Psychosocial Aspects of Crohn's Disease

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Although the understanding of inflammatory bowel disease (IBD) has advanced significantly over the past decade, knowledge of the etiology, natural history, and clinical expression of Crohn's disease is still in evolution. Crohn's disease varies not only in the extent and severity of intestinal and extraintestinal involvement but also in its clinical presentation. In these circumstances, the management of these patients usually is determined by the presenting type (e.g., inflammatory, fistulizing, or fibrotic), location, activity, and severity of the disease. Several indices have been designed and used to measure the disease activity and severity. These indices usually are based on scoring clinical signs and symptoms (e.g., Crohn's Disease Activity Index [CDAI]), Harvey-Bradshaw Index,10, 59 objective endoscopic or laboratory data,121 or a combination of physical findings and laboratory data (e.g., Cape Town Index).128

Nevertheless, the activity and severity of the disease usually are insufficient to explain the variability in the clinical presentation of the disease.50 Some physicians care for patients in whom significant discrepancies exist between the “disease” activity and severity, as defined by the disease related factors, and the patients' symptom experience and behavior (i.e., the “illness”). For example, with an 8-cm segment of ileitis, one patient may be disabled because of severe symptoms, whereas another may report no complaints and functions normally.

Discrepancies between the “disease” and the “illness” cannot be explained by the biological or morphologic findings; usually they are considered as related to psychosocial factors.43, 50

The important influence of psychological and social factors on the clinical expression, response to treatment, and outcome has been shown in various chronic diseases, but studies addressing this issue are limited in IBD.

A survey of a random sample of 1000 members of the American Gastroenterological Association92 showed that physicians believed that psychosocial factors do not contribute to the cause of IBD but that psychosocial factors affect the clinical exacerbation of symptoms. Conversely, more than half of the patients with IBD believe that stress or personality is a major contributor to the development of their disease, and more than 90% think that stress influences their disease activity.78, 103

Although physicians and patients have considered psychosocial factors as important in the clinical expression of IBD, confusion and controversy still exist as to their precise role, often because opinions are formed from anecdotal observations or from limited scientific data. Also, the general tendency is to view IBD from a purely biomedical perspective and to regard the contributing role of psychosocial factors with speculation or bias.

This article reviews the relationship of psychosocial factors with the pathogenesis and clinical expression of Crohn's disease. Because much of the literature in this field does not separate between chronic ulcerative colitis and Crohn's disease, this article relates mainly to Crohn's disease but, in some parts, to IBD in general. The advances in the scientific understanding of the relationships between the neural, endocrine, and immune systems are reviewed to close the gap between clinical observations and basic investigation. Some of the common psychosocial concomitants and consequences of IBD are discussed. A comprehensive model of illness and disease is suggested, and ways to integrate psychosocial factors and issues in the diagnosis and patient care are presented.

Section snippets

Human Studies

Social disorganization and major changes in a person's lifestyle correlate with medical disorders and subsequent illness or injury.13 Although several studies link social stress in humans to chronic diseases, only a few have evaluated IBD, and many are anecdotal, retrospective, or uncontrolled studies. Even the few well-designed studies of IBD give mixed results: in a 6-month prospective study, Duffy et al44 studied the relationship of monthly major life events with symptoms and disease

Stress Effects on Gut Function

Psychological and emotional stressors may affect the GI motor, sensory, and secretory function directly or indirectly through the richly innervated nerve plexuses existing between the enteric nervous system, the spinal and autonomic connections, and the CNS (i.e., the “brain–gut axis”).84, 85 Stress effects on intestinal motility have been reported in laboratory animals and in humans. Immobilization stress and conditioned fear cause significant changes in intestinal myoelectric activity in

PSYCHOSOCIAL CONCOMITANTS AND CONSEQUENCES OF INFLAMMATORY BOWEL DISEASE

In addition to the influencing role of psychosocial factors on the pathogenesis or exacerbation of Crohn's disease, once the disease develops, psychosocial concomitants must be understood and considered to understand the clinical expression of the illness and to provide proper care.

As with any chronic and painful illness, Crohn's disease may have emotional and psychological consequences. The spectrum of the psychological disorders that may be associated with Crohn's disease is beyond the scope

NEED FOR AN INTEGRATED MODEL OF ILLNESS AND DISEASE

Disease activity and severity are insufficient to explain the variability in the patient's symptoms or behavior (i.e., the illness).50 Other domains of the patient's health, such as psychological factors and environmental modulators, have to be included and considered to allow for a more comprehensive assessment of the patient's health status (or illness).

The biopsychosocial model29, 30, 47 permits a broader and more practical framework to deal with the complexity of the patient's illness. It

Assessment and Evaluation of Psychosocial Factors

The assessment of a patient's psychosocial well-being is an essential part of diagnosis and patient care. The data collection requires the willingness to address the biologic and psychosocial aspects of the illness.31 Physicians should create a trusting clinical environment so that the patients will feel comfortable disclosing their thoughts and feelings. Nevertheless, some patients (e.g., patients with alexithymia) have difficulty in expressing their feelings or relating them to their illness.

SUMMARY

Patients and clinicians have always recognized the importance of psychosocial factors as consequences of IBD and as predeterminants for symptom exacerbation.92 Over the past decade, improvements in psychosocial assessment and clinical research design methodology, coupled with new data in brain–gut physiology and psychoneuroimmunology, have led investigators and clinicians to accept a broader approach to illness and disease (i.e., the biopsychosocial model). Based on this understanding and the

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    Address reprint requests to Yehuda Ringel, MD, Division of Digestive Diseases, 774 Burnett-Womack Building CB7080, University of North Carolina, Chapel Hill, NC 27599–7080

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