The psychoanalytic treatment of ulcerative colitis revisited

A review of the literature indicates that very little is known about the role of psychological factors in the etiology, exacerbation, and treatment of ulcerative colitis. Most phenomenological consensus seems to take place around recognizing that the patient has great difficulty in expressing aggression and is frightened of loss of control. Episodes of ulcerative colitis are often related to the sudden loss of an important love-object and/or severe narcissistic wounding. Chronic narcissistic rage is not at the center of the psychological phenomena as I (Chessick, 1985) have described it in narcissistic psychosomatic disorders. In ulcerative colitis, acute episodes of object loss, narcissistic wounding, or bitter disappointment, along with a sense of entrapment and helplessness, produce the threat of an explosion of uncontrollable rage. Such an explosion would result in disruption of the patient's life and expulsion from significant and needed relationships. This produces an acute internal conflict, hopelessness, and despair, with the danger of resolution by paranoid projection. Why in these patients these events seem to be followed by changes in the colonic mucosa is simply unknown, nor is it clear whether they are related to these changes directly or indirectly. The defensive inability to feel the archaic rage at early significant caretakers or their later life substitutes is clearly an important determinant of the psychosomatic condition. I believe that the treatment problems raised by the patient presented here are fairly typical of what will be encountered in any effort to psychoanalyze a patient with ulcerative colitis. Perhaps because of the failure of Alexander's specificity hypothesis, there has been a loss of interest in the psychoanalytic treatment of such patients, and this is regrettable because at least some of them, like the present case, respond well and it makes a vital difference in their future. One certainly cannot say that psychoanalytic treatment represents any sort of "cure" for ulcerative colitis, but it seems clear that resolving underlying psychopathology to whatever extent is possible lessens the chance for ulcerative colitis to be exacerbated by stressful events, such as severe narcissistic wounding or substantial unexpected object loss, because the ego has been strengthened and the patient has an improved tension-reduction capacity. Psychoanalysts should not be afraid to consider the treatment of such patients as long as they are not in the acute phase of the disease. Acute manifestations require active medical, pharmacological, and supportive psychological intervention.