completed paper

Symptom Severity and Psychological Distress in IBD Patients 1

Reducing Symptom Severity in Patients with Inflammatory

Bowel Disease by Treating Psychological Distress

Danielle R Olson

Kent State University


Inflammatory Bowel Disease, or IBD, is a disease of the digestive system that

has debilitating symptoms, and patients are usually given several types of incredibly

strong prescriptions that often have their own adverse side effects. Aside from

severe physical symptoms, the disease is often accompanied by negative

psychological symptoms as well. In fact, research has shown that there is a

correlation between psychological distress and the severity of symptoms in patients

suffering from IBD. However, there is currently no positive treatment or

standardized psychological support for these patients, with the main focus primarily

on pharmaceutical and biological aspects. In this proposal, an intervention will be

developed and administered to newly diagnosed patients in an effort to decrease

psychological distress and in turn, hopefully decrease the severity of physical

symptoms that accompany the disease.

Definition

IBD is a chronic autoimmune disease that affects the digestive system,

causing severe inflammation of the smooth muscles and lining of the digestive tract.

(CCFA) In autoimmune diseases, the immune system mistakenly attacks healthy

cells and tissues in different areas of the body. The inflammation seen in IBD is

caused by the body’s immune system attacking the digestive tract. This causes

irritability and sensitivity in the bowels due to the body’s inability to regulate the

immune system. (Porcelli & Leandro, 2007) This inflammation causes severe and

often incapacitating symptoms. There are no known causes or cures for the disease,

and patients’ experience lifelong periods of relapses and remissions. Patients are


faced with lifelong unpredictability and current treatments focus on medication to

achieve and prolong remission. (Rochelle & Fidler, 2012)

There are two specific types of IBD, Crohn’s disease and Ulcerative Colitis. Crohn’s

disease, which is typically the more severe of the two, is characterized by inflammation and

symptoms anywhere in the digestive tract, from the mouth to the rectum. The severe

inflammation can cause scar tissue leading to bowel blockage, deep tissue ulcers, and fistulas,

which are abnormal passageways from the digestive tract to nearby tissue and organs. (Cleveland

Clinic, 2016) Those suffering from Ulcerative Colitis, or UC, experience the same type of

inflammation, but it is primarily restricted to the large intestine and rectum rather than the entire

digestive tract. UC is characterized by “tiny ulcers and small abscesses…that flare up

periodically and cause bloody stools and diarrhea.” (Cleveland Clinic, 2016) Both diseases are

diagnosed by undergoing a number of tests including endoscopy, blood tests, stool samples,

barium x-rays and colonoscopies, MRIs, and CT scans. (Cleveland Clinic, 2016)

Historical Misconceptions & Stigmas

Until recently, there have been a number of misconceptions and stigmas that prevented

the understanding and treatment of these diseases. When it was first recognized as an illness in

the early 1900’s, IBD was thought to be a psychosomatic disorder, meaning that the cause and

symptoms that were physically expressed came from a psychological origin. Stress, psychiatric

disease, and psychological illness were regarded as the only cause, with no attention or

acknowledgment given to a possible biological origin. (Porcelli, Leoci & Guerra, 1996) Patients

experiencing symptoms of IBD were often institutionalized for insanity. Others felt that the

disease was a manifestation of a hostile family dynamic. Some doctors and researchers felt that

an unstable relationship with one’s mother could eventually lead to a rage filled implosion that


manifested as an upset of the digestive system. (Gerson, Grega, & Nathan-Virga, 1993)

However, research and medical advancements have since shown that IBD is in fact an organic

disease, helping to prove that symptoms and flare-ups have a biological basis and are not a

mental manifestation. The nature of the symptoms stemming from IBD also make it difficult to

discuss and therefore can hinder diagnosis and research. Due to society’s reluctance to discuss

bodily functions, it is not surprising that patients would be embarrassed to discuss the symptoms

and difficulties they face, even with medical professionals. (Hatch, 1996) This stigma makes

talking about the disease embarrassing for patients and can create psychological distress. It has

been discovered that physical, as well as psychological stress, can have devastating effects on

patients with IBD.

