The use of older data and references is becoming increasingly disfavored for publication. A myopic focus on newer research risks losing sight of important research questions already addressed by now-invisible older studies. This creates a 'Groundhog Day' effect as illustrated by the 1993 movie of this name in which the protagonist has to relive the same day (Groundhog Day) over and over and over within a world with no memory of it. This article examines the consequences of the recent preference for newer data and references in current publication practices and is intended to stimulate new consideration of the utility of selected older data and references for the advancement of scientific knowledge.

Examples from the literature are used to exemplify the value of older data and older references. To illustrate the recency of references published in original medical research articles in a selected sample of recent academic medical journals, original research articles were examined in recent issues in selected psychiatry, medicine, and surgery journals.

The literature examined reflected this article's initial assertion that journals are emphasizing the publication of research with newer data and more recent references.

The current valuation of newer data above older data fails to appreciate the fact that new data eventually become old, and that old data were once new. The bias demonstrated in arbitrary policies pertaining to older data and older references can be addressed by instituting comparable treatment of older and newer data and references.

This study sought to determine whether gastric symptoms are associated with later eating disorder (ED) symptoms during early adolescence, and whether this relationship is moderated by parental warmth/acceptance and/or the child's sex.

Longitudinal data from the Adolescent Brain Cognitive Development^SM Study were utilized. Participants ages 9-10 years old (N = 4,950; 2,370 female) completed measures at baseline and 1 year later (Y1). At baseline, gastric symptoms were measured by parent-reported items from the Child Behavior Checklist (CBCL), and perceived parental acceptance was measured by youth report on the Children's Report of Parent Behavior Inventory (CRPBI) Acceptance subscale separately for mothers and fathers. ED symptoms at Y1 were assessed by parent report on a computerized version of the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS). Linear mixed-effects models were conducted separately for maternal and paternal acceptance to test relationships among variables.

A three-way interaction between baseline gastric symptoms, sex, and maternal acceptance predicted Y1 ED symptoms (𝛽 = 0.08; p < .01). Post-hoc analyses revealed that the interaction between gastric symptoms and maternal acceptance was significant for girls only (𝛽 = -0.06, p < .01), such that low maternal acceptance was associated with a stronger relationship between baseline gastric symptoms and Y1 ED symptoms. No statistically significant main effects or interactions were found in the model for paternal acceptance.

Gastric symptoms and low perceived maternal acceptance may interact to result in heightened risk for EDs in young adolescent girls.

The aim of this study was to investigate the associations among depression, anxiety and physical symptoms in peri- and postmenopausal women in a clinical setting.

Two hundred and thirty-seven peri- and postmenopausal women enrolled in the Systematic Health and Nutrition Education Program at the Menopause Clinic of the Tokyo Medical and Dental University Hospital. Their responses to the Menopausal Health-Related Quality of Life (MHR-QOL) and Hospital Anxiety and Depression Scale (HADS) questionnaires were subjected to a cross-sectional analysis. The study focused on the relationship between the scores for HADS depression (HADS-D) and anxiety (HADS-A) subscales and those for somatic (nausea, dizziness, numbness, muscle and joint pains, tiredness, headaches), urinary (frequent urination), and vasomotor symptoms (hot flashes, night sweats) in the MHR-QOL questionnaire.

The correlations among the scores for the six somatic symptoms and HADS-D and HADS-A were stronger than those for urinary or vasomotor symptoms. Multiple logistic regression analysis revealed that the score for headaches and that for HADS-A were significantly associated with severe depression after adjustment (odds ratio (OR) [95% confidence interval (CI)]: 1.49 [1.06-2.10] and 1.58 [1.37-1.83], respectively), whereas the scores for nausea and numbness, as well as HADS-D, were significantly associated with severe anxiety (OR [95% CI]: 1.65 [1.15-2.39], 1.39 [1.05-1.84], and 1.36 [1.23-1.50], respectively).

Headaches were associated with depression, whereas nausea and numbness were associated with anxiety in peri- and postmenopausal women. The assessment of underlying mood disorders is required for the management of middle-aged women presenting with these somatic symptoms.

