Psychiatric symptoms among patients with acute abdominal pain

Abstract

Background: Abdominal pain is a common cause of visits to emergency facilities. It is related to psychiatric disorders in primary care, but it is unclear if this also holds in emergency departments.

Objective: Is to explore potential differences between diagnostic groups in patients with acute abdominal pain in an emergency ward regarding concurrent somatic-and psychiatric symptoms, ‘Length of stay’ (LOS) and perceived health.

Method: The patients (N = 137) were divided into three groups; organic dyspepsia, specific abdominal diagnoses, and non-specific abdominal pain. The Prime-MD results for extra gastrointestinal symptoms (outside the gastrointestinal tract), psychiatric symptoms, frequency of symptoms, self-reported health, and LOS within the month before admittance were compared between the diagnostic groups.

Results: There was a significant positive correlation between the number of physical extra gastrointestinal and psychiatric symptoms (p < .001), especially regarding anxiety (p < .001) and depression (p = .002). Patients with organic dyspepsia reported significantly more total (p = .016), extragastrointestinal (p = .026) (chest pain; p = .017, dizziness; p = .004, palpitations; p = .005, insomnia; p = .005 and worries; p = .001), and summarized anxiety and depression symptoms (p = .001–0.002) besides poorer general health (p < .001) compared to other abdominal conditions. Also, organic dyspepsia patients needed longer hospital stay than the non-specific abdominal group (p = .002) but similar to the specific abdominal disorders group.

Conclusion: Organic dyspepsia is accompanied by more co-occurring physical, anxiety and depression symptoms as well as poorer perceived health than other abdominal pain conditions and comparably increased LOS. This suggests that psychiatric consultations might be beneficial for diagnosing and treating psychiatric comorbidity in emergency care.

Keywords:

• Anxiety
• depression
• emergency ward
• health
• organic dyspepsia
• prime-MD

Introduction

The prevalence of psychiatric comorbidity with somatic disorders is estimated to be around 20–40%, but of these only 40–60% are recognized in clinical work [1–6]. This is worrisome since the presence of psychiatric comorbidity may not only increase medical morbidity but also impact mortality [7–10]. Abdominal pain accounts for 5–8% of visits to emergency departments [11,12] and about 8% in primary care [13]. Abdominal pain is frequently shown to coexist with psychiatric disorders, for instance in primary care where depression is found in around 19% and anxiety in 19% [13]. Studies regarding psychiatric comorbidity in emergency surgical wards are scarce but high prevalence of psychiatric comorbidity has been reported [14,15]. A report from a surgical department highlighted the need for psychiatric consultations due to anxiety and depression symptoms [16] which seems indicated for acute abdominal pain as no organic causes were found in as many as 17% in another study [17]. Results from surgical and medical outpatient clinics provide further support for such a statement, where thorough psychiatric and somatic investigation of recurrent or persistent abdominal pain among 96 patients, diagnosed only 15.6% with the organic disorder while the majority 84,4% receivedpsychiatric disorders [18]. In part, this may be explained by the known comorbidity of abdominal functional gastrointestinal disorders (FGID) [19–21] with personality traits, psychiatric disorders and psychosocial factors. Furthermore, similar psychosocial factors have been linked to organic dyspepsia despite its distinct organic cause (e.g., peptic ulcer) [22–26].

The psychiatric factors may influence in several ways as they have been associated with more abdominal symptoms, lower experienced quality of life and health-care utilization [19–21]. More precisely, depression or anxiety symptoms may lead to a more negative interpretation of symptoms and ones’ health besides generating a feeling of helplessness, all of which can influence the ‘Length hospital stay’ (LOS). As a matter of fact, comorbidity of psychiatric disorders have been shown to increase the LOS [27–29] in other disorders, but less is known about acute abdominal pain. To date, the places for inpatient emergency ward may be limited and therefore of interest to clarify whether psychiatric symptoms prolong the length of stay of patients in emergency wards due to abdominal complaints.

Furthermore, it is of importance to find psychiatric comorbidity among patients with abdominal pain in the emergency ward because a substantial part of them eventually will receive the diagnosis of non-specific abdominal pain which is likely to become chronic [30,31]. In order to increase the identification of psychiatric comorbidity, which will enable the offer of beneficial treatment, further knowledge is required regarding the diagnostic overlap.

