Illness Perceptions in Journal of Health Psychology

Copyright 2003 SAGE Publications

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People with Acute www.sagepublications.com
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Bacterial Gastro- Vol 8(6) 693704; 038238

Enteritis Abstract
Functional gastro-intestinal
disorders (FGID) like irritable
bowel syndrome (IBS) are common
and can develop after gastro-
enteritis. Illness representations
may be important influences on the
development of post-infectious
FGIDs. Here, we studied both the
relationship between prior chronic
SALLY D. PARRY, SALLY CORBETT, symptoms (FGIDs) and illness
PETER JAMES, J. ROGER BARTON, & perception during an acute illness
MARK R. WELFARE (bacterial gastro-enteritis) as well as
University of Newcastle Faculty of Medicine, UK the relationship between illness
perception during an acute illness
(bacterial gastro-enteritis) and the
subsequent development of chronic
S A L LY D . PA R RY ,
MB, is a Teaching and Research abdominal symptoms. Two hundred
Fellow at the University of Newcastle Faculty of and seventeen people with recent
gastro-enteritis completed a
Medicine, North Tyneside Hospital, UK.
questionnaire asking about gut
symptoms consistent with a
S A L LY C O R B E T T , PhD, is a Research Health
diagnosis of IBS, functional
Psychologist at the University of Newcastle Faculty of dyspepsia or functional diarrhoea
Medicine, North Tyneside Hospital, UK. and the Illness Perception
Questionnaire. Those without a
P E T E R JA M E S ,
D.Clin.Psych., is a Clinical Health prior FGID were followed up and
Psychologist in the Northumbria Health Care Trust, completed a similar gut
North Tyneside Hospital, UK. questionnaire at six months. People
with a prior FGID had significantly
more symptoms and scored
J . R O G E R BA RT O N ,
PhD, is Professor of Clinical
significantly higher on the timeline
Medicine at the University of Newcastle Faculty of
and consequence scores than those
Medicine, North Tyneside Hospital, UK. without. People who developed a
FGID had a non-significantly higher
M A R K R . W E L FA R E , MD, is Senior Lecturer at the number of symptoms and higher
University of Newcastle Faculty of Medicine, North consequence and timeline scores
Tyneside Hospital, UK. than those who did not. Neither
comparative group differed in the
control/cure scores or causation
scores. The implications of the
findings are discussed.
AC K N OW L E D G E M E N T S . This work was funded by a grant from
Northumbria Healthcare NHS Trust.
Keywords
COMPETING INTERESTS: None declared.
bacterial gastro-enteritis, functional
ADDRESS. Correspondence should be directed to: gastro-intestinal disorders, illness
S A L LY D . PA R RY , Northumbria Division, University of Newcastle perceptions, irritable bowel
Faculty of Medicine, North Tyneside Hospital, Rake Lane, UK. syndrome

