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  Psychology and Biography of Patients with Ulcerative Colitis and Crohn's Disease (Part 2)
  

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By: Klaus Fischer and Sibylle Grosshans

Original German title: Colitis ulcerosa- und Morbus Crohn-Patienten in psychischer und biographischer Hinsicht - Eine Studie (2. Teil), from Der Merkurstab 5/89, pages 267-286. Part I appeared in JAM, Vol. 9, No. 3, 1992. English by Anna R. Meuss, FIL, MITI.

4.2       Ulcerative colitis
The ages of the 29 colitis patients ranged from 18 to 66 years (mean age 31.6). The ratio of women to men was 1.6:1. Mean duration was 5.4 years (two months to 20 years). The mean age at onset (identical with age at diagnosis) was 25.9 years (12 - 59 years), with 72% reporting onset between the ages of 11 and 30.

Table 2 shows the degree of severity (Feiereis system). Involvement was as follows:

24% proctocolitis, 10% left colon, 20.7% subtotal colitis and 41% total colitis, in some instances with retrograde involvement of the ileum. One patient had had a colonoscopy elsewhere, with the diagnosis of ulcerative colitis confirmed by biopsy. Here we found only clinical signs of colitis; endoscopy and histology were nonspecific.

Table 9 gives details on age and sex distribution, duration, degree of severity, period in hospital, occupation and educational background.

For marital status, partnership and number of children, see Table 4, diseases in childhood and youth, Table 7. Extraintestinal manifestations are listed in Table 6.

At interview, it was noted that almost all colitis patients were spontaneous, open and free from distrust and replied readily to questions. After a few questions to gain a basic orientation, patients would speak at length about their childhood and youth. Most of them remembered those times well. 51% described them as distinctly harmonious and happy. The majority got on well with their parents, although 34% said they preferred one parent (usually the mother). Three patients lost a parent when still children and then had a particularly close connection with the remaining parent. An above average percentage of colitis patients had been the youngest child at home (51%). Only two had been only children.

Patients often said they had been spoiled at home, being the smallest, or the frequently ill, weak child. They had clearly been happy to accept the role, which also became evident to us in a few cases where we were able to observe the relationship to the mother. Even the older patients did not resent the dominant role played by their mothers and never seriously questioned their mother's right to have a say, among other things also relating to who their friends should be or to marital problems.

They would say that people did not expect much of them when they were children, and they therefore tried to get out of the situation of being the "poor little one who can't do things". They would copy their older brothers and sisters or try and do well at school.

This type of relationship, already evident in the dominance shown by one parent, characteristically means that these individuals seek the help of dominant

persons in making decisions or seek to imitate them, taking them as examples, sometimes well into maturity.

Table 1
Distribution of Sexes

31 patients with Crohn's disease
16 F: 15 M        —> F: M = 1.06: 1

29 patients with ulcerative colitis
18 F: 11 M        —> F: M = 1.63: 1

Mean age at onset                               Crohn's disease             23.0 years
(onset = onset of typical symptoms)    ulcerative colitis             25.9 years

Mean age on admission to                  Crohn's disease              29.3 years
Herdecke Hospital                               ulcerative colitis              25.9 years

Mean duration on admission to           Crohn's disease              6.27 years
Herdecke Hospital                               ulcerative colitis              5.44 years

DURATION

 

Table 2
31 Patients with Crohn's Disease Classified According to Stage

Stage 1                2 patients                    =         6.4%
Stage 2                9 patients                    =        29.0%
Stage 3                20 patients                  =        64.5%

1 mild signs and symptoms, no appreciable reduction in general condition
2 definite signs and symptoms (colics, diarrhea, weight loss, lack of appetite, depression)
3 marked reduction in general condition, definite signs and symptoms and/or concomitant disease

29 Patients with Ulcerative Colitis Classified According to Stage

Stage 1             3 patients                    =       103%
Stage 2             12 patients                  =       41.3%
Stage 3             14 patients                  =       483%

1 minor subjective and objective symptoms
2 between 1 and 3
3 full syndrome, with temperature, marked tenesmus, marked general symptoms, 10 -30 diarrheic stools per day, with considerable local inflammation (after Feiereis)

34% of our patients had suffered from gastric and intestinal disorders in childhood (diarrhea, vomiting, chronic constipation). Another 34% had been sickly and delicate as babies or infants, with frequent respiratory infections.

