Functional gastrointestinal disorders are a group of digestive disorders caused by the interaction of physiological, psychological and social factors. As a gastroenterologist, how to assess the psychosocial status of patients? Many patients with functional gastrointestinal disorders are often associated with psychosomatic problems. About 40% of patients with functional dyspepsia have psychological problems. Functional constipation is slightly lower, accounting for about 1/3 of the patients; more than half of the patients with irritable bowel syndrome have psychosocial problems, the most prominent is the patients with functional abdominal pain. The degree of their combined mental and psychological disorders varies from person to person. Some patients have very mild symptoms and only need some appropriate explanations and guidance. In some patients, the problem of psychological disorders can be more pronounced, and unlike patients seen in psychological specialties, patients with functional gastrointestinal disorders seldom say, “I’m depressed,” or “I’m anxious,” when they visit the doctor. In the face of this situation, gastroenterologists are required to have a more comprehensive understanding of some of the emotional issues behind the symptoms of functional gastrointestinal disorders, and to master some communication skills. First, in the process of seeing such patients, some clues can often be found through their description of digestive symptoms. Patients will be particularly vivid description of the symptoms of the digestive tract itself, to functional dyspepsia, for example, patients in the description of epigastric bloating described this way: I eat a small bun will feel bloated, this bloating, “as if a small ball of skin in the stomach,” “with the nine months of pregnancy,” almost. “It’s almost like being pregnant for nine months. In fact, we can imagine that if we only eat such a small bun, it is unlikely to cause such a strong feeling of bloating. As we can see from this example, the patient’s description of the symptoms is vivid and at the same time somewhat exaggerated. The patient may also feel the symptoms particularly heavily. Taking bloating as another example, the patient may feel that the bloating symptoms make it impossible for him to do anything for the day, and even brushing his teeth and washing his face may be affected. I once came across a patient with irritable bowel syndrome who found the bloating so heavy and unbearable that she had to find a way to pass six farts when she woke up every morning before she could start her day. Moreover, the patient’s way of coping with these symptoms is very special. Take constipation as an example, the patient would say, “I cannot pass stools for a day, so I have to do something about it”, such as picking it up with the fingers or hammering the lower back with a hammer. Therefore, when the doctor listens to the patient’s description of the symptoms, their feelings and responses, and even their assessment of previous treatments, he finds that they are very characteristic, and in fact, these characteristics give us a hint that this patient may have problems in terms of emotions. Second, the doctor should pay attention to the patient’s expression and behavior during the consultation. For example, if the patient looks very depressed and does not know how to answer the simple questions asked by the doctor, but will come up with a sentence such as “living is too much suffering”, “it is better to die than to live”, etc., it suggests that the patient may have some depression. There is also a group of patients who will ask the doctor, “If there is nothing wrong with my stomach, why does it hurt? But you will find that your answer to this question has not been answered, he began to ask the second question, the third question …… They speak very fast, and do not seem to have listened attentively to the doctor’s answer, which is actually a sign of anxiety. Third, in the process of the previous consultation, the doctor should think about this functional gastrointestinal disease patients why his symptoms are so serious? Why did the doctor give him good treatment before that didn’t work? What does the patient mean by his GI symptoms? In other words, this patient is coming to see the doctor for digestive problems, and he has already had many tests and medications, so what is the purpose of his visit? If he has had an obvious incident of family discord, it is likely that he is using his GI symptoms to express his concern about his current strained family relationships, or to achieve relief from the current state of his family through his illness. In that case, we would be able to understand it well, and the next step would be better to help him come to terms with his GI symptoms. Usually, when the doctor mentions emotional problems, many patients will say, “I am the most open-minded in our organization, I give the most in our family, I don’t have anxiety, and I can never be depressed, and so on. However, when the doctor further asks him, “Do you have any unhappy things, is there anyone who always makes you angry? Such questions, the