Buy this Article for $10.95

Have a coupon or promotional code? Enter it here:

When you buy this you'll get access to the ePub version, a downloadable PDF, and the ability to print the full article.


irritable bowel syndrome, psychological distress, quality of life, sense of coherence



  1. Motzer, Sandra Adams
  2. Hertig, Vicky
  3. Jarrett, Monica
  4. Heitkemper, Margaret M.


Background: Despite ongoing physical and psychological distress, little is known about sense of coherence (SOC) and holistic quality of life (QOL) in women with irritable bowel syndrome (IBS).


Objectives: The purposes of this study were to (a) describe and compare SOC and holistic QOL of women with and without IBS, and (b) examine the relationships among SOC, holistic QOL, and gastrointestinal (GI) and psychological distress symptoms.


Method: A two-group comparison design was used to test the study hypotheses that women with IBS would have lower SOC and holistic QOL than control women without IBS, and that SOC and holistic QOL would be inversely related to GI and psychological distress. A total of 324 women were studied (n = 235 with IBS, n = 89 controls). Measures included the 13-item SOC Questionnaire, Modified Flanagan QOL Scale, Bowel Disease Questionnaire, and Symptom-Checklist-90-R.


Results: Both SOC and holistic QOL were lower in women with IBS (p <.001). Correlations between SOC and global distress, depression, anxiety, and somatization without GI symptoms were moderately and inversely related (r = -.64, -.64, -.53, and -.31, respectively; p <.001) in the total sample. Relationships between holistic QOL and psychological distress indicators were universally of lower magnitude (r = -.56 to -.27, p <.001). The only GI symptom indicator significantly related to SOC and holistic QOL was alternating constipation and diarrhea ([tau] = -.21 and -.17, respectively; p <.001).


Discussion: Women with IBS have a reduced SOC and holistic QOL when compared to women without IBS. It remains to be determined whether interventions targeted at enhancing SOC and holistic QOL can impact the psychological distress associated with IBS.


Irritable bowel syndrome (IBS) is a chronic, functional bowel disorder characterized by abdominal discomfort or pain relieved by defecation and/or associated with a change in stool frequency or appearance (Thompson, 1999). In the United States as well as other industrialized countries, IBS predominantly affects women (American College of Gastroenterology Functional Gastrointestinal Disorders Task Force, 2002;Kay & Jorgensen, 1996), often beginning in individuals in their early adolescent or adult years. Health-related quality of life (QOL) is reduced in patients with IBS (International Foundation for Functional Gastrointestinal Disorders, 2002) possibly due to several factors including:


* the chronic and relapsing nature of IBS symptoms


* the lack of treatment strategies that are consistently effective for all symptoms


* the concurrence of other symptoms (e.g., psychological distress)



Recent surveys of women with IBS have validated the disorder impacts on multiple aspects of the individual's life. Two-thirds of persons with IBS describe their gastrointestinal (GI) symptoms as extreme or bothersome in regards to interference with daily comfort, work, or leisure activities (International Foundation for Functional Gastrointestinal Disorders, 2002). In addition, many women feel that their healthcare providers do not take their symptoms seriously or provide adequate information regarding the condition (Heitkemper et al., 2002). To date, the exact etiology of IBS remains elusive. There is neither known organic pathology nor consistently effective medical treatment for the multiple symptoms often experienced by patients with IBS (American College of Gastroenterology Functional Gastrointestinal Disorders Task Force, 2002;Brandt et al., 2002). In addition, its diagnosis remains one of exclusion (Cash, Schoenfeld, & Chey, 2002).


