Abstract
Background and aims
Past studies have shown a substantial overlap between irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD). This study investigated the prevalence of DCPR-revised (DCPR-R) syndromes in patients with IBS alone and those with overlapping IBS-GERD. We also explored the relationship of these syndromes with various psychological scales.
Methods
In total, 341 patients from the Chinese IBS cohort completed the GerdQ scale and a series of psychological questionnaires. Semi-structured interviews were conducted to evaluate DCPR-R, as well as scores on the Psychosocial Index (PSI), Psychosomatic Symptom Scale (PSSS), World Health Organization (WHO)-5 Well-being Index, Euthymia Scale, Patient Health Questionnaire-9, and 7-item Generalized Anxiety Disorder Scale.
Results
Compared with patients with IBS alone, patients with overlapping IBS-GERD had a significantly higher prevalence of DCPR-R syndromes, particularly in areas such as demoralization, persistent somatization, despair-related demoralization, hypochondriasis, disease phobia, anniversary reaction, thanatophobia, and conversion symptoms. Patients with two or more types of DCPR-R syndromes were more likely to exhibit psychological disorders. In patients with IBS alone, the WHO-5 Well-being Index and PSI well-being scores were predictive of two or more DCPR-R syndromes. For patients with overlapping IBS-GERD, the PSSS score was an independent predictor.
Conclusion
This study highlights key differences in psychosomatic factors between patients with IBS alone and those with overlapping IBS-GERD. The DCPR-R syndromes and various psychological scales offer valuable tools for diagnosing and assessing these differences.
Keywords: Irritable bowel syndrome, Gastroesophageal reflux disease, DCPR-R syndromes, Psychology
Introduction
Irritable bowel syndrome (IBS) is a commonly diagnosed functional gastrointestinal disorder (FGID) with a global prevalence of 3.8% under Rome IV criteria and 10.1% under Rome III criteria, as estimated reported by the Rome Foundation[1]. IBS manifests through alterations in bowel function and abdominal pain, severely impacting the quality of life of patients[2, 3]. Although the exact mechanisms underlying IBS are not fully understood, the Rome IV criteria propose that IBS onset is linked to gut–brain interactions. Potential contributing factors include imbalances in intestinal microbiota, abnormal gastrointestinal motility, mucosal immune responses, increased visceral sensitivity, and central nervous system dysfunction[4–6]. Gastroesophageal reflux disease (GERD), another globally prevalent gastrointestinal disorder, also significantly affects patient’s quality of life and incurs high healthcare costs[7]. The global prevalence of GERD varies widely from 2.5 to 51.2%, with the highest rates reported in Western countries[8]. In the United States, up to 40% of the population experiences esophageal symptoms occasionally, while 10–20% report symptoms at least weekly. Typical GERD symptoms include heartburn and reflux[9], with preliminary diagnoses often based on these typical symptoms and the response to empirical treatment with proton pump inhibitors (PPIs)[10–12].
Research has demonstrated a frequent overlap between IBS and GERD[13, 14], as well as with mental health conditions such as anxiety and depression[15]. GERD symptoms are noted in up to 42.0% of IBS patients, a rate four times higher than that in the general population[16]. In patients with concurrent GERD and IBS, symptoms such as acid reflux and heartburn may present as abdominal pain or discomfort, with mechanisms such as visceral hypersensitivity and gastrointestinal dysmotility potentially contributing to the overlap[3]. Patients experiencing both FGID and GERD tend to have more severe mental health challenges, poorer quality of life, and a greater likelihood of seeking medical assistance[17]. These overlapping conditions can complicate symptoms and hinder effective treatment[13].
An increasing awareness exists regarding limitations in classifying psychological factors within current psychiatric diagnostic systems, particularly concerning the psychosocial impact of physical symptoms. The Diagnostic Criteria for Psychosomatic Research (DCPR) was introduced to address these issues, offering a psychosocial classification system that provides insights into illness behavior and the subjective distress experienced by patients in general medical settings. Studies support DCPR’s value in understanding the development, progression, and prognosis of various somatic diseases[18].
The DCPR is a psychosomatic framework designed to assess patients’ psychosocial dimensions[19]. Building on insights from its extensive clinical application, this framework was refined in 2017, resulting in the Diagnostic Criteria for Psychosomatic Research-Revised (DCPR-R), which expands diagnostic criteria to encompass constructs such as stress (allostatic load), personality traits (e.g., Type A behavior, alexithymia), illness behaviors (e.g., health anxiety, disease phobia, hypochondriasis, thanatophobia, illness denial, persistent somatization, conversion symptoms, anniversary reaction), and psychological symptoms (e.g., functional somatic symptoms secondary to psychiatric disorders, demoralization, irritable mood)[20]. This revision has converted a spectrum of psychosocial factors, atypical illness behaviors, and somatization symptoms into a streamlined, reliable semi-structured interview format, enabling clinicians to systematically screen for and accurately diagnose psychosocial factors related to somatic health. The DCPR-R broadens the traditional disease model, facilitating its application in clinical settings for various psychosomatic conditions, especially in digestive disorders[18, 21–24].
