Warsaw, Poland).
Pearsons test and Fishers exact test were
used to compare prevalence between the groups.
Ap<0.05 was considered statistically significant.

Results
On the basis of the predominant symptoms,
constipation-predominant IBS was diagnosed
in 34 patients (32.1%), the diarrhea-predominant form was found in 35patients (33%), and 37
(34.9%) had the alternating form.
Among the IBS patients, 47 subjects (44%) did
not meet the diagnostic criteria for either anxiety disorders or depressive disorders during their
lifetimes. Lifetime depressive or anxiety disorders
were diagnosed in 59 patients (56%). In the control group these disorders were diagnosed in 19 individuals (35.8%). The difference between the lifetime prevalence of depressive and anxiety disorders
in patients with IBS and in those with GERD was
statistically significant (=5.5, p=0.018; Fishers
exact test p=0.014).
At least 1 anxiety disorder was diagnosed in
50 IBS patients (47%). There were 12 individuals
(11%) who met the diagnostic criteria for more
than 1 anxiety disorder. The most common disorders were specific phobias (mainly the animal
type, blood type, environment type and situational type), which were diagnosed in 35patients
(23.6%). General anxiety disorder was diagnosed
in 11 patients with IBS (10.4%). Similarly, social

989

Anxiety Disorders Among Patients with Irritable Bowel Syndrome

subjects had depressive disorder, 12 had anxiety

disorders and 3 had some other diagnosis (chronic sleep disorder and eating disorders). In the control group with GERD, there were no patients with
apast diagnosis of mental disorders.

phobia was found to have occurred during the lifetime of 11patients (10.4%). Other phobic anxiety
disorders were diagnosed in 10 individuals (9.4%),
agoraphobia in 9 subjects (8.5%) (including 5patients with alifetime diagnosis of agoraphobia with
panic attacks and 4patients without panic attacks),
and anxiety disorder with panic attacks in 4 patients (3.8%).
In the control group with GERD, anxiety disorders were diagnosed in 16patients (30%). Among
these, 6 subjects (11.6%) met the criteria for specific phobias, 2 (3.8%) for general anxiety disorder,
3 participants (5.6%) were diagnosed with lifetime
social phobia, 3 (5.6%) with other phobic anxiety disorders, and 2patients (3.8%) were found to
have agoraphobia with panic attacks. None of the
patients with GERD met the diagnostic criteria for
lifetime anxiety disorders with panic attacks. Furthermore, in the control group with GERD, no comorbidity of anxiety disorders was found.
The difference in the frequency of anxiety disorders between the two groups was statistically
significant ( = 4.2, p = 0.04; Fishers exact test
p=0.03). There was no statistically significant difference in the frequency of anxiety disorders between women and men with IBS ( = 0.088,
df = 1, p = 0.76), nor between women and men
with GERD (=0.61, df=1, p=0.43). The prevalence rates of anxiety disorders in IBS and GERD
patients are shown in Table1.
Comorbidity of depressive and anxiety disorders was found in 24patients with IBS (22.6%) and
6 subjects in the control group (11.3%).
In the IBS group, in 28 subjects (26%) amental disorder was diagnosed in the past. Mental disorders were diagnosed most often by a general
practitioner, agastroenterologist or apsychiatrist.
Among the patients with aprevious diagnosis, 13

Discussion
According to the available literature, there is
a higher prevalence of anxiety disorders among
patients with IBS than in the general population
(47% vs. 26%)[24, 25]. Data showing that depressive disorders are also more prevalent in the group
of patients with IBS in comparison to general population (33% vs. 16%) were published in an earlier article[26].
In a model epidemiological study using the
CIDI the National Comorbidity Survey, that was
conducted in 19901992 and again in 20012003
and comprised agroup of 9000persons from the
general population in the USA, the following lifetime prevalence rates were reported: major depressive disorder (according to DSM-IV criteria)
16.5%; general anxiety disorder 5.7%;, anxiety
disorder with panic attacks 4.7%;, agoraphobia
1.4%;, social phobia 12.1%,; and specific phobias 12.5%[23, 24]. In comparison with these data, in patients with IBS the prevalence of specific
phobias, general anxiety disorder and agoraphobia
was higher than in the general population, whereas social phobia and anxiety disorder with panic
attacks occurred in individuals with IBS less frequently than in the general population. The higher
prevalence of general anxiety disorder among IBS
patients was pointed out by Lee etal.[25]. In arandom sample from the general population general anxiety disorder was 5 times more frequent in