Results from general population studies suggest a relationship between gastrointestinal (GI) symptoms, depression, and anxiety. However, no primary care study has investigated this issue. This study investigates the prevalence of GI symptoms in primary care and their association with depression and anxiety.

Within a cross-sectional survey, 2091 consecutive patients from 15 primary care clinics in the United States completed self-report questionnaires regarding GI symptoms [15-item Patient Health Questionnaire (PHQ-15)], anxiety [seven-item Generalized Anxiety Disorder Scale (GAD-7)], and depression (PHQ-8). Of those, 965 randomly selected patients additionally underwent a criterion standard diagnostic telephone interview (Structured Clinical Interview for DSM-IV) for the most common anxiety disorders.

A total of 380 [18% (95% CI, 16.3% to 19.3%)] patients reported to be substantially bothered by at least one GI symptom in the previous 4 weeks. The prevalence of severe levels of depression (PHQ-8 score > or =15) was nearly fivefold in patients with GI symptoms compared to patients without GI symptoms (19.1% vs. 3.9%; P<.001), and the prevalence of severe levels of anxiety (GAD-7 score > or =15) was nearly fourfold in patients with GI symptoms compared to patients without GI symptoms (19.4% vs. 5.6%; P<.001). Similarly, with each additional GI symptom, the odds for an interview-based diagnosis of specific anxiety disorders increased significantly: For example, compared to patients with no GI symptom, the odds ratio (OR) (95% CI) for generalized anxiety disorder in patients with one GI symptom was 3.7 (2.0 to 6.9); in patients with two GI symptoms, OR=6.5 (3.1 to 13.6); and in patients with three GI symptoms, OR=7.2 (2.7 to 18.8).

GI symptoms are associated significantly with depression and anxiety in primary care. It is suggested to screen as a routine for anxiety and depression in patients with GI symptoms and, if indicated, to initiate specific treatment.

The definition of irritable bowel syndrome (IBS) by Rome criteria was a major advancement in the nosology of the disease, but this goal was achieved by employing symptoms related to the gastrointestinal tract and by eliminating all symptoms that were nonspecific. The description of the course of the illness and response to treatment has been hampered by restrictions to the defining characteristics, abdominal pain and altered bowel habit. Other abdominal symptoms (e.g., bloating, nausea, and epigastric discomfort) and general somatic symptoms (e.g., fatigue, headache, and sleep disturbance) are not included in the Rome definition, yet are commonly reported by patients with IBS. This article addresses the following questions: Are comorbid conditions part of or distinct from the syndrome of IBS and other functional gastrointestinal disorders (FGIDs)? Are there overlapping abdominal or extra-abdominal symptoms confounding the definition of IBS? Are extra-abdominal somatic symptoms and/or syndromes part of the clinical presentation of IBS? Are "nondiagnostic" abdominal symptoms important in defining symptom burden in IBS? Is the concept of somatization related to IBS, and, if so, how? How can we better define the symptom burden in IBS and other FGIDs? In short, have we hampered the evaluation of IBS (and other FGIDs) by making the definitions too reductionist? While definite answers to the above questions are not possible at this time, this article proposes that the definitions of IBS or other FGIDs not be altered, but that in the process of evaluation of the clinical end points and/or severity of the diseases, consideration be given to the possibility of including other components of the symptom burden of these disorders.

According to the psychiatric hypothesis, the symptoms of dyspepsia may be due to depression, anxiety or a somatization disorder. We investigated the frequency of psychiatric symptoms in patients undergoing endoscopic procedures with dyspepsia, either with or without pathological findings, and compared this with control subjects without dyspeptic symptoms.

Ninety patients with dyspeptic symptoms and 90 control subjects participated in the study. Both the patients and the controls were asked to complete a questionnaire about socio-demographic characteristics, the Turkish version of the Spielberger State-Trait Anxiety Inventory (STAI) and the Symptom Check List-90 (SCL-90). In order for us to determine whether the criteria for any of the conditions listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) were met, the patients were asked to take part in the Structured Clinical Interview for DSM-IV disorders.

