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Psychiatric comorbidities in women with Celiac Disease

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Although the physical consequences of Celiac Disease are well studied, less is known about co-occurring psychiatric symptoms. This study examines psychiatric risk and comorbidities of women with Celiac Disease, who may be at increased risk for psychiatric symptoms (e.g. depression, and disordered eating behaviours). Women (N = 177) with Celiac Disease responded to an extensive web-mediated survey assessing dietary compliance, illness symptoms, psychiatric functioning, and disordered eating. Despite high reported dietary compliance, patients reported marked illness symptoms and impaired quality of life. A substantial minority endorsed symptoms that met criteria for the diagnosis of psychiatric disorders: 37% (n = 65) met the threshold suggesting depression, and 22% (n = 39) for disordered eating. Participants whose symptoms exceeded these clinical thresholds reported greater perceived stress and reduced overall mental health, relative to women below the clinical cutoffs. Despite largely adhering to a gluten-free diet, a substantial subset of women with Celiac Disease report clinically relevant symptoms of depression and disordered eating; such symptoms are associated with increased psychosocial distress in other domains. These results suggest potential to improve the patient well-being through attention to psychosocial care, in addition to existing dietary recommendations for individuals with Celiac Disease.
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Chronic Illness
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DOI: 10.1177/1742395311417639
2012 8: 45 originally published online 20 September 2011Chronic Illness
Danielle Arigo, Alicia M Anskis and Joshua M Smyth
Psychiatric comorbidities in women with Celiac Disease
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Article
Psychiatric comorbidities
in women with Celiac Disease
Danielle Arigo,
1
Alicia M Anskis
2
and
Joshua M Smyth
3
Abstract
Objective: Although the physical consequences of Celiac Disease are well studied, less is known
about co-occurring psychiatric symptoms. This study examines psychiatric risk and comorbidities
of women with Celiac Disease, who may be at increased risk for psychiatric symptoms (e.g.
depression, and disordered eating behaviours).
Methods: Women (N¼177) with Celiac Disease responded to an extensive web-mediated survey
assessing dietary compliance, illness symptoms, psychiatric functioning, and disordered eating.
Results: Despite high reported dietary compliance, patients reported marked illness symptoms and
impaired quality of life. A substantial minority endorsed symptoms that met criteria for the diagnosis
of psychiatric disorders: 37% (n¼65) met the threshold suggesting depression, and 22% (n¼39) for
disordered eating. Participants whose symptoms exceeded these clinical thresholds reported greater
perceived stress and reduced overall mental health, relative to women below the clinical cutoffs.
Conclusions: Despite largely adhering to a gluten-free diet, a substantial subset of women with
Celiac Disease report clinically relevant symptoms of depression and disordered eating; such
symptoms are associated with increased psychosocial distress in other domains. These results
suggest potential to improve the patient well-being through attention to psychosocial care, in
addition to existing dietary recommendations for individuals with Celiac Disease.
Keywords
Celiac Disease, eating disorders, depression, gastrointestinal disorders, quality of life
Received 9 June 2011; accepted 28 June 2011
Introduction
Celiac Disease represents a growing but
understudied autoimmune disorder that is
associated with a variety of short- and long-
term physical symptoms. Clinical recom-
mendations for patients with Celiac Disease
focus on avoiding the ingestion of gluten
1
to
prevent inflammation in the small intestine
and consequent symptoms. As gluten is
found in wheat, rye, barley, and other
common foods; however, individuals with
Celiac Disease often find it challenging to
Chronic Illness
8(1) 45–55
!The Author(s) 2011
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DOI: 10.1177/1742395311417639
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1
Department of Psychology, Syracuse University, Syracuse,
NY, USA
2
Department of Biology, Drexel University, Philadelphia,
PA, USA
3
Department of Biobehavioral Health, Pennsylvania State
University, University Park, PA, USA
Corresponding author:
Joshua M Smyth, Department of Biobehavioral Health, 315
Health and Human Development East, University Park, PA
16802, USA
Email: jms1187@psu.edu
avert immediate symptoms.
2
Further, many
patients suffer uncomfortable gastrointesti-
nal symptoms even when adhering to a
gluten-free diet.
3
Such experiences can dis-
rupt patients’ daily physical, emotional, and
social functioning, which can lead to psy-
chiatric distress that further impedes illness
management.
4
Previous reports show that Celiac
patients’ quality of life in various mental
health domains is somewhat lower than that
of healthy individuals in the general popu-
lation.
3,5,6
Quality of life is particularly low
among women with Celiac Disease;
7,8
spe-
cifically, women report more difficulty in
managing feelings of deprivation associated
with a gluten-free diet, and greater desire to
control the preparation of the food they eat,
than do men with the disorder.
9
Intense
focus on food intake is necessary to control
symptoms of Celiac Disease, but may give
rise to excessive concern with other aspects
of consumption (e.g. overall calorie count)
that is characteristic of eating disorders
such as anorexia or bulimia nervosa. A
growing body of literature links Celiac
Disease to the onset of clinically relevant
eating disorders, which carry high risk for
medical complications and, potentially,
early death.
10
Existing work on the association between
Celiac Disease and eating disorders has pri-
marily focused on reviewing case reports.