One practical self-report for screening psychiatric morbidity is Prime-MD which has been validated for use in patients seeking for somatic complaints, some of which may be ascribed to both psychiatric and somatic conditions [32]. Research data based on the instrument also have shown that the total number of self-reported psychiatric or somatic co-occurring symptoms and general health associates with psychiatric comorbidity [33–35] although this has not been proved for acute abdominal pain to our best knowledge.

Recently, our group showed that personality traits differ between three main diagnostic groups seeking the emergency ward due to abdominal symptoms i.e., organic dyspepsia, specific abdominal diagnoses, and non-specific abdominal pain. The difference was most prominent between organic dyspepsia patients and those with specific organic disorders, while those with non-specific abdominal pain were in between the other two [36]. Since personality factors may be related to psychiatric comorbidity [37], it seems relevant to explore psychiatric symptoms in patients with abdominal pain in emergency wards and to clarify whether there are differences reliant on the underlying conditions.

The main aim is to explore differences between diagnostic groups (organic dyspepsia, specific abdominal diagnoses and non-specific abdominal pain) in patients with acute abdominal pain in an emergency ward regarding plausible indicators of psychiatric comorbidity; concurrent somatic-and psychiatric symptoms, ‘Length of stay’ (LOS) and perceived health. A second aim was to explore potential associations between concurrent somatic symptoms with distinct psychiatric symptoms in patients with abdominal pain at an emergency ward.

Methods

Sample

In total, 165 consecutive patients admitted to the emergency ward due to abdominal pain completed a battery of self-reports [36]. One hundred thirty-seven of these (83.0%) completed the questionnaire Prime-MD as well, while 28 (17.0%) refused to or left incomplete answers. In total, 77 women and 60 men completed the questionnaire.

The study was approved by the Regional Ethical Review Board in Linköping, Sweden (D-nr 98404). Informed consent was obtained from all participants and the procedures of the project comply with the ethical standards of the Helsinki Declaration of 1964.

Study design and data collection

Besides collecting the above-mentioned self-reports, medical records were searched for previous health care utilization for both somatic and psychiatric causes. Psychiatric contact, with the local psychiatric clinic, within 3 months prior to admission to the emergency ward was defined as current psychiatric contact. Medical chart notes were searched for information on smoking and reliable data was found in 90 cases (66%). In order to follow-up previous results for this group [36] the somatic diagnoses were clustered into the same three groups; organic dyspepsia, specific abdominal diagnoses and non-specific abdominal pain. These groups were chosen in respect to the following facts: The first group pertaining to organic dyspepsia (n = 19) contained diagnoses determined by gastroscopy which are related to peptic acid. These include peptic ulcers, ventricular ulcers, gastro-esophageal reflux disease (GERD) and gastritis. The second group (n = 63) comprised of specific abdominal diagnoses with their maining identifiable organic causes, for instance, diverticulosis, ileus, cancer etc. See complete lists of diagnoses in footnotes of tables for example Table 2. The third group (n = 55) encompassed abdominal pain where no organic causes were found. (chapter XVIII in WHOs ICD-10 of symptoms and signs not elsewhere classified, e.g., R10.0 Acute Abdomen).

Prime-MD

The Prime-MD has been validated and a high level of correspondence with interviews by psychiatric personnel [32] has been confirmed. It is a two-sequenced tool for detection of psychiatric morbidity for the last month, based on DSM-III R [32]. The first part is a 28 items questionnaire with ‘yes’ or ‘no’ questions regarding somatic (e.g., abdominal pain) and psychiatric (e.g., depressed mood) symptoms. The Prime-MD contains CAGE-questions recommended for inpatient use to identify problems with alcohol [38–41]. Prime-MD also has a multiple-choice section where the patients rate their general health in one of 5 separate categories: Excellent, Very Good, Good, Fair or Poor. In this study these 5 categories were reduced to two by letting Fair and Poor be ‘Not so well’ and Excellent, Very Good and Good be ‘Well’. In this study, physical symptoms not related to the gastrointestinal tract are classified as extra-gastrointestinal. The Prime-MD questionnaire’s results were classified into somatic symptoms from the gastrointestinal system (gastrointestinal), from other parts of the body (extragastrointestinal) and psychiatric alongside perceived health.

