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Abstract

The history of gastroenterology is rich with observations that patients with chronic gastrointestinal symptoms, such as abdominal pain, constipation, diarrhea, and esophageal spasm, often display symptoms suggestive of concomitant emotional disturbance. The classic writings of Bockus et al9 and Alvarez,2 among others, are filled with such references. Alvarez,2 in writing about irritable bowel syndrome (IBS), described his IBS patients as being “tense, sensitive, nervous and having a worrisome temperament. They may be calm externally, but they usually seethe internally, and any strong emotion is likely to affect all those organs which are under the control of the autonomic nerves.” Bockus9 described IBS patients as “constipated, dyspeptic, depressed, introspective, exhausted, emotionally unstable or asthenic.” These observations are unacceptably vague and nonspecific when viewed from a contemporary perspective. The observations of these gastroenterologists also have been made obsolete by cultural changes that have occurred throughout the twentieth century. Because these disorders are seen more commonly in women, qualitative descriptions of these patients often have been influenced negatively by perceptions tainted by gender bias. The first step toward scientifically studying the functional gastrointestinal disorders was to create a common nomenclature for clinicians and for investigators.For most of the twentieth century, the absence of standardized diagnostic criteria for functional gastrointestinal and psychiatric disorders hampered precise description and classification of these syndromes. In the last 15 years, however, significant advances have been made in diagnosis and classification of patients who suffer from functional gastrointestinal disorders. Beginning in 1988, international working teams that convened in Rome have formulated diagnostic criteria (Rome criteria) for the functional gastrointestinal disorders revolving around the various anatomic regions of the gut. The most recent update of these criteria was published in 2000.24, 25 These diagnostic criteria for functional gastrointestinal disorders are not meant to be a conclusive document. Rather they are designed to provide a common basis for clinical description and research. In that sense, the Rome and Rome II criteria represent a living document that continues to be refined as knowledge improves. The diagnostic criteria for IBS, the most common functional gastrointestinal disorder, are listed in Box 1.74 Although these criteria have not been validated completely, preliminary studies suggest that they describe adequately the key clinical features of IBS.83 The real value of the Rome II criteria lies in more standardized descriptions of functional gastrointestinal syndromes, however, and a move away from the use of vague terms, such as abdominal pain, bloating, or cramping, which in themselves have little meaning. Using standardized nomenclature to differentiate functional gastrointestinal syndromes can help differentiate functional dyspepsia from IBS or functional abdominal pain (Boxes 2 and 3). This more standardized nomenclature can be extremely helpful in designing treatment trials, epidemiologic studies, and studies of medical comorbidity and extraintestinal manifestations.76 By describing more precisely the various functional gastrointestinal disorders, the psychosocial factors associated with each of them can be defined more precisely.A parallel process has evolved in psychiatry. The publication of the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM III) by the American Psychiatric Association in 1980 and the subsequent publication of the DSM III-R (1987) and DSM IV (1994) have contributed immensely to the standardization of psychiatric nomenclature.3 The ability to apply standardized nomenclature for the various psychiatric disorders enhances further the quality of research undertaken to correlate psychiatric disturbance with functional gastrointestinal complaints.