These patients, too, showed nervousness and hypersensitivity, but with a different nuance. Years afterwards they would still have powerful, highly negative memories of being in a hospital or sent to a children's home to convalesce, events which they saw as one of the causes of their excessive nervousness. The problem for them had not been so much the loss of reference persons, as was the case with patients with Crohn's disease, but rather the totally different conditions which affected their own habits. These patients have to cope with being very easily hurt, and their attitude usually is a passive one.

More than 80% of colitis patients had parental homes that were intact, at least outwardly, though the way they spoke of each of their parents was often very different, with the real situation put in a more favorable light in retrospect.

It was usually the mother who had sole charge of their upbringing and also concerned herself with their progress at school. 58% showed dependence on someone close even whilst in hospital. It proved necessary to talk to these reference persons, particularly if the situation was such that the patient was not given freedom of decision so that there was no question of their being independent. Where the dominance did no longer come from the parents it usually did from the marriage partner.

Table 3
In-Patient Stay

Mean in-patient stay (excluding any in-patient stay following referral) was as follows:

31 patients with Crohn's disease        50.0 days
29 patients with colitis                         54.4 days

Classified according to stage, the figures are as follows:

 

20% stated that they felt unloved at home, but it seems that this did not touch them as deeply as it did the patients with Crohn's disease.

It was also noted that most of these patients did well at school. Intellectual development was often high, and in marked contrast to their maturity, which evidently develops much more slowly and with difficulty.

45% of our patients had A-levels, 21% a university degree.

As already stated, dependence on a parent would usually be followed by dependence on the marriage partner. Contact with others is much desired; the patients are sociable and have friends. They seem to be fairly uncomplicated in this respect. Male patients evidently also like older women; female patients look not so much for partnership but for protection. Colitis patients find it difficult to manage on their own and can hardly bear to be solitary. Patients with Crohn's disease are much more tolerant in this respect.

Professional or occupational training usually goes smoothly, with no major problems; again this is not the case in patients with Crohn's disease. Careers are however often taken up on the advice of others, and the relationship to their occupation is a relatively indifferent one. Professional ambition is considerable, with particular efforts made that their disease should not put them in a special position. This is all the more remarkable as patients often have to cope with extended periods in the hospital interrupting their working life. The patients themselves feel this is partly due to their finickiness and tidiness, which they themselves had noted from early childhood (25%). Sometimes the opposite is the case, with some patients quite unable to be tidy and being extremely careless and indifferent in conducting their affairs. This is in direct opposition to their parental home and the impression one gets is of a defiance reaction to their dependence on their parents (Freyberger's active group [20]). Almost all patients have a marked fear of failure and will therefore make light of their disease. Not one of our patients had discontinued training, stopped work or applied for early retirement on account of the disease.

Onset of the disease ranged widely, from the 12th to the 59th year, and the peak, between the ages of 17 and 21, is not as marked as with Crohn's disease. On the other hand, onset clearly related in almost all cases to a negative experience in the biography (e.g. stress situation, examinations, overwork, a loss, or separation). In some instances, pregnancy and the birth of a child or professional advancement and the added responsibilities this brought would precede the onset. There is an overall impression that these individuals do not find it easy to take on responsibilities. In their premorbid personality structure they have considerable problems with developing sufficient powers of will and of heart.

The "anxiety" problem showed many variations. In some cases it is triggered by the patient knowing that the disease ranks as a precancerous condition, but in others by all kinds of imagined things which are not always mentioned and have to be looked for if one wishes to gain access for therapeutic purposes. With powers of will and heart somewhat limited, patients do to some extent feel inadequate in relation to their life partners. Inner space is not usually well developed, so that they easily appear empty inside, with lack of self-awareness. Feeling for life is poor, adaptation to the social environment a necessity. Smoldering conflicts are often suppressed, and patients are concerned to make a good impression whilst in the hospital, e.g. by doing everything prescribed, irrespective of how they feel about it (e.g. art therapy).