Statistical analysis

Statistical analyses were performed by using Statistica ver.12 as follows: Chi-square test was employed using two-tailed Fisher’s exact test for categorical parameters including a comparison of Prime-MD symptoms between the diagnostic groups.

The extra-gastrointestinal symptom fatigue, related both to somatic or psychiatric disorders, was not significantly associated with any of the diagnostic groups i.e., Organic Dyspepsia, Specific Abdominal diagnoses, or Non-Specific Abdominal pain, and was therefore excluded from the consecutive statistical analysis. Similarly, menstrual, or sexual problems were excluded, as the former was only applicable to women, and that the latter was infrequent. In addition, all gastrointestinal symptoms (e.g., abdominal pain, constipation/diarrhea, nausea/vomiting/gas or indigestion, poor appetite or overeating) were excluded in the subsequent analysis as they may relate to the cause of visits to the emergency care. However, they are shown in tables for completeness.

One-way ANOVA followed by Duncan’s post-hoc test in case of significance was used for the analysis of group (Organic Dyspepsia, Specific Abdominal diagnoses and Non-specific abdominal pain) differences regarding age, length of stay and the total number of anxiety and depression symptoms(chest pain, dizziness, palpitations, dyspnea, insomnia, nervousness, worrying, decreased interest and depressed mood). All symptoms were labelled as psychiatric if in accordance with the DSM-5 psychiatric criteria for depression or anxiety.

Multiple linear regression was used to explore various associations between extra-gastrointestinal symptoms and length of stay (outcome variable; logarithmic of LOS variable, exploratory variables; extragastrointestinal symptoms).

In order to clarify the association between extragastrointestinal and psychiatric symptoms, a follow-up analysis was performed. Four groups were created depending on the number of physical extragastrointestinal symptoms: (a) one symptom, (b) two symptoms, (c) three symptoms and (d) more (maximum 8 symptoms). These four groups were subsequently cross-tabulated based on the diagnostical groups.

Results

Demographic characteristics

Demographic data are shown in Table 1. Patients with organic dyspepsia are significantly older than patients with specific abdominal diagnoses (p = .042) and non-specific abdominal pain (p < .001). Patients with non-specific abdominal pain had a significantly shorter length of stay than patients with organic dyspepsia (p = .002) and specific abdominal diagnoses (p = .005). Patients with specific abdominal diagnoses had significantly fewer problems with alcohol consumption as rated by CAGE (p = .006), compared to organic dyspepsia and non-specific abdominal pain.

Table 1. Demographic characteristics.

		Organic Dyspepsia	Specific Abdominal Diagnoses	Non-Specific Abdominal pain
		n = 19	n = 63	n = 55
		(%)	(%)	(%)	p
Gender	Female	12 (63.2)	32 (50.8)	33 (60.0)
	Male	7 (36.8)	31 (49.2)	22 (40.0)	n.s.
Age	Mean ± SD	54.2 ± 12.8	47.2 ± 13.9	41.8 ± 15.1	.004 †
Length of stay (days)	Mean ± SD	3.5 ± 2.2	3.7 ± 2.4	2.2 ± 1.5	<.001 ††
Employment	Retired by age	2 (10.5)	6 (9.5)	2 (3.6)
	Unemployed	3 (15.8)	3 (4.8)	4 (7.3)
	Sick leave	5 (26.3)	4 (6.3)	7 (12.7)
	Employed	6 (31.6)	39 (61.9)	33 (60.0)	n.s.
Smoker	Smoker	5 (26.3)	11 (17.5)	9 (16.4)
	Non-smoker	10 (52.6)	29 (46.0)	26 (47.3)	n.s.
Alcohol	CAGE <2	15 (78.9)	60 (95.2)	47 (85.5)
	CAGE ≥2	4 (21.1)	1 (1.6)	8 (14.5)	.006 †††
Contact with psych	No contact	15 (78.9)	58 (92.1)	47 (85.5)
(within 3 months)	Contact	4 (21.1)	2 (3.2)	3 (5.5)	n.s.