This study aims to assess the prevalence of DCPR-R psychosomatic syndromes in patients with IBS alone and those with IBS-GERD overlap, examining the correlations with additional psychological assessment tools, including the Psychosocial Index (PSI), Psychosomatic Symptom Scale (PSSS), World Health Organization (WHO)-5 Well-Being Index, Euthymia Scale, Patient Health Questionnaire-9 (PHQ-9), and 7-item Generalized Anxiety Disorder Scale (GAD-7). To the best of our knowledge, this is the first large-scale study in China to explore the utility of DCPR-R in distinguishing psychosomatic symptoms in functional gastrointestinal disorders with comorbid syndromes.
Materials and methods
Study design and patient recruitment
This multicenter, cross-sectional study was conducted across 20 comprehensive tertiary hospitals across China, distributed regionally as follows: 9 hospitals in the eastern region, 5 in the central region, 4 in the west and 2 in the northeast. The number of hospitals was determined based on the population and socioeconomic conditions in the four administrative regions of mainland China. The eastern region had the largest population and the most advanced economic development, followed by the central, western, and northeastern regions.The aim was to assess the prevalence and distinctions of DCPR-R psychosomatic syndromes and other psychological measures, including the PSI, PSSS, WHO-5 Well-being Index, Euthymia Scale, PHQ-9, and GAD-7, in Chinese patients diagnosed as having IBS and IBS overlapping with GERD. The study population comprised consecutive adult patients visiting the gastroenterology departments of these 20 hospitals between 2022 and 2023 who met the established criteria for IBS (details below). Ethical approval was obtained from the Ethics Committee of Zhongda Hospital, affiliated with Southeast University, and the study was registered with the Chinese Clinical Trials Registry on January 30, 2022 (No ChiCTR2200055990).
Inclusion and exclusion criteria
The inclusion criteria for IBS patients were as follows: (1) age between 18 and 75 years; (2) meeting the Rome IV IBS diagnostic criteria[25]; and (3) obtaining an informed consent form signed by the patient or their legal guardian. The exclusion criteria were as follows: (1) presence of organic gastrointestinal diseases confirmed by diagnostic tests, such as blood work, stool analysis, biochemical tests, colonoscopy, abdominal ultrasound, and imaging; (2) presence of concurrent metabolic disorders, including diabetes or thyroid dysfunction; (3) coexistence of malignant tumors and significant organ dysfunction; (4) abuse or dependence on psychoactive substances including alcohol, tobacco, or drugs; (5) Pregnant and lactating women; and (6) patients unable to participate in effective interviews due to physical or mental health conditions.
IBS diagnosis criteria
IBS diagnosis was based on the Rome IV criteria[25, 26], which includes abdominal pain occurring at least 1 day/week in the past 3 months, along with at least two of the following: (1) symptoms associated with defecation, (2) changes in stool frequency, or (3) changes in stool form. Symptoms should have first appeared 6 months before diagnosis and met the specified diagnostic criteria over the last 3 months.
GERD diagnostic criteria
GERD symptoms were assessed using the GerdQ scale, a self-administered diagnostic tool for evaluating reflux symptoms in the past week. The questionnaire comprises six items: frequency of reflux, frequency of burning sensations in the stomach, frequency of nausea, frequency of upper abdominal pain, frequency of sleep disturbances, and frequency of use of over-the-counter (OTC) medications[27]. Studies have found a cutoff score of 8 for optimal specificity and sensitivity in GERD diagnosis[28]. Thus, a GerdQ score of ≥ 8 was used as the diagnostic indicator for GERD.
DCPR-R psychosomatic syndrome assessment
The DCPR-R comprehensive scale evaluates 14 psychosomatic syndromes, namely stress (allostatic load), illness behaviors (health anxiety, disease phobia, hypochondriasis, thanatophobia, denial of illness, persistent somatization, conversion symptoms, and anniversary reaction), psychological manifestations (somatic symptoms secondary to mental disorders, demoralization, demoralization with despair and irritable mood), and personality attributes (type A behavior and alexithymia)[23]. A structured interview based on the DCPR-R was used to determine the presence of any of these 14 psychosomatic syndromes in each participant. Reliability for the DCPR-R categories in this sample was high, with Cronbach’s α coefficients for the four categories being 0.757, 0.834, 0.889, and 0.823.
Psychological measurements
The PSI was a comprehensive scale assessing five dimensions: stress (17 items), well-being (6 items), psychological distress (15 items), abnormal illness behavior (3 items), and quality of life (1 item). This tool has been widely validated across clinical populations in various countries, demonstrating high sensitivity in effectively distinguishing degrees of psychosocial disorders among these populations[29]. In our sample, the Cronbach’s α values for the first four PSI dimensions were 0.607, 0.557, 0.878, and 0.707, respectively.