Table 4
Marital Status, Partnership, Children

                        Patients with Crohn’s Disease          Patients with Colitis

Married                                      41.9%                         48.3%
Est. partnership                        25.8%                         24.1%
Divorced                                   16.1%                         10.3%
Married more than once           9.7%                           10.3%
Currently separated                  6.4%                           - - -
Frequent change of partner      9.7%                           10.3%
Children                                    28.8%                         51.7%


Table 6
Colitis patients
Extraintestinal Manifestations

Joint pain, arthritis                                                       7 patients = 24.1 %
Erythema nodosum.                                                    2 patients =     6.8 %
Stomatitis aphthosa                                                     2 patients =     6.8 %
Febrile episodes                                                          12 patients = 41.3%
Raised hepatic and biliary enzyme levels                     - - -
indicative of cholangitis or concomitant hepatitis        5 patients = 17.2 %
Pyoderma gangrenosum                                             - - -
Fistulas                                                                        - - -
Raised pancreatic enzyme levels                                 - - -
No extraintestinal manifestations                                14 patients = 48.2 %

 
If we feel our way into the greatly narrowed-down world of these people, where imagined ideas play much more of a role than a feeling for reality, we become aware that free and open access to the world is a primary problem. They feel at ease in our relatively uniform world, but if demands are made - and perhaps the unexpected comes up - they immediately react with an aggravation. In contrast to patients with Crohn's disease, the basic mood tends to be relatively sanguine, so that they are able to overcome their "sore points" more easily.

When taking the history and biography, it was found that colitis patients are generally much better at remembering than those with Crohn's disease. Accurate recall goes back to earliest childhood, even remembering which year it was, and the sequence of events comes to mind relatively easily. Anything not so nice or positively unpleasant is less likely to be remembered, which again suggests a somewhat more positive basic attitude than that found with patients suffering from Crohn's disease. On the other hand, colitis patients describe events that go a long way back and from which they should by now have gained some distance, as if they had happened just a few days ago. In some cases, an aggravation developed as they described their memories, an indication of the spontaneous and immediate reactions of which colitis patients are capable.

In several cases emotions were found to be somewhat unstable: harmless questions would result in tears, with profuse apologies for such an embarrassing show. Digesting our experiences, developing an inner attitude to them and integrating the lessons learned in the body of life experience and knowledge are processes that call for a capacity for inner change without losing one's identity. Colitis patients are limited in this respect, and this is not contradicted by the outward mobility and adaptability shown, with generosity shown, as it were, in putting their own interests last. This is, in fact, only an apparent flexibility, designed more to avoid conflict, the aim being to maintain social integration at all costs. Personal life goals are made subordinate to the same goal. In brief, the present is everything for these patients, with the past rating relatively low and not seen as binding in the usual way. The future therefore seems to some extent uncertain and suspect, though the idealizing attitude tends to balance this out to some extent.

As to therapy, it must be our concern to enable these patients to develop independence and to gain definition and distance relative to the world. This is required in both body and soul. In our opinion, it is also important to get them to accept their own biographies, which should not be interpreted for the given moment, with no real commitment. It appears that to them, biography is merely a sequence of events, rather like a time line, and their relationship to it is sometimes extremely superficial.

Table 7
Diseases of childhood and youth in

31 patients with Crohn's disease
29 colitis patients

frequent, in some cases severe                      Crohn's disease           51.6%
upper respiratory tract disease                       colitis                           34.5%

frequent gastrointestinal problems                 Crohn's disease           19.6%
                                                                        colitis                           13.8%

allergic conditions (hayfever,                           Crohn's disease           32.2%
asthma, food allergies, etc.)                            colitis                           17.0%

other conditions                                              Crohn's disease           22.6%
                                                                        colitis                           24.1%
tonsillectomy                                                   Crohn's disease           35.5%
                                                                        colitis                           24.1%

appendectomy prior to the diagnosis              Crohn's disease           42.0%
being made                                                     colitis                           3.4%

Table 9

Colitis patients - sex, age, duration of disease,
degree of severity, education and present occupation


 

One criterion in assessing progress under treatment was the extent to which individual patients are able to establish a responsible conscious relationship to their past that goes beyond present concerns, and out of this to set goals for the future. Patients with Crohn's disease are much more connected with their past, being less able to let go of it. The future presents a problem in their case in so far as past experiences are preventing them from moving on. Colitis patients take a relatively non-committal view of the future. Patients with Crohn's disease look to the past and therefore have difficulties in seeing the future. The unique feature of both groups is that they are least able to maintain a relationship to the present and therefore to reality.