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JOURNAL OF HEALTH PSYCHOLOGY 8(6)
Introduction
F U N C T I O NA L gastro-intestinal disorders
(FGIDs) such as irritable bowel syndrome (IBS)
are very common in the general population,
being responsible for approximately one in 12
consultations in primary care in the UK (Royal
College of General Practitioners, 1995) and 50
per cent of all gastroenterology out-patient
appointments (Ferguson, Sircus, & Eastwood,
1977; Harvey, Salih, & Read, 1983). They also
have significant effects on patients quality of
life (Whitehead, Burnett, Cook, & Taub, 1996).
FGIDs are defined by the presence of particular
symptom complexes in the absence of any
evidence of organic disease and are commonly
associated with psychological and emotional
problems (Bennett, Tennant, Piesse, Badcock,
& Kellow, 1998; Dancey, Taghavi, & Fox, 1998;
Whitehead, 1996). In addition to IBS, other
common FGIDs include functional diarrhoea as
well as those related to the upper gastro-
intestinal tract, such as functional dyspepsia.
Increasing evidence suggests that FGIDs result
from interactions between subtle abnormalities
of gut motility and somatic sensation and cogni-
tive, behavioural and emotional factors. Increas-
ingly it is also being recognized that IBS may
develop after triggers such as an episode of
bacterial gastro-enteritis (Gwee, Leong,
Graham, McKendrick, Collins, Walters, Under-
wood, & Read, 1999; McKendrick & Read,
1994; Neal, Hebden, & Spiller, 1997; Rodriguez
& Ruigomez, 1999). Bacterial gastro-enteritis is
typically a self-limiting disease and persistence
of infection is rare with the majority of cases
clearing the bacteria from the stools within three
weeks (Jones & Harrop, 1981; Noguerado,
Garcia-Polo, Isasia, Jimenez, Bermudez, Pita, &
Gabriel, 1995). We have recently reported in a
community case-control prospective study that
the odds ratio of a person with recent bacterial
gastro-enteritis developing post-infectious IBS
at six months is 10.10 (95% CI [3.2330.69])
(Parry, Barton, & Welfare, 2002). We have also
found that people with bacterial gastro-enteritis
are more likely to have a prior FGID compared
with controls (odds ratio = 3.30 [95% CI
2.175.00]) (Parry, Barton, & Welfare, 2003).
Illness perceptions are psychological
constructs that can be used to explore and
understand the ways that patients can be active
694
participants in the health care process. One
widely cited framework for predicting the
impact of illness beliefs is the self-regulation
model of Leventhal (Leventhal, Nerenz, &
Steele, 1984), which has received considerable
empirical support and theoretical development
(Leventhal, Benyamini, Brownlee, Diefenbach,
Levanthal, Patrick-Miller, & Robitaille, 1997;
Leventhal & Diefenbach, 1991). This suggests
that the way in which individuals develop cogni-
tive and emotional responses to illness gives rise
to individualized cognitive, problem-based and
emotional coping mechanisms. The model
suggests that illness perceptions are therefore
possible factors influencing medical, psycho-
logical (depression, self-esteem, life satis-
faction) and behavioural outcomes in patients
with chronic illnesses.
Weinman, Petrie, Moss-Morris and Horne
(1996) used five components of Leventhals
model of cognitive representation of disease to
develop the Illness Perception Questionnaire
(IPQ), which taps an individuals lay represen-
tation of illness in relation to a particular
medical condition. These five domains are:
Identity, which describes whether the patient
presently experiences the symptoms of their
illness; Causation, which describes their percep-
tions about what caused their illness in the first
place; Timeline, which describes whether they
feel that their illness will last for a long time;
Consequences, which describes whether they
feel that their illness has or will have serious
consequences; and Control/cure, which
describes whether they feel in control of their
illness and anticipate that they will be cured by
their treatment. Because of the comprehensive
nature of this questionnaire, this instrument is
applicable in a range of settings and for a variety
of purposes. For example, the IPQ has been
used to compare cognitive representation of
disease between different patient groups
(Scharloo, Kaptein, Weinman, Hazes, Willems,
Bergman, & Rooijmans, 1998) and in the evalu-
ation of the relationship between cognitive
factors, coping behaviour and disease outcomes
(Sacks, Peterson, & Kimmel, 1990; Scharloo,
