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Life events stress in ulcerative colitis: A case-control study

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Life events stress in ulcerative colitis: A case-control study

Authors: Abumadini Saed, H. Hafeiz, AL-Quorain Abdulaziz, Yasawy Ismail and Abdulkarim Mustafa
Date: May 1, 2002
From: Saudi Journal of Gastroenterology(Vol. 8, Issue 2.)
Publisher: Medknow Publications and Media Pvt. Ltd.
Document Type: Clinical report
Length: 2,599 words

Full Text:
Byline: Abumadini. Saed, H. Hafeiz, AL-Quorain. Abdulaziz, Yasawy. Ismail, Abdulkarim. Mustafa

Background: Ulcerative colitis (UC) is significantly associated with life events stress. Aim: To investigate the relationship between
ulcerative colitis, and life events stress. Methods: A prospective study of 30 patients with ulcerative colitis and 30 healthy controls. A
semi-structured psychiatric interview and clinical mental state examination were used in the psychiatric assessment of the patients
and controls. Psychiatric diagnoses were made according to ICD-10. A modified version of Life Events Scale by Tennant and
Andrews was used in the assessment of life events stress. Results: Life events stress were significantly experienced by more
patients than the controls. The total number of life events, the number of individual significant life events and the total number of
unpleasant events were all significantly more in patients than the controls. Conclusions: In this study the association between the
ulcerative colitis and life events stress is substantiated at all levels. However, further more extensive studies are needed to elucidate
the nature of this relationship.

Since the early thirties, an association was observed between emotional factors and ulcerative colitis[sup] [1] . In fact it was
occasionally argued that the condition is in the essence of a psychosomatic disorder, caused by emotional factors[sup] [1],[2] .[sup]
Others believed that ulcerative colitis has a multi-factorial etiology and that emotional aspects are partly responsible[sup] [3],[4],[5],[6],
[7],[8] . Recent communications claimed that psychological stress has been positively correlated with exacerbation of UC[sup] [8],[9],
[10] . Life events stress is also thought to be associated with both objective and subjective aspects of activity in UC[sup] [11] . To add
to the controversy, some considered the psychological problem encountered in UC is to be the result of such severe and chronic
illness, and not the cause[sup] [12],[13],[14] .[sup] Based on this presumed association between UC and emotional factors, various
modalities of psychological treatments were found to be effective[sup] [15],[16] . On the other hand there are those who held the view
that UC is a purely physiologic condition[sup] [17],[18],[19] . Serious flaws in the research design, in many of those studies
advocating positive association of UC with psychiatric factors, are thought to be responsible[sup] [19] . Recall bias, distressing
psychological consequences of the disease, psychogenic symptom exaggeration and irritable bowel component of UC are thought to
complicate the problem further. The scarcity of prospective and controlled studies in this field is a further handicap for objective and
replicable findings. Although ulcerative colitis had been reported frequently in Saudi Arabia and other countries in the Middle
East[sup] [20],[21] ,[sup] its association with stress has not been studied. The aim of the present study is to investigate the
relationship between life events stress and ulcerative colitis in a prospective way. The psychopathology of ulcerative colitis is dealt
with in a separate communication.

Patient and Methods

Patient Selection: The study duration was for one year (1/11/99-31/10/2000). Ulcerative colitis is defined as recurrent abdominal pain,
chronic diarrhea with or without rectal bleeding who had endoscopic features of hyperemia, contact bleeding, friability of mucosa with
or without ulceration and biological features of chronic procto-colitis. The endoscopic (macroscopic) impression was confirmed hi
stopatho logically. Colonic infections were excluded by repeated stool examinations and culture. Patients with evidence of irritable
bowel syndrome and previous mental illness were also excluded from the study. Physical examination, lower gastrointestinal
endoscopy and abdominal sonography were carried out by the gastroenterologists in charge of the two clinics at King Fahad Hospital
of the University (KFHU). An equivalent number of healthy volunteers from the hospital and university staff, matched for age and sex
were recruited randomly as normal controls. They had no past history of irritable bowel syndrome or severe medical or psychiatric
illness.