The PSSS is a reliable and effective self-assessment tool for identifying psychosomatic symptoms, consisting of 26 sub-items that measure symptom frequency over the past month [30]. A score of ≥ 10 for males and ≥ 11 for females suggests a potential psychosomatic disorder. The Cronbach’s α for the PSSS in our sample was 0.925.
The WHO-5 Well-being Index is a concise measure of subjective well-being over the past 2 weeks, consisting of 5 5 simple and non-invasive questions. Respondents are asked to complete the questionnaire based on their feelings over the past 2 weeks. This scale has shown high clinical validity as a screening tool for depression and is effective for assessing treatment outcomes in clinical trials[31]. The Cronbach’s α in our sample was 0.95.
The Euthymia Scale assesses the respondent’s mood resilience through 10 sub-items, with “yes” responses scoring 1 point and “no” scoring 0 points, yielding a total score range of 0–10 points[32]. For psychological resilience (items 1–4), a score of ≤ 4 points may indicate depression, and for mental health status (items 5–10), a score of ≤ 1 point may indicate depression. The Cronbach’s α in our sample was 0.84.
The PHQ-9, based on DSM-IV criteria, is used to screen and assess depression severity[33]. Comprising 9 sub-items scored from 0 to 3, the scale ranges from 0 to 27 points, with higher scores indicating more severe depression: 0–4 points (none), 5–9 points (mild), 10–14 points (moderate), 15–19 points (moderate to severe), and 20–27 points (severe). The Cronbach’s α in this sample was 0.879.
The GAD-7 is a reliable and effective 7-item tool for assessing generalized anxiety validated for use in both general and clinical populations[34]. Scored from 0 to 3 per item, the total score ranges from 0 to 21 points, with cut-offs as follows: 0–4 points (none), 5–9 points (mild), 10–14 points (moderate), and 15–21 points (severe). The Cronbach’s α in this sample was 0.938.
Statistical analysis
Descriptive statistics were used to summarize patient characteristics, clinical features, and psychological status in both patients with IBS alone and those with overlapping IBS-GERD. For normally distributed continuous variables, data were expressed as mean ± standard deviation and compared using independent samples t-test. For non-normally distributed continuous variables, data were reported as the median and interquartile range (IQR) and compared using the Wilcoxon test. Categorical variables were expressed as frequencies (percentages), with comparisons made using the chi-square test or Fisher’s exact test. Subsequently, Differences in the prevalence of DCRP-R diagnoses between the IBS-alone and IBS-GERD overlap groups were examined using chi-square tests. Univariate and multivariate logistic regression analyses were then conducted to assess associations between general characteristics, clinical features, psychological variables, and DCPR-R syndromes (> 1). Variables with significant univariate associations were included in multivariate models to identify independent risk factors. Statistical analyses were performed using SPSS (Version 24, New York, NY, USA), with p values < 0.05 (two-sided) considered statistically significant.
Results
General characteristics and psychological status of patients
This study included 341 patients with IBS, of whom 97 (28.4%) exhibited overlapping reflux symptoms. As shown in Table 1, we compared the general, clinical, and psychological characteristics of patients with IBS alone and those with the overlapping IBS-GERD. No significant differences were found between the two groups in demographic and clinical characteristics, including disease duration and IBS subtype, except for age (p = 0.022). The mean age of the patients with overlap syndrome (53.04 ± 12.71) was higher than that of patients with IBS alone (49.34 ± 13.65). On the PSI scale, patients with overlapping IBS-GERD exhibited lower well-being scores (4.56 ± 1.46 vs. 4.03 ± 1.55, p = 0.003) and higher psychological distress levels (4.35 ± 2.98 vs. 5.31 ± 2.73, p = 0.005) than those with IBS alone. However, no significant differences were observed in PSI stress, abnormal illness behavior, or quality of life scores (p > 0.05) between the two groups. Patients with overlap syndrome also had lower scores on the WHO-5 Well-being Index (55.1 ± 27.7 vs. 48.29 ± 27.87, p = 0.042) and Euthymia Scale scores (8.00 ± 2.41 vs. 7.09 ± 2.78, p = 0.005). By contrast, they had higher PSSS scores (12.73 ± 10.42 vs. 19.59 ± 11.68, p < 0.001), PHQ-9 scores (5.12 ± 4.76 vs. 8.08 ± 5.6, p < 0.001), and GAD-7 scores (4.24 ± 4.46 vs. 6.59 ± 5.08, p < 0.001), suggesting worse psychosomatic health, increased psychosomatic disturbances, emotional distress, depression, and anxiety.
Table 1.