Kaptein, Weinman, Bergman, Vermeer, &
Rooijmans, 2000).
To date, few studies have examined the illness
perceptions of patients with gastrointestinal
disease and none with FGIDs, although there
 PARRY ET AL.: ILLNESS PERCEPTIONS OF ACUTE BACTERIAL GASTRO-ENTERITIS
are many a priori reasons why cognitive factors
may affect patients experience of the illness and
vice versa. In addition, there are few prospective
studies of illness representation to validate the
model and confirm that cognitive representation
of illness really does influence coping and
disease outcomes. Post-infectious FGIDs
including IBS thus provide an excellent oppor-
tunity to explore the model of illness represen-
tation prospectively and longitudinally in a new
disease setting. In this study we are focusing on
two areas of interest. First, the effect of prior
chronic symptoms (FGIDs) on illness percep-
tion during an acute illness (bacterial gastro-
enteritis). At present little is known about the
effect of chronic symptoms of one illness on
illness perception during another illness. This is
of interest because we hypothesized that people
suffering from a FGID may experience a more
severe illness perception with bacterial gastro-
enteritis. Second, we were interested in the
relationship between illness perception during
an acute illness (bacterial gastro-enteritis) and
the subsequent development of chronic abdomi-
nal symptoms. This is of interest because we
hypothesized that people who experience a
more severe illness perception with bacterial
gastro-enteritis may be more likely to develop
chronic abdominal symptoms consistent with a
FGID at six months.
The relationship between illness perception
during an acute illness and later symptoms and
function has only been studied in myocardial
infarction as far as we are aware. Previous
studies on illness perceptions in hospital in-
patients with myocardial infarctions have noted
that negative expectations about their illness
and the future are associated with a slower
return to work and impaired functioning
(Byrne, 1982; Maeland & Havik, 1987). A longi-
tudinal study has looked at patients initial
perceptions of their myocardial infarction to see
if illness perceptions could predict subsequent
attendance for rehabilitation, return to work,
disability and sexual dysfunction (Petrie,
Weinman, Sharpe, & Buckley, 1996). It was
found that the patients initial perceptions of
illness were related to different aspects of their
recovery, although the relationship was not very
strong. Illness perceptions in people with a self-
limiting illness to see if they could somehow
predict who might go on to develop a different
but possibly related illness such as a FGID, have
not been studied before.
The main aims of this study were twofold.
First, we wanted to assess illness perceptions of
people with bacterial gastro-enteritis diagnosed
on positive stool culture to see if there was any
difference between those with and without a
prior FGID. Second, we wanted to assess if
there was any difference in the illness percep-
tions of people with bacterial gastro-enteritis
who go on to develop a FGID at six months and
those who do not. This would enable us to
explore whether peoples perception of their
bacterial gastro-enteritis at the outset could
influence their likelihood of developing a FGID
at a later date. In addition we wished to provide
some descriptive data on the illness perceptions
of this cohort of patients who have not been
studied before.
Methods
Participants
All people between the ages of 1880 with a
positive bacterial stool culture identified
through the microbiology laboratories of
Northumbria Healthcare NHS Trust in the
north-east of England over a one-year period
were invited to participate in the study.
Exclusion criteria were inability to give
informed consent, pregnancy, current severe
psychiatric illness and chronic illnesses such as
cancer and inflammatory bowel disease that
would be predicted to affect abdominal symp-
toms.
Design
This study was a prospective, community-based
cohort study following patients with proven
bacterial gastro-enteritis for six months after
their initial diagnosis.
Baseline and outcome
measures
Rome II criteria for FGIDs Since FGIDs do
not show any specific biochemical or structural
abnormalities (Lennard-Jones, 1983), diagnoses
are defined by symptom criteria. A diagnosis of
IBS, functional dyspepsia or functional diar-
rhoea was made on the basis of the subjects
response to a questionnaire incorporating ques-
