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Studies in ulcerative colitis
Journal of Psychosomatic Research, 1964, Vol. 8, pp. 89 to 100. Pergamon Press Ltd. Printed in Northern Ireland
STUDIES
IN ULCERATIVE
COLITIS*
FINN ASKEVOLD (Received 8 March 1964)
CONSIDERED generally as a disease entity, ulcerative colitis is defined as a chronic inflammatory disease in the colon and/or rectum with stools containing blood and/or pus. Some authors exclude hemorrhagic proctitis from ulcerative colitis proper. There seems not to be any real distinguishing features in the pathology to substantiate this division, so that hemorrhagic proctitis is here considered only as a special localization of the ulcerative colitis. The diagnosis of ulcerative colitis is fairly simple, and there is a high degree of agreement between different diagnosticians. It is based on the clinical, radiological and proctoscopic findings. Despite the 70 years which have elapsed since the first description of ulcerative colitis [l] its etiology is still obscure, and opinions on pathogenesis are often very controversial. The first mention of the importance of psychological factors in this disease was put forward in 1930 [2], at a time when most of the other psychosomatic hypotheses were also formulated. As so much is still hypotheses, it would seem worthwhile to compare reports on ulcerative colitis from different investigators in different parts of the world. METHOD From October 1959 to July 1962 all patients with an established diagnosis of ulcerative colitis admitted to the two medical departments of Oslo University Hospital (Rikshospitalet) were referred for psychiatric examination. The two surgical departments were omitted for practical reasons, and in nearly all cases the patients were first admitted to the medical department while under consideration for surgery. No children are included, as the pediatric department has its own psychiatric service. This makes the distribution askew, but no different from the other reports which will be compared with our own case material. Oslo University Hospital admits patients from the whole country, and it is only rarely that they are admitted for their first attack of the disease-all had been hospitalized in their local hospitals on at least one or more occasions. Thus it seems to be the more severe cases, often resistant to numerous therapeutic procedures, who are admitted to the hospital, mostly for consideration over surgery or not. RESULTS Sex distribution
The material consisted of 60 patients, 34 males and 26 females. This gives a ratio 1:0.8 which corresponds with that found by BOCKUS et al. [3] who in 182 American patients have a ratio of 1:0*9, but not with ENGEL [4] from America, and PAULLEY [5] from England who both give a ratio of 1 :2, the same ratio being reported from Austria by BOLLER [6] in 89 patients. The possibility of more males being referred for hospital treatment is excluded by the prevalence study from Norway by USTVEDT [7] and GJONE and MYHREN [S] where in 400 cases the ratio is also 1: 1. The patient’s age of onset of the disease is shown in Table 1, and is in accordance with others, especially with the total figures from Norway by GJONE and MYHREN [8] showing no specially preferred decade for the onset of the disease. * From the Oslo University Hospital (Rikshospitalet), Norway. 89
90
FINN ASKEVOLD TABLE 1.
AGE AT ONSET OF DISEASEAND DURATION AT TIME OF PSYCHIATRIC EXAMINATION Males
Females
__~__~~_~_
1~_________
Mean
Age in years Duration in years Number of patients
32.0 3.5
Limits
Mean
9.0-60.0 0.2-l 3.0 34
30.1 5.8
Limits 10.0-39~0 0.5-38.0 26
Total
----
Mean 31.2 4.5 60
The types of occupation were too varied to give any hints as to the possible importance of this factor but it could not support the views of BOLLER [6] who states that these patients belong to intellectual, sedentary professions. Geographical
distribution
From rates based on hospital admissions at a given time MELROSE [9] found differences in different parts both of the United Kingdom and of European countries. The lowest figures were found in Scotland, Switzerland and Finland and the highest in England. The latest figures were 14.8 per 10,000 hospital beds. USTVETD [7] has criticized this method of sampling, as it gives no real incidence figures. In a survey covering all Norway for the years 1946-1950 and 1951-1955 he obtained reports from all hospitals on first admissions for ulcerative colitis. This survey has been continued for the years 1956-1960 by GJONE and MYHREN [8], the findings showing a definite rise in incidence from 8.6 per 1,OOO,OOOpopulation in the first five-year period to 15.1 in the second and 20.6 in the last. The increase was most marked in the youngest age groups below 20. As figures from different authors are not uniformly collected they are not comparable, but what was found as differences within the United Kingdom also was shown in the Norwegian report. A higher incidence was found in the eastern and middle part of the country. My own figures are not incidence figures, as admission to the University Hospital is not evenly distributed throughout the country, and the patients are not firstadmissions. Table 2 shows the patients home-area, compared with the relative population. TABLE 2.
BIRTH PLACE AND RESIDENCEIN NORWAY IN RELATIONTO THE POPULATION Birth area n C%)
Oslo-Akershus Oslofjord countries Southern Norway
Western Norway Eastern and middle Northern Norway Total * 3 patients disease started Norway).
Norway
13 7 9 6 14 8 57*
Living area
Population
n
(%I
(%I
22.8 12.2 15.8 10.6 24.5 14.1
19 9 6 3 17 6
31.7 15.0 10.0 5.0 28.3 10.0
100.0
60
100.0
18.8 15.5 9.5 24.7 19.3 12.2 -100.0
were born abroad, 2 foreigners after they had settled in Norway
and one Norwegian and their (2 in Oslo and 1 in Western
91
Studies in ulcerative colitis
The same tendency to an over-representation from the eastern and middle parts of Norway can be seen. When the patient’s birth place is taken into account there is a tendency to “normalize” the figures. In Norway the population tends to be very stable with little movement. Only those who have moved outside their own county after their birth, and before the onset of the disease are counted as “movement”. This indicates that these patients might have reacted to moving or to the adaptation difficulties in the new place in a way harmful to themselves. TABLE3. INITIALSYMPTOM
Diarrhoea only Diarrhoea with blood Blood only
Males
Females
Total
21 8 5
12 8 6
33 16 11
The figures are too small to provide any conclusive evidence of type of movement, but there is a tendency for a move from rural to urban areas to give an increase in skewness in the different geographical areas. The factors responsible are unknown and it would seem worthwhile to investigate these parts more thoroughly than has been possible in this material. Initial symptoms ENGEL [4] found that the passage of blood was the initial symptom in 22 of his 32 cases. He refers to BARGEN [lo] whose finding that bleeding was the first symptom in 50 per cent of cases was the only exception to the general statement that ulcerative colitis begins with diarrhoea. This has been confirmed by KOLLAR et al. [I l] who in 62 episodes of the disease in 47 patients found bleeding with normal, formed stools in 24, and bleeding with diarrhoea in 17. Diarrhoea preceding bleeding was present in 21 cases. In the present study, Table 3 illustrates that in more than half of the cases the disease started with the frequent passage of more than three watery to semi-fluid stools per day and in only 11 were there cases of blood only passed. This may indicate a difference in the course of the disease in the United States and in Europe, but the number of reports are too few to allow any conclusion. Other psychosomatic
complaints
ENGEL [12] found constipation in the premorbid bowel history in 12 out of 20 cases, KOLLAR [l l] included a study of symptoms usually regarded as psychosomatic, whilst FERNANDEZ-HERLIHY [ 131 has especially focused on arthritis in combination with ulcerative colitis, which was found in 17 per cent of 85 cases. Both KOLLAR [ 1 I] and ENGEL [12] emphasize the high incidence of headaches in their patients; ENGEL found it in nearly all his cases, whilst KOLLAR found it in 13 of 42 patients; in addition 42 of 47 patients had different psychosomatic complaints either previous to, or in combination with the ulcerative colitis. Table 4 shows that only half of the present group had other psychosomatic complaints than their ulcerative colitis. The results are not directly comparable, as the table shows only those symptoms present prior to the onset of ulcerative colitis, whilst other workers’ lists include those occurring during the course of illness. Jt can
FINN
92
ASKEVOLD
be seen that all the symptoms have relation to organs regulated by the autonomic nervous system. There was no record of psychiatric disturbance in the material as had been carried out by KOLLAR et al. [l l] but one patient had been hospitalized for a psychosis prior to the onset of his ulcerative colitis. This was a 19 year old sailor who had an attack of a schizophreniform psychosis, which disappeared when his bowel started to bleed. He had a recurrence of his psychosis when his gut healed. When he was put on TABLE 4.
