功能性消化不良依據羅馬三準則不同次分類的精神病理與人格特質

Abstract

研究背景: 功能性消化不良(functional dyspepsia)是一個異質性很高的症狀綜合體(heterogeneous symptom complex)，而非同質的單一疾病(homogeneous disease)。功能性消化不良診斷主要依據慢性的或反覆性的，源自於上腸胃道(胃，十二指腸)的症狀，並且常規的檢查不能發現可解釋症狀的器質病灶(organic lesions)。由於是臨床上很常見的問題，功能性消化不良對患者個人的生活品質以及整個社會在健康照護上的支出，皆有很大影響。有鑑於高度的異質性，目前的診療準則(羅馬III準則，Rome III criteria) 提議以更專一的疾病診斷來取代功能性消化不良:羅馬III準則將功能性消化不良作進一步次分類，因而定義兩個症候群: 功能性上腹痛症候群(epigastric pain syndrome)和餐後不適症候群(postprandial distress syndrome)。以往的研究發現功能性消化不良和精神病理壓力與人格特質有關聯，但是尚未有研究去探討不同次分類的消化不良是否具有不同的精神病理壓力或人格特質。 研究目的: 比較功能性消化不良不同次分類的病人，其精神病理壓力與人格特質是否不同 研究方法: 這是單一中心的橫斷面研究。自2008年4月至2008年12月，我們以羅馬III準則來評估所有因上腹部症狀而到羅東博愛醫院腸胃科門診的病人，收案病患必須填寫羅馬III準則的標準診斷問卷，以確認症狀符合功能性消化不良的定義，而且必須接受上消化道內視鏡檢查，以確認沒有引起症狀的器質性病灶。納入收案者經由面談，以簡式症狀量表(Brief Symptoms Rating Scale)來評量九個面向的精神病理壓力，以蒙氏人格量表(Maudsley Personality Inventory)來衡量三個面向的人格特質。我們比較功能性消化不良不同次分類在精神病理各面向與人格特質上是否有差異，並且以多元線性回歸分析來探討功能性消化不良的次分類診斷是否和精神病理壓力有獨立相關性。 研究結果: 一共215位病人符合羅馬III準則對功能性消化不良的診斷標準。排除21位不願參與研究與7位未能完成所有評估者，共187位病人納入分析(72.2%為女性，平均42.6歲)；其中157位(84%)可診斷為功能性上腹痛症候群，而94位(50.3%)可診斷為餐後不適症候群，因此有64位病人(34.2%)在次分類診斷上是重疊的(同時符合功能性上腹痛症群和餐後不適症後群)。同時符合兩個次分類診斷的病人，比起只符合其中一種次分類診斷的病人，具有更嚴重的精神病理壓力。多元線性回歸分析則顯示餐後不適症候群和整體精神病理壓力有獨立相關性，特別是在身體化症狀(somatization; p=0.034)，憂鬱(depression; p=0.028)，恐懼(phobia; p=0.044)，和附加症狀(additional symptoms; p<0.001)等面向上，餐後不適症候群是獨立危險因子。反之，功能性上腹痛症候群和精神病理並無顯著相關。人格特質方面，雖然單變數分析發現餐後不適症候群的病人有較高的神經質傾向(neuroticism)，但是多元回歸分析顯示這個關聯未達顯著水準 (p=0.136)。 結論: 依據羅馬III準則對功能性消化不良的定義與分類，兩個次分類的病人有相當程度的重疊。這些同時符合兩個次分類診斷的病人，比不重疊的病人有更嚴重的精神病理壓力。餐後不適症後群作為次分類診斷和精神病理壓力具有獨立相關性。

Background: Functional dyspepsia is a heterogeneous symptom complex, of which diagnosis is based on chronic or recurrent symptoms thought to originate in gastroduodenal region without organic lesions shown on routine diagnostic examinations. It is a common clinical disorder associated with significant impact on quality of life and cost of health care. Because of heterogeneity of functional dyspepsia, Rome III criteria proposed to replace functional dyspepsia by more specific disorders, namely epigastric pain syndrome and postprandial distress syndrome. Although previous studies have revealed that functional dyspepsia is associated with psychopathological factors and personality, the association is heterogeneous among FD patients, reflecting their diverse underlying pathophysiological mechanisms. It remains uninvestigated whether psychopathology and personality trait differ in the subgroups of FD defined by Rome III criteria Aims: The aim of this study was to explore the association of psychopathology and personality trait in subgroups of FD based on the Rome III criteria. Methods: This was a cross-sectional single-center study. Between April 2008 and December 2008, consecutive dyspeptic outpatients were evaluated with standard Rome III diagnostic questionnaire. All patients underwent upper gastrointestinal endoscopy to exclude organic diseases. Those fulfilling Rome III criteria of functional dyspepsia were interviewed and evaluated by the brief symptom rating scale for severity of psychopathology, and the short form Maudsley personality inventory for personality trait. Differences of psychopathological distress and personality traits are compared between patients divided by the diagnosis of each Rome III subgroup. Multiple linear regression models were built for each psychopathological dimension and personality trait to assess the independent association with each subclass diagnosis of functional dyspepsia. Results: A total of 215 patients fulfilled Rome III criteria for functional dyspepsia. After excluding 21 patients who did not consent to participate and 7 patients who did not complete psychiatric evaluation, we analyzed 187 patients (72.2% female, mean age 42.6 years old). There was an overlap (n=64, 34.2%) between the patients diagnosed with epigastric pain syndrome (n=157, 84.0%) and those with postprandial distress syndrome (n=94, 50.3%). Patients with compatible symptoms of both syndromes were psychopathologically more severe than either subgroup without overlapping. Multiple linear regression analysis demonstrated that the diagnosis of postprandial distress syndrome was independently associated with higher scores in overall psychopathological stress, and specifically in somatization (p=0.034), depression (p=0.028), phobia (p=0.044), and additional symptoms (p<0.001). However, epigastric pain syndrome was not associated with psychopathology. Postprandial distress was univariately associated with neuroticism, but the association was insignificant in the multivariate analysis (p=0.136). Conclusions: Rome III subgroups of functional dyspepsia significantly overlap. Patients fulfilling criteria for both subgroups were psychopathologically more severe than those without overlapping. Diagnosis of postprandial distress syndrome, but not epigastric pain syndrome, is independently associated with psychopathological factors.