Physical Symptoms

IBD can affect patients in a variety of different ways. The most obvious are the physical

symptoms that are experienced. The most common physical symptoms for both Crohn’s and UC

are chronic pain and fatigue, severe diarrhea, vomiting, rectal bleeding, malnutrition,

dehydration, and anemia. Others may include extreme urgency in defecation, body aches, muscle

cramps, perspiration, low appetite, malnutrition, weight loss, and fever. (Gerson et al., 1993)

There are also a number of physical symptoms external to the digestive system such as joint

pain, skin disorders and irritations, kidney and gallstones, swelling of the mouth and eyes, and

liver disease. (Cleveland Clinic, 2016)

Psychological Symptoms

Symptoms however, are not exclusively physical in nature. Having to deal with the

severity of the physical symptoms frequently experienced by IBD patients long-term


undoubtedly contributes to the psychological stress that also accompanies the disease. There is a

plethora of psychological symptoms that are experienced by patients with IBD. Anxiety and

depression are the two most common psychological disturbances found in patients and research

has shown that these can be a direct result from, and have a significant effect on the physical

symptoms presented by the disease. Research has shown that even though UC is no longer

thought to be psychosomatic in nature, psychological symptoms do largely contribute to the

course of the disease and to the patient’s quality of life. (Porcelli & Leandro, 2007) When given

assessments regarding stress associated with an ongoing medical condition, IBD patients

reported more disruption regarding psychological and social aspects than physical. (Drossman,

Patrick, Mitchell, Zagami, & Applebaum, 1989) This is not meant to downplay or discredit the

severity of the physical symptoms experienced by patients, but rather introduce and highlight the

importance and impact that psychological symptoms have on the patient’s well-being. This also

helps to introduce the correlation between a patient’s level of psychological distress and

symptom severity. Guthrie, Jackson, Shaffer, Thompson, Tomenson, & Creed all recorded

evidence showing an increase in psychological distress following an increase in physical

symptoms. (2002) Gerson et al. discuss how stress can be a causative factor, but only if there is

an underlying and biological predisposition. (1993) The major finding in the study done by

Porcelli, Leoci, and Guerra (1996) was that there is an overwhelmingly strong correlation

between symptom severity and the amount of psychological distress experienced by patients with

IBD.

This type of psychological stress cannot only exacerbate physical symptoms, but affect

how the patients sees themselves and their ability to control the disease. Personal perceptions can

play a contributing factor when it comes to patient’s psychological health. Negative personal


perceptions can especially cause an increase in psychological disturbances. Fear of symptoms

and public embarrassment, along with the fear of the inability to manage those symptoms and

control the disease can be incredibly stressful. This will not only increase the chance for

symptom severity due to increased stress, but will have a huge impact of the patient’s quality of

life, or QOL, from a personal and social standpoint. In a study done by Hall et al., (2005)

Interviewees saw their illness in terms of their bodies being ‘under attack’ by an

inconvenient, chronic, smelly, painful, and embarrassing disease. IBD was seen as an

unpredictable illness responsible for restriction in activity or freedom and affected all

aspects of everyday life. This included social and family relationships, fulfilling roles

such as caring for the family as well as social activities, work, travel, shopping and even

in some cases simply leaving the house. (p. 446)

When the normality of everyday life is disrupted, this can bring on depression, anxiety,

and feelings of hopelessness, all of which decrease a patient’s QOL. Increased fear, depression

and anxiety can also lead to social avoidance and isolation. Hall et. al. noted major issues among

patients to be a fear of bowel incontinence and avoidance of social situations, both of which

create a deficit in both physical and psychological control. (2005) Gerson et al., (1993) further

discussed how the disease can have a social impact on patients’ lives by stating that due to the

lifelong unpredictability of the disease, the patients are constantly preoccupied with avoiding

public embarrassment caused by disease symptoms, which makes forming healthy relationships

with others difficult. Disease knowledge and perceived control over the disease also had an

impact on QOL. As reported by Rochelle and Fidler, (2012) patients who did not understand the

lifelong consequences had a higher QOL score than those who were educated to the disease’s


progression and prognosis, and those who felt in control of the disease had higher QOL scores

that those who did not feel in control.

