Assessment
After participants’ sociodemographic data on sex, age, employment, marital status and their previous adherence to CRC screening were collected, patients were interviewed by a clinical psychologist, according to a comprehensive psychosomatic assessment [16]. The participants thus underwent three validated clinical interviews (SCID-5, DCPR-R, and Psychological Well-Being Interview - PWB-I) and completed a self-rating questionnaire (SQ). The clinical psychologist also detected patients’ lifestyle habits (physical activity, dietary habits, alcohol consumption and tobacco smoking). The psychological assessment lasted about thirty minutes.
Psychiatric diagnoses. Specific modules of the Structured Clinical Interview for DSM-5 (SCID-5) [19, 20] were used in order to identify major depression, anxiety disorders (panic disorder, generalized anxiety disorder, agoraphobia, social anxiety), eating disorders (bulimia, binge eating disorder, anorexia nervosa), obsessive-compulsive disorder, somatic symptoms and related disorders (somatic symptoms disorders; illness anxiety).
Psychosomatic syndromes. The Semi-Structured Interview based on the revised version of the Diagnostic Criteria for Psychosomatic Research (DCPR-R) [16] was used to identify psychosomatic syndromes. It allows to assess the presence of 14 psychosomatic syndromes (allostatic overload, type A behavior, alexithymia, hypochondriasis, disease phobia, thanatophobia, health anxiety, persistent somatization, conversion symptoms, anniversary reaction, illness denial, demoralization, irritable mood and somatic symptoms secondary to a psychiatric disorder) divided into 4 clusters: stress, personality, illness behavior, psychological manifestations [16]. The first cluster includes allostatic overload (characterized by the presence of a current identifiable stressor in the form of recent life event or chronic stress exceeding the individual coping skills). The cluster of personality includes two syndromes that can potentially affect general vulnerability to disease, such as type A behavior (characterized by high competitiveness, excessive degree of involvement in work and other activities subject to deadlines, tendency to speed up mental and physical activities) and alexithymia (represented by the inability to use appropriate words to describe emotions). Illness behavior refers to the ways in which given symptoms may be differentially perceived, evaluated, and acted (or not acted) by different kinds of persons. The clinical spectrum of illness behavior encompasses eight syndromes according to DCPR-R criteria: hypochondriasis (i.e., persistent fears of having, or the idea of having, a serious disease based on misinterpretation of bodily symptoms); disease phobia (i.e., persistent, unfounded fear of suffering from a specific disease); thanatophobia (i.e., sense of impending death and/or conviction of dying soon); health anxiety (i.e., generic worry about illness, concern about pain, and bodily preoccupations); persistent somatization (i.e., functional medical syndromes such as fibromyalgia or chronic fatigue that cause distress and seeking medical care, and result in impaired quality of life); conversion symptoms (i.e., one or more symptoms or deficits affecting voluntary motor or sensory function characterized by lack of anatomical or physiological plausibility); anniversary reaction (i.e., symptoms of autonomic arousal occurring at the anniversary of specific negative events); illness denial (i.e., persistent denial of having a physical disorder that needs treatment). The cluster of psychological manifestations includes: demoralization (i.e., a feeling state characterized by the perception of being unable to cope with some pressing problems); irritable mood (i.e., a feeling state characterized by frequent manifestations of irritability that lack of their cathartic effect) and somatic symptoms secondary to a psychiatric disorder (i.e., somatic symptoms occurring after a psychiatric disorders that cause distress and impaired quality of life) [16]. The use of DCPR was reported to be useful and reliable in the assessment and description of psychosomatic distress showing excellent interrater reliability, construct validity and predictive validity for psychosocial functioning and treatment outcome [21].
Distress. Kellner’s Symptom Questionnaire (SQ) [22, 23] was used in order to identify psychological distress. It is a 92-item dichotomous self-rating scale, including items that may be rated as ‘yes’/‘true’ or ‘no’/‘false’. It yields four scales (anxiety, depression, somatization and hostility-irritability) divided into four sub-scales of well-being (relaxation, contentment, physical well-being and friendliness) and four sub-scales of distress (symptoms of anxiety, depression, somatization and hostility-irritability). The score of each scale may range from 0 (no symptoms) to a maximum of 23 (all the symptoms are present). The Italian translation of the SQ resulted to be valid and sensitive in detecting differences between groups and changes of psychological distress [23].
Psychological well-being. The Interview for assessing Psychological Well-Being (PWB-I) [24] was used to assess psychological well-being, according to Ryff’s multidimensional model [25]. It encompasses six dimensions: self-acceptance, positive relationship with others, purpose in life, environmental mastery, personal growth, autonomy. The interview includes 18 questions with dichotomous Yes/No answers.
Lifestyle-related behaviors. Lifestyle-related behaviors were assessed with an adaptation of a questionnaire used in previous research on patients with medical conditions [26]. The instrument includes an evaluation of the frequencies of physical activity, specific eating habits (i.e., consumption of fruit, vegetables, fish, dairy products, red/processed and white meat), alcohol consumption and tobacco smoking (cigarettes), rated on a 4-point Likert scale (never/occasionally; 2/3 times a week; once a day; more than once a day).
Endoscopic outcomes. The endoscopic outcomes were obtained from the Bellaria Hospital Screening center a week after patients’ colonoscopy. Endoscopic outcomes were classified as “negative”, when the colonoscopy did not show any type of lesion, or “positive”, when the colonoscopy showed major endoscopic outcomes (i.e., precancerous lesions such as neoplasms and adenomas) or minor endoscopic outcomes (i.e., hyperplastic polyps, diverticula and hemorrhoids). Among positive endoscopic outcomes, we focused on major diagnoses involving precancerous lesions [27] that were treated with polypectomy afterwards.