Evolving concepts of psychopathology in inflammatory bowel disease. Implications for treatment

The role of psychiatric factors in inflammatory bowel disease has been increasingly relegated, according to Aronowitz and Spiro, to "patient's illness, but not to disease, to therapy, but not to etiology, to symptoms, but not to pathology, and finally to the course of the disease, but not to its cause." This is not surprising in view of the fact that to attribute psychological factors to an illness is seen by the patient and physician alike as an attempt to "blame the victim." As a result, there has been a concerted effort in the past two decades in the field to replace the seemingly archaic, developmental, romantic psychoanalytic concepts of causation with more "enlightened," "scientific" paradigms of psychoneuroimmunology and psychiatric comorbidity. Despite major advances in the biomedical understanding of inflammatory bowel disease and its treatment, however, the essential questions about the complex relationship between emotional and physical symptoms remain a source of frustration both to the patient and to the treating physician in the management of the chronic diseases of the bowel. Thus, early assumptions of a psychogenic basis of ulcerative colitis and Crohn's disease may have been imprecise, but the genuine contributions of investigators such as Alexander, Karush, and Engels ought not to be cast aside completely. Experience with the treatment of patients with inflammatory bowel disease shows that attention to psychiatric comorbidity, quality of adaptation to illness, and the patient-physician relationship are essential components of a comprehensive, successful approach to these chronic illnesses.