In extreme cases, the psychological disturbance experienced from IBD symptoms can be

so severe that an independent psychosomatic disorder called Bowel Obsession Syndrome can

develop. Bowel Obsession Syndrome, or BOS, is a relatively new diagnosis, gaining medical

recognition approximately twenty years ago. The clinical characteristics of BOS as described by

Porcelli and Leandro are,

Overwhelming and irrational severe fear of fecal incontinence

Ideational rambling over bowel habits, ranging from possible public humiliation

to perceived unavailability of bathrooms outside the home

Compulsive behaviors aimed at maintaining body control, including spending

excessive amounts of time on the toilet and restricting food intake

Various symptoms that overlap a number of disorders, including panic disorder,

social phobia, specific phobia, or agoraphobia without panic symptoms (2007)

Although extreme and rare, BOS is an excellent example of just how influential the

psychological symptoms that accompany IBD can be. In the case study done by Procelli and

Leandro (2007), the patient was diagnosed with IBD, an prescribed a treatment plan by his

doctor that included a very restrictive diet, lifestyle free of toxins (alcohol and tobacco), and total

avoidance of sexual and physical activity. This extreme treatment plan and lack of education on

the actual disease caused crippling fear and social isolation. As a result, “the patient began to

develop a deeper fear of leaving home and compulsive rituals of defecation-checking.” (Procelli

and Leandro, 2007)


In the case studies of BOS done by Hatch, (1996) social isolation and public

embarrassment are also discussed. Circumstances that were seen as the most stressful were those

that did not have a public restroom available such as driving on the highway, densely populated

public events, and public buses and trains. Hatch (1996) also noted that the deeply overwhelming

fear of accidental public defecation prevented patients from leaving their home and developing

social lives. Although these cases of BOS are rare, psychological distress brought on by physical

symptoms in patients with IBD are not. Clearly, treatment is needed to cure both the physical and

psychological aspects of this disease.

Current Treatments

The main focus in current treatments for IBD have a very strong pharmaceutical and

biological focus. The aim of current treatments is to get to and stay in a period of remission for

as long as possible. While controlling the physical symptoms and preventing relapses is a critical

part of treatment, little to no emphasis has been placed on psychological treatments. The most

common form of treatment is pharmaceutical medication, and if symptoms and disease

progression are severe, surgery. When patients were questioned by Hall et al. (2005) as to how

they were treating and controlling their disease and its symptoms, pharmaceuticals and diet

restrictions were seen as the main ways to obtain or achieve some level of control. The patients

also listed other strategies, some negative and some positive, regarding how they coped with

symptoms. The most common negative strategies were, “situational avoidance, planning outings

around toilet availability,” and “keeping secret about the disease”. (Hall et al., 2005) The positive

strategies listed are: “adapting or learning to cope, information seeking, social support seeking,”

and “seeking healthcare.” (Hall et al., 2005) It is clear that the majority of strategies, whether

positive or negative, focus on physical symptoms, and little regard is given to treating


psychological symptoms even by patients. This could be a direct result from the medical

community lacking information regarding psychological distress and its relationship with disease

and symptom severity.

Since medication is the primary form of treatment, it is worth noting what kinds of

medication are most commonly prescribed and what effect they have on IBD sufferers. During a

flare-up, IBD patients are often prescribed corticosteroids. This is an orally or rectally

administered anti-inflammatory drug that reduces swelling in the digestive tract and can bring on

remission. It is not however, prescribed for long term use due to its many and somewhat severe

side effects. Side effects include, but are not limited to: weakening of the bones, increased facial

hair, weight gain, mood swings, and psychosis and other psychiatric symptoms. (CCFA, 2015)

Although the side effects of this immune suppressing drug can actually increase psychologic

distress, therefore increasing symptom severity, it is still one of the most commonly prescribed

medications.

Other common medications include 5-aminosalicylic drugs, which reduce inflammation,

and immunosuppressants, which lower immune system functioning are often used to treat IBD

but can leave patients highly susceptible to infections. Biologics, or biological therapies are most

often used for moderate to severe disease activity. “Biologics are antibodies grown in the

laboratory that stop certain proteins in the body from causing inflammation.” (ccfa.org, 2015)

Biological therapies are created to be disease specific, and while the have fewer possible side

effects than other commonly prescribed medication, the ones that they do have can be much

more severe. While side effects from biologics usually only occur while taking other

medications, most IBD patients take several prescriptions simultaneously. Side effects from


biologic can include increased cancer risk, liver problems, lupus-like reactions, and nervous

system disorders. (ccfa.org, 2015)

If medications fail to treat the disease, the only other option is surgery. Surgeries can

include a full colectomy, a proctocolectomy, a permanent ileostomy, or an ileal pouch,

depending on the disease’s progression and severity. (Cleveland Clinic, 2016) While these and

other medications can help to prevent flare-ups and maintain remission, they do not serve to

alleviate the psychological symptoms if IBD. Pharmaceutical treatment alone is not enough to

help patients maintain a high QOL. The focus then, rather than relying heavily on strong

medication, should be on developing and administering a treatment that can help to alleviate the

symptoms and control the disease without the harmful, severe, and invasive side effects that are

currently available. Research has shown correlations between psychological distress and

symptom severity, therefore, if physical and psychological aspects play a role in disease

progression, why are we not treating both, rather than just the physical?