General features, clinical characteristics, and psychological status of patients with IBS alone and those of patients with overlapping IBS-GERD
| Characteristics | All patients (n = 341) |
Patients with IBS alone (n = 244) | Patients with overlapping IBS-GERD(n = 97) | p-value |
|---|---|---|---|---|
| General features | ||||
| Age, years (mean ± SD) | 50.39 ± 13.48 | 49.34 ± 13.65 | 53.04 ± 12.71 | 0.022 |
| Gender, n (%) | 0.101 | |||
| Male | 136(39.9) | 104(42.6) | 32(33.0) | |
| Female | 205(60.1) | 140(57.4) | 65(67.0) | |
| Nation, n (%) | 0.874 | |||
| The Han nationality | 321(94.1) | 230(94.3) | 91(93.8) | |
| Non-Han | 20(5.9) | 14(5.7) | 6(6.2) | |
| Educational status, n (%) | 0.147 | |||
| Below high school | 104(30.5) | 67(27.5) | 37(38.1) | |
| High school | 91(26.7) | 69(28.3) | 22(22.7) | |
| Above high school | 146(42.8) | 108(44.3) | 38(39.2) | |
| Marital status, n (%) | 0.490 | |||
| Unmarried, widowed, or divorced | 38(11.1) | 29(11.9) | 9(9.3) | |
| Be married | 303(88.9) | 215(88.1) | 88(90.7) | |
| Smoking status, n (%) | 0.542 | |||
| Never smoker | 281(82.4) | 198(81.1) | 83(85.6) | |
| Current smoker | 34(10.0) | 27(11.1) | 7(7.2) | |
| Former smoker | 26(7.6) | 19(7.8) | 7(7.2) | |
| Alcohol consumption, n (%) | 0.536 | |||
| Never drinker | 264(77.4) | 192(78.7) | 72(74.2) | |
| Current drinker | 38(11.1) | 27(11.1) | 11(11.3) | |
| Former drinker | 39(11.4) | 25(10.2) | 14(14.4) | |
| Permanent residence, n (%) | 0.515 | |||
| Urban | 281(82.4) | 199(81.6) | 82(84.5) | |
| Rural | 60(17.6) | 45(18.4) | 15(15.5) | |
| Clinical characteristics | ||||
| Duration of disease (years), median (IQR) | 2.0(1.0–4.0) | 2.0(1.0–4.0) | 2.0(1.0-4.5) | 0.644 |
| Source of cases, n (%) | 0.111 | |||
| Outpatient | 178(52.2) | 134(54.9) | 44(45.4) | |
| Ward | 163(47.8) | 110(45.1) | 53(54.6) | |
| IBS subtypes, n (%) | 0.583 | |||
| IBS with predominant constipation | 91(26.7) | 69(28.3) | 22(22.7) | |
| IBS with predominant diarrhea | 147(43.1) | 106(43.4) | 41(42.3) | |
| IBS with mixed bowel habits | 62(18.2) | 41(16.8) | 21(21.6) | |
| IBS Unclassified | 41(12.0) | 28(11.5) | 13(13.4) | |
| Psychological status | ||||
| PSI Stress(Mean ± SD) | 1.99 ± 2.06 | 1.89 ± 2.11 | 2.27 ± 1.9 | 0.106 |
| PSI Well-being(Mean ± SD) | 4.41 ± 1.5 | 4.56 ± 1.46 | 4.03 ± 1.55 | 0.003 |
| PSI Psychological Distress (Mean ± SD) | 4.62 ± 2.94 | 4.35 ± 2.98 | 5.31 ± 2.73 | 0.005 |
| PSI Abnormal Illness Behavior (Mean ± SD) | 1.8 ± 1.66 | 1.7 ± 1.58 | 2.06 ± 1.83 | 0.069 |
| PSI Quality of Life (Mean ± SD) | 2.5 ± 0.77 | 2.5 ± 0.76 | 2.48 ± 0.79 | 0.832 |
| PSSS total score (Mean ± SD) | 14.68 ± 11.21 | 12.73 ± 10.42 | 19.59 ± 11.68 | < 0.001 |
| WHO-5 Well-being Index (Mean ± SD) | 53.16 ± 27.88 | 55.1 ± 27.7 | 48.29 ± 27.87 | 0.042 |
| Euthymia Scale score (Mean ± SD) | 7.74 ± 2.55 | 8 ± 2.41 | 7.09 ± 2.78 | 0.005 |
| PHQ-9 score (Mean ± SD) | 5.96 ± 5.18 | 5.12 ± 4.76 | 8.08 ± 5.6 | < 0.001 |
| GAD-7 score (Mean ± SD) | 4.91 ± 4.75 | 4.24 ± 4.46 | 6.59 ± 5.08 | < 0.001 |
DCPR-R syndromes of the patients
As seen in Table 2, the prevalence of patients with at least one DCPR-R syndrome was higher in those with overlapping IBS-GERD (81.4%) compared to that in patients with IBS only (77.9%); however, no relevant statistical difference was noted in this regard (p > 0.05). The prevalence of at least two DCPR-R syndromes was statistically significantly different between the two groups (patients with IBS only: 40.2%, patients with overlapping IBS-GERD: 56.7%, p < 0.05). The most prevalent DCPR-R diagnoses in both the groups were alexithymia, irritable mood, and demoralization; however, of these three syndromes, patients with the overlapping IBS-GERD showed a higher statistically significant prevalence of demoralization only (17.2% vs. 28.9%, p = 0.016). In addition, the prevalence of persistent somatization symptoms, demoralization with despair, hypochondriasis, disease phobia, anniversary reaction, thanatophobia, and conversion symptoms were higher in patients with overlapping IBS-GERD (all p < 0.05).