Psychological distress symptoms commonly reported by persons with IBS include anxiety, depression, and somatization (Jarrett et al., 1998;Whitehead, Bosmajian, Zonderman, Costa, & Shuster, 1988). Levels of anxiety and depression are significantly greater among persons with an IBS diagnosis or IBS symptoms compared to apparently healthy persons without IBS (Jarrett et al.;Jones et al., 2001;Kumar, Pfeffer, & Wingate, 1990). In addition, patients with IBS frequently report somatic complaints (Whorwell, McCallum, Creed, & Roberts, 1986) including:


* headache


* back pain


* fatigue


* poor sleep


* urinary symptoms


* dyspareunia


* bad breath/unpleasant taste in mouth


* heart palpitations


* muscle soreness and stiffness (Zaman, Chavez, Krueger, Talley, & Lembo, 2001).



Persons (50%) with comorbid somatic conditions, (e.g., fibromyalgia, chronic fatigue syndrome, temporomandibular joint disorder, chronic pelvic pain) also report having IBS (Whitehead, Palsson, & Jones, 2002).


Another factor that may contribute to the reduction in health-related QOL in patients with IBS is reduced sense of coherence (SOC). This is associated with resilience in individuals with other chronic health problems. The SOC is defined as a global orientation that expresses the extent to which one has a pervasive, enduring, though dynamic feeling of confidence that life is comprehensible, manageable, and meaningful (Antonovsky, 1987).


It is the key construct of Antonovsky's (1979; 1987) salutogenic theory, which focuses on why some persons remain healthy despite otherwise stressful conditions. The salutogenic theory and the SOC emerged from interviews of 51 Holocaust survivors who were thought to be doing well in their everyday lives. Subsequently, Antonovsky developed the 29-item SOC questionnaire (SOCQ). An expert panel assessed its content validity, and known-groups technique across Israeli, US, Canadian, and Nordic samples provided evidence of construct validity. Antonovsky posited that a strong SOC allows persons to successfully cope with life stressors. Stress has been identified as a symptom-precipitation factor for persons with IBS. Although same-day psychological distress predicted same-day GI symptom distress levels in women with an IBS diagnosis (n = 32) or IBS symptoms (n = 30), it remains unclear whether psychological distress precipitated the GI symptoms or whether the GI symptoms precipitated the psychological distress (Jarrett et al., 1998).


Strauss and colleagues (1984) and Corbin and Strauss (1988) believed that chronic illness potentially causes multiple problems of daily living for persons with the illness and their families, resulting in the need to accommodate to the demands of the illness, often on a daily basis. Within Strauss' (1984) framework, problems of living with a chronic health disturbance might include:


* predicting and controlling symptoms


* adjusting to changes in symptoms


* pursuing a diagnosis


* covering healthcare costs


* confronting attendant psychological, marital, and familial problems.



These problems are applicable to IBS as well as other chronic health conditions, such as chronic heart disease or fibromyalgia. Predicting and controlling symptoms may be especially problematic for the 25% of persons with IBS who experience alternating constipation and diarrhea (International Foundation for Functional Gastrointestinal Disorders, 2002). Each of these problems of daily living could be considered as stressors. Thus, a strong SOC might lessen the impact of the stressor on well-being, or stressors themselves might weaken SOC.


Motzer and colleagues (Dantas, Motzer, & Ciol, 2002;Motzer & Stewart, 1996) previously examined SOC in survivors of cardiac arrest and patients after coronary artery bypass graft surgery. Using Antonovsky's (1987) questionnaire, SOC was found to be higher than expected in a sample of persons (N = 149) with coronary heart disease surviving a cardiac arrest (Motzer & Stewart, 1996), but not higher than anticipated in a sample of persons (N = 84) with coronary heart disease following bypass graft surgery (Dantas et al., 2002).


To date only two studies have examined SOC in patients with IBS. Sperber and colleagues (1999) have demonstrated that SOC was lower in IBS participants (n = 54) and IBS-fibromyalgia participants (n = 25) compared to age- and sex-matched control participants (n = 72) (p <.001). No differences were found in SOC between IBS-only subjects compared to IBS-fibromyalgia subjects. The levels of SOC in Sperber's IBS group were equivalent to normative levels seen in undergraduate student groups (Antonovsky, 1987). Although Sperber's participants were matched for sex, specific sex differences in SOC were not described in their predominantly female sample (77% female IBS/fibromyalgia vs. 75% female controls). In an earlier study (Motzer, Jarrett, Heitkemper, & Tsuji, 2002), SOC was examined in a small cohort of women with IBS (n = 12) and women controls without IBS (n = 9). Although control women had higher SOC scores than IBS women, the differences were not significant, likely due to the small sample size.