Treating with Psychology

There is evidence showing that treating psychological symptoms can be an effective way

of managing the illness and increasing the QOL for patients. By treating the psychological

symptoms and decreasing psychological distress, it is proposed that the symptom severity will

decrease and that patient QOL will increase. Rochelle and Fidler, (2012) stressed the need of

addressing the psychological and well as the physical aspects when discussing any type of

chronic disease. There is obviously more to IBD than strictly biological and physical elements.

Therefore, a multi-faceted disease needs a multi-faceted treatment approach.


By using a biopsychosocial model of treatment, a patient can receive treatment in all

areas of life that is affected by the disease including, physical, mental, and social aspects. This

approach has been suggested in other research as well. Drossman, (1996) supports a

biopsychosocial treatment approach in his study and discusses how this will best help to find

suitable treatments for the disease. Research done by Seres, Kovacs, Kovacs, Kerekgyarto, Sardi,

Demeter, et. al., shows that disease activity and symptom severity are the factors affecting

patients the most. (2008) If it is acknowledged that psychological distress has a direct impact on

symptom severity, and that symptom severity is one of the most important factors for patients, it

stands to reason that they should be receiving treatment for the psychological distress caused by

the disease. This point is best demonstrated by Guthrie, et al.,

The presence of psychological disorder in inflammatory bowel disease contributes to

poor health-related quality of life, regardless of the severity of the condition. Detection

and treatment of psychological disorder in inflammatory bowel disease carries the

potential to improve health-related quality of life for these patients. (2002)

In the case study done by Porcelli and Leandro (2007) regarding BOS, treatment was

successful and used a collaboration of healthcare professionals working together, including a

gastroenterologist, psychiatrist, and psychologist. Hatch (1996) gives yet another example of

how this biopsychosocial approach can be effective by stating that using therapy along with

biological treatments prove to be the most successful. While these are small and isolated cases, it

is believed that a standardized program of education, social support, and psychological screening

and treatment can be developed for a widespread application to newly diagnosed IBD patients in

an effort to decrease psychological distress and symptom severity.


Introducing Additional Treatments

Illness education is a crucial part of helping patients to cope and accept this disease.

Being diagnosed with a chronic, lifelong illness and not understanding the implications of that

diagnosis are sure to cause some level of anxiety. Very few newly-diagnosed patients have ever

heard of the disease, and those who did have knowledge did not hold a deep understanding. (Hall

et al., 2005) This shows a strong educational and informational foundation is critical to patient’s

confidence in understanding the disease and feeling able to manage it. However, care must be

taken in exactly how this information in administered. In one study by Rochelle and Fidler,

(2012) it was demonstrated how patients that had a good understanding of their disease had

higher levels of anxiety than those who did not have a good understanding. It is proposed that the

reason for this correlation is due to the fact that having a good understanding of the disease also

means that patients have been informed on the limited number of treatments available. It is

hypothesized that by administering education along with psychological support, that the

correlation between knowledge and anxiety will weaken. In the same study, Rochelle and Fidler

(2012) state that they encourage disease education, and patient understanding will increase

patients’ confidence and sense of control.

Introducing and teaching different coping mechanisms is another way to increase patient

control and confidence. Educational programs made specifically for IBD patients are thought to

be potentially beneficial regarding personal perceptions. (Rochelle & Fidler, 2012) By

introducing stress relieving techniques and learning how to lower anxiety levels, the patient may

have less symptom related psychological stress. Social support is another fundamental part of a

successful integration plan. By creating support groups for patients with IBD, whether in person

or online, being able to discuss the emotional and physical difficulties of the disease with other


patients could prove to be therapeutic and beneficial. Social awareness may be the most difficult

part for patients to deal with. Trying to explain the disease and symptoms to others can be

difficult and embarrassing. By giving patients tools and ideas on how to educate others, this

could help to alleviate a large source of the patients stress and anxiety. Studies have shown that

there are a common set of concerns that most IBD patients share. These include normality of

personal health, restrictions on personal freedom, disease control, coping strategies, self-

management, reluctance to confide in physicians, and a wide knowledge range. (Hall et al.,

2005) This intervention hopes to address these concerns.