Psychological Assessment: The psychiatric evaluation was carried out by the psychiatric team (the authors). They used a semi-
structured psychiatric interview and a clinical mental state examination. Attention was focused on socio--demographic data like age,
sex, marital status and life events. The psychiatric diagnoses were made along the lines cited in 1CD-10[sup] [22] . The severity of
mental illness was graded as mild, moderate and severe according to ICD-10 mentioned above. Personality in our study has been
assessed clinically in accordance with ICD-10 guidelines, which is a valid international research tool. Cognitive function was
assessed clinically and the level of intelligence was judged by: general information, school and work records only. The measure of life
events stress in the last six months before evaluation was carried out, using a modified version of the scale by Tennant and Andrews.
This scale has been validated and extensively used internationally[sup] [23] . It has been translated in Arabic and also backtranslated
in English [Table 1]. In addition, this same scale has been used before by the same authors and items unsuitable to Saudi family
culture (extramarital relationship, adoption) were omitted. Life events were not scaled and no numerical values were given for the
degree of life change or stress, due to technical difficulties. Only life events experienced six months prior to the evaluation of the
patients were included in the study. To render the results comparable to other studies, the findings in the present study were
analyzed in a more or less similar way. Chi-square test, Fisher's exact test and Student's t test were used whenever relevant.

Results

The majority of the patients and controls were between the ages of 20 and 50 years. Only one patient was below 20 and one above
50 [Table 2]. Twenty patients and 17 controls were males and ten patients and 13 controls were females. Twenty-two patients and 19
controls were married, seven patients and nine controls were single. 29 patients and all controls were employed. The differences
between patients and controls in age, group, sex, marital status and employment were not statistically significant.

Distribution of number of events per person

All the patients and 21 controls experienced one or more life events [Table 3]. Twelve patients and five controls experienced more
than six life events. The mean numbers of life events for the patients and controls were 6.6 and 4.1 respectively; differences being
statistically significant (p< 0.001, 0.05, respectively).

Individual Events

Only events reported by ten or more patients or control were considered for comparison purposes. Five of the eight significant
individual life events were experienced by more patients than the controls; of these four events were unpleasant ones; while only
three life events were experienced by more controls; none of them was unpleasant. Events of "minor illness or injury", "difficulties with
the police", "law suit" and "things lost" were reported significantly more

patients than the controls (p< 0.02, 0.02, 0.0003; respectively). The differences in life events experienced by more controls were not
statistically significant [Table 4]. More patients reported, desirable, "undesirable" and neutral (ambiguous) life events than the
controls; differences between the first two groups were statistically significant (p< 0.0051,0.00006, respectively). It is also noticed that
more patients than controls experienced more than two life events, in the undesirable group; differences being statistically significant,
again (p< 0.03).

Discussion

The relationship of life events stress and gastrointestinal disorders is still controversial. While earlier reports[sup] [1],[2] and more
recent ones confirm this relationship [sup][3],[4],[5],[6],[7],[8],[9],[10] ; others were unable to prove [sup] [17],[18],[19] . Such
controversy is most probably due to methodological problems and serious flaws in research design such as the non-quantitative
methods used in evaluating stress and that most of the research published in this area was retrospective and not controlled[sup] [19]
.

Although no scaling (intensity of life events) was carried out in this study, a degree of quantification was achieved by studying the
frequency of the most common individual life events and the number of life events per person. In addition, desirability and
undesirability of life events, which correlate with the magnitude of stress, i.e. objective, positive and negative impacts were also
included in the study[sup] [24] . The six-month period for life events before the evaluation of the patient was selected to reduce recall
bias. The prospective nature of the study and the selection of a control group are further attempts in the quantification process.