11–13
One exception is Karwautz et al.’s
14
examination of eating pathology among
adolescents with Celiac Disease. This study
found rates of disordered eating among
Celiac patients (16% of their sample) that
were substantially higher than estimates
for the general population (1% in
Western countries
15,16
). Karwautz et al.
14
also found eating disorders only among
women, and the onset of disordered eating
typically followed (rather than preceded) the
diagnosis of Celiac Disease. Ongoing exam-
ination of this possible comorbidity in
large samples of women with Celiac Disease
could increase practitioners’ awareness of
problematic behavioural and emotional
responses to disease management (i.e. exces-
sive restriction in range of intake). Including
adult women in such investigations is increas-
ingly important, as many women now
develop disordered eating symptoms at later
ages.
15
In addition, previous studies of qual-
ity of life and emotional functioning
among women Celiac Disease have typically
focused on Europeans. This trend highlights
a contrast between the rising prevalence of
Celiac Disease in the United States and the
scarcity of empirical literature on American
patients’ well-being. The overarching goal of
this study was to gather preliminary descrip-
tive information about the psychiatric func-
tioning of American women with Celiac
Disease across a wide variety of domains.
These domains included depressive symp-
toms, perceived stress, and health-related
quality of life, with a particular focus on
body image concerns and disordered eating
symptoms.
Our first aim was to determine average
levels of psychiatric functioning in a
sample of American women with Celiac
Disease. We predicted that individuals with
Celiac Disease would demonstrate elevated
depressive symptoms, perceived stress, dis-
ordered eating symptoms, and interference
with everyday activities (resulting in low
quality of life), relative to available norma-
tive information for the measures used.
Second, we aimed to identify associations
between various psychiatric symptoms (e.g.
depression and perceived stress), and
between physical and psychiatric symptoms,
with a focus on disordered eating thoughts
and behaviours. We predicted that higher
reported psychiatric symptoms would be
associated with decreased dietary compli-
ance, increased illness severity, and
decreased physical and emotional quality
of life. We also expected higher reported
disordered eating symptoms to be associated
46 Chronic Illness 8(1)
with lower physical and emotional quality of
life, more depressive symptoms, and higher
perceived stress.
Method
Female residents of the United States who
were over the age of 18 and reported a
physician-provided diagnosis of Celiac
Disease were eligible to participate in this
study. Participants were recruited using
three methods: (1) through contact persons
for local and national Celiac Disease orga-
nizations, (2) through support networks
found on social networking websites, and
(3) through online newsletters distributed by
the supporting institution. Interested indi-
viduals were directed to an anonymous web-
mediated survey that consisted of several
questionnaires, described below. All data
collection took place between January and
April of 2008. Respondents (N¼177) were
mostly Caucasian (98%), married (56%),
and high-school educated (75%); mean age
for the sample was 39.24 years. The demo-
graphic profile of the present sample appears
largely reflective of the population of indi-
viduals with Celiac Disease.
3,17,18
Data col-
lection used the following measures to assess
a range of physical, behavioural, and emo-
tional experiences; all measures were chosen
based on their previously demonstrated
ability to briefly and reliably capture each
domain of functioning.
Dietary Compliance Scale
A brief, five-item questionnaire that deter-
mines a respondent’s level of adherence to a
gluten-free diet.
19
Responses to items such
as ‘When I feel well I sometimes discontinue
my diet’ are given as either ‘yes’ or ‘no’. For
the purpose of this study, ‘yes’ responses
were given values of 1 and ‘no’ responses
given values of 0; one item was reverse-
scored (‘I never forget about my diet’), so
that higher scores on this measure would
reflect increased gluten-free diet adherence.
The Kuder––Richardson reliability estimate
for the present sample was 0.65.
Celiac Disease Symptom Questionnaire
This 19-item inventory assesses various
symptoms of Celiac Disease under four
symptom groupings: gastrointestinal (e.g.
abdominal bloating), emotional (e.g. happi-
ness), worry (e.g. worried or anxious due to
the disease), and social (e.g. avoiding eating
at certain events).
20
Items are worded to
determine the frequency of each symptom.
Responses range from 1 (‘of the time’) to 7
(‘of the time’); higher total and subscale
scores indicate more frequent symptoms.
The overall scale and subscales demonstrate
high internal consistency (Cronbach’s alpha
ranging from 0.80 to 0.90) and adequate
discriminant validity when compared to
more general measures of physical and emo-
tional health (e.g. Short-Form Health
Survey
21
physical functioning subscale,
r¼0.34; emotional role subscale, r¼0.49).
Cronbach’s alpha for this study was 0.93.
Short-Form Health Survey
A 36-item inventory that assesses the degree
to which physical symptoms interfere with
functioning in multiple domains of physical
and mental health.
21
Interference with indi-
vidual activities is rated as occurring
between ‘none of the time’ and ‘all of the
time’ during the past 4 weeks. Estimates of
internal consistency and test-retest reliabil-
ity range from 0.70 to 0.95 across samples.
In this study, Cronbach’s alphas for the
Physical and Mental Health subscales were
0.84 and 0.64, respectively.