CONDITIONS OF POSSIBLE IMPORTANCE PRESENT BEFORE ONSET OF ULCERATIVE COLITIS Males
Allergic disposition Asthma Polyarthritis Eosinophilia Dyspepsia from childhood “Colic” Constipation Headaches
2
ataractic drugs this rhythm was broken, colitis and his psychosis at the same time. from both illnesses.
5 1 3 4 11 2 9 5
23
17
40
15 19
15 11
30 30
2 3 9 2 3 1
Total
Total
3 0 I I 2 0 6 4
I
No. of subjects involved No complaints in
Females
and he suffered from both his ulcerative After hemicolectomy he seemed to recover
KIRSNER et al. [14] have found a decrease of serum albumin in 63 of 65 patients and an increase in the globulin content, most marked for the gammafraction. In some of these there was an increase in t-globulins, probably a sign of an auto-immunization process being present. BENANDI [ 151 showed the same decrease of serum albumin and increase in globulins, in the alpha part, and especially in the alpha-2-globulins. There is agreement that marked changes in serum proteins indicate a severe somatic condition and KIRSNER [14] could show that a return to normal values paralleled improvement. This was not related to any special type of treatment; in one patient who had no drug treatment, receiving psychotherapy alone, the same trend could be observed. In 44 patients the same decrease in serum albumin was found (Table 5). The lowest TABLE 5. DISTURBANCES IN SERUM PROTEINS, SEDIMENTATION RATE (SR) AND HEMOGLOBIN (Hb) DURING ACTIVE PHASES OF THE DISEASE
Albumin Albumin Gamma Gamma Increased Anaemia
3.3-2.5 (g:<,) below 2.5 (g%) globulin exceeding 2.0 (g %) globulin 1.8-2.0 (g li’,) SR
Males
Females
18 6
15 5
Total 33 11
44 26
7 9
4 6
l3 13
14 9
12 8
26 17
Studies
in ulcerative
colitis
93
range of normal values is 3.6 g and an additional 10 per cent safety range has been added. In only 26 could the same increase in gamma-globulins be found. The highest normal value is l-6, but in the present report 1.8 is counted as the lowest value. The alpha-globulins were raised in only 13 cases and BENANDI’S findings [15] could not be confirmed. Parallel to the protein changes there is an increased sedimentation rate, 20 mm being taken as the highest normal value in females and 15 mm in males. There were no cases with especially high values and only 26 had abnormal values. 17 patients had an anemia below 85 per cent Hb., but there were no very low values, except when gross bleedings occurred or when the patient was in extremis. All these values are expressions of the disease process, and are not etiological factors, as to some degree they might be said to parallel the actual status of the illness. This parallelism is not complete, as less than half of the patients have an increased sedimentation rate during an active phase of the disease. Nearly all the patients are admitted to our hospital during active phases of their ulcerative colitis and it is surprising that this part of the pathophysiology is not more affected. Localization
of the disease
In 8 cases the disease was limited to the ascending colon (13.3 per cent)-in 23 (38.3 per cent) it was located in the distal part of the colon including rectum. In 29 (48.3 per cent) the whole colon was affected. BOCKUS [3] figures were 48.4 per cent for total colonic involvement, 14.8 per cent rectal, 21.4 per cent in the distal, 14.4 per cent for the ascending part. In this and in other respects there seems to be a good agreement between the cases investigated by BOCKUS and those in the present investigation. The initial symptom of passages of blood seem to be related to a distal involvement, especially sigmoid and rectal. There was no correlation between the localization and the severity of the disease.
Psychological
structure
In the present investigation the psychiatric interviews were carried out by the author, this being done to avoid the fallacies of catamnestic investigations where different observers have described their impressions in their own linguistic frame of reference which is not easily repeated by another individual. All patients are thus investigated in the same way and thus represent a uniform sample, but nevertheless with the possibility of a personal bias on the part of the investigator. Most investigators, psychiatrists, psychoanalysts and physicians, claim that psychological factors play an important role in this disease but there is no unanimity as to which psychological factors are active, to what degree they have to be present to seriously influence the disease process, and of their relative importance etiologically. In the research methods used two different trends were visible. The one is based on one or more interviews in a series of cases and the other based on psychoanalytical treatment of a few cases. Paulley [16] with his 173 cases might be regarded as the protype of the first trend. In all his patients he finds an almost uniform psychological structure. They are dependent, parent-controlled individuals, usually tied to their mothers. They have a tendency never to be able to express open aggression but are suffering under long protracted bitterness and brooding. They are hypersensitive and the males usually somewhat effeminate. In addition they show self-righteousness, false modesty and a poorly developed sense of humor. The most striking point in his opinion is the inability to
94
FINN ASKEVOLD
express emotions, which he regards as a sign of emotional immaturity. They also show a poor ability to establish sexual relationships. Moschcowitz et al. [17] are in agreement with Paulley on most points but underline the extreme dependence, tendency to subordination, weak wills, emotional immaturity and poor sexual adjustment. They do not consider that aggression, open or concealed, plays an important role. Groen et a/. [18] are in favour of the same homogeneous outlook on these patients and describe them in almost the same terms as Paulley. Engel [19] mentions the obsessional traits, rigidity and moralistic views as important and underlines the timid appearance of the patients. He is not so uniform in his outlook and reports querulous subjects and also sensitive, ruminative, passive ones. Kollar et al. [II] have not been so concerned with the personality structure, and base their view more on tests, especially the MMPI. They nevertheless report heterosexual inadequacy with fears of homosexuality. They have also observed a passive, inactive depression preceding the disease. The psychoanalytical group of investigators underlines the anal, obsessive traits [20]. Szasz [21] emphazises in addition the oral, incorporating needs, also included in Sperling’s [22] concept of the early oral damage with a symbiotic, ambivalent tie between mother and child and with repressed hostility and destructiveness. She also sees a relationship between ulcerative colitis and melancholia. This view is substantiated by Mushatt [23] and in relation to this it is interesting to note that quite recently Iisalo [24] report good therapeutic results with antidepressant drugs (MAO-inhibitors). When one considers all these statements concerning the personality structure one is struck by the fact that it is seldom one single personality trait, but rather a pattern which the different investigators emphazise. In some reports on psychosomatic diseases this way of describing a personality by one single trait still lingers on, but must now be considered extremely out-dated. The authors reported all describe a pattern, but one cannot say that there is unanimity as to exactly what this pattern is. In general it is believed that there is something peculiar both in the overt behaviour and in the dynamic structure of these patients which often distinguish them from other patients. In Groens and Paulleys opinion, patients with ulcerative colitis are more similar to each other than to other patients. The difficulty is that the different personality traits mentioned are of a rather general type, not very easy to define, and almost impossible to classify in a way that distinguishes them from other groups of patients. In many reports no control material is used. Kollar [ll] is the only one and he finds a difference in the depression score. The only conclusion to be drawn must be that there is general agreement that these patients have a personality structure which reveals itself in their behaviour and which was present before the onset of the disease, and they all give a clinical impression of peculiarity, uniform or not. A disease of such a severe nature, with its incapacitating qualities must have a profound influence on the person and his attitudes. This influence might also lead to a change in thought and phantasy processes which could change the Rohrshach responses to represent an actual situation and not the basic pre-morbid personality. The same reflections would also be valid for the interview as the “here and now” situation of the patients will give an unconscious direction to leading questions designed to substantiate that impression. Although all investigators firmly state that they always have been searching for pre-morbid character traits, one cannot easily discuss the possibility of a “closed circuit”-evaluation, but frequent interviews with the patients’ relatives have substantiated many of the assertions of a deviant personality structure from early childhood and long before the first sign of a colonic disease appeared. Another difficulty is the vagueness of the concepts regarding the personality traits recorded. Many are so common that they present in too high a percentage of normals to single out the persons with ulcerative colitis and separate them from the rest. In most papers the personality traits are not defined, but described in a loose and often ambiguous way and do not allow for comparison between them.
In this investigation an attempt has been made to describe groups of behavioural traits in a pragmatical frame of reference, based on what is clearly observable in the interview situation and reported by the patient to be a constant behaviour pattern from early life. For the more subjective traits the basis is what the patient says they feel as separating them from others, restricting their lives and having been present before the onset of the disease. This is similar to the method employed by others in the non-psychoanalytical area of investigation, but personality traits are defined in the following way: 1. Directly distance.
observable
deviant
behaviour
in the direction
of shyness,
timidity,
retraction
and
95
Studies in ulcerative colitis
“Internal action” concerning rigidity, obsessions and perfectionism. “External action” concerning inhibition of aggression in a broad perspective from considerable lack of ability in showing adequate self assertion to lack of ability in showing more hostile aggression, adequate or inadequate. Genera1 feelings concerning insecurity and a diffuse tendency to anxiety. Special feelings concerning frustrations and faulty self-evaluations.