Quality of life is an important variable used in descriptive, predictive, and experimental health-related research. Gill and Feinstein (1994) posited that QOL is a uniquely personal perception, and that its measurement can only be determined through patient self-report. Anderson and Burckhardt (1999) concurred, arguing for the importance of a holistic approach in evaluating QOL that specifically asks the respondent to rate satisfaction with life domains, including but not limited to the domain of health. The focus of health-related QOL assessment is narrowly defined around health and illness variables (Gill & Feinstein, 1994;Ware, 1995) such as physiological dysfunction, symptoms, and functional capacity (Anderson & Burckhardt, 1999). Although these variables are important to assess, they more aptly reflect health status and not QOL (Gill & Feinstein, 1994). Holistic QOL has not been reported in persons with IBS, but many investigators have examined disease-specific, health-related QOL (Gralnek, Hays, Kilbourne, Naliboff, & Mayer, 2000;Groll et al., 2002;Hahn, Kirchdoerfer, Fullerton, & Mayer, 1997;Hahn, Yan, & Strassels, 1999) using a variety of measures (e.g., Medical Outcomes Study Short-Form-36 [SF-36], IBS-36, and the IBS QOL Questionnaire). For example, Gralnek's group found lower self-report health-related QOL using the SF-36 (Ware & Sherbourne, 1992) in persons with IBS compared to normal controls. Those IBS participants (N = 877) were predominantly female (62%) and ranged from 19 to 84 years of age (45.6 +/- 13.4). Likewise, Hahn and colleagues (1999), also using the SF-36, found that persons with IBS (N = 630) had poorer health-related QOL than published norms. The majority of their respondents were women over the age of 45 years.


Flanagan (1982) conceptualized QOL holistically. Based on interviews with a random sample (N = 3000) of apparently healthy (30-, 50-, or 70-year-old) American men and women, Flanagan defined QOL as


* satisfaction with physical and material well being


* relations with other people


* social, community, and civic activities


* personal development and fulfillment


* recreation.



Subsequently, Flanagan developed a 15-item QOL scale from those interviews. After testing its reliability and validity in four chronic illness groups, Burckhardt, Woods, Schultz, and Ziebarth (1989) modified the definition and the scale by adding a domain of independence, or being able to do for oneself. It seems likely that accommodating to the demands of a chronic illness (e.g., predicting, controlling, and adjusting to changes in symptoms) would affect holistic QOL because the areas of life involved in this accommodation are congruent with these QOL domains.


Using the Modified Flanagan QOL scale (MQOLS) (Burckhardt et al., 1989;Flanagan, 1982), Motzer and colleagues (Dantas et al., 2002;Motzer & Stewart, 1996) examined holistic QOL in two samples of persons with chronic heart disease, and found them mostly satisfied with their QOL. For the cardiac arrest survivors, SOC contributed an additional (15%) of explained variance in QOL after social status, social support, self-esteem, and health-related variables had been entered into the model (Motzer & Stewart, 1996).


Little is known about SOC and holistic QOL in young-to-middle-aged women with IBS. It can be hypothesized that women with IBS in general have lower levels of SOC and holistic QOL relative to women without IBS, and that both SOC and holistic QOL are related inversely to symptom severity. Therefore, the purposes of this study were to:


* describe and compare SOC and holistic QOL of women 18 to 49 years of age


* examine the relationships among SOC, holistic QOL, and GI and psychological distress symptoms.



It was hypothesized that the relationships between SOC and holistic QOL with abdominal pain, global psychological distress, depression, anxiety, and somatization would be moderately strong and negative in all women.