Perceived Stress Scale
An 11-item scale with response options rang-
ing from 0 (‘never’) to 4 (‘very often’), captur-
ing respondents’ experience and management
Arigo et al. 47
of stressful situations.
22
The PSS shows ade-
quate reliability (¼0.84–0.86) and reason-
able overlap with the College Student Life
Event Scale (r¼0.20–0.38) and with ratings of
theimpactoflifeevents(r¼0.20–0.49) across
multiple samples. Cronbach’s alpha was 0.90
in the present sample.
Center for Disease Studies—Depression
Scale
This measure lists 20 symptoms of clinical
depression, asking respondents to rate how
intensely they are currently experiencing
each feeling or behaviour; responses are
rated from ‘not at all’ to ‘very much’.
23
Previous estimates of reliability were 0.85 in
healthy individuals and 0.90 among patients
with clinical depression; in patient samples,
there has been moderate overlap with other
measures of depressive symptoms prior to
treatment (e.g. r¼0.44 with the Hamilton
clinician rating scale
24
).
Eating Disorders Examination
Questionnaire
This 29-item measure asks participants to
report on the frequency of thoughts and
behaviours associated with eating and body
image, with a time frame of the past 28 days.
25
Items are rated from ‘not at all’ to ‘every day’,
andresponsesarescoredonsubscalesthat
include shape concern, weight concern, eating
concern, and restraint. These subscales have
previously demonstrated good reliability:
26
¼0.81 (eating concern), ¼0.93 (shape
concern), ¼0.89 (weight concern), and
¼0.85 (restraint). Cronbach’s alpha coeffi-
cients for this study were 0.93 (total score),
0.78 (restraint), 0.83 (eating concern), 0.89
(shape concern), and 0.78 (weight concern).
Results
A sample size of at least 175 would allow us
adequate statistical power to detect modest
correlations (i.e. power of 0.8 for r¼0.20).
Two hundred women started the survey and
provided at least some data. Of this total
number, 23 women were excluded prior to
analyses due to insufficient data (i.e. missing
>80% of the items included; these women
started, but did not complete the survey),
leaving a final sample of 177 women. A
majority of these women (n¼108) indicated
that they received ongoing professional care
(from primary care physicians, gastroenter-
ologists, gynaecologists, psychiatrists, or
nutritionists/dieticians) to help manage
their symptoms of Celiac Disease or related
conditions (e.g. vitamin deficiencies and
menstrual irregularities).
Our first goal was to characterize the
reported physical and psychiatric function-
ing of women with Celiac Disease by exam-
ining averages on each descriptive scale.
Participants reported a high average level
of dietary compliance (mean [M]¼4.47 of a
possible 5 on the Dietary Compliance Scale),
indicating that most participants frequently
adhere to a gluten-free diet. In fact, only 8%
(n¼14) of the present sample reported
compliance below the midpoint of the scale
used. Despite high compliance, however,
participants also endorsed high levels of
disease symptoms, body image concerns
(particularly concern about one’s shape),
depressive symptoms, and perceived stress
on the measures used to assess these expe-
riences. Reported levels of self-rated physi-
cal and emotional health varied, but were
suggestive of marked impairment for many
patients in the areas of bodily pain, vitality,
and social functioning. (Please refer to
Table 1 for mean scores and standard devi-
ations). Our first hypothesis was thus par-
tially supported by high average levels of
psychiatric symptoms and low quality of life
in specific domains.
Our second goal was to examine associ-
ations between physical (e.g. dietary com-
pliance and nausea) and psychiatric (e.g.
depressed mood) experiences, and between
48 Chronic Illness 8(1)
distinct psychiatric symptoms (e.g.
depressed mood and perceived stress). The
resulting correlation coefficients (r-values)
and significance tests can be found in
Tables 2 and 3; statistical significance for
all tests was set at p<0.05. Analyses
revealed moderate to strong associations
between illness behaviours/symptoms and
psychiatric functioning. Greater compliance
with a gluten-free diet was related to
increased vitality, reduced impairment in
daily emotional role performance, lower
stress, decreased depressive symptoms, and
greater overall emotional health. Increased
dietary compliance was also, however,
related to more frequent disordered eating
concerns and behaviours, particularly con-
cerns about shape and weight. Dietary
compliance was unrelated to illness symp-
tom severity, physical role performance,
self-reported mental and general health, or
bodily pain. Increased illness-specific symp-
tom severity similarly was associated with
various areas of dysfunction, including
greater depression, stress, disordered eating
concerns and behaviours, and most quality
of life domains. Symptom severity was not
associated with disordered eating symptoms
or bodily pain.
Likewise, correlation tests revealed mod-
erate to strong associations between distinct
domains of psychiatric functioning. Reports
Table 1. Descriptive statistics for disease-relevant
and psychosocial variables
Variable M
a
SD
b
Dietary compliance 4.47 1.06
CD symptom severity 99.68 34.37
Perceived stress 16.30 8.08
Depressive symptoms 14.96 10.90
Disordered eating—total 1.56 1.19
Restraint 1.49 1.48
Eating concerns 0.76 1.08
Shape concerns 2.36 1.61
Weight concerns 1.57 1.39
Physical functioning 84.72 19.96
Physical role 66.57 38.49
Bodily pain 42.10 10.30
Emotional role 66.08 38.80
Vitality 46.82 25.34
Mental health 70.14 19.35
Social functioning 43.42 28.71
General health 50.15 12.19
Physical health subscale 60.73 14.53
Mental health subscale 56.53 14.97
Note:
a
Mdenotes the mean value for each experience
assessed (across the entire sample).
b
‘SD’ denotes the associated standard deviation.
