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In recent years there has been increasing recognition by doctors as well as patients that psychological stress can worsen the course of inflammatory bowel disease (IBD).1–3 In this issue, Bitton et al (see page 1386) report that the way in which some patients cope increases the risk of relapse of their Crohn’s disease after 1 year4: in other words, the wrong sort of coping can be bad for your health.
STRESS AND COPING
Stress can be defined as a threat, whether physical or psychological, to an organism’s homeostasis.5 The term coping describes the thoughts and behaviours used to manage the internal and external demands of situations that are perceived as taxing.6 Coping theory states that an individual’s ability to deal with stress depends both on their coping resources and on the strategies they employ when stressed. Resources include not only the social support a patient has, but also their stable personality traits: people who cope well are optimistic and have a strong sense of self-control and high self-esteem.7
Coping strategies have been variously classified and may change with the passage of time. Commonly quoted categories of coping behaviour, which are not mutually exclusive, include problem-solving, emotion-oriented, avoidance-oriented and supportant (table 1).8–11 While most gastroenterologists will have experience of questionnaires for assessing patients’ psychological state and perceived stress levels,12 fewer will be familiar with those devised to identify people’s coping strategies.13
A recent meta-analysis examining coping strategies in health and disease returned heterogeneous results, but in general emotion-focused strategies such as distancing and avoidance were negatively associated with health outcome, while problem-solving approaches were more beneficial.9 It is possible that, by attempting to problem-solve, an individual may reduce the length or intensity of the stressor, and the consequent psychoneuroimmunological response.
PSYCHONEUROIMMUNOLOGY OF STRESS AND COPING
Psychoneuroimmunology as it relates to IBD is an emerging field.2 As indicated in fig 1,2 stimuli such as those arising from psychological stress are relayed from higher cortical sensory centres to the hypothalamus, amygdala and periaqueductal grey matter that then govern the neuroendocrine stress response via the hypothalamic–pituitary axis and via the autonomic and enteric nervous systems. Nerve fibres form close associations with immunoregulatory cells in lymph glands, bone marrow, thymus, spleen and mucosa-associated lymphoid tissue: these immunoregulatory cells carry receptors for several neurotransmitters.
Coping can influence the response to stress through these pathways. Thus, in an exam stress model, students with distraction or comforting cognitions had a more prolonged cortisol response after the exam than did problem-orientated copers.14 Similarly, the highest cortisol levels were associated with avoidance coping in a cohort of orthopaedic patients recovering from laparoscopic knee surgery.15
STRESS AND COPING IN IBD
Despite the difficulties associated with its study, there is increasing evidence that psychological stress can affect the natural history of IBD.1–3 There is also a growing literature about the coping strategies adopted by patients with IBD. To date, most reports have been cross-sectional: they indicate that patients use strategies ranging from passive and escape-avoidance approaches,11 16 to confrontive, optimistic and self-reliant approaches.10 Some11 17 18 but not all10 19 studies suggest that a positive coping strategy improves health-related quality of life.
In this issue, Bitton et al report, for the first time, that coping strategy, like stress, can affect disease activity in IBD.4 Thus, as in quiescent ulcerative colitis,12 multivariate analysis showed that perceived stress increased the risk of relapse in patients with inactive Crohn’s disease (see their table 3). Conversely, patients with low levels of stress and using low avoidance behaviour (ie, keeping themselves to themselves, table 1) had sustained remission (85% at 1 year). The authors imply that such patients help keep their stress levels low by restricting their activities, thereby avoiding potentially embarrassing situations and overextending their limits.
There are other plausible explanations for the apparently protective effect of low avoidance behaviour (when combined with low stress) in Crohn’s. For example, in patients with HIV, high avoidance behaviour (table 1) has been associated with reduced adherence to drug treatments, and poor outpatient clinic attendance20: these factors adversely affect the natural history of IBD.21 Patients opting for a distraction and social diversion strategy may do so through unhealthy, albeit pleasurable, behaviours7: in the context of Crohn’s these could include smoking.22 It is also possible that such behaviour increases the risk of acquiring gut (by faecal–oral transmission) or other infections which might provoke23 or mimic relapse. Lastly, it is likely that avoidance behaviour is associated with more sleep disturbance, a factor influencing at least quality of life in patients with IBD.24
In contrast, coping through avoidance can be beneficial in certain situations—for example, when the stressor is short lived and uncontrollable. Thus women undergoing breast cancer screening who were given an abnormal mammogram result reported less anxiety after being informed they did not have breast cancer if they had used avoidance coping than if they had not.24 In the present report, the maintenance of remission curve in fig 2 suggests that high avoidance behaviour in the highly stressed group during the first 4 months may be protective, with only 15% of such patients having relapsed by that time compared with 30% of highly stressed patients using low avoidance strategies.