Organic dyspepsia; peptic ulcer, ventricular ulcer, GERD, gastritis. Specific abdominal diagnoses; gallbladder diseases, diverticulitis, ileus, pancreatitis, appendicitis, Chron’s disease, ulcerous colitis, ileus, obstipation, gastroenteritis, ventricular tumor, Mallory-Weiss. Non-specific Abdominal pain; Acute Abdomen.

†ANOVA: F = 5.74; df = 2, 134; post hoc Duncan; Organic Dyspepsia vs Specific Abdominal diagnoses; p = .042; vs non-specific abdominal pain; p < .001.

††ANOVA: F = 9.40; df = 2, 134; post hoc Duncan; Non-specific Abdominal pain vs Organic Dyspepsia; p = .002; vs Specific Abdominal diagnoses; p = .005.

†††Maximum-Likelihood Chi-Square followed by Fisher's exact test; Specific Abdominal diagnoses vs Organic Dyspepsia and Non-specific Abdominal pain; p = .006 Excluded from the table is missing data; Employment; 23, Smoking; 47, Alcohol; 2, Contact with psych. clinic within 3 months; 8.

Prime-MD symptoms

Table 2 shows symptoms often experienced during the month before admittance to emergency care. Compared to patients with specific abdominal diagnoses, patients with organic dyspepsia reported more chest pain (p = .027), dizziness (p = .004), insomnia (p = .006) and alcohol problems (p = .01). Compared to both specific abdominal diagnoses and non-specific abdominal pain, organic dyspepsia patients endorsed more worries (p = .01 and p = .002, respectively), palpitations (p = .005 and p = .039, respectively), and chest pain (p = .027 and p = .023, respectively). Patients with non-specific abdominal pain reported more insomnia (p = .022), headache (p = .012) and problems with alcohol (p = .05) compared to patients with specific abdominal diagnoses, and also more headache (p = .048) compared to both organic dyspepsia and specific abdominal diagnoses.

Patients with organic dyspepsia reported significantly more total (sum of psychiatric and extragastrointestinal) (F(2,132) = 4.25; p = .016) and extragastrointestinal symptoms (F(2,134)= 3.77; p = .026) than those with specific abdominal diagnoses (p = .002 and p = .004, respectively), and non-specific abdominal pain (p = .025; p = .048, respectively).

Table 2. The frequency (%) of physical and psychiatric symptoms according to PRIME-MD among patients (n = 137) with organic dyspepsia, specific abdominal diagnoses and non-specific abdominal pain at the emergency ward.

	Organic Dyspepsia	Specific abdominal diagnoses	Non-specific abdominal pain
	n = 19	n = 63	n = 55
During the last month often experienced	%^a	%^b	%^c	p
Gastrointestinal symptoms
Abdominal pain	73.7	61.9	58.5	.489
Constipation/diarrhea	31.6	42.6	38.2	.671
Nausea, vomiting, gas or indigestion	68.4	50.0	59.3	.308
Poor appetite or overeating	15.8	12.7	3.7	.128
Extragastrointestinal symptoms
Back pain	33.3	39.7	31.5	.638
Joint or limb pain	52.6	29.0	34.5	.178
Menstrual problems	12.5	10.0	10.2	.960
Sexual problems	5.6	3.3	5.6	.826
Headache	47.4	25.8*	49.1	.022
Chest pain	42.1*	16.1	14.8*	.042
Dizziness	52.6**	16.1	29.1	.008
Fainting	16.7	4.8	3.6	.192
Palpitations	36.8**	8.1	13.0*	.016
Dyspnea	36.8	9.7	12.7	.408
Fatigue	73.7	47.6	53.7	.126
Psychiatric symptoms
Insomnia	52.6**	17.7*	37.0	.006
Little interest or pleasure in doing things	57.9	29.0	29.6	.059
Feeling down, depressed or hopeless	47.4	19.0	29.6	.052
Feeling nervous, anxious or on the edge	42.1	29.5	25.9	.429
Worrying too much about different things	57.9**	23.8	18.5**	.006
Suddenly feeling fear or panic	26.3	6.3	9.3	.076
Have you ever felt you needed to cut down on your drinking	21.1	6.6	13.0	.201
Have people annoyed you by criticizing your drinking	21.1*	1.6*	11.1	.013
Have you ever felt guilty about drinking	21.1	3.3	9.1	.062
Have you during a single day been drinking 5 or more glasses of beer, wine or liquor	21.1	21.3	27.3	.723
Recurrent ideas, fantasies or impulses that seem weird, strange, repulsive or awful	10.5	1.6	3.6	.262
Are there actions that you do repeatedly, or thoughts that you have to think repeatedly, in order to stay calm	0.0	9.5	3.6	†
Are you afraid to be embarrassed in social situations, or do you avoid such situations	36.8	17.5	14.5	.125