Table1. Lifetime prevalence of anxiety disorders among patients with IBS and GERD
Diagnosis

Patients with IBS

Patients with GERD

the total
number of
patients

all
patients
(%)

anxiety
disorders
(%)

the number of all

patients

all
patients
(%)

anxiety
disorders
(%)

Without diagnosis

56

53

37

70

Social phobia F40.1

11

10.4

22

5.6

19

Specific phobia F40.2

25

23.8%

50

11.3

38

Other phobic anxiety disorder F40.9

10

9.4

22

5.6

19

Agoraphobia F40.0

8.5

18

3.8

12.5

Anxiety disorder with panic attacks F41.0

3.8

General anxiety disorder F41.1

11

10.4

20

3.8

12.5

990

M.Grzesiak et al.

subjects with a diagnosis of IBS than in people

without IBS. It was also shown in this study that
there were more significant functioning disturbances among people with comorbid IBS and general anxiety disorder.
In the current study, lifetime prevalence rates
of anxiety and depressive disorders in the control
group with GERD are similar to the prevalence
rates obtained from epidemiological studies in
the general population (anxiety disorders 30% vs.
25%, depressive disorders 16% vs. 16%;) [2426],
whereas in the group with IBS the prevalence rates
ranged from 15% to 52% with respect to depressive disorders and from 22% to 44% with respect
to anxiety disorders[13, 2733].
The prevalence rates of anxiety disorders in
our study are lower than those shown in previous
studies that did not use structured diagnostic instruments. Higher prevalence rates of mental disorders among IBS patients were reported in studies employing simple screening diagnostic tools
for depressive disorders or anxiety disorders (such
as the Hospital Anxiety and Depression Scale
[HADS], the Beck Depression Inventory [BDI]
or the General Health Questionnaire [GHQ]) or
psychopathological scales (such as the Hamilton
Rating Scale for Depression [HDRS]). Screening
tools assess only the probability of mental disorders, which requires verification using more complex diagnostic methods. The majority of studies assessing the prevalence of mental disorders
in IBS patients had only aone-stage design. Similarly, using psychopathological scales for depressive and anxiety symptoms in IBS patients does
not permit a diagnosis of mental disorders. Such
tools only estimate the severity of depressive or
anxiety symptoms which could occur, among patients with medical conditions as areaction to the
illness, and are commonly related to the suffering
or limitations caused by amedical condition. The
results of the current study are similar to the data
presented in recent years in studies that employed
modern, highly structured diagnostic instruments
(such as the CIDI or the Schedules for Clinical Assessment in Neuropsychiatry, [SCAN]), allowing mental disorders to be diagnosed according to
the current ICD-10 or DSM-IV classification systems. The highest prevalence rates for depressive
and anxiety disorders were reported by Jarret etal.,
whose study group included only women [35].

Based on the Diagnostic Interview Schedule (DIS),

lifetime occurrence of depressive disorders according to DSM-III-R criteria was found in 52% out of
165women in the study, and anxiety disorders in
44% of them. Similar data were obtained in astudy
by Guthrie etal.[13], in which the diagnosis was
established using the SCAN according to ICD-10
criteria. Among 107patients with IBS (82% women), depressive disorders were diagnosed in 26%
of the patients and anxiety disorders in 30% of
them[13]. Somewhat lower prevalence rates of depressive and anxiety disorders were reported in
astudy conducted in China by Hao etal.[36]. Using the CIDI in the group of 83 IBS patients, researchers found that during their lifetimes, 47% of
the subjects met the diagnostic criteria for some
mental disorder, including depressive disorders,
which were diagnosed in 23% of the study group
and anxiety disorders in 25%[36].
In the current study, as in the aforementioned
study by Guthrie et al. [13], the majority of consecutive patients from the Department of Gastroenterology and Hepatology were women (85%),
which is consistent with previous epidemiological studies showing higher prevalence rates of IBS
among women[68].
The authors concluded that the current study
shows higher prevalence rates of anxiety disorders
among patients with IBS in comparison to the general population and to the control group of patients
with GERD.The authors found that mental disorders had been diagnosed earlier in only 25% of the
IBS patients with comorbid depressive or anxiety
disorders, in spite of often chronically persisting
symptoms of depression and/or anxiety. This suggests that the medical doctors diagnosing and treating IBS patients should devote more attention to the
comorbidity of mental disorders, which are sometimes severe. Clinical practice as well as published
data indicate that improvement of the mental state
during anti-depressive or anti-anxiety treatment
is often followed by decreased intensity of bowel
symptoms [34, 37]. At the same time, a low dosage of anti-depressive medication has proven analgesic action in IBS patients, even in cases of no comorbid mental disorders[2]. Differential diagnosis
between suffering and distress due to asomatic illness and depressive or anxiety disorder is not simple and requires cooperation between the internal
medicine specialist and the psychiatrist.