tions relating to the Rome II criteria. The Rome
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JOURNAL OF HEALTH PSYCHOLOGY 8(6)
II criteria for FGIDs have recently been refined
from the Rome I criteria which are widely
accepted (Drossman, Richter, Talley, Thomp-
son, Corazziari, & Whitehead, 1994) and a self-
report questionnaire as an instrument to assess
functional gastro-intestinal disease is estab-
lished (Tally, Phillips, Wiltgen, Zinsmeister, &
Melton, 1990). This has proved valid and repro-
ducible (Tally, Boyce, Owen, Newman, & Pater-
son, 1995). The applicability of Rome I to
patients seen in routine clinical practice has
been questioned, largely on the grounds that
symptoms need to be present consecutively
during the previous three months. The Rome II
criteria have been developed to address this
criticism of the Rome I criteria as being difficult
to apply. The new criteria state that symptoms
have to be present for a total of 12 weeks in the
last 12 months, which need not be consecutive.
For the purpose of research studies the criteria
can also be applied for other durations with the
duration of the symptoms being adjusted pro
rata (Drossman, Corazziari, Talley, Thompson,
& Whitehead, 1999).
The Illness Perception
Questionnaire
Illness perceptions were derived from the self-
complete IPQ, which has been shown to have
validity and reliability in several disease states
(Weinman et al., 1996). This has five domains,
four of which have summary scores as follows:
Illness identity (score 0 if response never and 1
for any other response; maximum score 12);
timeline (maximum score 15); consequences
(maximum score 35); control/cure (maximum
score 30). The illness identity items were
retained from the original IPQ article (Weinman
et al., 1996). These items refer to general symp-
toms such as fatigue, dizziness, loss of
strength, sleep difficulties as well as symptoms
that could be interpreted as being more specific
for bacterial gastro-enteritis like upset
stomach, nausea, weight loss.
Procedure
For a period of 12 months from January 2000 all
community cases were identified with a positive
stool culture from the local microbiology
laboratories. These cases were invited to partici-
pate in the study within two weeks of the stool
696
culture positive result. On consent, the cases
completed the gastro-intestinal disease ques-
tionnaire incorporating the Rome II modular
questions relating to IBS, functional dyspepsia
or functional diarrhoea at the start of the study
and six months later. At the start the cases were
specifically requested not to include their
symptoms relating to their recent episode of
diarrhoea. Baseline or prior FGID status was
assigned on the basis of the questionnaire
responses at the beginning of the study. Only the
cases without a prior FGID were eligible to
continue in the follow-up study and were asked
to complete the adapted Rome II modular ques-
tionnaire at six months, referring to symptoms
over the preceding three months only. Follow-
up FGID status was assigned on the basis of
responses to the Rome II questionnaire at six
months.
Shortly after initial recruitment, all cases were
asked to complete the IPQ in relation to their
recent gastro-enteritis. The IPQ was only filled
at baseline and was not repeated at six months.
Statistical analysis
Comparative statistics on group data (sex and
age) were calculated using 2 for sex and inde-
pendent t-test for age.
Differences between the proportion of people
agreeing, remaining neutral or disagreeing with
the cause of their illness were analysed using 2.
Binary multivariate logistic regression model-
ling was undertaken using the presence or not of
a FGID as the dependent factor with the IPQ
identity score, then the timeline score, conse-
quence score and control/cure score as the
explanatory variables to obtain estimated odds
ratio and 95 per cent confidence intervals. The
IPQ identity, timeline, consequence and
control/cure scores were catergorized using the
median scores of the whole cohort as the cut-off
value. FGIDs are more common in young
females and emotional factors are associated
with smoking (Kleinke, Staneski, & Meeker,
1983; Spielberger, 1986). Other variables thus
considered were age, sex and smoking. Vari-
ables with a p value of less than 0.05 were
retained in the model. Sex and smoking were
entered as categorical data.
Statistical analysis was carried out using SPSS
for Windows software package version 10.00.
 PARRY ET AL.: ILLNESS PERCEPTIONS OF ACUTE BACTERIAL GASTRO-ENTERITIS