Table 2. Correlation (r) values for relationships among dietary compliance, illness symptom severity,
distress symptoms, and body concerns
Variable DC CDS DS PS
DC –
CDS 0.15 –
DSs 0.28** 0.74*** –
PSS 0.25** 0.33* 0.54*** –
Disordered eating—total 0.19* 0.36** 0.43*** 0.43***
Restraint 0.68 0.17 0.22** 0.78***
Eating concerns 0.22** 0.36** 0.42*** 0.85***
Shape concerns 0.17* 0.33** 0.39*** 0.90***
Weight Concerns 0.20* 0.39** 0.44*** 0.92***
Note: As correlations between subscales representing distinct disordered eating behaviours and concerns are high
(reflecting that these are related constructs), these correlations are not reported.
DC, dietary compliance; CDS, CD symptom severity; DSs, depressive symptoms; and PSS, perceived stress.
*p<0.05, **p<0.01, and ***p<0.001.
Arigo et al. 49
of increased depressive symptoms were asso-
ciated with greater perceived stress; both
depressive symptoms and perceived stress
were related to more frequent disordered
eating concerns and behaviours, and to
lower quality of life (in each domain
assessed). These findings indicate that some
women with Celiac Disease reported
increased psychosocial distress across mul-
tiple domains (r-values for each correlation
can be found in Tables 2 and 3).
We also examined whether respondents’
reported psychiatric symptoms met the
thresholds for clinical ‘cutoffs’ (suggesting
symptom levels meeting or exceeding estab-
lished criteria for a psychiatric disorder).
For example, the present sample demon-
strated a relatively high average level of
depressive symptoms: the sample mean
scores (M¼14.93, SD ¼10.90) were just
below the clinical cutoff score of 16,
23
and
37% of the sample reported scores that met
or exceeded this cutoff (n¼65). Moreover,
women who were at or above the clinical
cutoff reported lower dietary compliance,
higher illness symptom severity, higher per-
ceived stress, and lower physical and emo-
tional quality of life, relative to women who
scores below the cutoff (see Table 4 for T-
values for tests on group means).
Our final goal was to explore the comor-
bidities of disordered eating symptoms in
women with Celiac Disease. Individuals who
reported more frequent disordered eating
behaviours (e.g. intake restriction) and
greater concerns about eating, shape, and
weight also endorsed lower quality of life in
most physical and health domains; only self-
reported physical functioning was unrelated
to disordered eating concerns or behaviours.
In addition, 22% of females in the present
sample (n¼39) scored in the clinically
meaningful range of disordered eating
symptoms (i.e., above a total score of
2.3
27
). These women reported more severe
illness symptoms, increased depressive
symptoms, greater perceived stress, and
Table 3. Correlation (r) values for relationships between illness-related/psychosocial distress and quality of life domains
Variable PF PR BP ER V MH SF GH PHS MHS
Dietary compliance 0.06 0.05 0.06 0.23** 0.17* 0.10 0.12 0.19 0.003 0.20**
CD Symptom Severity 0.43*** 0.50*** 0.08 0.60*** 0.69*** 0.59*** 0.50*** 0.26** 0.53*** 0.63***
Depressive Symptoms 0.32*** 0.44*** 0.17* 0.66*** 0.72*** 0.76*** 0.62*** 0.18* 0.41*** 0.68***
Perceived Stress 0.29*** 0.40*** 0.24** 0.66*** 0.72*** 0.66*** 0.53*** 0.19* 0.34*** 0.69***
Disordered Eating Total 0.02 0.23** 0.03 0.37*** 0.37*** 0.38*** 0.32*** 0.05 0.13 0.37***
Restraint 0.13 0.09 0.08 0.15 0.17* 0.16* 0.11 0.08 0.01 0.17*
Eating Concerns 0.05 0.21** 0.01 0.36*** 0.27*** 0.36*** 0.27*** 0.14 0.10 0.33***
Shape Concerns 0.05 0.22** 0.004 0.36*** 0.40*** 0.38*** 0.35*** 0.006 0.17* 0.36
Weight Concerns 0.05 0.26*** 0.03 0.42*** 0.42*** 0.42*** 0.36*** 0.02 0.20* 0.41***
Note: *p<0.05, **p<0.01, ***p<0.001. PF, physical functioning, PR, physical role; BP, bodily pain; V, vitality (energy); MH, mental health; SF, social functioning; GH, general health;
PHS, physical health summary; and MHS, mental health summary. As correlations between subscales representing distinct quality of life domains are high (reflecting that these are
related constructs), such correlations are not reported.
50 Chronic Illness 8(1)
reduced overall mental health, relative to
women who were below this clinical cutoff
(please refer to Table 5 for T-values).
Discussion
Individuals with chronic illnesses face the
daily challenge of managing their uncom-
fortable (and potentially deleterious) symp-
toms. As such, these individuals are often at
higher risk for experiencing physical and
psychiatric difficulties that reduce their qual-
ity of life.