Table 2.
Comparison of DCPR-R diagnosis between patients with IBS alone and those with overlapping IBS-GERD
| All patients (n = 341) | Patients with IBS alone (n = 244) | Patients with overlapping IBS-GERD (n = 97) | p-value | |
|---|---|---|---|---|
| DCPR-R > 0a | 269(78.9) | 190(77.9) | 79(81.4) | 0.466 |
| DCPR-R > 1b | 153(44.9) | 98(40.2) | 55(56.7) | 0.006 |
| Alexithymia | 196(57.5) | 147(60.2) | 49(50.5) | 0.101 |
| Irritable mood | 92(27.0) | 61(25.0) | 31(32.0) | 0.191 |
| Demoralization | 70(20.5) | 42(17.2) | 28(28.9) | 0.016 |
| Health anxiety | 47(13.8) | 31(12.7) | 16(16.5) | 0.360 |
| Type A behavior | 46(13.5) | 28(11.5) | 18(18.6) | 0.084 |
| Allostatic load | 37(10.9) | 25(10.2) | 12(12.4) | 0.569 |
| Persistent somatization | 43(12.6) | 24(9.8) | 19(19.6) | 0.014 |
| Demoralization with despair | 31(9.1) | 14(5.7) | 17(17.5) | < 0.001 |
| Hypochondriasis | 27(7.9) | 14(5.7) | 13(13.4) | 0.018 |
| Disease phobia | 27(7.9) | 12(4.9) | 15(15.5) | < 0.001 |
| Illness denial | 6(1.8) | 5(2) | 1(1) | 0.850 |
| Anniversary reaction | 11(3.2) | 4(1.6) | 7(7.2) | 0.009 |
| Thanatophobia | 10(2.9) | 3(1.2) | 7(7.2) | 0.003 |
| Conversion Symptoms | 4(1.2) | 1(0.4) | 3(3.1) | 0.038 |
aAt least one type of DCPR-R syndrome
bAt least two types of DCPR-R syndromes
Comparison of DCPR-R syndromes and predictors of multiple psychosomatic syndromes
Given the differences in DCPR-R > 1 (i.e., having at least two or more DCPR-R syndromes) prevalence across the two patient categories, we further explores associations between DCPR-R > 1 status and general features, clinical characteristics, and scores on other psychological scales(Table 3 and Table 4). Univariate logistic regression analysis showed that, in both patients with IBS alone and those with overlapping IBS-GERD, patients with two or more DCPR-R syndromes scored significantly worse across all psychological measures compared with those without and with one syndrome (p < 0.05). Additionally, age and IBS subtypes were associated with a higher risk of DCRP-R > 1 in patients with IBS alone.
Table 3.
Univariate and multivariate logistic regression models of variables associated with DCRP-R > 1 in patients with IBS alone
| Variable | Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|---|
| OR (95% CI) | p | aOR (95% CI) | p | ||
| Age | 0.98 (0.96-1.00) | 0.040 | 1.01 (0.98–1.03) | 0.699 | |
| Gender | |||||
| Male | ref | ||||
| Female | 0.92 (0.55–1.54) | 0.745 | |||
| Nation | |||||
| The Han nationality | ref | ||||
| Non-Han | 1.12 (0.38–3.35) | 0.832 | |||
| Educational status | |||||
| Below high school | ref | ||||
| High school | 1.02 (0.51–2.03) | 0.965 | |||
| Above high school | 1.29 (0.69–2.42) | 0.418 | |||
| Marital status | |||||
| Unmarried, widowed, or divorced | ref | ||||
| Be married | 0.50 (0.23–1.09) | 0.083 | |||
| Smoking status | |||||
| Never smoker | ref | ||||
| Current smoker | 1.49 (0.66–3.34) | 0.333 | |||
| Former smoker | 1.44 (0.56–3.72) | 0.445 | |||
| Alcohol consumption | |||||
| Never drinker | ref | ||||
| Current drinker | 1.99 (0.88–4.49) | 0.096 | |||
| Former drinker | 0.90 (0.38–2.13) | 0.806 | |||
| Permanent residence | |||||
| Urban | ref | ||||
| Rural | 1.39 (0.72–2.66) | 0.326 | |||
| IBS subtypes | |||||
| IBS with predominant constipation | ref | ||||
| IBS with predominant diarrhea | 0.48 (0.26–0.89) | 0.020 | 0.87 (0.39–1.91) | 0.726 | |
| IBS with mixed bowel habits | 0.50 (0.23–1.12) | 0.093 | 0.51 (0.19–1.35) | 0.175 | |
| IBS Unclassified | 0.97 (0.40–2.34) | 0.948 | 0.57 (0.19–1.73) | 0.322 | |
| Duration of disease (years) | 1.01 (0.98–1.06) | 0.453 | |||
| PSI Stress | 1.33 (1.15–1.53) | < 0.001 | 0.97 (0.79–1.19) | 0.780 | |
| PSI Well-being | 0.53 (0.42–0.65) | < 0.001 | 0.64 (0.48–0.85) | 0.002 | |
| PSI Psychological Distress | 1.20 (1.09–1.31) | < 0.001 | 1.00 (0.86–1.15) | 0.951 | |
| PSI Abnormal Disease Behavior | 1.72 (1.41–2.10) | < 0.001 | 1.28 (0.99–1.67) | 0.064 | |
| PSI Quality of Life | 0.44 (0.30–0.65) | < 0.001 | 0.98 (0.57–1.70) | 0.946 | |