Of the participants, 47.8% had a psychiatric disorder according to DSM-IV criteria, somatoform disorder (44.2%) being the most common. While 42.2% patients were determined to have a pathological finding using endoscopic evaluation, 57.8% had no findings. Together with the somatization and obsessive-compulsive disorder subscale scores, the total SCL-90 score and the mean trait anxiety score were statistically significantly higher in participants with no pathological findings. There were trends for anxiety (13.2% vs. 7.7%) and mood (2.6% vs. 0.0%) disorders to be more frequent in patients with pathological findings, while somatoform disorder+depressive disorder (17.3% vs. 5.2%) was more frequent in patients with no findings, although the differences were not statistically significant (Z=0.7, P>.05). The scores of state-trait anxiety, somatization, obsession-compulsion, depression, anxiety, phobic anxiety and psychotism subscales, and the total SCL-90 score were statistically significantly higher in those participants without a pathological finding than in the controls.

Regarding the high frequency of psychiatric disorders in patients with dyspeptic symptoms, we think that such patients should be evaluated by two separate departments, gastroenterology and psychiatry.

The epidemiology of gastrointestinal (GI) symptoms has been described in population surveys, yet their distribution by socio-economic (social) class remains largely uninvestigated. The aim of this study was to evaluate the influence of social class on GI symptoms in an urban sample of Australian adults.

The prevalence of 25 GI symptoms was determined by postal questionnaire. Five latent symptom groups were identified by a principal components analysis (PCA) (Esophageal, Dysmotility-like, Nausea/vomiting, Constipation and Diarrhea). These components were used to model the association between GI symptoms and adult social class. Social class was assigned according to a census-based measure of area disadvantage, and to highest level of completed education. Age- and sex-adjusted odds ratios - as identified by unconditional logistic regression - were used to describe the relationship between symptom groups and adult social class.

The effects of area disadvantage and education on Esophageal and Dysmotility-like symptoms were pronounced, with persistent trends for elevated symptom rates amongst the lower social classes (all p<0.01 on age- and sex-adjusted effects). When defined by area disadvantage, the odds ratios for Nausea/vomiting were significantly elevated among the lowest social class group (p=0.01), whereas the odds for Constipation were significantly elevated among the upper-middle social class when defined by education (p=0.001). Diarrhea was not associated with social class whether defined by area disadvantage or education.

Low social class is a risk factor for upper GI complaints.

Clinical reports have shown that irritable bowel syndrome (IBS) is comorbid with anxiety/depression and stress-related events, and that the disorder is more prevalent among women than among men. In rodents, colorectal distention (CRD) induces abdominal contractions, and this visceromotor response is used to assess visceral pain. The activation of brain corticotropin-releasing factor (CRF) pathways has a key role in the behavioral and visceral responses to stress.

In this review of experimental studies that delineate the underlying mechanisms of the stress response, we focused on CRF signaling pathways and sex hormones in modulating visceral hypersensitivity induced by CRD in rodents.

The findings of our recent research on the development of an experimental model of visceral pain in female rats and the modulation of the hyperalgesic response to CRD by CRF antagonists were integrated with those of the published literature. A MEDLINE search of the years 1981 to 2005 was conducted using the key words stress, CRF, CRH, CRF1 receptor, IBS, CRD, female rat, visceral pain, estrogen, and anxiety.

CRF and other related mammalian peptides (urocortins) interact with the distinct CRF subtype 1 and 2 receptors. Well-documented preclinical studies have established the role of brain CRF1 receptors in mediating stress-related anxiogenic and visceral (stimulation of colonic motor function and sensitization to repeated CRD) responses in male rodents, whereas more limited studies have been performed in female rats. Our recent study indicated that the CRF1 antagonist antalarmin prevents visceral hypersensitivity induced by 2 sets of CRD in female rats. In several models of visceral pain induced by CRD, sex differences and a sensitization action of estrogen were reported. Our preliminary evidence indicated a potentiating interaction between CRF-CRF1 pathways and estrogen in the stimulation of colonic motor responses that may take place within the enteric neurons of the colon, where both CRF1 and estrogen receptors are present.

The results of this review suggest that overactivity of CRF1 signaling in the brain and the gut may have relevance in understanding the comorbidity of anxiety/depression and IBS in diarrhea-predominant female patients. Targeting these mechanisms with CRF1 antagonists may provide a novel therapeutic strategy.