In therapy, the relationship of colitis patients to perception of reality plays a critical role, particularly in art therapy. We believe it is possible to see differences here which relate to the extent to which the intestines are involved. Proctocolitis patients clearly have far fewer problems in this respect, patients with total involvement on the other hand have the most problems. Some patients feel themselves that their relation to reality is inadequate and look for opportunities to develop a better connection. The adapted and intellectually seemingly playful manner they exhibit tends to mask the real situation.

Summary

Our observations and impressions, partly objective, partly given special weighting by us, indicate that to some extent colitis patients are the opposite and complementary to patients with Crohn's disease. Needing protection, always looking for people who will create an area of trust for them, they persist to some extent in the situation that belongs to the first seven years of life. The intellect has made itself independent of this, and the development of will and heart appears to be difficult. Highly adaptive behavior usually provides for problem-free social integration. These patients live on the basis of imagined ideas rather than genuine perception, which makes it difficult to relate to reality. The relationship to the past does not normally go very deep, nor are they able to assume real responsibility for themselves.

To epitomize the situation with regard to will power we might say: colitis don't want to, though they could; patients with Crohn's disease can't, though they want to.

4.3        Results of treatment

Treatment had a number of components:

1) medical treatment
2) diet

3) art therapy

4) therapeutic discussions

1) In line with the wishes of most patients, the aim with medical treatment was to manage as far as possible without cortisone, sulfasalazine or mesalazine and chemotherapy. Instead, patients were given a differentiated anthroposophical therapy which in the individual case depended on whether it was necessary to take the disease to a stage where it was possible to tackle it or whether it was already at that stage and too much so. Different medicaments were given depending on whether the disease had to be approached more from the duodenum or from the colon. The nature of the psychological symptoms provided guidance in the choice of approach in art therapy and talks. Medical treatment also took account of other organs which might be involved. The basic mood, described above as either more melancholic or more sanguine, served as a criterion for the different way in which the ether body would be involved, in terms of a patient's feeling for life. These were the main aspects in assessing the given situation; with regard to the patient contracting the disease, a particular relationship of the four essential elements of the human being was assumed which will be discussed elsewhere.

With 37.8% of colitis patients and 29% of patients with Crohn's disease it proved possible manage with anthroposophical therapy only. 27.6% of colitis patients and 35% of patients with Crohn's disease showed definite or satisfactory improvement on anthroposophical medication in combination with mesasalazine or sulfasalazine.

Cortisone was used with 34.4% of colitis patients and 32.1% of patients with Crohn's disease (partly because they were already on it, and partly because of no response to the above-mentioned treatment). A definite improvement was however only seen in 20% of colitis patients and 13% of patients with Crohn's disease given cortisone (see Table 10).

Table 10

Colitis patients
Treatment and progress, incl. follow-up assessment 1 year after discharge


Notes on follow-up (Table 10)

progress excellent                   subjective improvement, in remission
progress moderate                  subjective improvement, 1 or more mild attacks
progress satisfactory               1 medium severe attack and/or several mild attacks;                                                                         subjective improvement maintained
progress not satisfactory         1 severe or prolonged moderately severe attack, may require                                               adm. to hospital
progress poor                          number of severe attacks or persistent active phase not                                                       completely controlled with heavy medication. 1 or more admissions to hosp. general condition                     questionnaire filled in by patient
                                                patient did not return questionnaire

A few patients were in poor general condition and therefore put on complete intravenous feeding. Anemia was treated with conventional iron preparations, as homeopathic iron preparations were found to have very little effect.

The most frequently prescribed anthroposophical medicines were Mercurius vivus 6x, Birch Charcoal capsules, Silicea (Quartz) 30x, Marmor (Marble)/Stibium, Tabacum 6x, Ferrum rosatum 6x, Cuprum sulphuricum 6x, and Phosphorus 6x. A large number of other preparations were used on individual indications.