Organic dyspepsia; peptic ulcer, ventricular ulcer, GERD, gastritis. Specific abdominal diagnoses; gallbladder diseases, diverticulitis, ileus, pancreatitis, appendicitis, Chron’s disease, ulcerous colitis, ileus, obstipation, gastroenteritis, ventricular tumor, Mallory-Weiss. Non-specific Abdominal pain; Acute Abdomen. Statistics: Maximum-Likelihood Chi-Square followed by two-tailed Fisher's exact test in case of significance.

^aLevel of significance in the comparison between organic dyspepsia and specific abdominal diagnoses.

^bLevel of significance in the comparison between specific abdominal diagnoses and non-specific abdominal pain.

^cLevel of significance in the comparison between non-specific abdominal diagnoses and organic dyspepsia.

*p < .05, **p < .01, †Fisher's exact test revealed no significant differences.

Number of extragastrointestinal symptoms and psychiatric symptoms

There was a significant positive correlation (F [8, 135] = 30.6, p < .001) between the number of reported extragastrointestinal symptoms and several distinct psychiatric symptoms. 1More precisely, as can be seen in Table 3, extragastrointestinal symptoms correlated positively to psychiatric symptoms of insomnia, depression, and anxiety. Among those with three or more extragastrointestinal symptoms, around 50%reportedsleeping problems, depressive or anxiety symptoms,20% alcohol problems and 32% panic symptoms (see Table 3).

Table 3. Correlationsofthe number of extragastrointestinalsymptoms with distinct psychiatric symptoms among patients with abdominal pain at the emergency ward.

	Number of extragastrointestinal symptoms
	0 (n = 37)	1 (n = 37)	2 (n = 26)	3-8 (n = 37)
During the last month often experienced	%	%	%	%	p
Sleepingproblems	10.8	19.4	34.6	58.3	<.001
Little interest or pleasure in doing things	16.2	28.6	30.8	56.8	.002
Feeling down, depressed or hopeless	13.5	19.4	26.9	48.6	.005
Feeling nervous, anxious or on the edge	5.4	20.6	34.6	59.5	<.001
Worrying too much about different things	13.5	16.7	19.2	54.1	<.001
Suddenly feeling fear or panic	0	2.8	3.8	32.4	†
Have you ever felt you needed to cut down on your drinking?	5.7	5.6	15.4	18.9	.176
Have people annoyed you by criticizing your drinking?	0	5.6	7.7	18.9	††
Have you ever felt guilty about drinking?	2.9	5.4	7.7	16.2	.195
Have you during a single day been drinking 5 or more glasses	20	21.6	11.5	37.8	.089
of beer, wine or liquor?
Recurrent ideas, fantasies or impulses that seem weird,	2.7	0	3.8	8.1	†††
strange, repulsive or awful
Are there actions that you do repeatedly, or thoughts that you	2.7	8.1	0	10.8	†††
have to think repeatedly in order to stay calm?
Are you afraid to be embarrassed in social situations?	10.8	13.5	23.1	29.7	.147
or do you avoid such situations?

Statistics; maximum-likelihood chi-square, in case of ‘zero symptoms’ Fisher's exact test. Extragastrointestinal symptoms; back pain, limb pain, chest pain, dizziness, fainting, palpations and dyspnea. †0 vs 3-8; p < .001, 1 vs 3–8; p = .001, 2 vs 3–8; p = .009.

