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Questions and Answers about Emotional Factors

Among the most commonly asked questions concerning Crohn's disease and ulcerative colitis (known generically as inflammatory bowel disease) are those pertaining to a possible relationship of emotional factors to the cause and course of inflammatory bowel disease. From among a large number of questions posed to various physicians, here are some of the most commonly asked questions and their appropriate answers based on a broad range of clinical experience.

1. Question: What is the cause of ulcerative colitis and Crohn's disease?

Answer: The origin of these inflammatory bowel diseases has not yet been determined. At present scientists are studying several different possibilities. A transmissible agent, such as a virus or bacterium may be at fault, or a breakdown in the body's immunological (natural) defence system. Possibly some combination of these two factors, in which an immunological deficiency allows the body to be susceptible to a transmissible agent, may be the underlying cause.

2. Question: Can tension and anxiety cause Crohn's disease and ulcerative colitis?

Answer: There is no evidence for this. Scientists now studying these diseases do not believe they are caused by emotional factors.

3. Question: Friends and neighbours often say that ulcerative colitis is caused by nerves and emotional upset. Who is right?

Answer: When lay people and sometimes physicians speak of colitis, they may mean the specific disease ulcerative colitis, or they may be referring to a completely different condition known as the irritable bowel syndrome, also called spastic colon or spastic "colitis". The irritable bowel syndrome is caused by abnormal functioning of the bowel. Unlike ulcerative colitis, the irritable bowel syndrome is not associated with inflammation or structural changes in the intestine. The cause of the irritable bowel syndrome is not fully understood either, but it is widely believed that emotional factors play a strong part. In ulcerative colitis, a condition which is associated with inflammation or structural changes, there is no evidence that emotions play a causative role. This information can be offered as a reference when friends and colleagues seem to think that Crohn's disease or ulcerative colitis are caused by being "overly emotional". It is very important to correct this common and erroneous impression.

4. Question: Are certain personality types more prone to develop ulcerative colitis or Crohn's disease?

Answer: No. In a controlled study done several years ago at Johns Hopkins University and Medical School U.S.A., a group of investigators analysed the emotional and personality aspects of patients with inflammatory bowel disease and of healthy individuals. There were no significant differences found between the personality traits of patients with inflammatory bowel disease and "normal" controls.

5. Question: Do emotional factors play any part at all in the course of inflammatory bowel disease?

Answer: Body and mind are inseparable and are interrelated in numerous and complex ways. It has been observed that flare-ups of inflammatory bowel disease can occur at the time of stressful situations either physical or emotional. For instance, the first onset of inflammatory bowel disease may occur at the time of an attack of a viral or other infectious illness. It also appears likely that some flare-ups of the disease can be triggered by nervous tension or by emotionally stressful life situations. However, this flare-up effect should be carefully separated from the primary cause of inflammatory bowel disease, which is not emotionally based.

6. Question: Can the symptoms of Crohn's disease and ulcerative colitis, such as severe pain and chronic diarrhoea, cause emotional problems?

Answer: Indeed they can. Different persons cope with physical illness in different ways. Some people can cope with severe illness without an extraordinary emotional reaction. Other individuals experience emotional distress when they develop serious organic and chronic illnesses, among them inflammatory bowel disease.

7. Question: What are some of the responses of individuals to inflammatory bowel disease?

Answer: Some patients find it difficult to cope with a serious illness, be it juvenile diabetes, rheumatic heart disease, asthma, or inflammatory bowel disease. Such diseases pose a threat to the person's physical well-being and feeling of security, and he or she may develop signs of anxiety, insecurity and dependence. These reactions constitute a response to the illnesses and not its cause.

8. Question: Are patients justified in feeling guilty that they have brought the illness upon themselves, and thus caused problems to themselves and their families?

Answer: Not at all. Guilt feelings may be the result of the patient's thinking that inflammatory bowel disease is caused by psychological factors, and that somehow the patient might have brought on this disease by not controlling his or her emotions. There is no basis for this way of thinking. Inflammatory bowel disease is not caused by emotions, nor is there anything that patients could have done or could have avoided doing that might have prevented bringing on this disease. Guilt feelings are entirely unjustified and unwarranted. Indeed, they make it more difficult to cope with the difficult physical burden that patients with inflammatory bowel disease have to bear; it is therefore important to dispel such guilt feelings.

9. Question: Are family members justified in feeling guilty that they somehow brought on the disease in the patient/relative?

Answer: Not at all. As above, there is no basis to assume any guilt or causation in the onset of inflammatory bowel disease, either on the part of the patient or on the part of any family members such as a husband, wife, children, parents or siblings.

10. Question: What is the best way to deal with the fear of a flare-up of the diseases?

Answer: The main way to deal with inflammatory bowel disease is to seek effective treatment. Most patients with inflammatory bowel disease can now be handled very well by means of anti-inflammatory drugs administered by a physician who is expert in dealing with the diseases. It has also been shown, particularly in ulcerative colitis, that with low dose maintenance therapy of sulfasalazine (Azulfidine) the recurrence rate can be markedly diminished in patients not allergic to the drug and responsive to it during flare-ups.

