Isr J Psychiatry Relat Sci - Vol.

52 - No 1 (2015)

Cognitive Appraisal and Psychological Distress

Among Patients with Irritable Bowel Syndrome
Menachem Ben-Ezra, PhD,1 Yaira Hamama-Raz, PhD,1 Sharon Palgi, MA,2 and Yuval Palgi, PhD3
1

School of Social Work, Ariel University, Ariel, Israel

Department of Psychology, University of Haifa, Haifa, Israel
3
Department of Gerontology, University of Haifa, Haifa, Israel
2

Abstract
Background: Irritable Bowel Syndrome (IBS) is a debilitating
condition that affects mainly the patients mental
health and quality of life. There is a gap in the literature
regarding the relationship between cognitive appraisals
and adjustment to physical and psychological aspects
resulting from IBS. The aim of the current study was to
explore the psycho-social factors that are associated
with psychological distress among IBS patients and the
contribution of cognitive appraisal to their adjustment.
Methods: One hundred and three patients diagnosed with
Irritable Bowel Syndrome participated in the study. Each
participant filled a battery of questionnaires targeting
demographic and psycho-social factors. The study
variables were analyzed via hierarchical regression along
with supplementary analyses of multiple mediation tests
of indirect effects.
Results: The findings showed that psychological
distress and depressive symptoms among IBS patients
are better predicted by their global positive illness
cognition appraisal, specific illness cognition appraisal
of helplessness, resilience and to a lesser extent by social
support, perceived optimism, illness cognitions appraisals
of acceptance and perceived benefit. Global positive
illness cognition appraisal gives us a sum of positive and
negative appraisals into one unified appraisal.
Conclusions: Our findings highlight the salience of
cognitive appraisal and resilience in IBS psychological
adjustment. It seems that IBS patients might benefit from
psycho-educational interventions designed to assist them

Address for Correspondence:

54

in reducing their helplessness appraisal and increasing

the appraisal of their ability to cope with the symptoms
of their illness.

Introduction
Irritable bowel syndrome (IBS) is considered a significant
functional gastrointestinal disorder, with prevalence
ranging from 10% to 15% (1). It occurs more often in
women than in men, and it begins before the age of 35 in
about 50% of people (2). IBS is also regarded as a chronic
illness that can dramatically affect the quality of life (3).
Psychiatric disorders, especially depression and anxiety,
occur in up to 94% of IBS patients (2). Psycho-social
factors may play an important role in the development
as well as in the outcome and prognosis of the disorder
(4). The aim of the present study was to explore the
psycho-social factors that are associated with psychological distress among IBS patients and the contribution of
cognitive appraisal to their adjustment.
The study is based on the theoretical framework of
Lazarus and Folkmans model of adjustment to stress (5-8).
This theory proclaims that cognitive appraisal, personal
resources and social resources might alleviate or exacerbate
the perceived stress experienced by an individual.
Cognitive appraisal has been defined as a process
through which the person evaluates whether a particular
encounter with the environment is relevant to his or
her well being, and if so, in what ways (9). This process involves both primary and secondary appraisals
that occur at the same time and interact in order to
determine the significance and meaning of the event

Prof. Menachem Ben-Ezra, School of Social Work, Ariel University, Ariel 40700, Israel

menbe@ariel.ac.il

Menachem Ben-Ezra et al.

in regard to well being (7). Primary appraisal considers

the perceived implications of the stressor for well being
through interpretation of stressful situation in one of
three possible outcomes: irrelevant, challenge or threat.
Secondary appraisal refers to a cognitive-evaluative process that focuses on minimizing harm or maximizing
gains through coping responses. It involves purposeful
evaluations of cognitive, affective and behavioral efforts
to manage the perceived stress (7-9). Empirical studies
show that cognitive appraisal affects adjustment to illness, including HIV (10), cardio-vascular disease (11),
and cancer (12). However, there is a gap in the literature
regarding the relationship between cognitive appraisal
and adjustment to physical and psychological aspects
among IBS patients. The main difference between IBS
patients and the aforementioned medical conditions is
the existence of life threatening conditions in comparison
to IBS which is a debilitating condition that affects quality of life without the component of threat for ones life.
Other factors mentioned in Lazarus and Folkmans
model are personal resources which may contribute
to the cognitive appraisal component and to adjustment. We chose two coping resources optimism and
resilience, which may be especially relevant in the case
of IBS patients due to the association between physical
condition and mental condition.
Optimism is described as a relatively stable, general
tendency of individuals to expect positive outcomes (13).
Individuals high in optimism typically have better psychological adjustment to negative life events, report less
distress across a broad range of stressful situations, have
more positive social networks, and enjoy better physical
health (14-16). Optimistic individuals are prone to show
higher self efficacy, and adapt to stressors more effectively
during time of crisis (17). Studies with various ethnicities
have demonstrated that higher levels of optimism predict
lower levels of depression and stress (18-20). Optimism
also may serve as a protective factor that promotes resilient
adaptation, as found among individuals with cancer (21),
and coronary heart disease (22, 23).
Resilience is defined as the ability to resist, cope with,
recover from, and succeed in the face of adverse life experiences (24). Resilience represents the ability of adults
in otherwise normal circumstances who are exposed
to an isolated and potential highly disruptive event to
maintain relatively stable, healthy levels of psychological
and physical functioning as well as the capacity for generative experiences and positive emotions (25). Resilience
also refers to important psychological skills and to the