patient will often open the box, recounting a lot of things, home, units, coworkers have a lot to make him dissatisfied with the place, they are accustomed to blame these problems on others, these patients may have psychological problems. To try to accompany the family to understand the patient’s emotional and psychological situation and the family’s views on this, which requires the doctor to strategically control according to the patient’s specific situation, the more sensitive patients will be very jealous of this, I sometimes use the patient to leave the clinic to go to the measurement of the weight of the gap in time to collect the history of this. For patients who may have emotional and psychological problems, if their cognition is better, they can do some psychological assessment, for example, the most commonly used self-assessment scale of anxiety and depression, the accuracy of the self-assessment scale is easily affected by the patient’s subjective influence, but it still has a certain reference value. Units with the conditions can carry out anxiety and depression other assessment, such as the Hamilton anxiety and depression scale, which requires specially trained medical staff to complete. Units that do not have the conditions to do psychological assessment, you can learn from the “functional gastrointestinal disease – Rome III psychological alert questionnaire”, ask a few simple questions, such as: do you often feel nervous and easily angry? Do you feel depressed and frustrated? How do you sleep? If necessary, ask if you think there is any meaning in living. This last question is to assess whether the patient has any thoughts of suicide. For patients who are found to be more serious and have thoughts of losing their lives, we must refer them to the psychiatric department. Some units do not have a psychiatric unit, so we can recommend that the patient see a neurologist, as many neurologists are still very experienced in dealing with psychosomatic issues. There will also be some patients with functional gastrointestinal diseases who are reluctant to go to the psychiatric and neurological departments, which requires gastroenterologists to learn to master some knowledge in this area and gradually improve. As gastroenterologists, our assessment and management of functional gastrointestinal disorders, or even psychiatric disorders in patients with other gastrointestinal disorders, is actually an accumulative process. Interested doctors can often attend academic conferences such as today’s, or participate in specialized training courses to learn. I also recommend that patients should be allowed to return to the gastroenterology department after the consultation in the psychiatry department, or that these patients should receive certain psychiatric guidance and treatment before discussing the previous psychological problems with the patients, which will help to improve our gastroenterologists’ ability in this area. In clinical work, clinical practice often encounter some patients, their digestive symptoms are not enough to diagnose functional gastrointestinal disease, may belong to the “medically unexplained symptoms” you talked about today, these patients are often combined with more obvious psychological problems, how do you communicate with the patient, the start of anti-anxiety and depression treatment? Indeed, in our clinical practice, we often come across patients who have no obvious problems in their laboratory tests and examinations, but they have a lot of digestive symptoms and some symptoms outside the digestive tract. According to the diagnostic criteria of functional gastrointestinal disease, some patients can be diagnosed as functional gastrointestinal disease, such as functional dyspepsia, functional constipation, irritable bowel syndrome, etc., while some patients’ symptoms do not meet the diagnostic criteria of functional gastrointestinal disease, and now we collectively refer to these cases as “medically unexplained symptoms”. Among them, in addition to functional gastrointestinal disease, some patients’ symptoms may be anxiety and depression in the gastrointestinal tract; there is also a part of the patient may be somatization of the symptoms, known as somatoform disorders (now known as somatic symptomatic disorders), which is emotional stress, psychological problems in the physical manifestations; does not rule out the possibility that there are a small number of patients may be a more serious psychiatric and psychological problems, such as obsessive-compulsive symptoms, gastroenterologists It is difficult to recognize these symptoms. Therefore, overall, the proportion of patients with “medically unexplained symptoms” combined with psychological problems is very high, especially those patients other than functional gastrointestinal diseases, psychological problems tend to be more serious. Finally, it should be noted that among the symptoms of medically unexplained symptoms, we cannot rule out the possibility that a small number of patients have organic diseases that are clinically hidden or not yet prominent, and therefore we need to follow up with