2) The colitis diet we use progresses in stages from gruel to cooked foods excluding milk and pork, and finally a normal diet with a high proportion of raw food (in some cases omitting milk products). Depending on the severity of the condition, patients would start on stage 1 or 2 of the diet. In some cases - mainly those of patients with Crohn's disease - the diet produced remarkable symptomatic improvement; with colitis, on the other hand, diet appears to play only a minor role.

3) All patients had at least one form of art therapy. Eurythmy therapy was most frequently prescribed, other forms were painting therapy, and music therapy. After some initial problems most patients made good progress. Many of them found eurythmy therapy pleasant and some found that it reduced the pain. A group composed of the particular therapist and the physicians involved in each case monitored the progress of every patient, with regular weekly meetings. A first treatment outline and first therapeutic criteria for the indications of the different forms of art therapy were evolved side by side.

4) Apart from the above three lines of treatment, discussions were held with individual patients to clarify their present situation, make them aware of biographical facts, and discuss practical aspects of their future life style as well as developing a view of the future, particularly in severe cases, which would include discussing the realization of plans. Many patients also had counseling from our dietitian, and we also had talks with members of the family or marriage partners.

5          Discussion of methods and "psychosomatic aspects"

The question as to the nature of "psychosomatic disease" has always been part of the background when individual authors discussed chronic inflammatory intestinal diseases. The literature is full of separate observations and facts, some of them contradictory and difficult to fit into the picture, and so far it has not been possible to arrive at a clear concept of the relationship between psyche and soma. This is due to the method and to the fact that the more subtle observations relating to the psyche are not, as a rule, taken seriously. When we attempt to make our own observations and look for the reality experienced by these patients, it is not productive to gather the isolated details that play a role in statistical assessment and draw conclusions from which to construct this reality. Instead, we must take the totality of our experience of the patient and see the rank and significance of details within this context. Every individual builds his own reality on the significance he attaches to individual objects. This observation has, incidentally, led to the conclusion that reality is to be found only in the individual person. That is not what is meant, however. Objects have their inherent significance. We are individual, however, in making choices and assigning ranking values. The road to this is what we call individuation.

The particular method we had chosen was to enter into the process of individuation. Like any other method, it does, of course, have its potential faults, though in our view these are no greater than with statistical methods, which furthermore do not relate to the individual. What matters is that they can be repeated and recognized by others. We have therefore made a conscious attempt to paint a typical picture, which will not be found in its pure form in reality but relates to similar elements in a given case. This is analogous to the situation commonly known in morphology, except that these are similarities to be found at the psychic level and recognized in a differentiated way at different levels.

The fact that other authors have observed similar psychological elements indicated that we are dealing with something that is not as highly individual as one would like to assume. A syndrome such as ulcerative colitis, and in some respects also Crohn's disease, results in a relatively similar psychological state, with a problem-creating pattern that is also reflected in the biography. This immediately brings us to the question as to how to define the individual. If we are serious in assuming that an individual human being faces us wearing the four essential human elements as if they were garments, then there must be something behind all this which is the true individual. If we can set the essential elements aside, we really experience the ego of the other person as being without qualities; it is pure activity, and we must take care not to identify anything else as exclusively part of this ego. On the other hand, the sovereignty of this ego over everything that wants to come to manifestation should be our most important therapeutic principle.

The things we perceive are due to the disease and therefore rather uniform; and they are the basis, among other things, for making the diagnosis. The situation usually becomes more individual when it becomes reactive and comes to manifestation (similar to morphology, where we are also dealing with a number of reactive processes). Some of the phenomena which then arise are highly individual in origin and due to the individual nature of the patient — e.g. how he comes to terms with his disease. This individual note has to be recognized; it probably plays a role in the prognosis. Yet again the things we observe are far from straightforward. It is not necessarily true that an active individual will be better able to cope. There has to be some ability to change as well if there is to be an effect on the prognosis. This is something we noted in the present study and also with cancer patients.

