The psychosocial aspects of inflammatory bowel disease

Four-year follow-up of psychiatric and psychosomatic profile in patients with Inflammatory Bowel Disease (IBD)

Psychological characterization of patients affected by Inflammatory Bowel Disease (IBD) focuses on comorbidity with psychiatric disorders, somatization or alexithymia. Whereas IBD patients had higher risk of stable anxiety and depression for many years after the diagnosis of the disease, there is a lack of studies reporting a comprehensive psychosomatic assessment addressing factors of disease vulnerability, also in the long-term. The objective of this investigation is to fill this gap in the current literature. The aims were thus to assess: a) changes between baseline and a 4-year follow-up in psychiatric diagnoses (SCID), psychosomatic syndromes (DCPR), psychological well-being (PWB-I), lifestyle, gastrointestinal symptoms related to IBD and Irritable Bowel Syndrome (IBS)-like symptoms b) stability of psychiatric and psychosomatic syndromes at 4-year follow-up. A total of 111 IBD outpatients were enrolled; 59.5% of them participated at the follow-up. A comprehensive assessment, including both interviews and self-report questionnaires, was provided at baseline and follow-up. Results showed increased psychiatric diagnoses, physical activity, consumption of vegetables and IBS-like symptoms at follow-up. Additionally, whereas psychiatric diagnoses were no longer present and new psychopathological pictures ensued at follow-up, more than half of the sample maintained psychosomatic syndromes (particularly allostatic overload, type A behavior, demoralization) from baseline to follow-up. Long-term presence/persistence of such psychosocial burden indicates the need for integrating a comprehensive psychosomatic evaluation beyond traditional psychiatric nosography in IBD patients. Moreover, since psychosomatic syndromes represent vulnerability factors of diseases, further studies should target subgroups of patients presenting with persistent psychosomatic syndromes and worse course of the disease.

Group-based intervention program in inflammatory bowel disease patients: effects on quality of life

BACKGROUND

Inflammatory bowel diseases (IBD) such as ulcerative colitis (UC) and Crohn's disease (CD) have great impact on patients' health-related quality of life (HRQOL). The aim of this study was to develop an integrated medical and psychological/ psychosocial group-based intervention program for IBD patients and to evaluate if such a program could influence the patients' HRQOL and coping abilities.

METHODS

IBD patients in remission or with low disease activity were randomized to intervention or control groups. The intervention comprised nine weekly sessions, alternating lectures, and group therapy sessions. The Inflammatory Bowel Disease Questionnaire (IBDQ) and the Sense of Coherence scale (SOC) were used to measure HRQOL and coping ability at 0, 6, and 12 months. The intervention was evaluated by a visual analog scale (VAS) and written comments by a content analysis.

RESULTS

In all, 24 patients were included in the intervention group and 20 in the control group. The mean IBDQ score showed no statistically significant differences before (173.9) or after the intervention at month 6 (175.7) or at month 12 (171.8), or when comparing intervention and controls at month 12. Similarly, there were no statistically significant differences in mean SOC before or after intervention or when comparing groups. The VAS and the content analysis showed that the intervention was well appreciated by the patients.

CONCLUSIONS

The group-based intervention program was feasible and highly appreciated. There were no statistically significant differences in average IBDQ or SOC over time or in comparison with controls, although a significant increase was seen in patients with short disease duration.

Psychosocial aspects of Crohn's disease

In clinical practice, significant discrepancies occur between disease activity and severity, and the patient's symptom experience and behavior. Discrepancies cannot be explained by biologic or morphologic findings, and usually are considered to be related to psychosocial factors. Recent advances in the scientific understanding of the relationship between environmental stress and the neural, endocrine, and immune systems, combined with new methodologies in clinical research, provide a challenging opportunity for clinicians and researchers to establish a more comprehensive understanding of Crohn's disease. This article reviews the important relationship of psychosocial factors, pathogenesis, clinical expression, response to treatment, and outcome of Crohn's disease, and presents a comprehensive model of illness, disease, and ways to integrate psychosocial factors with diagnosis and patient care.

The psychoanalytic treatment of ulcerative colitis revisited

A review of the literature indicates that very little is known about the role of psychological factors in the etiology, exacerbation, and treatment of ulcerative colitis. Most phenomenological consensus seems to take place around recognizing that the patient has great difficulty in expressing aggression and is frightened of loss of control. Episodes of ulcerative colitis are often related to the sudden loss of an important love-object and/or severe narcissistic wounding. Chronic narcissistic rage is not at the center of the psychological phenomena as I (Chessick, 1985) have described it in narcissistic psychosomatic disorders. In ulcerative colitis, acute episodes of object loss, narcissistic wounding, or bitter disappointment, along with a sense of entrapment and helplessness, produce the threat of an explosion of uncontrollable rage. Such an explosion would result in disruption of the patient's life and expulsion from significant and needed relationships. This produces an acute internal conflict, hopelessness, and despair, with the danger of resolution by paranoid projection. Why in these patients these events seem to be followed by changes in the colonic mucosa is simply unknown, nor is it clear whether they are related to these changes directly or indirectly. The defensive inability to feel the archaic rage at early significant caretakers or their later life substitutes is clearly an important determinant of the psychosomatic condition. I believe that the treatment problems raised by the patient presented here are fairly typical of what will be encountered in any effort to psychoanalyze a patient with ulcerative colitis. Perhaps because of the failure of Alexander's specificity hypothesis, there has been a loss of interest in the psychoanalytic treatment of such patients, and this is regrettable because at least some of them, like the present case, respond well and it makes a vital difference in their future. One certainly cannot say that psychoanalytic treatment represents any sort of "cure" for ulcerative colitis, but it seems clear that resolving underlying psychopathology to whatever extent is possible lessens the chance for ulcerative colitis to be exacerbated by stressful events, such as severe narcissistic wounding or substantial unexpected object loss, because the ego has been strengthened and the patient has an improved tension-reduction capacity. Psychoanalysts should not be afraid to consider the treatment of such patients as long as they are not in the acute phase of the disease. Acute manifestations require active medical, pharmacological, and supportive psychological intervention.