Results between the groups. The mean percentage

scores agreeing with statements for causal
From an original cohort of 500 patients, 283 did
explanations were similar in both groups and
not respond or consent to follow up. Therefore,
using 2 no statistically significant differences
217 people with a recent positive stool culture
were found on any causal item. For people with
were recruited. Of the 217 cases recruited, 204
and without a prior FGID, the median and inter-
returned both the initial Rome II modular ques-
quartile range for their illness identity, timeline,
tionnaire and the IPQ. There were 122 cases
consequence and control/cure scores are shown
without a prior FGID and 82 cases with a prior
in Table 2. The responses to the IPQ identity
FGID. Of the 122 cases without a prior FGID
score of people without a prior FGID and those
who were followed up for six months, four with-
with were examined. People with six or more
drew and 11 did not return the six-month Rome
symptoms were nearly three times more likely
II modular questionnaire. Therefore 107 cases,
to have a prior FGID (adjusted odds ratio 2.84
42 per cent male, returned both the IPQ and the
(95% CI [1.75.8]). Statistically significant
six-month Rome II modular questionnaire.
differences were also found between the
Twenty-five (23.4%) cases, 11 men and 14
timeline and consequence scores and FGID
women, developed a FGID compared with 82
status (Table 3). No significant association was
(76.6%), 35 men and 47 women, who did not
found between control/cure scores and FGID
(Fig. 1).
status.
Looking at the whole cohort, the control/cure
scores were on the high side of the maximum
Differences between those with
score, the timeline scores on the low side and the
and without a FGID at follow up
consequence and illness identity scores in the
Of the 122 people eligible for the follow-up
mid-range of the maximum scores. The numbers
study, data is available on 107. Of these, 25
and mean percentage scores of patients agreeing
developed a FGID and 82 did not. There were
with statements for causal explanations are
no significant differences in age and sex between
shown in Table 1. Using 2 no statistically signifi-
the two groups. The mean percentage scores
cant differences between either comparative
agreeing with statements for causal explanations
group were found on any causal item.
were similar in both groups and using 2 no
significant differences were found on any causal
Differences between those with
item. For people who developed a FGID and
and without a prior FGID
those who did not, the median and inter-quartile
Of the 204 people with complete data, 82 had a
range for their illness identity, timeline, conse-
prior FGID on the responses to the Rome II
quence and control/cure scores are shown in
modular questionnaire and 122 did not. There
Table 4. The responses to the IPQ identity score
were no significant differences in age and sex
of people who developed a FGID and those who
Table 1. Causation scores: number of cohort agree- did not were examined. People with six or more
ing with statements as to the cause of their gastro- symptoms were two and a half times more likely
enteritis to develop a FGID (adjusted odds ratio 2.65
Consented cases (95% CI [1.017.04]). Statistically significant
with complete data Agree differences were also found between the time-
n = 204 (%) line and consequence scores and the develop-
Germ/virus 182 (89) ment of a FGID (Table 5). No significant
Diet 43 (21) association was found between control/cure
Pollution 14 (7) scores and follow-up FGID.
Family history 8 (4)
Chance 126 (62)
Stress 20 (10) Result summary
Own behaviour 19 (9) To summarize, significant differences appear to
Other people 47 (23) exist in the illness perception of people with
Poor medical care 3 (2) bacterial gastro-enteritis diagnosed by positive
My state of mind 9 (5) stool culture depending on whether or not they

697
JOURNAL OF HEALTH PSYCHOLOGY 8(6)

217 cases recruited (43% male, 57% female)

Mean age = 46.6
All sent Rome II modular questionnaire and then
pyschological questionnaires including IPQ at
baseline

204 returned both

Rome Q and IPQ

122 without a prior FGID 82 prior FGID

eligible to continue not eligible to continue

107 returned 6-month Rome

Q
(42% male)

(4 withdrew: 11 did not

return 6-month Rome (Q)

25 had a FGID on follow up 82 did not have a FGID

(23.4%): 11 male, 14 female on follow up (76.6%):
34 male, 48 female
16 IBS (15%)
6 F diarrhoea (5.6%)
3 F dyspepsia (2.8%)

Figure 1. Flow chart of recruitment.

Notes:
Rome Q = Rome II Modular Questionnaire.
IPQ = Illness Perception Questionnaire.
FGID = Functional gastro-intestinal disorder.
IBS = Irritable bowel syndrome.
F diarrhoea = Functional diarrhoea.
F dyspepsia = Functional dyspepsia.

698
 PARRY ET AL.: ILLNESS PERCEPTIONS OF ACUTE BACTERIAL GASTRO-ENTERITIS
Table 2. Frequency statistics for IPQbaseline study
Whole cohort Cases without a prior FGID Cases with a prior FGID
n = 204 n = 122 n = 82
Median Median Median
(IPQ) (IQR) (IQR)
Illness identity 6.00 5.00 7.50
(4.08.00) (3.07.25) (5.010.0)
Timeline 6.00 6.00 6.00
(4.007.00) (3.07.0) (4.08.25)
Consequence 16.00 15.00 17.00
(1319.75) (12.019.0) (14.021.0)
Control/cure 21.00 21.00 21.00
(19.024.0) (19.024.0) (19.024.0)
Notes:
FGID = Functional gastro-intestinal disorder.
IQR = Interquartile range.

