Psychological Factors in Gastroenterology

Psychological Factors in Gastroenterology

Inflammatory Bowel Disease

Ulcerative colitis is another disorder that was described in the early literature as a psychosomatic disease, but no specific psy-chogenic factor contributing to the development of ulcerative colitis or Crohn’s disease has ever been substantiated. As with other chronic medical diseases, patients with more psychological distress tend to be those with more severe physical disease and poorer functional capacity, but the causal relationships are not clear. Psychological stress does appear to aggravate both symp-tom complaints and mucosal disease activity in ulcerative colitis. Disability and distress in patients with inflammatory bowel dis-ease are increased by the presence of a concurrent psychiatric disorder. In fact, depression is a better predictor of subjective impairment in inflammatory bowel disease than is inflammatory activity. Psychotherapy has the potential to improve outcomes in inflammatory bowel disease, as suggested by controlled trials.

Peptic Ulcer Disease

The central role of the bacterium Helicobacter pylori in the etiology of peptic ulcer disease (PUD) has been clearly established. Many physicians have consequently discarded the longstanding belief that stress causes PUD, and concluded that PUD is an infectious disease, except when attributable to nonsteroidal anti-inflamma-tory drugs (NSAIDS). Nevertheless, psychological factors appear to be a significant part of the explanation for why only a fraction of those colonized by H. pylori or taking NSAIDS develop ulcers. Psychological stress is an independent risk factor for the develop-ment and recurrence of duodenal ulcer. The frequency of peptic ulcer increases following catastrophic stressful events, including bombardment, earthquake, economic crisis, or being a prisoner of war or “boat people” refugee. Overall, psychosocial factors contrib-ute between 30 and 65% of peptic ulcers (Levenstein, 2000), and are most likely to be present in patients with duodenal ulcers who do not have conventional medical risk factors (H. pylori, NSAIDS). Occupational stress, family conflicts, depression, maladjustment and hostility also are prospectively associated with PUD.

Psychological factors appear to influence PUD through both health risk behaviors (smoking, alcohol abuse, overuse of NSAIDS, poor diet, poor sleep) and psychophysiologic mecha-nisms (pepsinogen and acid secretion, altered blood flow, impair-ment of mucosal defenses, and slowing of healing related to the action of cortisol) (Levenstein, 2000).

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a heterogeneous condition with a high frequency of comorbid anxiety especially panic at-tacks, depression and somatization. Whereas patients with IBS are psychologically more distressed than normal subjects, they do not have a common profile of psychological symptoms or per-sonality traits. Patients with IBS are more likely to have a history of childhood sexual abuse than are those with other gastrointesti-nal disorders in studies of patients seeking care at tertiary refer-ral centers. In fact, almost all psychological characteristics and psychopathology thought to be more common in IBS are differ-entially increased only in those who seek medical care for their symptoms.

Both IBS patients and their physicians observe that their gastrointestinal symptoms seem aggravated by stress, but there is no clear evidence that stress causes a different gastrointesti-nal smooth muscle response than in control subjects. Instead, psychological factors’ effects on IBS appear predominantly on perception of pain and other somatic symptoms, and on health care seeking behaviors. After an acute episode of infectious gas-troenteritis, individuals with more life stress, and who were more hypochondriacal, were the ones most likely to go on to develop IBS, without any differences in intestinal physiology (Gwee et al., 1999).

Psychological Factors in Dermatology

Dermatologists routinely observe the effect of psychological fac-tors, especially anxiety, in the aggravation of a wide variety of dermatological conditions. There are few systematic studies, and perhaps the most important relationships are not uniquely related to particular dermatological disorders. Both anxiety and depres-sion appear to worsen pruritus (itching). So-called neurotic exco-riation complicates many dermatological disorders and is aggra-vated by anxiety, depression and other behavioral factors. That so many skin diseases appear to be precipitated or exacerbated by psychological stress also suggests a nonspecific impairment of cutaneous function. There is now evidence in both animals and humans that stress negatively affects skin’s function as a perme-ability barrier.

Dermatologists clinically observe important relationships between psychological factors and urticaria, angioedema, atopic dermatitis, hyperhidrosis, acne and psoriasis, but controlled stud-ies are lacking. Excessive sun exposure is a maladaptive health behavior contributing to skin cancer and various other dermato-logical conditions.