††0 vs 3–8; p = .012.

†††Fischer's exact test revealed no significant differences.

Further analysis shows that organic dyspepsia is significantly associated with the sum of symptoms correlating to anxiety or depression (e.g., chest pain, dizziness, palpitations, dyspnea, insomnia, nervousness, worry, decreased interest and depressed mood) compared to both specific abdominal diagnoses (p < .001) and non-specific abdominal pain (p = .002), (F(2,126)= 6.301, p = .002).

General health in the last month

Approximately 2/3 of the patients with organic dyspepsia rated their general health as ‘not so good’ compared to 1/5 of patients with specific abdominal diagnoses or non-specific abdominal pain, which is a significant group difference (p < .001) as shown in Table 4.

Table 4. Perceived health the last month in organic dyspepsia, specific abdominal diagnoses and non-specific abdominal pain among patients at emergency wards.

	Organic Dyspepsia	Specific abdominal diagnoses	Non-specific abdominal pain
	n = 19	n = 63	n = 55
Perceived health	(%)	(%)	(%)	p
Not so good (n = 34)	12 (63.2)^a	12 (19.0)	10 (18.2)
Good (n = 103)	7 (36.8)	51 (81.0)	45 (81.8)	<.001

Organic Dyspepsia; Peptic ulcer, Ventricular ulcer, GERD, gastritis. Specific Abdominal diagnoses; Gallbladder diseases, Diverticulitis, Ileus, Pancreatitis, Appendicitis, Chron’s disease, Ulcerous colitis, Ileus, Obstipation, Gastroenteritis, Ventricular tumor, Mallory-Weiss. Non-specific Abdominal pain; Acute Abdomen. Statistics: Maximum-Likelihood Chi-square followed by Fisher's exact test (two tail) in case of significance.

^aOrganic dyspepsia vs specific abdominal diagnoses and non-specific abdominal pain; p < .001.

Multiple linear regression revealed no significant associations between the length of stay and number of extra gastrointestinal symptoms (total or somatic or psychiatric) (F(3,133)=1.25, p = .292, R²=0.006) and perceived general health (F(1,135)=0.674, p = .413).

Attrition analysis

The attrition analysis revealed no differences regarding age (Mann–Whitney U-test), gender (Fischer’s exact test) or smoking habits (Maximum-Likelihood Chi-Square). Furthermore, no differences regarding length of stay (ANOVA) or proportions between the diagnostic groups were detected (Maximum-Likelihood Chi-Square).

Discussion

The main findings are that the organic dyspepsia patients had most co-occurring somatic, anxiety and depression symptoms alongside poorer perceived health during the month before admittance to emergency care. Non-specific abdominal pain patients showed comparably fewer deviations with specific abdominal disorder patients. Generally, strong relations were noted between comorbid somatic and psychiatric symptoms, chiefly insomnia, depression, and anxiety, in abdominal pain patients.

This is in line with the distinguishable patterns of personality traits previously illustrated in the three abdominal pain groups, where the organic dyspepsia group also differed most from the specific abdominal group [36]. In particular, the high harm avoidance noted in organic dyspepsia harmonises well with the present observations of high comorbidity in patients with psychiatric disorders, especially anxiety and depressive disorders [37,42,43]. Furthermore, our results parallel those of a previous study showing that organic dyspepsia may be differentiated from specific abdominal disorders regarding both personality and hypochondriasis [44]. Additionally, the observed tendency of more frequent contacts with the psychiatric clinic by the organic dyspepsia patients provides further support for more psychiatric comorbidity among these patients, compared to the other two diagnostic groups.

Higher frequency of psychiatric symptoms was noted in organic dyspepsia patients compared to the other groups including worrying, insomnia, palpitations, chest pain, dizziness, and criticism for alcohol drinking. All of the symptoms, except criticism for alcohol drinking, are reckoned in DSM-5 as symptoms of anxiety disorders, in particular generalized anxiety and panic disorders [45]. Of note, two of the cardinal symptoms of depression i.e., the compromised interest or pleasure in doing things and more depressive feelings or hopelessness tended to be more frequent in organic dyspepsia. Since insomnia may also be a symptom of depression, a higher occurrence of comorbid depressive symptoms may be implied in organic dyspepsia.