Table 3. Adjusted odds ratiobaseline study

Adjusted estimated odds
ratio
No FGID Prior FGID (95% confidence interval)
Illness identity
Score 05 64 23 2.81 (1.545.13)
Score 612 58 59
Timeline
Score 35 60 28 1.84 (1.033.28)
Score 615 62 54
Consequence
Score 715 62 29 1.90 (1.073.39)
Score 1635 60 53
Control/cure
Score 620 60 32 1.56 (0.882.78)
Score 2130 62 50
Note:
FGID = Functional gastro-intestinal disorder.

Table 4. Frequency statistics for IPQfollow-up study

Follow up cohort No FGID at follow-up FGID at follow-up
n = 107 n = 82 n = 25
Median Median Median
(IPQ) (IQR) (IQR)
Illness identity 5.00 4.50 7.00
(2.007.00) (2.007.00) (4.008.00)
Timeline 6.00 5.00 6.00
(3.007.00) (3.007.00) (5.008.50)
Consequence 15.00 15.00 17.00
(12.0018.00) (11.7518.00) (14.5019.00)
Control/cure 21.00 21.00 22.00
(19.0024.00) (19.0024.00) (19.0024.00)
Notes:
IQR = Interquartile range.
FGID = Functional gastro-intestinal disorder.

