The Development of a Cognitive Scale for Functional Bowel Disorders BRENDA B. TONER, PHD, CPSYCH, NOREEN STUCKLESS* PHD, ALISHA ALI, M S C , FIONA DOWNIE, BSC, SHELAGH EMMOTT, PHD, CPSYCH, AND DONNA AKMAN, MSC, CPSYCH ASSOC Objective: The importance of psychosocial factors in patients with Functional Bowel Disorders (FBD) has been well-established. However, most psychosocial measures used in research with FBD patients were not designed or validated on this population. A recent international team report recommended that psychosocial measures be developed to increase our understanding and treatment of FBD. The purpose of this study was to develop a reliable and valid instrument designed specifically to assess cognitions of patients with FBD. Method: An initial set of 204 scale items was generated from a large pool of thought diaries from patients diagnosed with FBD. [terns were additionally refined using several methods, including consultation with a multidisciplinary team of international experts on FBD. The remaining 95 items were administered, along with a set of validating questionnaires, to a new sample of 75 FBD patients in Canada and the United States. Results: The findings indicate that the final 25-item scale has high reliability (Cronbach's a = .93; inter-item correlation = .36); high concurrent criterion validity evidenced by the correlation of the scale with a global rating of life interference caused by bowel symptoms (r = .71; p < .001); acceptable convergent validity evidenced by the correlation of the scale with the Dysfunctional Attitudes Scale (/• = .38; p < .01); high content validity and face validity; and minimal social desirability contamination (r = .15; NS). Conclusions: The Cognitive Scale for Functional Bowel Disorders is a valid and reliable scale that can be used as an outcome measure in evaluating the efficacy of different forms of psychotherapeutic intervention for FBD, and can also serve as a helpful assessment tool for health professionals working with patients diagnosed with FBD. Key words: functional bowel disorders, scale development, cognitive-behavioral therapy, irritable bowel syndrome. FBD = functional bowel disorders; DAS = dysfunctional attitudes scale; IBS = irritable bowel syndrome; CS-FBD = cognitive scale for functional bowel disorders; ENS = enteric nervous system; CNS = central nervous system. INTRODUCTION FBD are very common, chronic disorders that significantly interfere with quality of life (1). They are estimated to affect 8% to 19% of the general adult population in a given year (2-5,). Although most affected individuals do not seek med- ical attention, those who do seek medical consultation and treatment for these disorders make extensive use of the health care system. FBD accounts for 3.5 million physician visits every year and for 20% to 70% of all referrals made to gastroenterologists in Western societies (6-13). The cost to the health care system and the general eco- nomic impact of FBD is considerable. These disorders lead to over 2 million prescriptions per year in the United States (14) and are associated with unnecessary and often harmful tests, procedures, and surgeries (15, 16). FBD have been ranked as the second most common cause of industrial absenteeism caused by illness, next to the common cold (14, 17), and they account for 8 billion dollars of physician, laboratory, and radiology charges annually in the United States white popu- lation. All of these factors demonstrate the importance of cost-effective evaluation and treatment of patients with FBD. Consensual criteria now exist (18) to diagnose FBD, depending on the predominant symptoms of functional con- stipation, functional diarrhea, and chronic functional abdom- inal pain. However, no physiological or psychosocial markers From the Women's Mental Health Research Programme, Clarke Institute of Psychiatry (B.B.T. A.A., F.D., S.E., D.A.). Women's Mental Health Programme and Department of Psychiatry (B.B.T.), University of Toronto, and Division of Society, Women & Health, Women's College Hospital (N.S.) and Department of Psychiatry(N.S.), University of Toronto, Toronto, Ontario, Canada. Address reprint requests to: Brenda B. Toner, PhD, CPsych, Women's Mental Health Research Programme, Clarke Institute of Psychiatry, 250 College St., Toronto, Ontario M5T IR8 Canada. Received for publication July 30, 1997; revision received November 10, 1997. for FBD have been identified. Rather, several predisposing, precipitating, and perpetuating factors have been identified as contributing to the expression and maintenance of FBD. As summarized by Drossman (1), IBS, the most prevalent and clinically significant diagnostic group, is best conceptualized using a biopsychosocial framework. Symptoms may be gen- erated from physiological disturbances (enhanced motility and visceral sensation), which are closely connected to central nervous system activity (via the central nervous system- enteric nervous system axis). The clinical expression of these symptoms (eg, the decision to take medication or seek health care) is strongly influenced by psychosocial factors (13, 19, 20). For this reason, the high frequency of psychosocial disturbance (eg, psychiatric diagnoses, sexual abuse history) in the absence of modulating factors (eg, social support, coping strategies) reported among IBS patients may, in part, relate to their self-selection into referral practices. The importance of psychological factors in patients who seek repeated specialized consultation for FBD has been well documented (13, 21). However, there have been surprisingly few controlled studies investigating psychological treatments for FBD patients. The most common treatment approach to date includes cognitive-behavioral packages (20). Within the last 12 years, there have been nine controlled studies involving cognitive and/or behavioral therapy packages (22-30). In general, studies found a reduction in bowel symptoms and psychosocial distress. However, to date, no study has mea- sured the association between cognitive change and reduction in bowel symptoms using validated cognitive measures for FBD. Although these studies are promising in that they support cognitive-behavioral principles in the treatment of FBD, they suffer from substantial methodological flaws that limit the interpretation of their findings (20). One of the most serious limitations of work in this area is that most assessment and outcome measures used in research with patients having FBD were not designed and validated on this population. The majority of psychosocial questionnaires were normalized on psychiatrically ill or healthy populations. A recent interna- tional team report (31) recommended that measures be devel- oped that are relevant to the psychosocial concerns of patients with FBD. A review of the literature indicates that there are no 492 0033-3174/98/60O4-O492$03.00/0 Copyright © 1998 by the American Psychosomatic Society Psychosomatic Medicine 60:492-497 (1998)