individuals ability to use familial, social, and external

support in order to cope better with stressful events (26,
27). In light of this, we aim to explore the contribution
of social support to the IBS patients health.
The relationship between social support and health,
functioning, and quality of life is well established in the
literature (28-30). Two types of mechanisms have been
described when studying this relationship: The direct
positive path that relates to support and the buffering
effect, by which social support moderates the impact of
acute and chronic stressors on health (31). In the general
population, social support buffers against stressful life
events, increases adherence to medical treatments, and
improves recovery from medical illness, among other
health-promoting effects (28, 32-35). A recent study (4) has
found that among IBS patients, feelings of social isolation
existed regardless of the efforts of the family, friends and
some physicians to be supportive. The reasons were lack
of understanding relating to the complexity and severity
of the disorder. Additive strain from relative and friends
telling the patients to ignore or minimize their experience,
telling them to relax or do something else. These actions
have facilitated the creation of a social barrier impeding
normal functioning.
The goal of the current study was to further explore the
psycho-social factors that are associated with psychological
distress among IBS patients and to gain more information
on psychiatric symptoms and cognitive attitudes, which can
be further utilized in the development of psychotherapeutic
treatment strategies. More specifically, we assessed the
relationships between psychological distress and depressive
symptoms among IBS patients and their socio-demographic
and medical variables, personal resources resilience and
perceived optimism, interpersonal resource - social support and cognitive appraisal. Based on the aforementioned
studies, we hypothesize that IBS patients with higher resilience, perceived optimism, and perceived social support
will exhibited less psychological distress and depressive
symptoms. Our second hypothesis predicted that participants with the highest combination of positive cognitions
regarding their illness will have lower psychological distress
and depressive symptoms in comparison to those with
lower positive cognitions.
Method
Participants

One hundred and three patients diagnosed with Irritable

Bowel Syndrome participated in the study. The sample
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(2015)

consisted of 69 men and 34 women, aged 18-50. The average age was 24.53 (S.D. =6.243), 79.6% of the sample were
unmarried (n=82). No history of previous medical conditions or psychiatric illnesses was reported by the subjects.
Measures

Demographic and medical information: Digestive disease

report derived from the questions: Were you diagnosed
with IBS by a gastroenterologist? Did you suffer from it
for at least one year? Only participants who answered
yes to those questions were enrolled into the study.
The respondents provided demographical data: age,
gender coded as 0 = men, 1 = women, marital status
coded as 0 = unmarried, 1 = married.
The following self-report questionnaires were used in
this study:
Subscales of Cognitive appraisal were measured by the
Illness Cognition Questionnaire (ICQ) (36), which is
an 18-item scale intended to measure the personal perception of ones own illness and his ability to function.
The ICQ has three subscales: Acceptance, perceived
benefit and helplessness. High score in the acceptance
scale reflects positive cognitions regarding ones illness,
while perceived benefit and helplessness reflect negative cognitions regarding ones illness. The reliability of
these scales were very good (Acceptance: Cronbachs
alpha = 0.804; Perceived benefit: Cronbachs alpha =
0.851; Helplessness: Cronbachs alpha = 0.892).
Global positive illness cognition was measured by the
ICQ subscales using the median score of each subscale. In order to create the positive appraisal groups
we selected participants who had scored the following:
above the median in the acceptance sub-scale, under
the median in the perceived benefit and helplessness
sub-scales). This led to four groups: high global positive
appraisal and low global positive appraisal groups with
two intermediate groups.
Perceived optimism was measured by the single item
statement: given you current situation, do you consider yourself optimistic about the future? This item
was coded as 0 = no, 1 = yes.
Resilience was measured by the Connor-Davidson
Resilience Scale (CD-RISC) (37), which is a 25-item
scale intended to measure the personal resilience,
tolerance for negative affect and social support. High
scores reflect higher resilience. The reliability of this
scale was very good (Cronbachs alpha = 0.91).
Perceived social support was measure by a single item
56