In 53 of the 60 patients one or more of these behavioural traits were found to be present. No estimate is made of the degree to which these traits are present in the individual cases. Similar evaluation of other groups of patients was not carried out, but from clinical experience it seems likely that these traits will probably be present also in other diseases, but not to the same extent and not in the same proportion within the group. Shyness was present in 23 patients, 13 males and 10 females. This was often felt to conceal dynamic traits loaded with inhibited hostility. As the method of investigation is cross-sectional the possible dynamic traits are not taken into consideration. Rigidity was seen in 24 patients, 13 males and 11 females, but not always in combination with shyness. Inhibition of aggression was reported by 22 patients with even sex distribution and seems also to be a very prominent feature in these patients, but not The most prominent trait was the feeling of as constantly as others have found. insecurity, both as a general diffuse feeling and in relation to other people. This was always combined with restlessness and a feeling of uneasiness, sometimes felt directly as anxiety. Frustration of ambition is, in my experience, rather important, but was It is important because it conceals not found in more than one sixth of the patients. a high degree of neurotic self-evaluation. In only 7 patients were none of the mentioned traits detected. Four were in the youngest age group, mostly with a severe attack of the disease. The remaining three were scattered in age and sex, and lack of deviant personality traits bore no relation to the severity of illness. TABLE
1. 2. 3. 4. 5.
6.
OBSERVABLE
Shyness Rigidity Inhibition of aggression Insecurity Frustration of ambition Total No. of subjects involved No abnormalities detected
BEHAVIOUR
TRAITS
Males
Females
Total
13 13 11 15 6 58 30 4
10 11 11 15 4 51 23 3
23 24 22 30 10 109 53 7
In Table 6 the distribution of the traits will be seen. In 3 patients all five groups were present, in 3 one could see four groups, in 16 three, and in 13 two groups, while in 8 patients only one of the groups was present. KOLLAR et al. [I l] see depression as a prominent trait, but even if one consider the traits mentioned here as types of withdrawal no real depression can be said to be present. Even if my traits can not be said to be mutually exclusive it will appear from the table and the commentaries that the concept of a complete uniformity in personality structure evaluated from the behavioural aspect can not be upheld. On the other hand there is a possibility that a finer discrimination of the traits
FINN ASKEVOLD
96
perhaps will show a difference towards the other groups of psychosomatic The method used show only too great overlappings to give any conclusion.
diseases.
Early environment PAULLEY [5] states that in his patients it was extremely difficult to obtain informations on the hierarchial structure in the family by the interview method and he developed a special method of presenting the patient with imaginary situations. My experience is different. If one has the interest focused on getting information about the family structure it is not so difficult even with these patients, by employing a technique of indirect questions and contraquestions. By regarding even slight indications toward an abnormal emotional setting as a fact I nevertheless could not find such in more than half of the patients. This will be seen in Table 7. In the remaining half it was impossible to regard the home as other than harmonious. TABLE 7. THE
EARLY
ENVIRONMENT Males
Harmonious Dominated by mother Dominated by father Loss of father below 15 Loss of mother below 15 Total No. of subjects involved
-
16 8 3 7 3 37 34
Females 11 9 6 3 3 32. 26
TOtal
27 17 9 10 6 69 60
In the disharmonious half the most prominent feature was the mother dominance which also includes overprotection, fussiness and indications of the ambivalent, symbiotic relationship described by SPERLING [22]. In some instances loss of one or other of the parents coincided with this dominance from the remaining parent. In only 6 of the females was father dominance found; three of these had lost their mother before the age of 15. On the basis of my investigation a uniform view on pathological patterning of the early environment is not present. This might be due to a lack of thoroughness in the method chosen but it may also be due to a special theoretical bias in other investigators. This may be substantiated by the fact that the correlation between the different observers is very low on this aspect. I here exclude the psychoanalytical investigators as they are not so much concerned with the objective patterning of the enviroment as to what this enviroment represents in the patient’s phantasies and in the libidinal structure of it. My method give no possibility of testing out this factor. Possible precipitating
factors
Most observers state that ulcerative colitis is precipitated by some major event of emotional significance immediately prior to the onset of disease. GROEN [24] states that this event takes place within 48 hours of the onset of the disease, and further that this event do not always seem very important to an observer but for the patient it is felt as a humiliating experience, and involves a loss, or fear of the loss of a key person in the patient’s environment. This loss of a key person is elaborated more by LINDEMAN [26] who finds this to be very important but states that this does not mean loss of one of the parent figures, but it may be another object related to by the patient with dependent, neurotic bounds.
Studies in ulcerative colitis
97
ENGEL [ 191 is in favour of regarding the disturbances in interpersonal relationships more generally as important. In accordance with SPERLING [22] he is concerned with the mother/child relationship. MOSCHCOWITZ [17] emphasizes the sexual maladjustment as most important and points to the high frequency of ulcerative colitis starting during or just after honeymoon. TABLE 8. POSSIBLE PRECIPITATING PSYCHOLOGICAL FACTORS Males
Loss of key person Separation from home Pregnancy and other sexual conflicts Economic problems Different and mixed problems Total No. of subjects involved No conflicts observable
Females
Total
3 4
6 0
4
1
9
2 6 16
9 0 8
10 2 14
23
39
14 20
18 8
32 28
From Table 8 will be seen that in less than half of the males and in 8 of the females a possible precipitation could be found. In the females with such factors present half of them had reacted to conflicts regarding sexual problems. In my cases they were not related to honeymoon experiences but to acceptance of motherhood and female responsibility. The picture was in no way uniform and one case was a girl of 16 on whom a legal abortion was carried out owing to her youth. Her boyfriend broke the relationship with her just after the abortion and within a week her ulcerative colitis started. This might be viewed as a loss of a key person, but as a serious relapse occurred when, several years later, she got engaged and followed her first intimate relationship with her fiance, one has more right to consider this as a more important sexual conflict. Among my cases only a minor proportion developed their first symptoms in relation to the loss of a key person. The four males who developed illness after separation from home had no special relationship to any single person. They missed the whole home environment, but if one considers their relationship to this as an object relation with a personified value, then this may be regarded as loss of a key figure. This explanation is somewhat far-fetched. In the remaining 16 patients with economic and different problems there are two with a marked religious and moral conflict. The others were concerned with financial troubles, responsibility conflict, and problems in relation to superiors. In none of these cases was there any loss of object relationships, actual or threatened. The humiliating experience with not more than 48 hours time interval between situation and onset of disease could not be traced in one single case. In 32 of the 60 patients there were a situation of significant psychological stress value to the individual patient present and in a time relationship so close to the onset of the disease that it might be justifiable to regard it as a possible precipitating factor. In the remaining 28 patients no psychological event could be found which could be said to have been important in the initial disease process. DISCUSSION
The method chosen for elevation of personality traits restrict the area of research has not been to to observable behavioural aspects. The purpose of this investigation
98
FINN ASKEVOLD