Furthermore, the number of concurrent somatic symptoms associated significantly and positively with the symptoms of anxiety and depression in the abdominal pain patients, in particular organic dyspepsia consistent with previous results from a surgical department [16]. More exactly, they related strongly to worrying, being nervous or anxious, on the edge, sleeping problems, low interest, or pleasure in doing things and depressive feelings or hopelessness. These symptoms primarily belong to generalized anxiety or depression disorders according to the diagnostical manual the DSM-5. This suggests that the recognized high comorbidity of psychiatric and somatic disorders [11,32,36] is also valid for emergency care [6,14,46,47]. Hence, a substantial part of the concurrent somatic symptoms may be indicative of psychiatric, as well as somatic morbidity. Considering that only a few criteria of the psychiatric disorders are used for screening in the Prime-MD, the present findings are suggestive, but not conclusive, of more depression and anxiety disorders comorbidity in organic dyspepsia diagnosed in emergency care.

It is possible that the frequent comorbidity between organic dyspepsia and psychiatric related symptoms may be mediated through secretion of gastrin shown to respond differently to stress and personality in patients with organic dyspepsia/peptic ulcer disease versus normal controls [48]. Previously, before the era of Helicobacter pylori, the focus was more on psychiatric factors in the search for organic dyspepsia etiology but, despite the fact that the present study does not allow any causal conclusions, the results still underscore this research field as worth exploring.

Overall, the organic dyspepsia patients seem to have endured markedly more disease burden, manifested by that as many as 64% perceived not so good health. This is considerably higher than found in the other groups and could reasonably be linked to the numerous comorbid psychiatric and somatic symptoms. Additionally, they also needed a slightly longer stay at the hospital than those with non-specific abdominal pain and one as long as those with specific abdominal disorders, some of them having a serious medical condition e.g., cancer. Decoding what exactly motivated the relatively long stay is not straightforward, as in general the duration of the stay was neither found to be influenced by perceived health, nor by the number of concurrent somatic or psychiatric symptoms in the whole group. Yet, it cannot be excluded that the more frequently occurring psychiatric symptoms and personality deviations in organic dyspepsia [27–29] are involved in the somewhat longer hospital stay.

Taken together, the present data suggest that patients with organic dyspepsia may benefit from psychiatric consultations to identify treatable psychiatry comorbidity in line with reports from surgical units [2,16].

Noteworthy, the specific abdominal disorder group included all abdominal diagnoses of organic genesis except organic dyspepsia. Hence, it may be assumed that at least part of the diseases was of a more severe nature, demanding hospital treatment and longer hospital stay, compared to the non-specific abdominal pain group without any distinct somatic cause. The specific abdominal disorder group most probably represents individuals contracting an acute surgical disorder not clearly related to any psychiatric morbidity, but rather mirrors normal surgical inpatient populations. Hence, this group was used as a proxy for the normal population when exploring possible psychiatric comorbidity in the other groups. However, some influences of ongoing acute abdominal disease on psychiatric symptoms cannot be fully excluded.

The patients with non-specific abdominal pain did not manifest as many co-occurring symptoms, although more headaches, insomnia and criticism for alcohol drinking were revealed when compared to those with specific abdominal disorders. On the other hand, chest pain, palpitations and worrying were less frequent during the month before arrival than in the organic dyspepsia group, suggesting less co-occurrence of anxiety symptoms. This is slightly unexpected with regard to previous literature on functional gastrointestinal disorders, indicating high co-existence with psychiatric related symptoms [19–21]. One plausible explanation is that individuals enrolled in the group suffered from some acute, but transient etiological factor, not always detected by the routine investigation at the emergency ward. If so, this group would rather represent a normal population similar to the specific disorders group. The shorter length of stay at the hospital supports such a theory while reports showing a chronic course of non-specific abdominal pain contradicts it [30,31].