Irritable bowel syndrome (IBS) is associated with psychological stress, alterations in gut motor function and/or visceral perception. Previous studies suggest 7-32% of people develop IBS after bacterial gastroenteritis but the exact mechanisms underlying post-infectious IBS are not clear. The present study's aim was to examine the role of possible causative factors in the development of post-infectious functional gastro-intestinal disorders (FGIDs), including IBS.

A prospective cohort study where 122 people without a prior FGID under study and with stool-positive bacterial gastroenteritis consented to participate. The presence or not of IBS, functional dyspepsia or functional diarrhoea was diagnosed at the start and on 6-month follow-up using self-complete Rome II modular questionnaires. Demographic data, smoking, alcohol use, anxiety and depression (using the Hospital Anxiety and Depression Scale), and life events and impact (using the Life Events Survey) were collected at the start of the study.

One hundred and seven questionnaires were returned with 25 participants (23.4%) developing a FGID and 16 participants presenting symptoms consistent with IBS (15%). Smoking was significantly associated with the development of a post-infectious FGID (odds ratio = 4.8, 95% confidence interval = 1.5-15.2) on regression analysis.

Post-infectious FGIDs appear to be associated with smoking. Smoking is known to moderate gut immunity in other disorders such as ulcerative colitis and Crohn's disease. This study adds to increasing evidence for an organic basis to post-infectious FGIDs, perhaps moderated via inflammatory pathways.

The diagnosis of functional abdominal pain should be made based on the Rome II symptom criteria with only limited testing to exclude other disease. During physical examination the clinician may look for evidence of pain behavior which would be supportive of the diagnosis. Reassurance and proper education regarding the clinical entity of functional abdominal pain is critical for successful treatment and good patient satisfaction. Education should include validation that symptoms are real, and that other individuals experience similar symptoms. No further treatment may be required for those with mild symptoms. For patients with more severe symptoms, a long-term management plan of either pharmacological or psychological treatments is warranted. This will require a commitment by both the patient and the physician to engage in a partnership with active involvement and responsibility by both individuals. The goal of treatment--to decrease pain and increase function over time, not to cure the disorder-- should be explained. Strong consideration should be made for the use of an antidepressant to treat analgesic effects. Tricyclic antidepressants are the mainstay of therapy for functional pain disorders. The analgesic effect is generally quicker in onset and occurs at a lower dose than their effect on mood. To maximize patient compliance, patients should be told the rationale behind their use, warned of the potential side effects, and reassured that many of the side effects will disappear with time. Choice of an antidepressant should be based on the presence of concomitant symptoms (eg, depression), cost, and physician familiarity with specific agents. All patients with functional abdominal pain should be screened for underlying psychiatric disturbance as an untreated mood disorder will adversely affect response to treatment. If a concurrent mood disorder is found, it should be treated by either using a higher dose of the tricyclic antidepressant or by adding another antidepressant agent. Psychological interventions such as cognitive behavioral therapy may be important as adjuvant therapy or as an alternative to treatment with antidepressants for those patients who find antidepressants ineffective or are intolerant to them. Narcotics and benzodiazepines should not be used to treat chronic abdominal pain due to the high risk of physical and psychological dependence.

1. The characterization of corticotropin releasing factor (CRF) and, more recently, the discovery of additional CRF-related ligands, urocortin 1, urocortin 2 and urocortin 3, the cloning of two distinct CRF receptor subtypes, 1 (CRF(1)) and 2 (CRF(2)), and the development of selective CRF receptor antagonists provided new insight to unravel the mechanisms of stress. Activation of brain CRF(1) receptor signaling pathways is implicated in stress-related endocrine response and the development of anxiety-like behaviors. 2. Compelling evidence in rodents showed also that both central and peripheral injection of CRF and urocortin 1 mimic acute stress-induced colonic response (stimulation of motility, transit, defecation, mucus and watery secretion, increased ionic permeability and occurrence of diarrhea) in rodents. Central CRF enhances colorectal distention-induced visceral pain in rats. Peripheral CRF reduced pain threshold to colonic distention and increased colonic motility in humans. 3. Nonselective CRF(1)/CRF(2) antagonists and selective CRF(1) antagonists inhibit exogenous (central or peripheral) CRF- and acute stress-induced activation of colonic myenteric neurons, stimulation of colonic motor function and visceral hyperalgesia while selective CRF(2) antagonists have no effect. None of the CRF antagonists influence basal or postprandial colonic function in nonstressed animals. 4. These findings implicate CRF(1) receptors in stress-related stimulation of colonic function and hypersensitivity to colorectal distention. Targeting CRF(1)-dependent pathways may have potential benefit against stress or anxiety-/depression-related functional bowel disorders.

Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) are intestinal diseases perceived differently by patients and doctors: the former is considered essentially as an 'organic' disease (i.e. an illness in which the role of stress or psychological factors is at best secondary to the disease itself), whereas the latter is acknowledged as a 'functional' disorder (i.e. illness thought to be more in the 'mind' than in the body of the patient). Accordingly, the respective impact of the two diseases on patients' health-related quality of life (HRQOL) is perceived to be very different. We aimed to compare the relative impact of the disease on HRQOL, psychological profile and perceived burden of stressful life events in two groups of outpatients suffering from IBS and IBD and attending our outpatient department at an Italian university hospital. Eighty patients with IBD (26 with ulcerative colitis and 54 with Crohn disease) and 85 controls with IBS formed the patient samples of the study.

Three questionnaires were given to the patients while they were attending the outpatient department because of their previously diagnosed disease, namely the SF-36 (a generic well-validated tool for measuring HRQOL), the SCL-90 (for assessing the psychological profile of patients), and the Holmes & Rahe schedule (for the assessment of stressful life experiences). The results were then compared by means of analysis of variance (ANOVA) and Bonferroni-adjusted t test, when appropriate.

HRQOL appeared to be similarly reduced in both disease groups (SF-36 overall mean value: 58.2 +/- 16.1 in IBS patients versus 56.4 +/- 22.3 in IBD patients: P > 0.05) in comparison with normative Italian data. Furthermore, the overall severity of psychological symptoms was not statistically different between patients suffering from IBD versus IBS, as shown by SCL-90 mean scores of 0.89 + 0.45 versus 0.83 +/- 0.48, respectively (P > 0.05). On the contrary, the severity of recent stressful life experiences was perceived to be higher by IBS than by IBD patients (mean SRE score: 110.8 = 110.2 versus 61.6 +/- 78.8; P < 0.05).

Our study supports the notion that, at least in referral centres, patients with IBS show health-related quality of life, psychological distress and recent occurrence of stressful life events of severity at least comparable with age-matched IBD patients.

It is unclear if there is a causal link between psychiatric disorders and unexplained chronic gastrointestinal (GI) symptomatology. The role of personality is also in dispute. We aimed to assess the association of these factors with functional GI symptoms in a birth cohort study.

The Dunedin birth cohort is well characterised and has been followed-up prospectively to age 26 (n=980). Measured were upper and lower GI symptoms over the prior year at age 26 using a validated questionnaire, psychiatric diagnoses at ages 18 and 21 by standardised interview applying DSM-III-R criteria, and personality at age 18 using the Multidimensional Personality Questionnaire (MPQ). Natural symptom groupings were identified using factor analysis and k-means clustering. The association of these clusters and psychiatric diagnoses or personality was assessed by logistic regression.

The k-means analysis produced a six-cluster solution, which was made up of a health group, and five "disease" clusters defined by higher than average scores on a single symptom. A diagnosis of depression at age 18 or 21 years was associated with increases in the odds of 1.69 (95% CI: 1.27-2.25) for all GI, of 2.16 (95% CI: 1.12-4.16) for dysmotility and of 2.07 (95% CI: 1.13-3.80) for constipation, but not with the other clusters. Similar results were observed with respect to anxiety disorders for the odds of GI overall (OR=1.42, 95% CI: 1.01-1.99) and constipation (OR=2.11, 95% CI: 1.17-3.79). The personality subscales were not strongly linked; membership of "any" diseased cluster was associated with a reduced odds of being in the fourth quartile for the well-being scale (OR=0.64, 95% CI: 0.46-0.88) but increased odds of being in the fourth quartile for the social potency scale (OR=1.64, 95% CI: 1.18-2.28).