uncover the unconscious attitudes of the patients, but to compare our scientific knowledge in the field of ulcerative colitis to determine if there really is a basic structure of uniform character common to all patients with ulcerative colitis, and separating them from patients with other diseases. This postulate is implicit in the different formulations of uniformity of personality structure. The literature reveals that this uniformity is consistent for the individual investigator but with very little inter-rater agreement. This is not a critique of the observers as the same phenomenon is stated by ROSENZWEIG et al. [27] for even more This only serves to show that we elaborate simple forms of psychiatric evaluations. our own tools of investigation which are difficult to ascertain in an objective way, and it is even more difficult to itemize the clues from which we make our conclusions. It must be emphasized that the investigation of psychological factors based on the clinical interview was focused on these factors being present before the first sign of disease. The type of disease no doubt profoundly influences the overt behaviour of the patient, and may thus possibly effect the evaluation of premorbid traits. Awareness of this fact may have made for over-caution in this retrospective evaluation, and may be responsible for the differences reported in this study as compared with others. The inter-rater disagreement speaks against this, the conclusion being that methods for evaluating personality structures in a way communicable from one investigator to another are still in their infancy. Other factors are not so dependent on similarity in thinking and training. They include the evaluation of the early environment and of precipitating factors. The general uniformity here indicates the possibility of biassed interviewing when compared with this investigation, and with others. This confusion on the psychological side might stimulate an attempt to search for better and more objective methods in this field, were it not for the fact that comparison between investigators on the somatic and epidemiologic is even more confusing. This fact is astonishing when one considers the relative ease of diagnosis and the high international diagnostic conformity. If the disagreements are only due to differences in the cases investigated this would mean that different hospitals are admitting different cases of ulcerative colitis or that this selection might be due to geographical factors, and that the disease may have a different structure dependent on where it may occur. Even if the epidemiological studies indicate a difference in geographical incidence, we do not know the factors responsible. My own findings on moving from one area to another might point more in the psychological direction than in the sociological, nutritional or cultural. TRUELOVE et al. [28-301 in their studies of hypermotility and hyper-irritability of the colon as a causative agent for the ulceration, found circulating antibodies to milk proteins, and a significantly higher proportion of artificially fed infants in their patients with ulcerative colitis. This subsumes an allergic factor, and indicates that ulcerative colitis is not a disease entity, but merely a manifestation of a more general, systematic disease. ENGEL [ 121 has made some interesting reflections on the colon as an inner surface of the body. Ulcerative colitis is a disturbance of the body’s system of defences. He believes the disease may begin before any manifest symptoms occur, and that the symptoms may be merely signs of the local internal struggle in the defensive system. The present investigation shows that ulcerative colitis is a complicated disease, or a syndrome where many factors seem to be responsible as etiological agents. The
Studies in ulcerative colitis
99
combination of these agents may be different in different individuals, in one allergic or infective factor may be more important than the psychological and vice versa. It appears that each factor is important in the etiological pattern which is necessary The investigations of all these factors calls for interdiscifor the disease to develop. plinary research, not only in one country, but also on an international level. A start should be made in defining concepts which can be used by members of each school of thought. SUMMARY
60 Norwegian patients with ulcerative colitis have been investigated with regard to somatic, epidemiological and psychological factors, and the findings compared with other investigations. In the psychological field there is a high increase of deviant behavioural factors, but not in any uniform structure. Nor do the early environment and the possible precipitating factors show the uniformity which others have claimed. There is a skewness in the geographical distribution, but this possibility may depend on a move between birth and the onset of disease. REFERENCES 1. WHITE W. H., On simple ulcerative colitis and other rare intestinal ulcers Glrys Hosp. Rep. 30, 131 (1888). 2. MURRAYC. D., Psychogenic factors in the etiology of ulcerative colitis Amer. J. Med. Sec. 180, 239 (1930). 3. BOCKUS H. L., ROTH J. L. A., BUCHMANE., KALSER M., STAUBW. R., FINKELSTEINA. and VALDES-DEPENAA., Life history of non-specific ulcerative colitis Gnstroenterologia 86,549 (1956). 4. ENGELG. L., Studies of ulcerative colitis. I. Clinical data bearing on the somatic process Psychosom. Med. 16, 496 (1954).
5. PAULLEYJ. W., Ulcerative colitis. Gastroenterology 16, 566 (1950); The emotional factors in ulcerative colitis Gustroenterolo@ 86, 709 (1956); Stress and the gut Brit. J. Clin. Pratt. 13, 314 (1959). Psychotherapy in &erative colitis Lancer 270, 215 (195g). 6. BOLLERR.. Exueriences in 89 cases of ulcerative colitis. Gastroenterolopiu 86. 693 (1956). Recent Studies in zpidekologi. Biackwell, 7. USTVEDTH. j., Ulcerative colitis in Norway. Oxford (1958). 8. GJONE E. and MYRENJ., Ulcerative colitis in Norway. Nord. Med. 71, 143 (1964). 9. MELROSEA. G., Observations on the European incidence of chronic ulcerative colitis. Gastroenterologia 86, 626 (1956).
10. BARGENJ. A., The modern manq~ement of ulcerative colitis. Thomas, Springfield (1943). 11. FULLERTOND. T., KOLLAR E. J. and CALDWELLA. B., A clinical study of ulcerative colitis. J. Amer. Med. Ass. 181, 463 (1962). 12. ENGELG. L., Studies of ulcerative colitis-II. The nature of the somatic process and the adequacy . _ of psychosomatic hypotheses. Amer. J. Med. 18, 416 (1954). L.. Ulcerative colitis and ioint disorders. New Ew. J. Med. 261.259 (1959). 13. FERNANDEZ-HERLIHY 14. BICKS R. O., KIRSNERJ.’ B. and PALMERW. L.: Serum proteins in ulc&ative colitis &strknte;olog,v 2, 37, 256 (1959).
15. BENANDIA., Liver function in ulcerative colitis. Gustroenterologiu 86, 658 (1956). 16. FLATMARKA., Surgical treatment of ulcerative colitis. Nord. Med. 67, 221 (1960). E. and ROUDIN M. B., Association of psychosomatic disorders and their relations 17. MOSCHCOWI-~Z to personality types in some individuals. N. Y. State J. Med. 48, 1375 (1948). 18. GROENJ. and VAN DERVALK J. M., Psychosomatic aspects of ulcerative colitis Gastroentero/ogiu 86, 591 (1956).
19. GROEN J. and BASTIAANSJ., Studies on ulcerative colitis. Personality structure, emotional conflict situations and effects of psychotherapy. Modern trends in Psychosomatic Medicine. Butterworth & Co, London (1954). 20 ENCEL G. L., Studies of ulcerative colitis-III. The nature of the psychological process. Amer. J. Med. 19, 231 (1955); Studies of ulcerative colitis-IV. Significance of headaches. Psychosom. Med. 18, 334 (1956); Studies of ulcerative colitis-V. Psychological aspects and their implication for treatment. Amer. J. Dis. 3, 315 (1958). 21. ALEXANDERF., Psychosomatic Medicine. Norton, New York (1950). 22. SZASZ T. S., Physiologic and psychodynamic mechanisms in constipation and diarrhoea. Psychosom. Med. 13, 112 (1951).
100
FINN ASKEVOLD
23. SPERL~NG M., The psychoanalytical treatment of ulcerative colitis Internat. J. Psychoanal. 38, 341 (1957). 24. IISALO E., MAO-inhibitors in ulcerative colitis. Nord. Med. 67, 219 (1962). 25. MUSCHATT C., Psychological aspects of non-specific ulcerative colitis. Recent Development in Psychosomatic Medicine. London (1954). 26. GROEN J., Psychogenesis and psychotherapy of ulcerative colitis Psychosom. Med. 9, 151 (1947). 27. LINDEMAN E., Modifications in the course of ulcerative colitis in relationship to changes in life situations and reaction patterns. AWL Res. Nerv. Mental Dis. 29, 706 (1950). 28. ROSENZWEIG N., VANDERBERG S. G., MOORE K. and DUBAY A., A study of the reliability of the mental status examination. Amer. J. Psychiat. 117, 1102 (1961). 29. TRUELOVE S. C. and CHAUDHARY N. A., Human colonic motility: A comparative study of normal subjects, patients with ulcerative colitis and patients with the irritable colon syndrome. Gastroenterology 40, 1 (1961). 30. TRUELOVE S. C. and TAYLOR K. B., Circulating antibodies to milk proteins in ulcerative colitis. &it. Med. J. 5, 924 (1961). 31. TRUELOVE S. C., Early weaning in the aetiology of ulcerative colitis. Brit. Med. J. 5, 929 (1961). 32. SCHNEIDER P., Ulcerative colitis as a psychosomatic disease. Schw. Arch. Nevrol. Psychiat. 17, 78 (1956). 33. KU&N H. A., Prognosis and therapy in ulcerative colitis. Fortschr. der Gastroenterofogie (Ed. Wildhirt E.) Muenchen und Berlin (1960). 34. TITCHNER j. L., RISKIN J. and EMERsoN’R., The family in psychosomatic process Psychosom. Med. 22, 127 (1960). 35. KRAWIT-~ E. L., Ulcerative colitis and pregnancy. Obstet. & Gynic. 14, 354 (1959). 36. BALTZ J. I., Observations on the course of non-specific ulcerative colitis. Postgrad. Med. 24, 17 (1958). 37. BARENDREGT J. T. and CORNELISSENR. L., A comparative study of character descriptions based on biographical anamnesis and the results of Rohrshach investigations. Ned. Tijdschr. Geneeskunde 99, 2717 (1955).