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JOURNAL OF HEALTH PSYCHOLOGY 8(6)
Table 5. Adjusted odds ratiofollow-up study
No FGID
Illness identity
Score 05 50
Score 62 32
Timeline
Score 35 45
Score 615 37
Consequence
Score 716 49
Score 1735 33
Control/Cure
Score 620 39
Score 2130 43
Notes:
IQR = Interquartile range.
FGID = Functional gastro-intestinal disorder.
have a history consistent with a diagnosis of a
prior FGID. Those patients with a prior FGID
have higher IPQ scores in the illness identity,
timeline and consequence domains.
Comparing the follow-up groups, the patients
who went on to develop a post-infectious FGID
under study, also had a prior significant differ-
ence in the illness identity, timeline and conse-
quence domains.
In both the prior and follow-up comparative
groups no statistical differences were found
between the control/cure domain and FGID
status.
Discussion
Leventhals self-regulation model is used to
assess an individuals appraisal of their illness
and cognitive coping style. These constructs, as
measured by the IPQ, have been used in a
variety of ways. Previously they have been used
in studies in people with chronic diseases
together with other instruments to assess levels
of functioning (Scharloo et al., 2000; Scharloo et
al., 1998) or cognitive depression (Sacks et al.,
1990) and in acute illnesses such as myocardial
infarction, alone but sequentially, to help in
predicting functional recovery (Petrie et al.,
1996).
In our study, we assessed if people with a prior
FGID mentally represented their episode of
bacterial gastro-enteritis differently to those
700
Adjusted estimated odds
ratio
Follow-up FGID (95% confidence interval)
10 2.65 (1.017.04)
15
7 2.96 (1.068.32)
18
7 3.67 (1.3210.23)
18
11 1.08 (0.412.85)
14
without a prior FGID. We also looked to see if
people who develop chronic abdominal symp-
toms consistent with a diagnosis of a FGID after
bacterial gastro-enteritis had represented their
episode of bacterial gastro-enteritis differently
to those who did not.
Overall our results show that people generally
believed that a germ or virus caused their illness
and that chance played a role. Surprisingly,
pollution and diet were generally not perceived
to play a role in their gastro-enteritis in this
cohort of patients who had bacterial gastro-
enteritis that was most likely to have arisen from
food-borne infection. This could possibly repre-
sent the fact that people may have difficulty in
relating the term diet to food and it may be that
the IPQ would need adapting if further used in
people with gastro-intestinal symptoms. The
relatively low scores on the timeline and high
scores on the control/cure domains indicate that
patients did perceive bacterial gastro-enteritis as
being a self-limiting illness, which would resolve
relatively quickly.
People with recent bacterial gastro-enteritis
and a prior FGID had more symptoms relating
to their gastro-enteritis, thought their illness
would last longer and had greater consequences
than those without a prior FGID. The aetiology
of FGIDs are not yet fully understood but both
central and peripheral neurohumoral mechan-
isms are thought to be involved in symptom
generation (Collins, 2001). People who already
 PARRY ET AL.: ILLNESS PERCEPTIONS OF ACUTE BACTERIAL GASTRO-ENTERITIS
had gut symptoms consistent with a FGID
perceived a worse illness experience with
bacterial gastro-enteritis than those without a
prior FGID. We suggest that the higher illness
identity score in the prior FGID group may be
due to the presence of already sensitized
neuronal circuits, an accurate perception of the
illness experience or to an increased tendency to
attend to sensations through prior FGID
experience. The higher timeline and conse-
quence belief scores may reflect an accurate
reflection of a more intense and lasting under-
lying physiological process. They could reflect a
shift in perception through prior gut symptom
exposure. Indeed it is possible that concerned
beliefs about gut symptoms could be associated
with neurohumoral changes (Kiecolt-Glaser,
McGuire, Robles, & Glaser, 2002) that per-
petuate the underlying condition. A more inter-
esting finding is that people with recent bacterial
gastro-enteritis who go on to develop a post-
infectious FGID also had more symptoms,
believed their gastro-enteritis to be more
serious and would last longer than those who did
not develop a FGID. Factors involved in the
development of post-infectious FGIDs are still
being unravelled. The fact that people with
bacterial gastro-enteritis seem at more risk of
developing a post-infectious FGID if they have
more symptoms, perceive their gastro-enteritis
to be more serious and longer lasting could be
due to either physiological or psychological
mechanisms or a combination and interaction of
the two. From a physiological perspective, the
people with more symptoms who believe their
gastro-enteritis is more serious and longer
lasting may perceive their illness experience
reasonably. They may indeed suffer from a more
virulent form of bacterial gastro-enteritis and
suffer more severe symptoms for longer rather
than saying that the differences in illness percep-
tion identified play a causative or influential role
in the development of post-infectious FGIDs.
From a psychological perspective, it is known
that the reporting of physical symptoms is influ-
enced by psychological processes such as
perceived seriousness and other attentional
ones (Pennebaker, 2000). These health beliefs
as well as the presence of associated psycho-
logical morbidity distress such as anxiety or a
personal history of recent trauma will influence
symptom reporting (Pennebaker, 1994). In
addition, there is some evidence that IBS and
somatization disorder are associated (Miller,
North, Clouse, Wetzel, Spitznagel, & Alpers,
2001) suggesting that physical gut-related symp-
toms may be used by some to address unmet
psychological needs. The belief system con-
sistent with developing a somatization process
