Abstract

Inflammatory Bowel Disease: Psychological Factors

Ulcerative colitis and Crohn's disease are two chronic inflammatory bowel disorders of unknown ethiology and unpredictable evolution that usually result in diarrhoea and /or abdominal pain sometimes associated with fever, weight loss and other extra-intestinal symptoms. Specialised literature often reports the main role of psychosocial factors in the breaking out and evolution of this disease. These factors, that clinically and subjectively seem utterly important, in some ways nevertheless remain untouched by a methodological and systematic investigation, as their results seem contradictory, uncertain and not at all specific.

This work was designed to approach this set of problems through a global and integrated model of psychosocial exploration, in order to pursue some specificity of the psychological and social phenomena as they may be present in the chronic inflammatory bowel disease(s). The study was meant to relate the intensity of the symptoms with the adaptation towards them as a function of the personality and of the simultaneous psychosocial events. The last goal was to achieve one or more discriminatory patterns of behavioural and situational variables that would prove to be somehow specific, or at least characteristic of such adaptation from these patients.

Bearing this intent in mind we first noted that these patients' personality tends to come out of the C cluster (DSM), and that it could be peculiarly described as characterised by the avoidance of potentially harmful situations. And the more outstanding the harm avoidance it may be, the more dysfunctional the respective family can be recognised. However, more than any idiosyncrasy from these patients, what comes out from this study is a possible association of a noxious action, or on the contrary propitiator of a better quality of life, that some aspects may assume whenever actually present. And we place in such a context the behavioural style, that we would say "toxic", characterised by resorting to coping strategies of escape / avoidance; such a style is related with an external locus of control and may be found among the alexithymics and/or the more dysphoric: anxious, depressed, irritable. On the contrary, thus clearly opposing to alexithymia and dysphoria, stands out the group characterised by an internal locus of control, the sub-group that resorts to emotional control. And this in so far as it has the particularity of not to resort to strategies such as seeking support, what can also prove to be rather inadequate, such as, postponing a clinical intervention that should be otherwise considered necessary. Except for a more prominent anxiety observed among women with ulcerative colitis, we found no significant differences between the nosographic groups in relation to the considered psycho-affective variables. The main discrepancies towards the observed variables between the two involved nosographic groups are essentially summarised by a difference of ten years less in the age / age of first outburst for Crohn's disease, as well as a much more use of health services in the part of these patients.

With a more active disease we can also notice, naturally, a bigger number of physician's visits in the last 6 months, but a lesser number of hospitalisation days in the last year. Also related with patients with a more active expression of their disease, and for both nosographic groups, we can observe that they have been submitted to a higher stressfulness due to a bigger sum of adaptive demands in the last year. As in the case of alexithymia, among with other characteristics that also get more evident along with morbidity, if on one hand it doesn't properly collide with the stability of the trace required by the construct - in their independence towards other socio-demographic variables -, it comes on the other hand to suggest some secondary reinforcement.

We do have to understress as already noted, and for both nosographic groups, the bigger number of adaptive demands considered of an important kind during the last year among patients with a more active expression of their disease. Furthermore, such a situation of accumulated stress as it may result from environmental factors, more than in the disease activity itself, it comes to disclose a worst quality of life. We also have to emphasise on this matter the positive correlation of this summation of life events with dysphoria - depression and anger in particular - and difficulty identifying feelings, and with a lesser emotional control.

In relation with the inflammatory bowel diseased patients functional status and well being, and thus with what has been called health related quality of life, we can say according to the final considerations that an external locus of control / chance prevents planful problem-solving. While an internal locus promotes confrontive coping, seeking social support, accepting responsibility, planful problem-solving, and positive reappraisal, preventing inadequate solutions of escape-avoidance type. These assume a particular importance in dysphoric situations - anxiety, depression, anger -, while positive affects are more related with seeking social support, planful problem-solving and confrontive coping. Alexithymia in turn has a significant inverse relation with the aforementioned positive affects, as well as with sensation seeking, what is mainly due to the also mentioned bigger anxiety apparent when there is a bigger difficulty in identifying feelings. As a matter of the fact, be it the difficulty in identifying feelings, or else to describe them, they have an inverse relation with positive affects, but only the difficulty in identifying feelings prevents the coming into operation of mechanisms intended to reduce or else to resolve negative feelings. To a better quality of life among these patients we would then say that it corresponds naturally a less active disease, but also clearly an internal locus of control, lesser alexithymia / difficulty identifying feelings, and less dysphoria.