STUDIES
IN ULCERATIVE
COLITIS*
FINN ASKEVOLD (Received 8 March 1964)
CONSIDERED generally as a disease entity, ulcerative colitis is defined as a chronic inflammatory disease in the colon and/or rectum with stools containing blood and/or pus. Some authors exclude hemorrhagic proctitis from ulcerative colitis proper. There seems not to be any real distinguishing features in the pathology to substantiate this division, so that hemorrhagic proctitis is here considered only as a special localization of the ulcerative colitis. The diagnosis of ulcerative colitis is fairly simple, and there is a high degree of agreement between different diagnosticians. It is based on the clinical, radiological and proctoscopic findings. Despite the 70 years which have elapsed since the first description of ulcerative colitis [l] its etiology is still obscure, and opinions on pathogenesis are often very controversial. The first mention of the importance of psychological factors in this disease was put forward in 1930 [2], at a time when most of the other psychosomatic hypotheses were also formulated. As so much is still hypotheses, it would seem worthwhile to compare reports on ulcerative colitis from different investigators in different parts of the world. METHOD From October 1959 to July 1962 all patients with an established diagnosis of ulcerative colitis admitted to the two medical departments of Oslo University Hospital (Rikshospitalet) were referred for psychiatric examination. The two surgical departments were omitted for practical reasons, and in nearly all cases the patients were first admitted to the medical department while under consideration for surgery. No children are included, as the pediatric department has its own psychiatric service. This makes the distribution askew, but no different from the other reports which will be compared with our own case material. Oslo University Hospital admits patients from the whole country, and it is only rarely that they are admitted for their first attack of the disease-all had been hospitalized in their local hospitals on at least one or more occasions. Thus it seems to be the more severe cases, often resistant to numerous therapeutic procedures, who are admitted to the hospital, mostly for consideration over surgery or not. RESULTS Sex distribution
The material consisted of 60 patients, 34 males and 26 females. This gives a ratio 1:0.8 which corresponds with that found by BOCKUS et al. [3] who in 182 American patients have a ratio of 1:0*9, but not with ENGEL [4] from America, and PAULLEY [5] from England who both give a ratio of 1 :2, the same ratio being reported from Austria by BOLLER [6] in 89 patients. The possibility of more males being referred for hospital treatment is excluded by the prevalence study from Norway by USTVEDT [7] and GJONE and MYHREN [S] where in 400 cases the ratio is also 1: 1. The patient’s age of onset of the disease is shown in Table 1, and is in accordance with others, especially with the total figures from Norway by GJONE and MYHREN [8] showing no specially preferred decade for the onset of the disease. * From the Oslo University Hospital (Rikshospitalet), Norway. 89
90
FINN ASKEVOLD TABLE 1.
AGE AT ONSET OF DISEASEAND DURATION AT TIME OF PSYCHIATRIC EXAMINATION Males
Females
__~__~~_~_
1~_________
Mean
Age in years Duration in years Number of patients
32.0 3.5
Limits
Mean
9.0-60.0 0.2-l 3.0 34
30.1 5.8
Limits 10.0-39~0 0.5-38.0 26
Total
----
Mean 31.2 4.5 60
The types of occupation were too varied to give any hints as to the possible importance of this factor but it could not support the views of BOLLER [6] who states that these patients belong to intellectual, sedentary professions. Geographical
distribution
From rates based on hospital admissions at a given time MELROSE [9] found differences in different parts both of the United Kingdom and of European countries. The lowest figures were found in Scotland, Switzerland and Finland and the highest in England. The latest figures were 14.8 per 10,000 hospital beds. USTVETD [7] has criticized this method of sampling, as it gives no real incidence figures. In a survey covering all Norway for the years 1946-1950 and 1951-1955 he obtained reports from all hospitals on first admissions for ulcerative colitis. This survey has been continued for the years 1956-1960 by GJONE and MYHREN [8], the findings showing a definite rise in incidence from 8.6 per 1,OOO,OOOpopulation in the first five-year period to 15.1 in the second and 20.6 in the last. The increase was most marked in the youngest age groups below 20. As figures from different authors are not uniformly collected they are not comparable, but what was found as differences within the United Kingdom also was shown in the Norwegian report. A higher incidence was found in the eastern and middle part of the country. My own figures are not incidence figures, as admission to the University Hospital is not evenly distributed throughout the country, and the patients are not firstadmissions. Table 2 shows the patients home-area, compared with the relative population. TABLE 2.
BIRTH PLACE AND RESIDENCEIN NORWAY IN RELATIONTO THE POPULATION Birth area n C%)
Oslo-Akershus Oslofjord countries Southern Norway
Western Norway Eastern and middle Northern Norway Total * 3 patients disease started Norway).
Norway
13 7 9 6 14 8 57*
Living area
Population
n
(%I
(%I
22.8 12.2 15.8 10.6 24.5 14.1
19 9 6 3 17 6
31.7 15.0 10.0 5.0 28.3 10.0
100.0
60
100.0
18.8 15.5 9.5 24.7 19.3 12.2 -100.0
were born abroad, 2 foreigners after they had settled in Norway
and one Norwegian and their (2 in Oslo and 1 in Western
91
Studies in ulcerative colitis
The same tendency to an over-representation from the eastern and middle parts of Norway can be seen. When the patient’s birth place is taken into account there is a tendency to “normalize” the figures. In Norway the population tends to be very stable with little movement. Only those who have moved outside their own county after their birth, and before the onset of the disease are counted as “movement”. This indicates that these patients might have reacted to moving or to the adaptation difficulties in the new place in a way harmful to themselves. TABLE3. INITIALSYMPTOM
Diarrhoea only Diarrhoea with blood Blood only
Males
Females
Total
21 8 5
12 8 6
33 16 11
The figures are too small to provide any conclusive evidence of type of movement, but there is a tendency for a move from rural to urban areas to give an increase in skewness in the different geographical areas. The factors responsible are unknown and it would seem worthwhile to investigate these parts more thoroughly than has been possible in this material. Initial symptoms ENGEL [4] found that the passage of blood was the initial symptom in 22 of his 32 cases. He refers to BARGEN [lo] whose finding that bleeding was the first symptom in 50 per cent of cases was the only exception to the general statement that ulcerative colitis begins with diarrhoea. This has been confirmed by KOLLAR et al. [I l] who in 62 episodes of the disease in 47 patients found bleeding with normal, formed stools in 24, and bleeding with diarrhoea in 17. Diarrhoea preceding bleeding was present in 21 cases. In the present study, Table 3 illustrates that in more than half of the cases the disease started with the frequent passage of more than three watery to semi-fluid stools per day and in only 11 were there cases of blood only passed. This may indicate a difference in the course of the disease in the United States and in Europe, but the number of reports are too few to allow any conclusion. Other psychosomatic
complaints
ENGEL [12] found constipation in the premorbid bowel history in 12 out of 20 cases, KOLLAR [l l] included a study of symptoms usually regarded as psychosomatic, whilst FERNANDEZ-HERLIHY [ 131 has especially focused on arthritis in combination with ulcerative colitis, which was found in 17 per cent of 85 cases. Both KOLLAR [ 1 I] and ENGEL [12] emphasize the high incidence of headaches in their patients; ENGEL found it in nearly all his cases, whilst KOLLAR found it in 13 of 42 patients; in addition 42 of 47 patients had different psychosomatic complaints either previous to, or in combination with the ulcerative colitis. Table 4 shows that only half of the present group had other psychosomatic complaints than their ulcerative colitis. The results are not directly comparable, as the table shows only those symptoms present prior to the onset of ulcerative colitis, whilst other workers’ lists include those occurring during the course of illness. Jt can
FINN
92
ASKEVOLD
be seen that all the symptoms have relation to organs regulated by the autonomic nervous system. There was no record of psychiatric disturbance in the material as had been carried out by KOLLAR et al. [l l] but one patient had been hospitalized for a psychosis prior to the onset of his ulcerative colitis. This was a 19 year old sailor who had an attack of a schizophreniform psychosis, which disappeared when his bowel started to bleed. He had a recurrence of his psychosis when his gut healed. When he was put on TABLE 4.