Do you perceived yourself as reviewing enough social

support. This item was coded as 0 = no, 1 = yes.
Depressive symptoms were measured by the Short Center
for Epidemiologic Studies Depression Scale (SCES-D)
which is a 10-item scale intended to measure the severity
of depressive symptoms an individual experiences (38).
The items are rated by frequency on a 4-point scale,
where higher scores reflect higher risk for depression.
The reliability of this scale was very good (Cronbachs
alpha = 0.85).
Psychological distress was measured by the General
Health Questionnaire (GHQ-12) (39), which contains
12 items (e.g., felt you couldnt overcome your difficulties, been losing confidence in yourself ) for 12
specific psychological symptoms such as anhedonia
and personal competence. Each item is rated by its
frequency over the past few weeks on a 4-point scale.
Higher scores indicate poorer mental health. Cronbachs
alpha coefficient for this sample was 0.86.
Procedure

The participants were recruited from the largest internet

forum in Israel dealing with gastroenterology. The initial
message stated the inclusion criteria: (a) a Gastroenterologist
diagnosis of IBS, (b) 18-50 years of age. The rationale to
impose age limitation was in order to prevent sample bias.
Participants received the questionnaires via e-mail. Along
with the questionnaires, participants received instructions
and a short explanation as to the purpose of the study. After
the completed questionnaires were sent back by e-mail, a
verification process was begun by the research assistant (DA)
who asked the participants for their permission to contact
them via phone in order to verify relevant details while guaranteeing complete anonymity and to thank them personally
for their contribution to the study. Only participants who
were willing to participate in the verification process were
enrolled in the study, in order to prevent potential biases
that are known in internet studies (40). All the participants
were given the opportunity to request further information.
The study was approved by the Institutional Review Board
committee at the Open University.
Statistical methods

Four sets of hierarchical multiple regression were conducted, each one corresponding respectively to an outcome
variable (psychological distress, depressive symptoms) in
order to test hypotheses 1 and 2. The hierarchical regression
had four steps. The first step consisted of socio-demographic
variables (age, gender, marital status). The second step con-

Menachem Ben-Ezra et al.

sisted of personal variables (resilience, perceived optimism).

The third step consisted of a cognitive appraisal variable
(global positive illness cognition) which reflects one global
illness appraisal. The fourth step consisted of an interpersonal variable (social support). A preliminary analysis
was conducted for potential multicollinearity. Applying
the rules used in the literature stating that tolerance of
less than 0.20 and/or variance inflation factor (VIF) of 5
and above indicate a multicollinearity problem (41). The
preliminary analysis of the regressions yielded tolerance
ranging from 0.486-0.972 and VIF of 1.029-2.058. These
results have indicated that there was no multicollinearity
problem. Finally, additional supplementary analyses of
multiple mediation tests of indirect effects were conducted
based on the after mentioned hierarchical regressions (42).
Results
For basic information and correlation matrix, see Table 1.
In line with hypothesis 1 and 2, as seen in Table 2 and
3, higher depressive symptoms were associated with lower
level of global positive illness cognition appraisal ( = -.409;
t = -4.803; p>.001) in step 3 and step 4 ( = -.394; t = -4.701;
p>.001). In addition, higher psychological distress was associated with lower global positive illness cognition appraisal
( = -.509; t = -6.435; p>.001) in step 3 and step 4 ( = -.494;
t = -6.375; p <.001). For more information, see Table 2 and 3.
The results of the multiple mediation tests of indirect
effects showed that the following mediators were significant
when depressive symptoms were the dependent variable:
resilience ( = -.11; t = -3.69; p <.001), perceived optimism
( = -1.708; t = -2.027; p <.05), global positive illness cogni-