patients diagnosed with “medically unexplained symptoms”. This is how I discuss with patients with “medically unexplained symptoms” in my clinic. Usually, before they come to me, they have already seen many doctors, undergone many tests, and used many medications, so they may feel that they are “difficult to treat” or “incurable”. The first question I discuss with patients is: What is the purpose of your visit to me? If a patient tells me, “I want to find out the cause of my illness”, and they are often most worried about serious illness (i.e. organic disease), cancer or carcinoma, I will explain in conjunction with the results of the tests that he has already undergone: the tests for your illness are already comprehensive and careful enough, and there is no sign of serious illness, cancer or carcinoma at present, so you can follow up with the doctor. This clarifies the issue very clearly. More often, the patient will say: My main purpose of the visit is “to stop feeling bad”, and the conversation can then proceed nicely. I would say to the patient: If we can work together to figure out how to make you feel better, then it doesn’t matter what I say you are suffering from. It can be further emphasized that: First, your symptoms are objective and they are difficult for you. Secondly, functional disease or somatization is also a disease, and it is a very common disease, many people will suffer from this disease, it is not pretending to be a disease; these diseases are very susceptible to emotional influences, and also affect the mood, especially for patients with a long course of the disease, but it is not the kind of what the people call “neurosis”; and will not become cancerous. Thirdly, you have been sick for a long time, resulting in bad mood, bad mood will affect the gastrointestinal tract sensory function, making you feel more uncomfortable with the symptoms, therefore, adjusting your mood will help to improve your gastrointestinal symptoms. Of course, as physicians we know that it is the emotions that cause our patients’ symptoms to develop, worsen, and how they feel about their symptoms. At this point, there is a gap between the explanations we give our patients and our understanding of the relevant scientific knowledge. Only in this way can we allow our patients to gradually understand the relationship between their emotions and their symptoms, and if we say that your symptoms are caused by your emotions, the vast majority of our patients will not be able to accept this, and sometimes it will aggravate their symptoms and their psychological burdens. Finally, discuss with the patient how to adjust their emotions. For a significant number of patients with mild psychological problems, effective explanations and guidance on emotional adjustment can be effective. For patients with more obvious psychological problems, often they have used a lot of good symptomatic drugs before this consultation, but the effect can not satisfy them, for those patients who need anti-anxiety and depression drug treatment, the doctor can ask: you have used so many good drugs, the effect is not very good, can we try to use a little mood adjustment drugs? For those patients with better cognition, the use of anti-anxiety and depression medication alone can be used, through the efficacy of the patient to further recognize the impact of emotional and psychological symptoms; for patients with limited cognition, it is recommended that the symptomatic medication for digestive symptoms be appropriately adjusted along with the anti-anxiety and depression treatment for 2-4 weeks, so that the patient can experience symptomatic relief in a relatively short period of time, and be able to adhere to sufficient courses of Anxiolytic Depression Therapy. For patients who are temporarily unable to accept that they have an emotional problem, they may be given time to consider the issue, self-adjust their mood, or adjust to an effective symptomatic regimen (e.g., combination of osmotic laxatives and prokinetic agents for slow-transmitting constipation), and then discuss the addition of antianxiety and depressive medications with the patient after 4-6 weeks when the patient’s major digestive symptoms have improved without a reduction in mood-related manifestations. This often initiates effective psychotherapy. In addition to the mechanism of action and efficacy characteristics of the drug, the choice of anxiolytic drugs should also take into account the possible effects of the drug on the digestive tract. Gastroenterologists should also acquire the skills to recognize “warning signs” of psychiatric problems and refer patients with symptoms of serious mental illness to psychiatric specialists. To be able to deal with the psychological problems of patients with functional gastrointestinal disorders or “medically unexplained symptoms,” gastroenterologists need to continue to learn the relevant knowledge, master the knowledge of commonly used medications, and follow up on patients referred to the Department of Psychosomatic Medicine in order to continue to improve and accumulate experience in this area in clinical practice.