The association of life events stress and ulcerative colitis has been confirmed at all levels of investigation in the current study. First;
there were significant differences between the patient and control groups in the total number and the mean numbers of life events
experienced by each group [Table 3]. Second; analysis of the significant individual life events between the patients and controls
revealed significant differences between the two groups, i.e. significantly more patients than the controls experienced five of the total
eight significant individual life events [Table 4]. Third; the patients experienced significantly more unpleasant life events than the
controls [Table 5]. These last findings are indicative of the magnitude and impact of stress, as mentioned before[sup] [24] .

Our findings in the present studies confirm a strong relationship between life events stress and ulcerative colitis. There were
significant differences between the patients and controls in the total number of life events experienced, significant events and the
unpleasant nature of the events themselves. These findings are in accordance with others published abroad. Earlier studies
advocated an etiological relationship between life events stress and ulcerative colitis[sup] [1],[2] .[sup] More recent studies showed
that emotional factors are partly responsible for the condition (3-8) or that stress is positively correlated with exacerbation of
ulcerative colitis[sup] [8],[9],[10] . Levenstein et al in a well-designed multidimensional cross-sectional study found that stress is
associated with both objective and subjective aspects of activity in ulcerative colitis[sup] [11] . In another study the same author
confirmed that high long-term stress tripled the risk of exacerbation of ulcerative colitis[sup] [10] . Mauner et al reported a high
prevalence of insecure attachment in ulcerative colitis[sup] [7] . Casselas et al and others associated ulcerative colitis with poor
quality of life[sup] [25],[26],[27],[28] . On the other hand, the above-mentioned findings supporting an association between stress and
ulcerative colitis were criticized by others. Thus, Carol et al in an important comprehensive review of the findings and methods in the
studies dealing with this problem came to the conclusion that serious flaws in research design were responsible for these positive
results. Systematic investigation failed to find such an association[sup] [19] . Lack of control subjects, data collection problems and
absence of diagnostic criteria are among these flaws. These rather negative views were carried further by claim that ulcerative colitis
is a purely physiologic condition[sup] [17],[18],[19]. Feldman et al had seriously questioned the very concept psychosomatic in
ulcerative colitis[sup] [2] . Murray observed that psychiatric factors in ulcerative colitis are rarely mentioned now[sup] [3] .
The present study attempted to overcome some of the mentioned above flaws by the selection of a control group, prospective nature
of the study and some _degree of quantification of life events, as described earlier. Nevertheless, the present study is definitely not
immune to criticism, in spite of the attempts made for quantification. There are limitations; mainly that the number of patients under
investigation is small and there was no scaling for life events. What was actually achieved in the present study is definitely not
enough to reach a final decision on such a complex matter as the relationship between life events stress and ulcerative colitis. The
response of a patient to stress depends on many other variables than those studied here, such as personality and cognition. The
impact of life events is a complex interaction of stress, availability of social support, individual ability to cope with stress and
personality.

Conclusion

The significance of life events stress in ulcerative colitis compared with a control group was strongly substantiated in the present
study. However, further extensive studies that address the various aspects of the problem, as mentioned above are no doubt needed
before a final conclusion is reached.

Acknowledgement

We are indebted to the Deanship of Scientific Research (KFU) for their invaluable financial help and support for the project.

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Copyright: COPYRIGHT 2002 Medknow Publications and Media Pvt. Ltd.. Saudi Gastroenterology Association
http://www.medknow.com
Source Citation (MLA 8th Edition)
Saed, Abumadini, et al. "Life events stress in ulcerative colitis: A case-control study." Saudi Journal of Gastroenterology, vol. 8, no. 2,
2002. Gale OneFile: Health and Medicine,
https://link.gale.com/apps/doc/A166386219/HRCA?u=pmbf&sid=HRCA&xid=7a21e34d. Accessed 10 Sept. 2019.
Gale Document Number: GALE|A166386219

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