As Bitton et al recognise, a potential confounding factor in their study is the use of the Crohn’s Disease Activity Index (CDAI) to define relapse, since it is likely that some stressed patients deemed to have relapsed were in fact reporting stress-induced functional symptoms. It is regrettable that confirmation of relapse of mucosal inflammation in these patients could not be sought using an objective non-invasive method such as faecal calprotectin.26 In this context, while irritable bowel syndrome (IBS) symptoms are more common in patients with apparently quiescent IBD than in the general population,27–29 coping strategies adopted by patients with IBD did not seem to influence the development of IBS-like symptoms in one study,29 and indeed were similar in the two disorders in another.16
Coping strategies may play a particularly important role in adolescent IBD, although the present study, which excluded patients under the age of 18, sheds no light on this possibility. Adolescents with IBD use more avoidance-oriented coping than healthy peers.11 IBD in adolescence interferes with growth, psychosocial and sexual development, education and employment. It is therefore not surprising that adolescents with IBD have a high prevalence of psychological distress, particularly depression.30 Adolescents with IBD whose coping style involves positive expectations about their disease, and those who use depressive reaction patterns less, have the best health-related quality of life.11 18 This patient group would seem to be particularly worthy of management focusing on coping as well as drug strategies.
There are many different types of psychological intervention, but well-designed studies of their efficacy in IBD are lacking. These studies are difficult to blind. Outcome measures have usually been self-reported symptom scores assessing not only gut symptoms but also psychological aspects such as well-being and distress. Few trials have used objective non-invasive measures of disease activity, let alone ileocolonoscopy.
In a review of 10 heterogeneous studies involving several types of psychotherapy, this modality did not appear to affect the course of IBD.31 In some cases, however, it did positively influence the patient’s psychological state, improving depression, anxiety, health-related quality of life and their ability to cope. Patients with psychological problems, especially if pertaining to their IBD, or associated with maladaptive coping, might therefore benefit from a psychotherapeutic approach, although which type is not clear.
Whether psychoactive drugs, for example antidepressants,32 influence disease activity in IBD has not yet been adequately evaluated.
Relaxation exercises are easy to learn and have been shown to ameliorate chronic pain in ulcerative colitis.33 Hypnotherapy has an established role in patients with IBS34 and experimentally reduces some measures of the inflammatory response systemically and in rectal mucosa in ulcerative colitis35: whether relaxation-inducing gut-focused hypnosis, which when self-administered could be considered a coping strategy, is beneficial in IBD awaits formal controlled evaluation.
Disease-specific training programmes, designed to improve self-management, are a way of enhancing problem-solving coping, and are successful in asthma and diabetes.36 In IBD, such tools improve access to outpatient clinics for patients with flares, reduce routine outpatient attendances and perhaps improve drug adherence,37–39 but have not been shown to alter relapse rate.
Social isolation and a lack of social support are associated with poor outcome from disease.40 Attempting to strengthen patients’ exogenous coping resources by manipulating their social environment is extremely difficult. Despite being unproven as a way of improving coping strategies and disease course, a supportive relationship between patients, whether in groups41 42 or as individuals, and their IBD team is likely to be important, as may be links with patient bodies such as, in the UK, the National Association for Colitis and Crohn’s disease and the Expert Patient Programme.42
Bitton’s study re-emphasises the importance of psychological stress in induction of relapse in IBD; for the first time it suggests that the way that patients cope may impact on relapse rate in Crohn’s disease. Further clarification of the biology of stress and coping may make possible new psychological and pharmacological treatments acting at defined targets in the psychoneuroimmunological pathway. In the meantime, identifying and addressing the needs of patients with maladaptive coping strategies, poor coping resources and limited social support may impact not only on their quality of life but also on the course of their disease.
We are grateful to the National Association for Colitis and Crohn’s disease for financial support to JG.
Competing interests: None.
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