would be for people to perceive their condition
as more serious and long lasting (thereby
impacting on others in a way that meets needs).
These underlying psychological processes may
explain the relationship between health beliefs
and subsequent FGID. Finally it is possible that
brain (belief, emotions) and gut (neurohumoral,
immune) processes interact to prolong or
exacerbate an otherwise self-limiting bacterial
gastro-enteritis.
We acknowledge that this study does have
some limitations. First, in the absence of any
biological marker, the diagnosis of a FGID is
based on self-report of patients experience of
symptoms giving rise to the possibility of false
negative and false positive results. However, we
have used the most recently refined criteria for
diagnosing the FGIDs, the Rome II, which are
generally more restrictive in the diagnosis of
IBS than the Rome I criteria (Mearin, Badia,
Balboa, Baro, Caldwell, Cucala, Diaz-Rubio,
Fueyo, Ponce, Roset, & Talley, 2001; Robinson,
Lee, & Thompson, 2001). Our aim was to define
a specific population with a FGID in our cohort
by use of the Rome II criteria. Second, there is
the possibility that the results were confounded
by the reporting characteristics of the indi-
viduals. For example, with the illness identity
(symptom score), there is the possibility that
people with a prior FGID may have overlapped
their FGID symptoms with the bacterial gastro-
enteritis symptoms. The fact that the symptoms
tended to be general (i.e. pain rather than
abdominal pain) and the subjects were specific-
ally asked to complete the IPQ in relation to
their recent bacterial gastro-enteritis reduces
this possibility. In addition, we have found that
the differences in IPQ results relate to both
prior and future FGID suggesting that simi-
larities in illness perception occurs in people
who already have a FGID or who are at risk of
developing a FGID after bacterial gastro-enteri-
tis. There was also no significant difference in
causation or control/cure scores in both the
baseline and follow-up groups suggesting that
701
JOURNAL OF HEALTH PSYCHOLOGY 8(6)
the sub-scales discriminate well rather than
inferring a generalized reporting bias. Third, we
acknowledge the relatively small numbers
recruited into the follow-up study, and it may be
that due to inadequate power of the follow-up
study, greater differences in the IPQ score
domains between the people with and without a
post-infectious FGID have not been detected.
Finally, a revised version of the IPQ (the IPQR
(Moss-Morris, Weinman, Petrie, Horne,
Cameron, & Buick, 2002; White, 2001) has been
developed that incorporates the emotional
aspects of illness representation that were
included in Leventhals original model but
excluded from the original IPQ. The IPQR also
takes into account further information about the
psychometric performance of the original IPQ
and allows more detailed classification of
identification with symptoms by dividing them
into symptoms that the patient has and those
that they specifically attribute to the disease in
question. This allows possible separation of
somatization-type symptoms. The IPQR also
separates out the control/cure domain into
personal control and self-efficacy versus treat-
ment control and outcome expectations. One
reason for not detecting any differences in the
control/cure scores in this study may be because
of the grouping of the control/cure constructs in
the original IPQ. Unfortunately the IPQR had
not been published at the start of our study.
We suggest that further work is required to
discover more about the symptom perception
and monitoring of the internal states of patients
with FGIDs such as IBS, to see if individual
differences in symptom perception and moni-
toring of internal states can predict a diagnosis
of a current FGID or a future FGID after an
episode of bacterial gastro-enteritis. A larger
prospective case study recruiting people with
recent bacterial gastro-enteritis and previously
normal bowel habit would be necessary to assess
whether people who go on to develop a post-
infectious FGID persistently have prior differ-
ences in the illness identity, consequence and
timeline scores compared with those who do
not. In addition, such a study could utilize the
IPQR to assess further whether differences in
the control/cure domain are uncovered.
To conclude, FGIDs are common and can be
difficult to manage to the satisfaction of the
patient. Differences in the illness perception of
702
bacterial gastro-enteritis do exist between
people with a prior FGID and people without as
well as between people who do and do not go on
to develop a FGID. The difficulty however,
exists as to whether the observed differences are
due to attribution (differences in cognition) or
actual differences in symptom severity due to
virulence of the acute illness. If the observed
differences uncovered in this study relate to
physiological mechanisms then reducing the
level of physiological impact by, for example,
prescription of antibiotics should be considered.
However, if the observed differences uncovered
in this study do indeed relate to differences in
cognition, we can hypothesize that it might be
possible to reduce the morbidity associated with
any future episode of gastro-enteritis in people
with a prior FGID or reduce the likelihood of
people developing a post-infectious FGID by
using cognitive techniques. An example of one
such technique could be to elicit and challenge
misconceptions about gastro-enteritis (self-
limiting and no serious consequences) using
standard cognitive therapy approaches (White,
2001). Interventional studies would be the way
forward for elucidating whether the greater
differences in the IPQ relating to gastro-
enteritis in people who then develop post-
infectious FGIDs have a role in causing the
development of post-infectious FGIDs or arise
because of the differences in virulence of the
episode of gastro-enteritis.
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