CONDITIONS OF POSSIBLE IMPORTANCE PRESENT BEFORE ONSET OF ULCERATIVE COLITIS Males
Allergic disposition Asthma Polyarthritis Eosinophilia Dyspepsia from childhood “Colic” Constipation Headaches
2
ataractic drugs this rhythm was broken, colitis and his psychosis at the same time. from both illnesses.
5 1 3 4 11 2 9 5
23
17
40
15 19
15 11
30 30
2 3 9 2 3 1
Total
Total
3 0 I I 2 0 6 4
I
No. of subjects involved No complaints in
Females
and he suffered from both his ulcerative After hemicolectomy he seemed to recover
KIRSNER et al. [14] have found a decrease of serum albumin in 63 of 65 patients and an increase in the globulin content, most marked for the gammafraction. In some of these there was an increase in t-globulins, probably a sign of an auto-immunization process being present. BENANDI [ 151 showed the same decrease of serum albumin and increase in globulins, in the alpha part, and especially in the alpha-2-globulins. There is agreement that marked changes in serum proteins indicate a severe somatic condition and KIRSNER [14] could show that a return to normal values paralleled improvement. This was not related to any special type of treatment; in one patient who had no drug treatment, receiving psychotherapy alone, the same trend could be observed. In 44 patients the same decrease in serum albumin was found (Table 5). The lowest TABLE 5. DISTURBANCES IN SERUM PROTEINS, SEDIMENTATION RATE (SR) AND HEMOGLOBIN (Hb) DURING ACTIVE PHASES OF THE DISEASE
Albumin Albumin Gamma Gamma Increased Anaemia
3.3-2.5 (g:<,) below 2.5 (g%) globulin exceeding 2.0 (g %) globulin 1.8-2.0 (g li’,) SR
Males
Females
18 6
15 5
Total 33 11
44 26
7 9
4 6
l3 13
14 9
12 8
26 17
Studies
in ulcerative
colitis
93
range of normal values is 3.6 g and an additional 10 per cent safety range has been added. In only 26 could the same increase in gamma-globulins be found. The highest normal value is l-6, but in the present report 1.8 is counted as the lowest value. The alpha-globulins were raised in only 13 cases and BENANDI’S findings [15] could not be confirmed. Parallel to the protein changes there is an increased sedimentation rate, 20 mm being taken as the highest normal value in females and 15 mm in males. There were no cases with especially high values and only 26 had abnormal values. 17 patients had an anemia below 85 per cent Hb., but there were no very low values, except when gross bleedings occurred or when the patient was in extremis. All these values are expressions of the disease process, and are not etiological factors, as to some degree they might be said to parallel the actual status of the illness. This parallelism is not complete, as less than half of the patients have an increased sedimentation rate during an active phase of the disease. Nearly all the patients are admitted to our hospital during active phases of their ulcerative colitis and it is surprising that this part of the pathophysiology is not more affected. Localization
of the disease
In 8 cases the disease was limited to the ascending colon (13.3 per cent)-in 23 (38.3 per cent) it was located in the distal part of the colon including rectum. In 29 (48.3 per cent) the whole colon was affected. BOCKUS [3] figures were 48.4 per cent for total colonic involvement, 14.8 per cent rectal, 21.4 per cent in the distal, 14.4 per cent for the ascending part. In this and in other respects there seems to be a good agreement between the cases investigated by BOCKUS and those in the present investigation. The initial symptom of passages of blood seem to be related to a distal involvement, especially sigmoid and rectal. There was no correlation between the localization and the severity of the disease.
Psychological
structure
In the present investigation the psychiatric interviews were carried out by the author, this being done to avoid the fallacies of catamnestic investigations where different observers have described their impressions in their own linguistic frame of reference which is not easily repeated by another individual. All patients are thus investigated in the same way and thus represent a uniform sample, but nevertheless with the possibility of a personal bias on the part of the investigator. Most investigators, psychiatrists, psychoanalysts and physicians, claim that psychological factors play an important role in this disease but there is no unanimity as to which psychological factors are active, to what degree they have to be present to seriously influence the disease process, and of their relative importance etiologically. In the research methods used two different trends were visible. The one is based on one or more interviews in a series of cases and the other based on psychoanalytical treatment of a few cases. Paulley [16] with his 173 cases might be regarded as the protype of the first trend. In all his patients he finds an almost uniform psychological structure. They are dependent, parent-controlled individuals, usually tied to their mothers. They have a tendency never to be able to express open aggression but are suffering under long protracted bitterness and brooding. They are hypersensitive and the males usually somewhat effeminate. In addition they show self-righteousness, false modesty and a poorly developed sense of humor. The most striking point in his opinion is the inability to
94
FINN ASKEVOLD
express emotions, which he regards as a sign of emotional immaturity. They also show a poor ability to establish sexual relationships. Moschcowitz et al. [17] are in agreement with Paulley on most points but underline the extreme dependence, tendency to subordination, weak wills, emotional immaturity and poor sexual adjustment. They do not consider that aggression, open or concealed, plays an important role. Groen et a/. [18] are in favour of the same homogeneous outlook on these patients and describe them in almost the same terms as Paulley. Engel [19] mentions the obsessional traits, rigidity and moralistic views as important and underlines the timid appearance of the patients. He is not so uniform in his outlook and reports querulous subjects and also sensitive, ruminative, passive ones. Kollar et al. [II] have not been so concerned with the personality structure, and base their view more on tests, especially the MMPI. They nevertheless report heterosexual inadequacy with fears of homosexuality. They have also observed a passive, inactive depression preceding the disease. The psychoanalytical group of investigators underlines the anal, obsessive traits [20]. Szasz [21] emphazises in addition the oral, incorporating needs, also included in Sperling’s [22] concept of the early oral damage with a symbiotic, ambivalent tie between mother and child and with repressed hostility and destructiveness. She also sees a relationship between ulcerative colitis and melancholia. This view is substantiated by Mushatt [23] and in relation to this it is interesting to note that quite recently Iisalo [24] report good therapeutic results with antidepressant drugs (MAO-inhibitors). When one considers all these statements concerning the personality structure one is struck by the fact that it is seldom one single personality trait, but rather a pattern which the different investigators emphazise. In some reports on psychosomatic diseases this way of describing a personality by one single trait still lingers on, but must now be considered extremely out-dated. The authors reported all describe a pattern, but one cannot say that there is unanimity as to exactly what this pattern is. In general it is believed that there is something peculiar both in the overt behaviour and in the dynamic structure of these patients which often distinguish them from other patients. In Groens and Paulleys opinion, patients with ulcerative colitis are more similar to each other than to other patients. The difficulty is that the different personality traits mentioned are of a rather general type, not very easy to define, and almost impossible to classify in a way that distinguishes them from other groups of patients. In many reports no control material is used. Kollar [ll] is the only one and he finds a difference in the depression score. The only conclusion to be drawn must be that there is general agreement that these patients have a personality structure which reveals itself in their behaviour and which was present before the onset of the disease, and they all give a clinical impression of peculiarity, uniform or not. A disease of such a severe nature, with its incapacitating qualities must have a profound influence on the person and his attitudes. This influence might also lead to a change in thought and phantasy processes which could change the Rohrshach responses to represent an actual situation and not the basic pre-morbid personality. The same reflections would also be valid for the interview as the “here and now” situation of the patients will give an unconscious direction to leading questions designed to substantiate that impression. Although all investigators firmly state that they always have been searching for pre-morbid character traits, one cannot easily discuss the possibility of a “closed circuit”-evaluation, but frequent interviews with the patients’ relatives have substantiated many of the assertions of a deviant personality structure from early childhood and long before the first sign of a colonic disease appeared. Another difficulty is the vagueness of the concepts regarding the personality traits recorded. Many are so common that they present in too high a percentage of normals to single out the persons with ulcerative colitis and separate them from the rest. In most papers the personality traits are not defined, but described in a loose and often ambiguous way and do not allow for comparison between them.
In this investigation an attempt has been made to describe groups of behavioural traits in a pragmatical frame of reference, based on what is clearly observable in the interview situation and reported by the patient to be a constant behaviour pattern from early life. For the more subjective traits the basis is what the patient says they feel as separating them from others, restricting their lives and having been present before the onset of the disease. This is similar to the method employed by others in the non-psychoanalytical area of investigation, but personality traits are defined in the following way: 1. Directly distance.
observable
deviant
behaviour
in the direction
of shyness,
timidity,
retraction
and
95
Studies in ulcerative colitis
“Internal action” concerning rigidity, obsessions and perfectionism. “External action” concerning inhibition of aggression in a broad perspective from considerable lack of ability in showing adequate self assertion to lack of ability in showing more hostile aggression, adequate or inadequate. Genera1 feelings concerning insecurity and a diffuse tendency to anxiety. Special feelings concerning frustrations and faulty self-evaluations.