In a young adult community sample, unexplained GI symptoms appear to be linked to psychiatric disorders but personality differences were minimal.

Functional GI disorders (FGIDs) are common in clinical practice, but little is known about the epidemiology of these disorders in the general population. We aimed to determine the prevalence, association with psychological morbidity, and health care seeking behavior of FGIDs in the population.

A random sample of subjects (n = 4500) aged > or = 18 yr and representative of the Australian population were mailed a validated questionnaire. For these subjects we measured all Rome I GI symptoms and physician visits over the past 12 months, as well as neuroticism, anxiety, depression, and somatic distress.

The response rate for the study was 72%. The prevalence of any FGID was 34.6%, and 62.1% of these subjects had consulted a physician. There was considerable overlap of the FGIDs (19.2% had more than two disorders). Independent predictors for an FGID diagnosis were neuroticism, somatic distress, anxiety, bowel habit disturbance, abdominal pain frequency, and increasing age. However, psychological morbidity did not independently discriminate between consulters and nonconsulters with an FGID.

More than one third of the general population have one or more FGIDs. There seems to be a modest link between psychological morbidity and FGIDs, although other unknown factors seem to be more important in explaining health care seeking for these disorders.

The treatment of patients with irritable bowel syndrome (IBS) is a difficult task, as the results from therapy with pharmacologic agents have been disappointing. Psychologic treatments, in particular cognitive behavior therapy, hypnotherapy, and dynamic psychotherapy have all shown to be effective in the treatment of patients with IBS. Underpinning all these treatments is a clear understanding of a biopsychosocial model of interaction between emotion and gut function in IBS. These psychologic therapies are intended to break the negative feedback loop between emotion and gut function in order to reduce symptoms. Attention to the psychologic issues underlying IBS helps reduce psychosocial factors that maintain the presence of symptoms and inappropriate health-care seeking behavior. There are a number of common elements in the psychologic approaches that can be used in routine clinical practice; these include a detailed assessment, psychoeducation, support, and reassurance.

Health care use is a costly outcome of the irritable bowel syndrome (IBS) and nonulcer dyspepsia (NUD), but the predictors of this behavior remain poorly defined. We aimed to systematically review the literature to determine which symptoms and psychosocial factors drive health care seeking in these disorders.

A broad based MEDLINE and Current Contents search between 1966 and 2000 identified 44 relevant publications. References from these articles were also reviewed.

The literature suggests that symptom severity is an important factor, but only explains a small proportion of the health care seeking behavior associated with these disorders in population-based studies. Psychosocial factors including life event stress, psychological morbidity, personality, abuse and abnormal illness attitudes and beliefs have been found to characterize those that seek help versus those that do not. The role of other psychosocial factors such as social support, coping style and knowledge about illness are as yet undetermined.

A model for health care seeking for IBS and NUD, with an emphasis on psychosocial factors is presented, but remains to be tested.

Psychiatric morbidity is high among patients who present to referral centers with irritable bowel syndrome (IBS). However, few studies have investigated the relationship between psychiatric disturbance and IBS in community samples. We hypothesized that psychiatric disorders are linked to IBS in the general community, but this is influenced by the criteria used to establish a diagnosis of IBS.

The data were collected from a birth cohort born in Dunedin (New Zealand) between April 1972 and March 1973. This cohort consisted of 1037 members (52% male), who were assessed at ages 3, 5, 7, 9, 11, 13, 15, 18, 21, and 26 yr. GI symptoms were recorded at age 26 yr, using an abbreviated version of the Bowel Symptom Questionnaire; psychiatric history was obtained at ages 18 and 21 yr, using a modified version of the Diagnostic Interview Schedule.

The prevalence of IBS was 12.7% according to the Manning criteria and 4.3% according to the Rome II criteria. The IBS was not significantly related to a diagnostic history for psychiatric illness overall, nor to a history of anxiety disorders, depressive disorders, and substance dependence. These results were independent of the IBS criteria used; there was no association between psychiatric history and IBS when IBS was defined according to the Manning criteria (p = 0.11 to 0.98) or the Rome criteria (p = 0.18 to 0.92): Rome and Manning criteria subjects did not significantly differ from each other in terms of psychiatric history (p = 0.16 to 0.89).