tion appraisal ( = -2.039; t = -4.701; p <.001) and perceived

social support ( = 1.763; t = 2.191; p <.05). This model
explained about 36% of the variance (R2 = .405; adjusted
R2 = .361; p < .001). For more information, see Table 2.
The results of the multiple mediation tests of indirect
effects showed that the following mediators were significant when psychological distress was the dependent
variable: resilience ( = -.13; t = -4.000; p <.001), global
positive illness cognition appraisal ( = -2.975; t = -6.375;
p <.001) and perceived social support ( = 2.090; t =
2.415; p <.05). This model explained about 45% of the
variance (R2 = .492; adjusted R2 = .454; p < .001). For
more information, see Table 3.
Discussion
The results have shown that psychological distress and
depressive symptoms among IBS patients are associated with
global positive illness cognition, specific illness cognition
of helplessness appraisal, resilience and to lesser extent by
social support, perceived optimism, illness cognitions of
acceptance and perceived benefit appraisals. These finding are in line with our hypotheses to some extent. While
showing that resilience, illness cognition of helplessness
appraisal add to the ample evidence that personal resources
help persons to cope with stressful or traumatic events
(7, 43) and account for at least some of the variability in
individuals adjustment to stressors (44, 45). The results
also provide further support for Lazarus and Folkmans
(7-9) claim that persons appraisals of stressful events are
more important to their psychological adjustment than
the objective stress of the events. Furthermore, our find-

Table 1. Baseline Characteristics of the Study Variables (n=103)

Predictors
Age

Mean (SD)
24.5 (6.2)

Gender (Men)

67.0

Marital status (Not Married)

Resilience

-.130

.519**
-.201*

-.065

79.6
93.2 (13.8)

Optimism

1.34 (.48)

Positive appraisal

1.66 (.96)

Social support

1.37 (.50)

Psychological distress

24.3 (5.8)

Depressive symptoms

19.6 (4.9)

-.115

.093

.043

-.068

-.045

-.079

-.010

-.045

-.031

.224*

.078

.063

-.007

-.047

-.084

-.091

-.171

-.130

.314**

.005

-444**

-.405**

-.045

.085

-.045

-.083

-.083

-596**

-.490**

.222*

.206*
.749**

Gender was coded as 0 = men; 1 = women

Marital status was coded as 0 = married/cohabitation; 1 = not married/cohabitation
Psychological Distress was measured by the GHQ-12.
Depressive symptoms were measured by the Short CES-D.
* p< .05; ** p<.01; ***p<.001

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Table 2. Hierarchical Multiple Regression Predicting Increased Risk of Depression (CES-D) (n=103)
Step 1: Model R = .181;
Model R2 = .033
Predictors

Standardized

Step 2: Model R = .474; Model

R2 = .224; R2 change = .191***
Standardized

Step 3: Model R = .612; Model

R2 = .375; R2 change = .150***

Standardized

Step 4: Model R = .636; Model

R2 = .405; R2 change = .030*
Standardized

Age

.060

.523

.031

.295

.034

.353

.043

.463

Gendera

.031

.308

.033

.366

.012

.144

-.027

-.328

Marital statusb

-.196

-1.675

-.210

-1.974

-.226*

-2.360

-.224*

-2.380

Resilience

-.435***

-4.792

-.307***

-3.562

-.312***

-3.691

Optimism

-.141

-1.555

Positive appraisal

-.145

-1.769

-.164*

-2.027

-.409***

-4.803

-.394***

-4.701

.180*

2.191

Social support
Gender was coded as 0 = men; 1 = women
b
Marital status was coded as 0 = married/cohabitation; 1 = not married/cohabitation
* p< .05; ** p<.01; ***p<.001
a

Table 3. Hierarchical Multiple Regression Predicting Increased Risk of Psychological Distress (GHQ-12) (n=103)
Step 1: Model R = .119;
Model R2 = .014
Predictors

Step 2: Model R = .477; Model

R2 = .228; R2 change = .213***

Standardized

Age

.054

.463

.016

.154

.019

Gendera

.064

.628

.070

.766

.043

-.106

-.901

Marital status

Standardized

Step 3: Model R = .679; Model

R2 = .460; R2 change = .233***

Standardized

Step 4: Model R = .701; Model

R2 = .492; R2 change = .031*
Standardized

.219

.029

.338

.560

.003

.041

-.117

-1.101

-.137

-1.542

-.135

-1.552

Resilience

-.466***

-5.152

-.307***

-3.839

-.312***

-4.000

Optimism

-.103

-1.134

Positive appraisal
Social support

-.108

-1.412

-.127

-1.695

-.509***

-6.435

-.494***

-6.375

.183*

2.415

Gender was coded as 0 = men; 1 = women

b
Marital status was coded as 0 = married/cohabitation; 1 = not married/cohabitation
* p< .05; ** p<.01; ***p<.001
a

ings contribute to the view of coping as contextual, that

is, influenced by persons appraisal of the actual demands
in the encounter and resources for managing them. The
emphasis on the context means that particular persons and
situation variables shape together the coping efforts (46).
More specifically, the findings highlight the importance
of resilience as an interpersonal resource that contributes to
ones ability to cope, function and adapt well to the stressful
situation. IBS patients who were less resilient were more
distressed and exhibited higher depressive symptoms.
Thus, if an individual exhibits behaviors associated with
low resilience, then there is an increased likelihood that the
individual will function poorly in stressful situations thus
showing lesser adaptation (47). Our findings are consistent
with the ample literature showing that individuals who
do not display a resilient adaptation exhibit difficulties
in regulating negative emotions and higher sensitivity to
stressful life events (48).
58