| PSSS total score | 1.08 (1.05–1.11) | < 0.001 | 0.98 (0.93–1.04) | 0.539 | |
| WHO-5 Well-being Index | 0.96 (0.95–0.98) | < 0.001 | 0.98 (0.96-1.00) | 0.010 | |
| Euthymia Scale score | 0.73 (0.65–0.83) | < 0.001 | 1.03 (0.86–1.24) | 0.755 | |
| PHQ-9 score | 1.22 (1.13–1.30) | < 0.001 | 1.06 (0.93–1.21) | 0.416 | |
| GAD-7 score | 1.29 (1.19–1.41) | < 0.001 | 1.13 (0.99–1.29) | 0.068 | |
aVariables that are statistically significant in univariate columns are shown in multivariate columns
Abbreviations: OR, Odds Ratio; CI, Confidence Interval; aOR, Adjusted Odds Ratio; IBS, Irritable Bowel Syndrome; IQR, Interquartile Range; PSI, Psychosocial Index; PSSS, Psychosomatic Symptom Scale; PHQ-9, Patient Health Questionnaire-9; GAD, Generalized Anxiety Disorder; DCPR-R, Diagnostic Criteria for Psychosomatic Research-Revised
Table 4.
Univariate and multivariate logistic regression models of variables associated with DCPR-R > 1 in patients with overlapping IBS-GERD
| Variable | Univariate analysis | Multivariate analysis | ||||
|---|---|---|---|---|---|---|
| OR (95% CI) | p | aOR (95% CI) | p | |||
| Age | 1.00 (0.97–1.04) | 0.824 | ||||
| Gender | ||||||
| Male | ref | |||||
| Female | 1.03 (0.44–2.41) | 0.950 | ||||
| Nation | ||||||
| The Han nationality | ref | |||||
| Non-Han | 0.36 (0.06–2.06) | 0.250 | ||||
| Educational status | ||||||
| Below high school | ref | |||||
| High school | 0.88 (0.30–2.59) | 0.815 | ||||
| Above high school | 0.61 (0.24–1.53) | 0.290 | ||||
| Marital status | ||||||
| Unmarried, widowed, or divorced | ref | |||||
| Be married | 0.63 (0.15–2.67) | 0.529 | ||||
| Smoking status | ||||||
| Never smoker | ref | |||||
| Current smoker | 1.91 (0.35–10.44) | 0.453 | ||||
| Former smoker | 0.57 (0.12–2.73) | 0.486 | ||||
| Alcohol consumption | ||||||
| Never drinker | ref | |||||
| Current drinker | 1.32 (0.36–4.92) | 0.676 | ||||
| Former drinker | 0.76 (0.24–2.38) | 0.633 | ||||
| Permanent residence | ||||||
| Urban | ref | |||||
| Rural | 2.37 (0.70–8.08) | 0.166 | ||||
| IBS subtypes | ||||||
| IBS with predominant constipation | ref | |||||
| IBS with predominant diarrhea | 0.44 (0.15–1.32) | 0.143 | ||||
| IBS with mixed bowel habits | 0.51 (0.15–1.77) | 0.292 | ||||
| IBS Unclassified | 1.05 (0.24–4.62) | 0.949 | ||||
| Duration of disease (years) | 0.96 (0.88–1.05) | 0.388 | ||||
| PSI Stress | 1.34 (1.05–1.71) | 0.020 | 1.02 (0.74–1.41) | 0.906 | ||
| PSI Well-being | 0.58 (0.42–0.80) | 0.001 | 0.88 (0.57–1.34) | 0.545 | ||
| PSI Psychological Distress | 1.32 (1.11–1.59) | 0.002 | 1.10 (0.84–1.42) | 0.494 | ||
| PSI Abnormal Disease Behavior | 2.26 (1.57–3.25) | < 0.001 | 1.29 (0.75–2.21) | 0.350 | ||
| PSI Quality of Life | 0.29 (0.15–0.55) | < 0.001 | 0.49 (0.19–1.25) | 0.136 | ||
| PSSS total score | 1.12 (1.06–1.17) | < 0.001 | 1.10 (1.01–1.19) | 0.022 | ||
| WHO-5 Well-being Index | 0.97 (0.95–0.98) | < 0.001 | 0.99 (0.96–1.02) | 0.580 | ||
| Euthymia Scale score | 0.67 (0.55–0.82) | < 0.001 | 0.91 (0.64–1.29) | 0.594 | ||
| PHQ-9 score | 1.16 (1.06–1.27) | 0.001 | 0.85 (0.72–1.01) | 0.061 | ||
| GAD-7 score | 1.27 (1.13–1.44) | < 0.001 | 1.05 (0.88–1.25) | 0.592 | ||
aVariables that are statistically significant in univariate columns are shown in multivariate columns
Abbreviations: OR, Odds Ratio; CI, Confidence Interval; aOR, Adjusted Odds Ratio; IBS, Irritable Bowel Syndrome; IQR, Interquartile Range; PSI, Psychosocial Index; PSSS, Psychosomatic Symptom Scale; PHQ-9, Patient Health Questionnaire-9; GAD, Generalized Anxiety Disorder; DCPR-R, Diagnostic Criteria for Psychosomatic Research-Revised
Using these varying psychological and general characteristics as independent variables, with DCPR-R > 1 as the dependent variable, a multifactorial logistic regression analysis (Table 3 and Table 4) revealed that in patients with IBS alone, the WHO-5 Well-being Index and PSI well-being scores were independent predictors of having at least two DCPR-R syndromes (adjusted odds ratio (aOR) 0.64, 95% confidence interval (CI): 0.48–0.85; aOR 0.98, 95% CI: 0.96–1.00). In patients with overlapping IBS-GERD, the PSSS score emerged as an independent predictor of having multiple DCPR-R syndromes (aOR 1.10, 95% CI: 1.01–1.19).