In 53 of the 60 patients one or more of these behavioural traits were found to be present. No estimate is made of the degree to which these traits are present in the individual cases. Similar evaluation of other groups of patients was not carried out, but from clinical experience it seems likely that these traits will probably be present also in other diseases, but not to the same extent and not in the same proportion within the group. Shyness was present in 23 patients, 13 males and 10 females. This was often felt to conceal dynamic traits loaded with inhibited hostility. As the method of investigation is cross-sectional the possible dynamic traits are not taken into consideration. Rigidity was seen in 24 patients, 13 males and 11 females, but not always in combination with shyness. Inhibition of aggression was reported by 22 patients with even sex distribution and seems also to be a very prominent feature in these patients, but not The most prominent trait was the feeling of as constantly as others have found. insecurity, both as a general diffuse feeling and in relation to other people. This was always combined with restlessness and a feeling of uneasiness, sometimes felt directly as anxiety. Frustration of ambition is, in my experience, rather important, but was It is important because it conceals not found in more than one sixth of the patients. a high degree of neurotic self-evaluation. In only 7 patients were none of the mentioned traits detected. Four were in the youngest age group, mostly with a severe attack of the disease. The remaining three were scattered in age and sex, and lack of deviant personality traits bore no relation to the severity of illness. TABLE
1. 2. 3. 4. 5.
6.
OBSERVABLE
Shyness Rigidity Inhibition of aggression Insecurity Frustration of ambition Total No. of subjects involved No abnormalities detected
BEHAVIOUR
TRAITS
Males
Females
Total
13 13 11 15 6 58 30 4
10 11 11 15 4 51 23 3
23 24 22 30 10 109 53 7
In Table 6 the distribution of the traits will be seen. In 3 patients all five groups were present, in 3 one could see four groups, in 16 three, and in 13 two groups, while in 8 patients only one of the groups was present. KOLLAR et al. [I l] see depression as a prominent trait, but even if one consider the traits mentioned here as types of withdrawal no real depression can be said to be present. Even if my traits can not be said to be mutually exclusive it will appear from the table and the commentaries that the concept of a complete uniformity in personality structure evaluated from the behavioural aspect can not be upheld. On the other hand there is a possibility that a finer discrimination of the traits
FINN ASKEVOLD
96
perhaps will show a difference towards the other groups of psychosomatic The method used show only too great overlappings to give any conclusion.
diseases.
Early environment PAULLEY [5] states that in his patients it was extremely difficult to obtain informations on the hierarchial structure in the family by the interview method and he developed a special method of presenting the patient with imaginary situations. My experience is different. If one has the interest focused on getting information about the family structure it is not so difficult even with these patients, by employing a technique of indirect questions and contraquestions. By regarding even slight indications toward an abnormal emotional setting as a fact I nevertheless could not find such in more than half of the patients. This will be seen in Table 7. In the remaining half it was impossible to regard the home as other than harmonious. TABLE 7. THE
EARLY
ENVIRONMENT Males
Harmonious Dominated by mother Dominated by father Loss of father below 15 Loss of mother below 15 Total No. of subjects involved
-
16 8 3 7 3 37 34
Females 11 9 6 3 3 32. 26
TOtal
27 17 9 10 6 69 60
In the disharmonious half the most prominent feature was the mother dominance which also includes overprotection, fussiness and indications of the ambivalent, symbiotic relationship described by SPERLING [22]. In some instances loss of one or other of the parents coincided with this dominance from the remaining parent. In only 6 of the females was father dominance found; three of these had lost their mother before the age of 15. On the basis of my investigation a uniform view on pathological patterning of the early environment is not present. This might be due to a lack of thoroughness in the method chosen but it may also be due to a special theoretical bias in other investigators. This may be substantiated by the fact that the correlation between the different observers is very low on this aspect. I here exclude the psychoanalytical investigators as they are not so much concerned with the objective patterning of the enviroment as to what this enviroment represents in the patient’s phantasies and in the libidinal structure of it. My method give no possibility of testing out this factor. Possible precipitating
factors
Most observers state that ulcerative colitis is precipitated by some major event of emotional significance immediately prior to the onset of disease. GROEN [24] states that this event takes place within 48 hours of the onset of the disease, and further that this event do not always seem very important to an observer but for the patient it is felt as a humiliating experience, and involves a loss, or fear of the loss of a key person in the patient’s environment. This loss of a key person is elaborated more by LINDEMAN [26] who finds this to be very important but states that this does not mean loss of one of the parent figures, but it may be another object related to by the patient with dependent, neurotic bounds.
Studies in ulcerative colitis
97
ENGEL [ 191 is in favour of regarding the disturbances in interpersonal relationships more generally as important. In accordance with SPERLING [22] he is concerned with the mother/child relationship. MOSCHCOWITZ [17] emphasizes the sexual maladjustment as most important and points to the high frequency of ulcerative colitis starting during or just after honeymoon. TABLE 8. POSSIBLE PRECIPITATING PSYCHOLOGICAL FACTORS Males
Loss of key person Separation from home Pregnancy and other sexual conflicts Economic problems Different and mixed problems Total No. of subjects involved No conflicts observable
Females
Total
3 4
6 0
4
1
9
2 6 16
9 0 8
10 2 14
23
39
14 20
18 8
32 28
From Table 8 will be seen that in less than half of the males and in 8 of the females a possible precipitation could be found. In the females with such factors present half of them had reacted to conflicts regarding sexual problems. In my cases they were not related to honeymoon experiences but to acceptance of motherhood and female responsibility. The picture was in no way uniform and one case was a girl of 16 on whom a legal abortion was carried out owing to her youth. Her boyfriend broke the relationship with her just after the abortion and within a week her ulcerative colitis started. This might be viewed as a loss of a key person, but as a serious relapse occurred when, several years later, she got engaged and followed her first intimate relationship with her fiance, one has more right to consider this as a more important sexual conflict. Among my cases only a minor proportion developed their first symptoms in relation to the loss of a key person. The four males who developed illness after separation from home had no special relationship to any single person. They missed the whole home environment, but if one considers their relationship to this as an object relation with a personified value, then this may be regarded as loss of a key figure. This explanation is somewhat far-fetched. In the remaining 16 patients with economic and different problems there are two with a marked religious and moral conflict. The others were concerned with financial troubles, responsibility conflict, and problems in relation to superiors. In none of these cases was there any loss of object relationships, actual or threatened. The humiliating experience with not more than 48 hours time interval between situation and onset of disease could not be traced in one single case. In 32 of the 60 patients there were a situation of significant psychological stress value to the individual patient present and in a time relationship so close to the onset of the disease that it might be justifiable to regard it as a possible precipitating factor. In the remaining 28 patients no psychological event could be found which could be said to have been important in the initial disease process. DISCUSSION
The method chosen for elevation of personality traits restrict the area of research has not been to to observable behavioural aspects. The purpose of this investigation