28
Celiac Disease is a relatively
understudied illness that impacts nearly all
domains of functioning, and may give rise to
comorbid psychiatric symptoms that paral-
lel those reported in other patient samples.
3
The primary goal of this study was to
examine the extent of psychiatric distress
among women with Celiac Disease, with
Table 4. Differences between women with Celiac Disease who fell below and above the clinical cutoff for
depressive symptoms
Center for Disease Studies—Depression Scale Clinical cutoff
Below Above
T-value
MSD MSD
Variable
Dietary compliance 4.63 0.82 4.29 1.26 2.12*
CC symptom severity 89.73 24.68 130.20 36.40 5.27***
Disordered eating symptoms 1.24 0.98 2.02 1.33 2.71*
Perceived stress 8.75 5.40 13.57 4.35 4.24***
Physical health summary 63.92 29.89 48.69 23.89 3.64***
Mental health summary 64.03 26.04 32.58 17.59 8.99***
Note: T-value is the result of a test for differences between means for women above and below the clinical cutoff for
depressive symptoms.
*p<0.05, **p<0.01, and ***p<0.001.
Table 5. Differences between women with Celiac Disease who fell below and above the clinical cutoff for
disordered eating symptoms
Eating Disorders Examination Questionnaire Clinical Cutoff
Below Above
T-value
MSD MSD
Variable
CC symptom severity 95.11 32.34 124.50 35.59 2.88*
Depressive symptoms 12.53 10.06 23.95 11.15 5.82***
Perceived stress 14.44 7.72 22.48 5.93 6.97***
Physical health summary 62.03 14.90 56.44 12.49 2.37*
Mental health summary 59.88 14.17 45.58 12.11 6.27***
Note: T-value is the result of a test for differences between means for women above and below the clinical cutoff for
disordered eating symptoms.
*p<0.05, **p<0.01, ***p<0.001.
Arigo et al. 51
particular emphasis on the suspected risk for
problematic eating concerns and behav-
iours. Analyses revealed several noteworthy
features of physical and psychiatric func-
tioning among women with Celiac Disease.
Despite reporting (on average) a high
degree of compliance with a gluten-free diet
(which is comparable to previous investiga-
tions of compliance
29
), participants in the
present sample report moderate to severe
illness symptoms and moderate self-rated
physical health that appeared unrelated to
their dietary adherence. Interestingly,
although increased dietary compliance was
not directly related to lower symptom inten-
sity, greater compliance was associated with
lower distress and increased vitality. It is
perhaps the case that individuals with Celiac
Disease are relieved of emotional distress
through their avoidance of gluten (i.e. know-
ing that they are following recommenda-
tions from their doctors may provide peace
of mind), rather than through the diet’s
direct physical effects.
This explanation is partially supported by
the inverse relationship between dietary
compliance and psychiatric stress, and the
positive relationship between psychiatric
stress and symptom severity. These relation-
ships indicate that those who follow their
diets have less distress (relative to those who
neglect their diets), and that those who have
less distress also experience less severe illness
symptoms. The bidirectional nature of these
correlational data, however, precludes
drawing strong conclusions about causal
pathways. Future work may benefit from
examining such pathways, and from deter-
mining additional contextual factors that
contribute to risk for psychosocial difficul-
ties among individuals with Celiac Disease.
For example, aspects of the social environ-
ment such as increased social support
30
and
the ability to compare oneself with other
patients
31
have shown positive effects on
psychiatric and medical outcomes among
patients with a chronic illness. Attention to
such influences may contribute to optimally
effective care for patients with Celiac
Disease.
Importantly, this study indicates that
certain individuals endorse more distress in
conjunction with their illness. Individuals
who experienced frequent illness symptoms
also reported more severe depressive and
pain symptoms, reduced energy, and
increased interference with emotional and
social functioning. Independent of illness
symptoms, those individuals with higher
depression scores or higher perceived stress
experienced disruption in multiple realms of
daily life. A substantial percentage of indi-
viduals with Celiac Disease (37%) scored in
the clinically relevant range of depressive
symptoms, which exceeds population-based
data for the measure used (i.e. 21%).
23
These findings provide evidence to suggest
that patients with more frequent illness
symptoms may be at risk for developing
psychiatric difficulties that warrant clinical
attention. This may be true even when
dietary restrictions are being followed, sug-
gesting the overall need for attention to
psychosocial functioning in addition to die-
tary recommendations in clinical practice.
We expected that the increased focus on
eating behaviours required to manage Celiac
Disease would be reflected in reports of
disordered eating. Although concerns about
eating were similar to published normative
levels among ostensibly healthy women
(M¼0.76 in the present sample), concerns
about one’s body shape were, unexpectedly,
slightly higher than normative levels.
Increased shape concern was also related
to greater perceived stress, more severe
illness symptoms, reduced physical and
mental health in multiple domains, and
decreased dietary compliance. Average
levels of disordered eating (using the total
score) were below the acknowledged clinical
cutoff for the measure used; of note, how-
ever, 22% of the present sample reported
symptoms in line with eating disorders of
52 Chronic Illness 8(1)
clinical significance. In contrast, only 6.3%
of young women from the general popula-
tion score above the clinical cutoff.