11. Question: How do you deal with attacks of gas, diarrhoea or pain in a public place?

Answer: For your own comfort and peace of mind, it helps to plan your itinerary when you are away from home. Be very practical. Learn where the rest rooms are located in restaurants, shopping areas, on a trip or while using public transportation. Always carry extra underclothing or toilet tissue in case of sudden need. Also try to be matter-of-fact about your needs and your attacks of pain. In this way you will be able to help yourself and gain co-operation from others because they will follow your lead and understand.

Close friends are aware that your condition causes you to have severe pains that come and go. They can learn, with your help, that despite their good intentions, there is little that they can do but allow you to handle your pain in the way that is best for you.

12. Question: Are there any specific suggestions for patients who are planning to travel?

Answer: Always tell your physician about your travel plans. Learn the generic name of your medication and be sure that you have enough supply to cover your needs. If possible, ask your physician to give some names of physicians who practice in the area that you plan to visit.

13. Question: Are tranquillisers recommended to cope with the anxiety and fear that goes with inflammatory bowel disease?

Answer: Tranquillisers can be very useful for some patients but are not necessary for all. If anxiety is difficult to handle, the careful use of tranquillisers can be very helpful, especially during acute flare-ups of the disease or during any stressful life situation.

14. Question: Is psychiatric consultation advisable for any patients with inflammatory bowel disease?

Answer: In the majority of patients who experience some anxiety and other emotional responses to the illness, formal psychotherapy is not needed. Physicians who have experience with Crohn's disease and ulcerative colitis patients are usually about to offer supportive help, including emotional support, that is so necessary.

However, for patients who wish to see a psychiatrist, or for patients who manifest more severe emotional disturbances, psychiatric consultation and co-operation with a psychiatrist can be useful. Care should be taken to find a psychiatrist who is experienced in dealing with inflammatory bowel disease patients so that optimal therapy can be obtained.

15. Question: Can other professionals, such as psychologists, family therapists and social workers, be of help to patients with inflammatory bowel disease?

Answer: They can, in selected situations and again with great care to select those professionals who are specifically versed in dealing with patients with inflammatory bowel disease.

16. Question: How can one go about finding the proper therapist?

Answer: Preferably, the attending physician should be able to assist the patient in finding the proper therapist. Sometimes other patients with inflammatory bowel disease can suggest the names of appropriate therapists. The patients should be aware, however, that while such treatment can offer support in coping with illness, it does not have any effect on the primary illness per se.

17. Question: Are there special attributes in a psychotherapist which are particularly helpful to patients with inflammatory bowel disease?

Answer: Yes, it is important that in addition to possessing the standard skills, the therapist be genuinely interested in treating patients with inflammatory bowel disease. The therapist should be thoroughly familiar with the normal and erratic course of these illnesses, should be acquainted with the various complications of inflammatory bowel disease, and familiar with the various drug therapies utilised. It is also of the utmost importance that the physician rendering the primary care for the inflammatory bowel disease and the psychotherapist maintain close working relationship so their efforts to help the patient are co-operative.

18. Question: How are youngsters affected by inflammatory bowel disease in terms of its emotional impact?

Answer: Youngsters tend to be more severely affected by any organic illness than individuals who have established a place in life for themselves and have learned to cope with adversity. Thus, the percentage of individuals who manifest emotional problems in conjunction with inflammatory bowel disease is somewhat higher in the younger age groups, among teenagers and young adults, than among older adults. Otherwise, the principles mentioned earlier apply to youngsters as well as adults.

19. Question: Is there an effect of ileostomy surgery on the patient's emotional state or coping ability?

Answer: Surgery is recommended for a minority of patients with inflammatory bowel disease, when the disease cannot be controlled by drugs. When surgery is needed, it poses some immediate risk to the individual, but in the appropriate circumstances this risk should be outweighed by the expected benefit. With modern surgery and pre and post operative care, the dangers of serious complications from surgery are quite low. Some patients who have not been able to be helped by medical drug treatment or standard resections of the bowel may have to undergo an ileostomy. This form of surgery poses some additional problems of adjustment. However, the problems can be more easily coped with by most patients with the help of informed and informative physicians. The various national and local Ostomy Associations address these questions in their numerous publications and meetings, and can often provide very helpful counsel for the surgery patient both during the pre-operative stage and following the surgery. This counsel is usually provided through an extensive in-hospital and home visitation program. One of the major concerns expressed at this time is about acceptability by sexual partners. Experience has shown that sexual activity is improved rather than worsened, especially in patients who were acutely ill prior to surgery.

20. Question: Could you list some of the attributes in patients with inflammatory bowel disease that might contribute to a good prognosis?

Answer: Ideally the patient should accept inflammatory bowel disease realistically, without self pity, without guilt feelings, and without blaming others for his or her illness. If possible, the patient should deal with the disease in a straight forward and matter-of-fact fashion; this will make it easier for friends and family to accept the illness as part of their relationship with the patient.

The patient should go about his or her daily activities as much as possible, follow physician's instructions and maintain a positive attitude and optimistic outlook upon life.

The patient should have to drive to get back to life if he or she has partially withdrawn, and should not attempt to escape the realities of life by retiring to a sick bed.

The patient should not use his or her illness to manipulate others in the family and should only seek help from family members when necessary. It should be emphasised that following the physician's advice with respect to clinical treatment is an important aspect of coping with illness.

Further Patient Information Sheets & Updates at:- http://www.nevdgp.org.au/tbbase.htm