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uncover the unconscious attitudes of the patients, but to compare our scientific knowledge in the field of ulcerative colitis to determine if there really is a basic structure of uniform character common to all patients with ulcerative colitis, and separating them from patients with other diseases. This postulate is implicit in the different formulations of uniformity of personality structure. The literature reveals that this uniformity is consistent for the individual investigator but with very little inter-rater agreement. This is not a critique of the observers as the same phenomenon is stated by ROSENZWEIG et al. [27] for even more This only serves to show that we elaborate simple forms of psychiatric evaluations. our own tools of investigation which are difficult to ascertain in an objective way, and it is even more difficult to itemize the clues from which we make our conclusions. It must be emphasized that the investigation of psychological factors based on the clinical interview was focused on these factors being present before the first sign of disease. The type of disease no doubt profoundly influences the overt behaviour of the patient, and may thus possibly effect the evaluation of premorbid traits. Awareness of this fact may have made for over-caution in this retrospective evaluation, and may be responsible for the differences reported in this study as compared with others. The inter-rater disagreement speaks against this, the conclusion being that methods for evaluating personality structures in a way communicable from one investigator to another are still in their infancy. Other factors are not so dependent on similarity in thinking and training. They include the evaluation of the early environment and of precipitating factors. The general uniformity here indicates the possibility of biassed interviewing when compared with this investigation, and with others. This confusion on the psychological side might stimulate an attempt to search for better and more objective methods in this field, were it not for the fact that comparison between investigators on the somatic and epidemiologic is even more confusing. This fact is astonishing when one considers the relative ease of diagnosis and the high international diagnostic conformity. If the disagreements are only due to differences in the cases investigated this would mean that different hospitals are admitting different cases of ulcerative colitis or that this selection might be due to geographical factors, and that the disease may have a different structure dependent on where it may occur. Even if the epidemiological studies indicate a difference in geographical incidence, we do not know the factors responsible. My own findings on moving from one area to another might point more in the psychological direction than in the sociological, nutritional or cultural. TRUELOVE et al. [28-301 in their studies of hypermotility and hyper-irritability of the colon as a causative agent for the ulceration, found circulating antibodies to milk proteins, and a significantly higher proportion of artificially fed infants in their patients with ulcerative colitis. This subsumes an allergic factor, and indicates that ulcerative colitis is not a disease entity, but merely a manifestation of a more general, systematic disease. ENGEL [ 121 has made some interesting reflections on the colon as an inner surface of the body. Ulcerative colitis is a disturbance of the body’s system of defences. He believes the disease may begin before any manifest symptoms occur, and that the symptoms may be merely signs of the local internal struggle in the defensive system. The present investigation shows that ulcerative colitis is a complicated disease, or a syndrome where many factors seem to be responsible as etiological agents. The
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combination of these agents may be different in different individuals, in one allergic or infective factor may be more important than the psychological and vice versa. It appears that each factor is important in the etiological pattern which is necessary The investigations of all these factors calls for interdiscifor the disease to develop. plinary research, not only in one country, but also on an international level. A start should be made in defining concepts which can be used by members of each school of thought. SUMMARY
60 Norwegian patients with ulcerative colitis have been investigated with regard to somatic, epidemiological and psychological factors, and the findings compared with other investigations. In the psychological field there is a high increase of deviant behavioural factors, but not in any uniform structure. Nor do the early environment and the possible precipitating factors show the uniformity which others have claimed. There is a skewness in the geographical distribution, but this possibility may depend on a move between birth and the onset of disease. REFERENCES 1. WHITE W. H., On simple ulcerative colitis and other rare intestinal ulcers Glrys Hosp. Rep. 30, 131 (1888). 2. MURRAYC. D., Psychogenic factors in the etiology of ulcerative colitis Amer. J. Med. Sec. 180, 239 (1930). 3. BOCKUS H. L., ROTH J. L. A., BUCHMANE., KALSER M., STAUBW. R., FINKELSTEINA. and VALDES-DEPENAA., Life history of non-specific ulcerative colitis Gnstroenterologia 86,549 (1956). 4. ENGELG. L., Studies of ulcerative colitis. I. Clinical data bearing on the somatic process Psychosom. Med. 16, 496 (1954).
5. PAULLEYJ. W., Ulcerative colitis. Gastroenterology 16, 566 (1950); The emotional factors in ulcerative colitis Gustroenterolo@ 86, 709 (1956); Stress and the gut Brit. J. Clin. Pratt. 13, 314 (1959). Psychotherapy in &erative colitis Lancer 270, 215 (195g). 6. BOLLERR.. Exueriences in 89 cases of ulcerative colitis. Gastroenterolopiu 86. 693 (1956). Recent Studies in zpidekologi. Biackwell, 7. USTVEDTH. j., Ulcerative colitis in Norway. Oxford (1958). 8. GJONE E. and MYRENJ., Ulcerative colitis in Norway. Nord. Med. 71, 143 (1964). 9. MELROSEA. G., Observations on the European incidence of chronic ulcerative colitis. Gastroenterologia 86, 626 (1956).
10. BARGENJ. A., The modern manq~ement of ulcerative colitis. Thomas, Springfield (1943). 11. FULLERTOND. T., KOLLAR E. J. and CALDWELLA. B., A clinical study of ulcerative colitis. J. Amer. Med. Ass. 181, 463 (1962). 12. ENGELG. L., Studies of ulcerative colitis-II. The nature of the somatic process and the adequacy . _ of psychosomatic hypotheses. Amer. J. Med. 18, 416 (1954). L.. Ulcerative colitis and ioint disorders. New Ew. J. Med. 261.259 (1959). 13. FERNANDEZ-HERLIHY 14. BICKS R. O., KIRSNERJ.’ B. and PALMERW. L.: Serum proteins in ulc&ative colitis &strknte;olog,v 2, 37, 256 (1959).
15. BENANDIA., Liver function in ulcerative colitis. Gustroenterologiu 86, 658 (1956). 16. FLATMARKA., Surgical treatment of ulcerative colitis. Nord. Med. 67, 221 (1960). E. and ROUDIN M. B., Association of psychosomatic disorders and their relations 17. MOSCHCOWI-~Z to personality types in some individuals. N. Y. State J. Med. 48, 1375 (1948). 18. GROENJ. and VAN DERVALK J. M., Psychosomatic aspects of ulcerative colitis Gastroentero/ogiu 86, 591 (1956).
19. GROEN J. and BASTIAANSJ., Studies on ulcerative colitis. Personality structure, emotional conflict situations and effects of psychotherapy. Modern trends in Psychosomatic Medicine. Butterworth & Co, London (1954). 20 ENCEL G. L., Studies of ulcerative colitis-III. The nature of the psychological process. Amer. J. Med. 19, 231 (1955); Studies of ulcerative colitis-IV. Significance of headaches. Psychosom. Med. 18, 334 (1956); Studies of ulcerative colitis-V. Psychological aspects and their implication for treatment. Amer. J. Dis. 3, 315 (1958). 21. ALEXANDERF., Psychosomatic Medicine. Norton, New York (1950). 22. SZASZ T. S., Physiologic and psychodynamic mechanisms in constipation and diarrhoea. Psychosom. Med. 13, 112 (1951).
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23. SPERL~NG M., The psychoanalytical treatment of ulcerative colitis Internat. J. Psychoanal. 38, 341 (1957). 24. IISALO E., MAO-inhibitors in ulcerative colitis. Nord. Med. 67, 219 (1962). 25. MUSCHATT C., Psychological aspects of non-specific ulcerative colitis. Recent Development in Psychosomatic Medicine. London (1954). 26. GROEN J., Psychogenesis and psychotherapy of ulcerative colitis Psychosom. Med. 9, 151 (1947). 27. LINDEMAN E., Modifications in the course of ulcerative colitis in relationship to changes in life situations and reaction patterns. AWL Res. Nerv. Mental Dis. 29, 706 (1950). 28. ROSENZWEIG N., VANDERBERG S. G., MOORE K. and DUBAY A., A study of the reliability of the mental status examination. Amer. J. Psychiat. 117, 1102 (1961). 29. TRUELOVE S. C. and CHAUDHARY N. A., Human colonic motility: A comparative study of normal subjects, patients with ulcerative colitis and patients with the irritable colon syndrome. Gastroenterology 40, 1 (1961). 30. TRUELOVE S. C. and TAYLOR K. B., Circulating antibodies to milk proteins in ulcerative colitis. &it. Med. J. 5, 924 (1961). 31. TRUELOVE S. C., Early weaning in the aetiology of ulcerative colitis. Brit. Med. J. 5, 929 (1961). 32. SCHNEIDER P., Ulcerative colitis as a psychosomatic disease. Schw. Arch. Nevrol. Psychiat. 17, 78 (1956). 33. KU&N H. A., Prognosis and therapy in ulcerative colitis. Fortschr. der Gastroenterofogie (Ed. Wildhirt E.) Muenchen und Berlin (1960). 34. TITCHNER j. L., RISKIN J. and EMERsoN’R., The family in psychosomatic process Psychosom. Med. 22, 127 (1960). 35. KRAWIT-~ E. L., Ulcerative colitis and pregnancy. Obstet. & Gynic. 14, 354 (1959). 36. BALTZ J. I., Observations on the course of non-specific ulcerative colitis. Postgrad. Med. 24, 17 (1958). 37. BARENDREGT J. T. and CORNELISSENR. L., A comparative study of character descriptions based on biographical anamnesis and the results of Rohrshach investigations. Ned. Tijdschr. Geneeskunde 99, 2717 (1955).