32
Women in the present sample whose symp-
toms exceeded the clinical cutoff reported
greater physical and mental health difficul-
ties than did women whose symptoms were
below the cutoff.
The nature of Celiac Disease is such that
increased dietary concerns and greater focus
on consumption management are indicated
for patients, relative to the general popula-
tion.
13
Yet the present findings suggest that
a subset of women with Celiac Disease
demonstrate extreme dietary (and appear-
ance) concerns that are associated with
reduced physical and emotional quality of
life. Such findings build upon existing liter-
ature (i.e. case histories,
11,12,13
studies con-
ducted in adolescent samples
14
)by
demonstrating this trend in a large sample
of adult women. The presence of disordered
eating symptoms in the present sample
indicates that attending to the risk for
extreme thoughts and behaviours related to
eating and shape is a large area of opportu-
nity for improving quality of life in women
with Celiac Disease. Disordered eating
symptoms may thus represent appropriate
targets for psychosocial intervention in this
patient group. Additional research is neces-
sary to determine the extent of risk for
disordered eating symptoms among women
with Celiac Disease, relative to the general
population.
A small number of existing studies have
demonstrated that Celiac Disease carries
increased risk psychiatric difficulty and
reduced quality of life in European sam-
ples.
3
To our knowledge, this present study
is one of the first to extend such findings to
an American sample of adult women, who
may be at particular risk for disordered
eating symptoms. This study was limited by
self-selection and a relatively small sample
of patients. Self-selection may have been
related to the time burden of completing the
survey (20 min for 110 items). In addition,
using internet recruitment may have intro-
duced the possibility of gathering a sub-
optimally representative sample, as it was
restricted to individuals with Celiac Disease
who had access to computers and searched
for Celiac-related information. As this
group tends to be female,
33
however, inter-
net recruitment and administration may
have increased the study’s reach and ease
of participation for the target group (relative
to traditional in-person and paper-and-
pencil techniques), and was cost-effective to
conduct. This method also resulted in a
sample that is comparable to the overall
population of women with Celiac Disease in
Western countries.
Finally, this study employed a number of
statistical tests and was thus potentially
vulnerable to Type 1 error. Of note, how-
ever, several of our hypothesis tests were
significant at the 0.001-level, reflecting
effects much less likely due to chance.
Consistency between the present findings
and existing data for European samples also
reduces the likelihood that the former are
entirely attributable to Type 1 error.
Although replication of these findings in
larger samples with biologically-verified
Celiac Disease is necessary (e.g. recruitment
from a Celiac Disease clinic, serologic
screening), this study is an important first
step toward identifying female patients in
the USA who are at risk for psychiatric
difficulties—particularly disordered eating
symptoms. This study also shows that var-
ious types of psychiatric distress co-occur
among patients with Celiac Disease. It is
possible that a brief, general screening tool
may allow care providers to quickly and
effectively assess for psychiatric risk in
clinics, hospitals, and outpatient offices,
which is another fruitful avenue for
research.
Notwithstanding the noted limitations,
this study demonstrates potential risk for
meaningful psychiatric difficulty among
Arigo et al. 53
patients with Celiac Disease, and highlights
the opportunity for improvement in patient
care via attention to emotional challenges.
The benefits of attending to psychiatric
concerns (in addition to standard medical
care) have previously been demonstrated in
samples with well-known gastrointestinal
disorders (e.g. irritable bowel syndrome,
34
ulcerative colitis and Crohn’s disease
35
).
This study adds to the growing body of
literature highlighting the need for psycho-
social care among individuals with Celiac
Disease, and provides preliminary evidence
to suggest that tests of psychosocial inter-
ventions for Celiac Disease (such as cogni-
tive and/or self-management therapies) are
warranted.
Authors’ note
Portions of this article were presented at the
annual meeting of the American Psychosomatic
Society, Portland, OR (10–14 March, 2010).
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
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Arigo et al. 55
... Numerous studies had also investigated the prevalence and risk of EDs in children and adults with CD and reported the mixed results (Arigo, Anskis, & Smyth, 2012;Basso et al., 2013;Butwicka et al., 2017;Garud et al., 2009;Hedman et al., 2018;Kaltsa et al., 2015;Karwautz et al., 2008;Latzer, Rachmiel, et al., 2018; Latzer, Lerner-Geva, Stein, Weiss, & Pinhas-Hamiel, 2018; Lebwohl et al., 2020;Leffler et al., 2007;Marild et al., 2017;Nacinovich et al., 2017;Passananti et al., 2013;Pynnönen et al., 2004;Raevuori et al., 2014;Saldanha, Weiselberg, & Fisher, 2018;Satherley, Howard, & Higgs, 2016;Vaknin, Eliakim, Ackerman, & Steiner, 2004;Wagner et al., 2015;Welch, Ghaderi, & Swenne, 2015;Wotton, James, & Goldacre, 2016;Zriouel, Cherkani-Hassani, Khadmaoui, & Ettair, 2020). ...