Psychological screenings could be the most critical and important part in preventing or

helping to reduce psychological distress in IBD patients. The best place for this screening to be

administered would be in the gastroenterologist’s office. By performing this screening at the time

of diagnosis, physicians would be able to see signs of distress much sooner and could refer

patients to a mental health professional to receive treatment before the symptoms become severe.

As mentioned in Guthrie et al., (1998) being able to receive a psychological assessment in the

gastroenterologist clinic would be both appropriate and beneficial. By using cognitive

restructuring and behavioral therapy, the patient in Porcelli and Leandro’s (2007) study no longer

experienced OCD-like symptoms and was able to leave their home without fear, anxiety, or

depression. Patients have shown to be more than willing to take an active role in disease

management. The majority of interviewees in the study by Hall et al. stated that they would in

fact prefer a treatment program where they could self-manage their disease with the help of their

doctor. (2005) If given the right set of tools and information, patients will not only be more at

ease and confident, but ready to take a more involved and proactive role in managing their

disease.


Proposed Intervention

In an effort to accomplish these suggested goals, an intervention will be introduced in an

effort to help newly diagnosed IBD patients lower their psychological distress and in turn

decrease the severity of their symptoms. This intervention will include illness and disease

education, coping mechanisms, social support and awareness strategies, and psychological

screenings and referrals. By introducing psychological treatments and implementing this

biopsychosocial approach, it will help to give patients a more complete treatment plan than what

is currently available.

By providing psychological support along with educational tools, it is hypothesized that

symptom severity will decrease among newly diagnosed patients, compared to those patients

who are newly diagnosed and not given additional psychological treatment.


Method

Participants

The population that will be included in this study will be an equally represented amount

of both men and women ranging in age from 18-30, as it is most common for IBD patients to be

diagnosed with the disease during this age range. This disease affects both men and women and

most patients are diagnosed before the age of 30. (CCFA, 2015) This sample will included newly

diagnosed IBD patients only, in an effort to see if the intervention will be successful when

presented with the diagnosis and part of treatment and education. For this study, we will obtain

an N of at least 34, based on a of .05 and power of .8∝ . While a minimum of 34 subjects in

required, our goal is to obtain an N of 50.

Materials

Educational Materials. Educational pamphlets discussing the disease symptoms,

treatments, and available support will be administered along with a list of contacts which provide

free support to IBD patients such as the CCFA and Cleveland Clinic websites. These will be

mailed to the patients after completing an online registration.

Disease Severity. Severity of symptoms will be measured using the CDAI (Crohn’s

Disease Activity Index, 2011), which calculates a patient’s symptoms, medication use, and

general well-being. This assessment uses both “yes” and “no” questions such as, “has the patient

in the last 7 days, taken any anti-diarrheal drugs?”, and a Likert scale of 0-3 or 4. A sample

question of this nature asks the patient to rate his or her general well-being on a scale of 0-4. This

scale is used by both doctors and researchers when assessing IBD symptom severity.

(http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0048967/)

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0048967/


Psychological well-being. Patients will be screened for depression, anxiety, and panic

disorders. Depression screening will be done using the Patient Health Questionnaire-9 (PHQ-

9) developed by Spitzer, Williams, Kroenke, and colleagues in 1998. It is a 4 point Likert scale,

ranging from not at all to nearly every day. Samples include, “little interest or pleasure in doing

things”. Anxiety screening will be done using the Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition developed by the American Psychiatric Association, 1994. It is a yes

or no scale of 18 questions. Sample includes “inability to control worry”. Panic disorders will be

screened using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Washington, DC, American Psychiatric Association, 1994. This is a yes or no scale consisting of

27 questions. Samples include, “repeated or unexpected “attacks” during which you suddenly are

overcome by intense fear or discomfort for no apparent reason”. All three of these assessments

can be found on the Anxiety and Depression Association of America’s website. Screenings will

be done at the initial time of diagnosis, and again after the 1 year study period to see if symptoms

were reduced.