References
[1] Longstreth GF, Thompson WG, Chey WD: Functional bowel disorders. Gastroenterology 2006, 130, 1480
1491.
[2] Mulak A, Waszczuk E, Paradowski: Irritable bowel syndrome as an interdisciplinary clinical problem. Adv Clin
Exp Med 2008, 17, 667675.

Anxiety Disorders Among Patients with Irritable Bowel Syndrome

991

[3] Drossman DA, Camillieri M, Mayer E, Whitehead WE: AGA technical review on irritable bowel syndrome.
Gastroenterology 2002, 123, 21082131.
[4] Nicholl BI, Halder SL, Macfarlane GJ, Thompson DG, OBrien S, Musleh M, McBeth K: Psychosocial risk
markers for new onset irritable bowel syndrome-results of alarge perspective population-based study. Pain 2007,
8, 161169.
[5] Ruigomez A, Wallender MA, Johansson S, Garcia-Rodrigez LA: One-year follow-up of newly diagnosed irritable
bowel patients. Aliment Pharmacol Ther 1999, 13, 10971102.
[6] Heitkemper M, Jarrett M, Bond EF, Chang L: Impact of sex and gender on irritable bowel syndrome. Biol Res
Nurs 2003, 5, 5665.
[7] Mulak A, Tach Y: Sex difference in irritable bowel syndrome: do gonadal hormones play arole? Gastroenterol
Pol 2010, 17, 8997.
[8] Drossman DA, Li Z, Andruzzi E, Temple R, Talley NJ, Thompson WG, Whitehead WE, Janssen J, FunchJensen P, Carazziari E, Richter JE, Koch GG US: householder survey of functional gastrointestinal disorders.
Prevalence, socialdemography and health impact. Dig Dis Sci 1993, 38, 15691580.
[9] Camilleri M: Management of irritable bowel syndrome. Gastroenterology 2001, 120, 652668.
[10] Whitehead WE, Palsson O, Jones KR: Systematic review of the comorbidity of irritable bowel syndrome with
other disorders: what are the causes and implications? Gastroenterology 2002, 122, 11401156.
[11] Creed F, Ratcliffe J, Fernandes L, Palmer S, Rigby C, Read N, Thompson DG: Outcome in severe irritable bowel
syndrome with and without accompanying depressive, panic and neurasthenic disorders. Br JPsychiatry 2005, 186,
507515.
[12] Lydiard RB, Fossey MD, Marsh W, Ballenger JC: Prevalence of psychiatric disorders in patients with irritable
bowel syndrome. Psychosomatics 1993, 34, 229234.
[13] Guthrie E, Creed F, Fernandes L, Ratcliffe J, Van der Jagt J, Martin J, Howlett S, Read N, Barlow J, ThompsonD,
Tomenson: Cluster analysis of symptoms and health seeking behaviour differentiates subgroups of patients with
severe irritable bowel syndrome. Gut 2003, 52, 16161622.
[14] witkowski M, Rybakowski J: Depression and Tlymphocytes in patients with irritable bowel syndrome. JAffective
Disorders 1993, 28, 199202.
[15] Sukowska A, Borys B, Majkowicz M, Sukowski B: Emotional background of irritable bowel syndrome analysis
based on the results of the study using MMPI.Gastroenterol Pol 2003, 10, 331334.
[16] Drossman DA, Talley NY, Whitehead WE, Corazziari E: Research diagnostic questions for functional gastrointestinal disorders: Rome II Modular Questionnaire: Investigations and Respondent Form. In: Rome II the
Functional Gastrointestinal Disorders. Eds.: Drossman DA, Corazziari E, Talley NY, Thomson WG. McLean.
Degnon Associates 2002, ed. 2nd, 669714.
[17] Klasyfikacja zaburze psychicznych izaburze zachowania wICD-10. Uniwersyteckie Wydawnictwo Medyczne
Versalius. Instytut Psychiatrii iNeurologii. KrakwWarszawa 1997.
[18] World Health Organization. The Composite International Diagnostic Interview. WHO.Geneva 1993.
[19] Wittchen HU: Reliability and validity studies of the WHO-Composite International Diagnostic Interview (CIDI).
Acritical review. JPsychiatric Research 1994, 28, 5784.
[20] Wittchen HU, Lachner G, Wunderlich U, Pfister H: Test-retest reliability of the computerized DSM-IV version
of the Munich-Composite International Diagnostic Interview (M-CIDI). Soc Psychiatry Psychiatr Epidemiol 1998,
33, 568578.
[21] Walker EA, Roy-Byrne PP, Katon WJ: Psychiatric illness and irritable bowel syndrome. A comparison with
inflammatory bowel disease. Am JPsychiatry 1990, 147, 16561661.
[22] Lydiard RB, Fossey MD, Marsh W, Ballenger JC: Prevalence of psychiatric disorders in patients with irritable
bowel syndrome. Psychosomatics 1993, 34, 229234.
[23] Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE: Lifetime prevalence and age-of-onset
distribution of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005, 62,
593602.
[24] Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshelman S, Wittchen HU, Kendler KS: Lifetime and
12-month prevalence of DSM-II-R psychiatric disorders in the United States. Arch Gen Psychiatry 1994, 51, 819.
[25] Lee S, Wu J, Ma Y, Tsang A, Guo WJ, Sung J: Irritable Bowel Syndrome is Strongly Associated with Generalized
Anxiety Disorder: ACommunity Study. Alimentary Pharmacology Therapeutics 2009, 30, 643651.
[26] Grzesiak M, Beszej JA, Szechiski M, Szewczuk-Bogusawska M, Waszczuk E, Mulak A, Kantorska M: Depressive
disorders in patients with irritable bowel syndrome diagnosed using the Composite International Diagnostic
Interview (CIDI). Adv Clin Exp Med 2010, 19, 601605.
[27] Lyriad RB: Irritable bowel syndrome, anxiety and depression: What are the links? J Clin Psychiatry 2001, 62,
3845.
[28] Cole JA, Rothman KJ, Cabral HJ, Zhang Y, Farraye F: Migraine, fibromyalgia and depression among people with
IBS: aprevalence study. BMC Gastroenterology 2006, 6, 2634.
[29] Ladep NG, Obindo TJ, Audu MD, Okeke EN, Malu AO: Depression in patients with irritable bowel syndrome in
Jos, Nigeria. World JGastroenterol 2006, 48, 78447847.
[30] Walker EA, Roy-Byrne PP, Katon WJ, Li L, Amos D, Jiranek G: Psychiatric illness and irritable bowel syndrome:
acomparison with inflammatory bowel disease. Am JPsych 1990, 147, 16561661.
[31] Lydiard RB, Fossey MD, Marsh W, Ballenger JC: Prevalence of psychiatric disorders in patients with irritable
bowel syndrome. Psychosomatics 1993, 34, 229234.