In a cohort of young adults with IBS from New Zealand, IBS appears to not be related to psychiatric disorders.

To examine a group of patients satisfying criteria for "frequent attending" as part of an audit of an outpatient gastroenterology service, and to note the prevalence of those with no conspicuous organic disease to account for their symptomatology.

We used the hospital computer (Oxford Patient Administration System, OXPAS) to identify 2530 consecutive patients who were given an appointment to attend the gastroenterology clinic during an 11-month period. Patients designated "frequent attenders" had their notes flagged before the clinic attendance and were examined in more detail. A frequent attender was defined as a patient who had attended any hospital outpatient clinic in the three Oxford general hospitals on four or more occasions in the previous 12 months. The gastroenterologist then interviewed the patients satisfying these criteria and indicated whether he/she was satisfied that there was no relevant organic disease to account for the symptoms.

Of the total 2530 patients, 762 (30%) satisfied our criteria for frequent attendance (FA). Of these, 452 (59%) had organic disease, 128 (17%) either did not attend or cancelled and 159 (21%) had no relevant organic disease. The diagnosis was uncertain in 23 patients (3%). Of patients satisfying our criteria for frequent attending, approximately 20-25% had no established gastroenterological disease.

Frequent attenders present formidable management problems for the gastroenterologist. If they can be identified by computer before the outpatient visit then assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff.

There has been an explosion in understanding of the psychosocial concomitants of functional gastrointestinal disorders. Detecting psychologic disturbance and eliciting a history of physical or sexual abuse are critical in suggesting comprehensive and efficacious treatment strategies for these patients. The challenge is to define further the use of psychopharmacologic agents, including the newer antidepressants, anticonvulsants, and anxiolytic agents, in the treatment of chronic functional gastrointestinal disorders. Further research to evaluate the usefulness of various forms of psychotherapeutic and behavioral interventions needs to be undertaken. Establishing a multicomponent treatment program delivered by a team of caregivers, each bringing their unique skills (internist, psychiatrist, psychologist, and others) to patients, must be based on further research on the efficacy of these modalities as opposed to empiric treatment.

The prevalence of irritable bowel syndrome (IBS) in psychiatric practice was studied in 41 consecutive psychiatric outpatients. Different criteria for IBS were applied to the data set to determine the effects on the rates of IBS obtained. Depending on an option in the Rome criteria, IBS rates varied from 13% using the "and" requirement for combining abdominal pain and altered bowel function symptoms, to 41% using the "and/or" option described in the formal definition statement in 1990. The resultant prevalence rates of IBS varied greatly according to which published criteria were applied, with a maximum of 71%. This wide variation in rates depending on the criteria underscores the critical importance of standardizing diagnostic research criteria for IBS. An exemplary model of empirically based validation has been developed for psychiatric disorder criteria which, like IBS, are symptom-based and lack physiological determinants. Validated diagnostic criteria for IBS await similar study.

Anecdotally, functional bowel disorders (FBD) such as the irritable bowel syndrome appears to cluster in some families, but no studies have investigated the heritability of FBD. We aimed to investigate the influence of heritable factors in FBD.

Same sex twin pairs enrolled in the Australian Twin Registry completed a structured interview that included questions related to symptoms consistent with FBD: abdominal pain, diarrhea, constipation, excessive gas or bloating, and nausea. Reasons for the occurrence of each symptom, including their physicians' diagnoses, were recorded. Lisrel 7.16 software was used to fit genetic models following standard procedures.

Of the 686 individual twins from same-sex pairs, 33 (4.8%) had one or more symptoms diagnosed by a medical practitioner as functional bowel disorder. Complete data on this symptom scale was available for 186 monozygotic and 157 same sex dizygotic twin pairs. A model in which 56.9% (95% CI: 40.6-75.9%) of the variance was attributed to additive genetic variance, with the remaining 43.1% attributed to the individual's unique environment, closely fitted the data (chi2=0.01, df=4, p=1.0).

Our results suggest that a substantial proportion of the liability for FBD may be under genetic control. Whether this liability is related to the disorder itself or to other potential predisposing factors requires clarification.