We found Prime-MD to be a practical tool in the screening of psychiatric morbidity in the diagnostic work at the emergency ward as it included both psychiatric and somatic symptoms thereby facilitating the practitioners’ awareness for possible comorbidity.

One major strength of this study is the use of gastroscopy examinations for determination of organic dyspepsia which were also undertaken directly without lag time, during which self-healing may occur [49,50]. To date, gastroscopy is the only reliable method for the correct diagnosis of organic dyspepsia, since no available data have shown that gastrointestinal conditions may be identified by questionnaire results [51,52]. Finally, the diagnose was determined after examination by a senior consultant from the surgical clinic through strict use of organic dyspepsia criteria and the requirement the symptoms to be based on gastroscopy findings and related to gastric acid. Other diagnoses usually comprised in the concept of organic dyspepsia (e.g., ventricular tumors) were sorted as specific abdominal diagnoses. Regardless, a longitudinal dimension was added to ensure that all diagnoses were correct, by searching medical records for diagnoses 7 years before and after the hospital stay. Hence, one major advantage of the study compared to previous research is the reliable diagnostic work-up, and in particular the verification of organic dyspepsia diagnosis through gastroscopy coinciding with the psychiatric investigation [36].

The study has some limitations which should be considered. The total number of patients is limited leading to that the size of the organic dyspepsia group is small. This suggests that some relevant associations were most likely missed, and the results must therefore be interpreted with caution. However, since proportionally strong associations with comorbid psychiatric morbidity repeatedly appear in accordance with earlier studies [23–26,36,53], we presume present results have some validity and warrant replication studies on larger populations. Unfortunately, diagnostical psychiatric interviews were not used and therefore no definitive conclusions regarding comorbidity of psychiatric disorders could be put forward.

Another consideration is whether the noted differences between organic dyspepsia and the other two diagnostic groups are due to the selection of diagnoses included in the groups. This cannot be ruled out without a specific analysis of psychiatric symptoms for every diagnosis, especially within the group of specific abdominal diagnoses. However, we find such an explanation unlikely, as the findings of more psychiatric symptoms in patients with organic dyspepsia compared to other abdominal disorders, is in agreement with primary care [22] and normal population investigations [23,24] were several different diagnoses were included although adding other specific diagnoses into the organic dyspepsia diagnosis [23,24]. Noteworthy is that our study extends these prior observations to also include emergency departments.

Prime-MD is based on the DSM-IIIR version [54] that deviates in some aspects from the latest version, DSM-5.However, as the screening symptoms are the same in both versions this does not influence the interpretation of presented data. Compared to those with specific abdominal diagnosis, patients with organic dyspepsia and non-specific abdominal pain admitted to more problematic alcohol use. These findings could be a potential confounding factor since alcohol use is also associated with psychiatric and gastrointestinal symptoms [55]. Nonetheless, self-report studies have demonstrated a link between peptic ulcers and some psychiatric conditions (mostly anxiety disorders) irrespective of alcohol and drug problems. This suggests that alcohol problems are not a major confounder, at least regarding psychiatric associations of organic dyspepsia [24].

The presented findings could not be explained by other plausible confounders comprising gender, smoking habits, and frequency of hospital contacts within 7 years before and after the visit, as there were no identifiable group differences. The attrition rate of 19.2% of all invited to participate is acceptable in individuals with acute abdominal symptoms staying at emergency care. The attrition group showed no difference concerning age and gender compared to the participants which suggest attrition had limited impact on results.

In conclusion, organic dyspepsia patients showed more co-occurring somatic, anxiety and depression symptoms and poorer perceived health than other patients with abdominal pain. Non-specific pain patients revealed less psychiatric comorbidity, which implies the symptoms were of a more transient nature. Taken together with the observed strong associations between comorbid somatic and psychiatric symptoms, the results highlight the need for psychiatric evaluation of abdominal pain patients and in particular for those receiving organic dyspepsia diagnosis in emergency wards.

Acknowledgements

The authors thank Maria Einarsson for important contributions in the revision of the paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Supported by a grant from the Research Council of Southeast Sweden (FORSS) who had no influence on the study design, data collection, analysis and interpretation of data, decision to write the report or the decision to submit for publication.