Discussion
Numerous studies have indicated a high overlap between IBS and GERD, with some reports showing co-occurrence rates as high as 62%. This overlap is significantly more common than in individuals without IBS or GERD[16, 35, 36]. Rome IV criteria recognize that these pathological conditions are interconnected within the gastrointestinal tract rather than existing as isolated diseases, suggesting that such overlap may be a typical clinical manifestation of FGIDs [37]. Our study similarly found a high overlap rate between IBS and GERD, with approximately 28.4% (97 out of 341) of patients exhibiting both conditions—substantially higher than the estimated 15% prevalence of GERD in the general Asian population[38].
The coexistence of IBS and GERD can result in often more complex symptom profiles, presenting significant treatment challenges, negatively impacting quality of life, and increasing healthcare costs[13]. Research has shown that individuals with overlapping syndromes (coexistence of GERD and FGIDs) exhibited worsened psychosomatic health, more severe symptoms, diminished functional capacity, and a greater likelihood of seeking medical care [17, 39, 40]. Both IBS and GERD are recognized as typical psychosomatic disorders that require treatment strategies emphasizing the role of psychological and social factors in the disease’s onset and progression, beyond the physical symptoms alone. Psychological factors are not only primary risk elements for the onset of IBS and GERD but also contribute to patients’ heightened perception and cognitive awareness of clinical symptoms[41–43], especially in cases of overlapping syndromes[39]. Based on the evaluation results of various psychological scales, this study found that patients with overlapping IBS-GERD have poorer psychosomatic health, higher levels of psychosomatic disorders, and increased rates of emotional disturbances, depression, and anxiety compared with those having IBS alone, in alignment with extensive prior research.
For functional syndromes, especially those with overlapping gastrointestinal conditions, patients and clinicians are encouraged to move beyond traditional biomedical perspectives and consider biopsychosocial regulatory factors[23, 44]. Psychological assessment plays a vital role in this approach, as symptoms often influence clinical judgments and may impact the physician’s treatment planning [45]. Research suggests that treatment outcomes for FIGDs could be improved by categorizing patients according to common psychosomatic characteristics, focusing solely on the disease classification[46]. The DCPR-R integrates psychosocial factors into a structured diagnostic framework, extending the traditional scope of the disease model[23, 47]. The DCPR-R, unlike conventional psychological assessments, incorporates diagnostic criteria to identify subclinical psychosocial issues that standard evaluations often miss.DCPR-R provides an overall assessment assessment of patients’ physical and mental health and is widely accepted and utilized in functional gastrointestinal disorders [21, 23, 48, 49]. When using DCPR to assess the psychosocial components of somatic illnesses, the prevalence of psychosomatic syndromes is 2.5 times greater than diagnosed by Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). Additionally, the severity of psychosomatic disorders, measured with the presence of more than one DCPR conditions, strongly predicts the treatment outcomes in patients with functional gastrointestinal disorders. Recent studies have also linked DCPR-R with subjective perceptions of IBS symptom severity, highlighting DCPR-R’s utility in identifying individual cognitive and emotional influences on the self-assessment of health[23].