The global positive illness appraisal was found to be discriminant predictor of psychological distress and depressive
symptoms even more than resilience among IBS patients.
More specifically, global perception of ones illness gave
us a sum of positive and negative appraisals into one unified construct. This is somewhat similar to other known
predictors of physical and mental health in the literature
such as self-rated health (49) and subjective well-being (life
satisfaction) (50). This may lead to a rather bold argument
favoring the unified construct of illness perception over
its subscale. These subscales were less salient predictors of
psychological distress and depressive symptoms.
Perceived social support was another predictor of higher
level of depressive symptoms among IBS patients. This finding
is somewhat surprising in view of the direct positive effect
of support and the buffering effect, by which social support
moderates the impact of acute and chronic stressors on health
(4). Another study (51) posits that social support is strongly

Menachem Ben-Ezra et al.

correlated with the stress and coping process. Specifically,

social support is considered a moderator in the stress process.
Moderators are the variety of appraisals, coping strategies,
resistance factors, and vulnerabilities that modify how stress
is experienced and what its effects may be (52). Moderators
are believed to reduce the appraisal of stress when functioning
in a positive manner. By reducing the appraisal it indirectly
facilitates the coping process. A possible explanation might
be that family and friends concerns add emotional burden
to the feelings of shame and embarrassment that the IBS
patients already experience. IBS patients sense that their life
was interrupted while not grasping fully how their condition
encompasses every domain of their lives. In this context, a
study by Stansfeld (31) has found that among IBS patients, a
predominant theme was perceived social stigma when others
did not understand or accept their feelings (4).
Limitations
There are several study limitations to be noted. Firstly, we
did not identify many differences in health status and illness
severity, as have been showed by other studies (53). Secondly,
our samples mean age and gender distribution are different
to that of IBS subjects demographic characteristics found in
epidemiologic studies (54). We feel that this fact limits the
generalization of our findings. Another limitation relates to
the sample recruitment - using an internet forum sample.
One may claim this sample is different from other means of
survey. However, recent studies have shown that with regard
to clinical data, internet samples do not differ from other,
more traditional samples (40). One possible explanation may
be the fact there is a perception of anonymity which helps
people disclose information about themselves. In addition,
we received the completed questionnaires by personal email
and our research assistant (DA) corresponded with them,
thus helping to lower the level of anonymity and make it
similar to phone survey. Thirdly, important medical factors were not obtained probably because of strict ethical
considerations and reluctance of the participants to share
medical information. This is important as severity, duration
and comorbidity with other disorders may influence the
results of the study. Finally, the use of single item measurement for perceived optimism and perceived social support
may also impede generalization of our findings. However,
it should be taken into account that we used a wide battery of scales that have merits and the use of single item
measurement is a price to be paid when using a long and
extensive questionnaire as in our study. Moreover, the use
of single items is known in the literature (49, 50).

Clinical implication and future research

Our findings highlight the salience of cognitive appraisal

and resilience in IBS psychological adjustment. It seems
that IBS patients might benefit from psycho- educational
interventions (CBT based) designed to assist them in
reducing their helplessness appraisal and increasing the
appraisal of their ability to cope with the symptoms of their
illness. More specifically, a cognitive-behavioral treatment
approach may help clients reconceptualize their experience
with IBS from helplessness and hopelessness to resourcefulness and optimism, may help clients identify relationships
among thoughts, feelings, behaviors, the environment, and
IBS symptoms, and may empower clients to develop and
implement increasingly more effective ways of coping with
IBS in order to improve their quality of life (55). Moreover,
psycho-social professionals should present resilience-based
interventions to IBS patients in order to help them to adapt
better to adversity inherent in their illness. Further research
is suggested to examine other factors that affect adjustment
to IBS. A possible direction to explore is working with
families using psycho-educational techniques in order
to make social support effective. Group therapy within
a cognitive framing context in order to enhance positive
appraisals and reduce negative appraisals thus reduces
both psychological distress and depressive symptoms.
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