... Additional screening of the studies yielded 114 full texts checked against eligibility criteria. Finally, 23 observational studies were included ( Figure 1; Arigo et al., 2012;Basso et al., 2013;Butwicka et al., 2017;Garud et al., 2009;Hedman et al., 2018;Kaltsa et al., 2015;Karwautz et al., 2008;Latzer, Lerner-Geva, et al., 2018;Latzer, Rachmiel, et al., 2018;Lebwohl et al., 2020;Leffler et al., 2007;Marild et al., 2017;Nacinovich et al., 2017;Passananti et al., 2013;Pynnönen et al., 2004;Raevuori et al., 2014;Saldanha et al., 2018;Satherley et al., 2016;Vaknin et al., 2004;Wagner et al., 2015;Welch et al., 2015;Wotton et al., 2016;Zriouel et al., 2020). Table 1 presents the characteristics of the included studies. ...
... Table 1 presents the characteristics of the included studies. Fourteen studies assessed the prevalence and risk of AN, BD, and ED in patients with a primary diagnosis of CD (Arigo et al., 2012;Butwicka et al., 2017;Garud et al., 2009;Karwautz et al., 2008;Latzer, Lerner-Geva, et al., 2018;Latzer, Rachmiel, et al., 2018;Lebwohl et al., 2020;Leffler et al., 2007;Passananti et al., 2013;Pynnönen et al., 2004;Satherley et al., 2016;Vaknin et al., 2004;Wagner et al., 2015;Zriouel et al., 2020). Seven studies reported the prevalence of CD in patients with a primary diagnosis of AN and ED (Basso et al., 2013;Kaltsa et al., 2015;Nacinovich et al., 2017;Raevuori et al., 2014;Saldanha et al., 2018;Welch et al., 2015;Wotton et al., 2016). ...
Article
Objectives: In the present systematic review and meta-analysis study, we aimed to review studies that assessed the prevalence and risk of eating disorders (EDs) in patients with celiac disease (CD) and vice-versa. Method: We conducted a systematic search in PubMed, Embase, Scopus, and Web of Science for studies that assessed the prevalence and risk of AN in patients with CD and vice-versa. Joanna Briggs Institute tools were used for critical appraisal. The STATA software was used for the meta-analysis of the random-effect model. Results: In this study, 23 observational studies were included. The results of the meta-analysis indicated that the pooled prevalence of EDs and bulimia nervosa in patients with CD was 8.88% [95% CI: 6.4, 11.7] and 7.26% [95% CI: 0.23, 21.57], respectively. Moreover, the risk of anorexia nervosa in patients with CD was significantly higher than in the healthy population (relative risk [RR]: 1.48 [95% CI: 1.32, 1.64]). The rates of CD in patients with AN and EDs were 0.96% [95% CI: 0.15, 2.31] and 0.90% [95% CI: 0.56, 1.31], respectively. Moreover, the overall risk of CD in patients with AN was significantly higher compared with healthy adults (RR: 2.35 [95% CI: 1.27-3.44]). Discussion: The result of the present meta-analysis showed the high prevalence of EDs in patients with CD. Moreover, there was a significant bidirectional association between CD and EDs.
... Two studies demonstrated this relationship using the HADS depression subscale [38,41]. Using the CES-D, Arigo et al. [32] found depressive symptoms to be significantly negatively correlated with both mental and physical health summary SF-36 QoL domains. Finally, Fera et al. [35] found depression to be significantly, negatively correlated with all SF-36 QoL domains except for physical functioning and role limitations due to emotional problems, although correlation coefficients were not presented. ...
... Three studies examined QoL in relation to a clinical cut-off for a probable mental disorder, all finding significantly reduced QoL among participants that met the clinical cut-off for a psychological disorder. Arigo et al. [32] found participants scoring above the clinical cut-off for depression (≥16) reported significantly poorer SF-36 mental and physical health summary scores than those below the cut-off. Similarly, two studies found reduced SF-36 QoL scores among participants with a "probable mental disorder" (i.e., HADS anxiety or depression score ≥ 11) [39,40]. ...
... One study of 177 females by Arigo et al. [32] examined SF-36 QoL domains in relation to disordered eating behaviours measured via the Eating Disorder Examination Questionnaire (EDE-Q). The EDE-Q measures both cognitive (restraint, eating concern, shape concern, weight concern) and behavioural (binge eating, vomiting, laxative/diuretic abuse, overexercising) aspects of disordered eating. ...
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Background Individuals living with coeliac disease generally experience a remission of symptoms after adopting the gluten-free diet, but often report substantial treatment burden and ongoing quality of life issues. Psychosocial factors have been suggested to play a significant role in post-diagnosis quality of life but have yet to be systematically reviewed. Aim To review the evidence for psychosocial factors associated with quality of life in adult coeliac disease cohorts. Methods Studies were identified via systematic searches of eight databases (MEDLINE, Embase, Emcare, PsycINFO, Ovid Nursing, CINAHL, Informit Health Collection, Cochrane Library) in May 2019. Results Fourteen studies were included involving 3372 participants (80.1% female, mean age = 46.3 years). Symptoms of depression and anxiety were the most examined psychosocial factors across all studies. Quality of life was differentially associated with psychological distress, illness perceptions, coping, and attitudes/behaviours regarding food and the gluten-free diet. Conclusion Several psychosocial factors are associated with quality of life in adults living with coeliac disease. Current evidence suggests these factors are interrelated and may influence QoL directly, via reduced psychological well-being, and indirectly, via reduced adherence to the gluten-free diet. Future research is needed to examine these processes concurrently, with the aim of elucidating the psychosocial mechanisms underlying post-diagnosis well-being and identifying potential targets for psychosocial intervention.