992

M.Grzesiak et al.

[32] Hillil MT, Siivola MT, Frkkil MA: Comorbidity and use of health-care services among irritable bowel syndrome sufferers. Scand JGastroenterol 2007, 42, 799806.
[33] Mykletun A, Jacka F, Williams L, Pasco J, Henry M, Nicholson GC, Kotowicz MA, Berk M: Prevalence of mood
and anxiety disorder in self-reported irritable bowel syndrome (IBS). An epidemiological population based study
of women. BMC Gastroenterology 2010, 10, 8897.
[34] Spiegel DR, Kolb R: Treatment of irritable bowel syndrome with comorbid anxiety symptoms with mirtazapine.
Clin Neuropharmacol 2011, 34, 3638.
[35] Jarret ME, Burr RL, Cain KC, Hertig V, Weisman P, Heitkemper MM: Anxiety and depression are related to
autonomic nervous system function in women with irritable bowel syndrome. Digestive Diseases Sciences 2003,
48, 386394.
[36] Hao JX, Han M, Duan LP, Ge Y, Huang YQ: Psychiatric comorbidities in patients referred for irritable bowel
syndrome. Zhonghua Yi Xue Za Zhi 2011, 91, 18861890.
[37] Kwon JG, Park KS, Park JH, Park JM, Park CH, Lee KJ, Park HJ, Rhee JC: Korean Society of Neurogastroenterology
and Motility: Guidelines for the treatment of irritable bowel syndrome. Korean JGastroenterol 2011, 57, 8299.

Address for correspondence:

Magdalena Grzesiak
Department of Psychiatry
Wroclaw Medical University
Kraszewskiego 25
50-229 Wrocaw
Poland
E-mail: magdalena.grzesiak@umed.wroc.pl
Tel.: +48 71 776 63 23
Conflict of interest: None declared
Received: 18.06.2013
Revised: 5.05.2014
Accepted: 15.10.2014