This study found that both patients with IBS alone and those with IBS-GERD overlap syndrome exhibited a higher prevalence of DCPR-R syndrome. Specifically, approximately 78.9% of IBS patients presented with at least one type of DCPR-R psychosomatic syndrome, which was consistent with previous results. However, epidemiological data on the prevalence of DCRP-R syndromes in patients with overlapping syndromes are lacking. In this study, the prevalence of at least one DCPR-R psychosomatic syndrome was higher in patients with the IBS-GERD overlap syndrome (81.4%) than in those with IBS alone (77.9%); nonetheless, this difference was not statistically significant. Conversely, the prevalence of at least two DCPR-R syndromes was significantly greater in patients with overlapping IBS-GERD (56.7%) than in those with IBS alone (40.2%). This indicates that patients with overlapping syndromes exhibited a greater degree of psychosomatic abnormalities, suggesting a correlation between overlapping syndromes and increased psychological disturbances.
We further examined the relationship between having more than one DCPR-R syndrome and scores on various psychological assessments among both patient groups. The results demonstrated that for individuals with either IBS alone or overlapping IBS-GERD, those with two or more DCPR-R syndromes had higher scores on all psychological scales, reflecting poorer overall outcomes, compared to those without or with only one syndrome. In both patient groups, we further analyzed the association between the DCRP-R classification and scores on other psychological scales. Among patients with IBS alone and overlapping IBS-GERD, those with two or more DCRP-R syndromes had worse scores on all psychological scales than those without and with one syndrome. Furthermore, logistic regression analyses indicated that specific IBS subtypes were associated with an increased risk of having multiple DCRP-R syndromes. Patients with diarrheal IBS, in particular, were more likely to exhibit more DCRP-R syndromes.
In the multivariate analysis, we sought to identify correlations between the prevalence of DCRP-R syndromes and other contributing factors. Studies have established a strong link between DCPR syndromes and psychological distress, health anxiety, and somatization [18, 23, 48]. Our findings indicated that among patients with isolated IBS, the WHO-5 Well-being Index and PSI well-being scores served as independent predictors for having multiple DCPR-R syndromes. Notably, patients with poorer subjective well-being were more likely to present with multiple DCRP-R syndromes, the PSSS score emerged as an independent predictor of having multiple DCPR-R syndromes. This suggests that PSSS is an effective tool for assessing psychosomatic disorders in this patient group, as greater severity of psychosomatic symptoms correlates with an increased number of DCPR-R syndromes. Therefore, conducting a DCPR-R assessment is advisable to identify multi-dimensional psychological issues in patients, enabling the development of more personalized diagnosis and treatment strategies.
This study has some shortcomings. First, we established two groups—those with overlapping IBS-GERD and those with IBS alone, without including a separate group for patients with GERD alone. Future research should address this oversight. Second, the limited number of overlapping IBS-GERD cases hinders the feasibility of conducting subgroup analysis. Future research should increase the sample size to identify additional useful risk factors for DCPR-R syndromes and eliminate potential confounding factors.Third, the cross-sectional nature of the study precludes any determination of causality. Given the prevalence of DCPR-R syndromes in both IBS and GERD overlapping syndromes, it is plausible that DCPR-R may contribute to the development of these overlapping conditions; therefore, longitudinal studies are warranted to clarify the causal relationships.
Conclusion
This study underscores the significant differences in psychosomatic factors between patients with overlapping IBS-GERD and those with IBS alone. The use of the DCPR-R in conjunction with various psychological scales allows for a more comprehensive diagnosis and assessment. Individuals with overlapping IBS-GERD exhibited a greater number of DCPR-R syndromes—including but not limited to demoralization, persistent somatization symptoms, despair, hypochondriasis, illness anxiety disorder, anniversary reactions, thanatophobia, and conversion symptoms—compared with individuals with isolated IBS. The DCPR-R assessment correlated with traditional psychological evaluations, revealing that both the WHO-5 Well-being Index and PSI well-being scores independently predict the presence of at least two DCPR-R syndromes in patients with isolated IBS. Conversely, only PSSS scores independently predict outcomes in individuals with overlapping IBS-GERD. Integrating specific psychosomatic medical criteria with psychological and psychiatric assessments can aid healthcare professionals in devising tailored, psychosomatic holistic intervention strategies.
Acknowledgements
We would like to thank the participating clinicians and patients.
Author contributions
Peicai Li and Yanping Tang conceived and designed the work. Peicai Li and Yanping Tang obtained funding. Peicai Li, Lei Liu, and Li Yang collected the data. Peicai Li, Zhongmei Sun, and Lei Yang statistically analyzed and all authors interpreted the data. Peicai Li wrote the paper. Zhongmei Sun, Yanxia Gong, and Yanping Tang were involved in project administration. All authors critically revised the manuscript and provided important intellectual content. All authors approved the manuscript for publication.
Funding
Youth Project of National Natural Science Foundation of China (No. 82204988); National Natural Science Foundation (No. 82274253 and No. 82074213); Tianjin Administration of Traditional Chinese Medicine Youth Project of China (No. 2021045).
Data availability
The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
The studies involving human participants were reviewed and approved by the IEC for Clinical Research of Zhongda Hospital, Affiliated with Southeast University (2021ZDSYLL349-P02).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Informed consent
The patients/participants provided their written informed consent to participate in this study.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.