(http://www.adaa.org/living-with-anxiety/ask-and-learn/screenings)

Procedure

Subjects will be recruited through Cleveland Clinic Gastroenterologists. Any patient

receiving a new diagnosis of IBD will be given the opportunity to participate in the study given

they meet the sample parameters. Upon agreeing to participate in the study, patients will be

given information on how to sign up online. Since the registration and majority of

communications will take place online, internet access will be required. Patients will sign up

online and receive educational materials via the mail. They will meet at a scheduled time for the

screenings to be administered both before and after the study period. After the initial screenings

http://www.adaa.org/living-with-anxiety/ask-and-learn/screenings


are complete, participants will partake in weekly scheduled support activities, whether online

chats, group meetings, or one on one psychological sessions. Consent and confidentiality forms

will be administered and filled out online as well. All participants will receive a $50 Amazon

Gift Card at the initial screening and for every scheduled activity they complete. The study will

last a time period of one year.


Budget

Personnel

1 Primary Researcher @ 50,000 per year x 1 year = 50,000

1 Graduate Assistant @ 15,000 per year x 1 year = 15,000

Total 65,000

Materials

Initial registration packet administered @ clinic x 50 = 69.99

Participation Manual and contact info x 50 = 497.75

Educational material in binder x 50 = 756.00

Support group/network pamphlet x 50 = 158.50

Total 1,483

Participants

Initial and Final Screenings @ $50/screening x 50 participants

x 2 screenings = 5,000

Weekly Meetings @ $50/meeting x 50 participants

x 50 meetings = 125,000

Total 130,000

Total Expenses 196,483


References

The Cleveland Clinic Foundation. (2012) Ulcerative Colitis. Retrieved from:

http://my/clevelandclinic.org/health/diseases_conditions/hic_ulcerative_colitis

The Cleveland Clinic Foundation. (2016) Crohn’s disease. Retrieved from:

http://my/clevelandclinic.org/health/diseases_conditions/hic_inflammatory_bowel_diseas

e_ibd_quanda/hic_crohns_disease

Drossman, D., Patrick, D., Mitchell, C., Zagami, E., Appelbaum, M. (1989). Health-related

quality of life in inflammatory bowel disease: Functional status and patient worries and

concerns. Digestive Disease and Sciences, 34(9), 1379-1386.

Gerson, M., Grega, C., Nathan-Virga, S. (1993). Three kinds of coping: Families and

inflammatory bowel disease*. Family Systems Medicine, 11(1), 55-65.

Guthrie, E., Jackson, J., Sc, Schaffer, J., Thompson, D., Tomenson, B., Creed, F. (2002).

Psychological disorder and severity of inflammatory bowel disease predict health-related

quality of life in ulcerative colitis and Crohn’s disease. The American Journal of

Gastroenterology, 97, 8.

Hall, N., Rubin, G., Dougall, A., Hungin, A.P.S., Neely, J. (2005). The fight for ‘health-related

normality’: A qualitative study of the experiences of individuals living with established

inflammatory bowel disease (IBD). Journal of Health Psychology, 10(3), 443-455.

Hatch. M. (1995). Conceptualization and treatment of bowel obsessions: two case reports.

Behaviour Research and Therapy, 35(3), 253-257.


Irwin M. and Suzanne R. Rosenthal IBD Resource Center. (2015, January). CCFA Fact Sheet

News from the IBD help center: Biologics. Retrieved from: http://www.ccfa.org

Irwin M. and Suzanne R. Rosenthal IBD Resource Center. (2015, January). CCFA Fact Sheet

News from the IBD help center: Corticosteroids. Retrieved from: http://www.ccfa.org

Mesalamine. (2009). Retrieved from: http://www.drugs.com/ppa/mesalamine-5-aminosalicyclic-

acid-5-asa.html

Porcelli, P., Leoci, C., Guerra V. A. (1996). A prospective study of the relationship between

disease activity and psychologic distress in patients with inflammatory bowel disease.

Scandinavian Journal of Gastroenterology, 31, 792-796.

Porcelli, P., Leandro, G. (2007). Bowel obsession syndrome in a patient with ulcerative colitis.

Psychosomatics, 48, 448-450.

Rochelle, T., Fidler, H. (2012). The importance of illness perceptions, quality of life and

psychological status in patients with ulcerative colitis and Crohn’s disease. Journal of

Health Psychology 18(7), 972-983.

Seres, G., Kovacs, Z., Kovacs, A., Kerekgyarto, O., Sardi, K., Demeter, P., …Tury, F. (2008).

Different associations of health related quality of life with pain, psychological distress

and coping strategies in patients with irritable bowel syndrome and inflammatory bowel

disorder. Journal of Clinical & Psychological Med Settings, 15, 287-295.

completed paper

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