... Moreover, Chan et al. (27) reported that symptoms of anxiety and depression were independently associated with IBD-related disability. Arigo et al. (37) suggested that fear and anxiety surrounding gastrointestinal symptoms can lead to disordered eating practices of a restrictive nature. In a French survey (38), nearly half of the subjects reported that the disease had changed the pleasure of eating, with only a quarter of the patients eating a normal diet during relapse. ...
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Background: The inflammatory bowel disease disability index (IBD-DI) was used to access body functional consequences and disease burden. However, Chinese population data are considerably limited. Objective: We aimed to screen for disability in patients with Crohn's disease (CD) and to assess potential associations with clinical parameters as well as indices related to sarcopenia. Methods: This cross-sectional study includes 146 CD patients from Ruijin Hospital in Shanghai, China. All patients were screened for disability and sarcopenia on the basis of the IBD-DI scale, and the criteria for Asian Working Group for Sarcopenia, respectively. Clinical and demographic variables were collected. Results: Approximately 52.05% of the subjects suffered from moderate or severe disabilities. The prevalence of sarcopenia (48.68 vs. 31.43%, P = 0.043), Patient-Generated Subjective Global Assessment score or PG-SGA≥4 (39.47 vs. 17.14%, P = 0.003), and high-level C- reactive protein (27.63 vs. 11.43%, P = 0.021) were higher in patients with moderate to severe disability than in those without to minimal disability. By multivariate regression modeling, the following were identified as independent factors related to moderate to severe disability: disease activity (OR:10.47, 95% CI: 2.09–52.42) and body mass index (BMI) (OR:4.11, 95% CI: 1.80–9.38). Conclusions: Disability is common in CD patients. Our study showed that moderate to severe disability is not directly associated with muscle mass or muscle quantity but is mostly correlated with disease activity as well as BMI. Thus, close monitoring and follow-up should be conducted on patients who are at high risk of disability, and effective measures should be taken, which may be the best way to prevent disability.
... Joelson et al. [40] suggested that depression may alter the relationship between GFD adherence and the presence of CD symptoms. According to Arigo et al. [41], a significant subset of CD women who adhere to GFD have clinically relevant symptoms of depression and disordered eating; these symptoms are associated with increased psychosocial distress in other domains. Furthermore, Zysk et al. [42] reported that a CD patient's economic status may be one of the most important factors influencing their social and emotional fears and worries, leading to a low level of social and emotional fears and worries. ...
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... Különösen nők számolnak be arról, hogy problémát jelent nekik a gluténmentes diétához kapcsolódó érzéseik kezelése, továb-bá jellemző rájuk, hogy az ételek elkészítésekor fokozott kontrollra törekednek [6,16,17]. Társuló pszichés zavarként a kutatások a leggyakrabban hangulatzavarokat és szorongásos tüneteket írnak le [6,18]. ...
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Background Coeliac disease is a chronic gastrointestinal condition associated with an increased risk of psychiatric comorbidity, and diminished quality of life. Ongoing gastrointestinal symptomatology is frequently reported post-diagnosis, despite undertaking a gluten-free diet. Purpose To examine the role of psychosocial factors in mediating the relationship between gastrointestinal symptoms and quality of life, using a cross-sectional structural equation modelling mediation analysis guided by the Common-Sense Model. Methods 1697 adults with coeliac disease (83.1% female, mean age = 55.79, SD = 14.98 years) completed an online questionnaire. Measures included gluten-free diet adherence, gastrointestinal symptoms, illness perceptions, coping, gastrointestinal-specific anxiety, pain catastrophising, psychological flexibility, psychological distress, and quality of life. Results A structural equation model was developed explaining 50.6% of the variation in quality of life and demonstrating good fit (χ2 (2) = 8.54, p = .014, χ2/N = 4.27, RMSEA = 0.04, SRMR = 0.01, CFI = 0.999, TLI = 0.98, GFI = 0.999). Gastrointestinal symptoms directly affected quality of life, and indirectly, via negative illness perceptions, maladaptive coping, pain catastrophising, and psychological distress. Conclusion Psychosocial processes affect adjustment in coeliac disease by mediating the relationship between gastrointestinal symptoms and quality of life. Individuals living with coeliac disease may benefit from interventions targeting maladaptive psychosocial factors.
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Chapter
Celiac disease is an immune-mediated enteropathy activated by gluten ingestion causing small bowel inflammation and chronic nutrient malabsorption. The CD prevalence has increased in the last years and is common in all parts of the world and in all ethnic groups. Once celiac disease is diagnosed, the only effective treatment is a strict gluten-free diet lifelong, which means that bread, pasta, and other processed foods made from unsafe grains cannot be eaten. This permanent restriction on foods containing gluten induces significant changes in the lifestyle of the affected individuals and may disrupt the individual’s overall emotional balance.
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