From the descriptions given in the above chapters and also from the literature it is evident that at the psychic level we are dealing with two basic phenomena:

1) The symptomatology, which is the outcome of the disease and can be divided into three groups:

a) Phenomena that emotionally determine outside relationships, e.g. the way in which stress is tolerated. Patterns of behavior emerge that the patients themselves find unacceptable, yet they are unable to change them. The problem is that they tend to react in a stereotyped way, often fully aware of the compulsive element in their behavior.

b) This seems to be due to an underlying "personality structure" which is evident from the biography on the one hand, and from certain character traits, such as excessive tidiness, finickiness or inability to stand on their own feet on the other hand.

c) The way in which earlier events in life are experienced. We have assumed that the particular nuance of these experiences is a basic mood due to organic causes. It may take the form of a depressive mood, or a fundamentally more sanguine approach which may reach pathological levels. It is possible that this is connected with the specific form of inflammation with these syndromes. It was certainly found that moods were subject to some degree of change, and a connection with the acuteness of the condition seemed obvious.

2) On the other hand there is the level of consciousness at which individuals have to come to terms with their own situation, and also with outside demands and the fact that their abilities do not match up to those that are demanded. In healthy individuals, conscious awareness shows a certain stability in that it occupies approximately the same space for each person. The patients we were working with have to cope with the problem of a conscious awareness that is under constant threat. It is unstable and frequently breaks down for brief moments. We might also say that it is continuously reduced, either because of the peculiar way in which these patients have to spend their nights (frequent interruptions, sometimes in a twilight state) or in the daytime because they experience their own inadequacy and difficulties, or have to withdraw into bodily functions – which do not leave one free for the world.

The two levels of which we spoke have thus been subdivided into four areas. One large level intervenes in the psychic sphere in particular ways that are more or less independent of the individual and produces symptomatology both there and subsequently also in the physical body. Depending on the basic structure, this may also take a reactive form. This level exists also in healthy people.37 It is the basis of our emotional and will life, not fully accessible to the conscious mind; it is the realm in which our destiny is shaped. Yet at the same time it also is the basis of our egoity and subjectivity. We experience and find ourselves because of it, which means that it is a sphere where our state of well­being can be upset.

The other level, where awareness arises, lets us participate in the world around us and allows this world to be present in us through conceptual thinking, ideation and sensory perception, enabling us to perceive it as it is, that is, free of all subjectivity. This is a matter of practice, however, and it will depend on the degree of ego activity how far individuals are able to make use of this sphere of consciousness. The more the sphere of will and emotions intervenes in the sphere of consciousness, seeking to make its own contents prevail, the more we lose the connection with the real world we have perceived.

Conversely, the more our perceptions are based on the ideas and concepts of collective thinking, so that the ego is unable to identify itself with the world but only with ideas of the world that derive from tradition, for example, the more the ego lives in an unreal world.

Both the above levels can thus have forms imposed on them or assume a compulsive character which then becomes pathological. The aim and purpose of treatment designed to go deeper is to help the patients to develop a more balanced view, to gain insights that will resolve the compulsive element, or to create a space that is not destiny-determined and make intervention possible.

On the basis of the literature and our own observations it is possible to say that we have two basic psychological configurations which are, relatively speaking, polar opposites. One of them is more typical for patients with duodenal disease, the other for patients with colonic disease. One remarkable finding was that patients with Crohn's will often show a configuration more like that of colitis patients, whilst the opposite is rarely the case. It finally emerged that in patients with Crohn's disease who fitted more the colitis pattern, the disease also affected the colon. If this were to be generally true, the specific organ involved would play a definite role in determining the basic psychic structure of these patients. In that case, dysfunction of the duodenum and colon respectively would either result in specific basic psychological traits, or else be caused by them. This will be the subject of further investigations.

Fig. 12
29 patients with Colitis


Individual patients are shown on the abscissa. The graph shows the time interval between negative experiences in the biography and diagnosis and/or onset. In colitis patients, diagnosis and onset coincide. The graph shows that the majority of negative experiences came around the seventh year of life, with no correlation to onset. A line has been drawn to connect individual experiences. Unlike colitis patients, patients with Crohn's disease also show an increased incidence of negative experiences around the 21st year of life.

The straight line represents regression relative to first negative experiences.

If we accept the above definition of levels, the two types of patients may also be described as follows. It appears that in a typical case of Crohn's disease, particularly with marked involvement of the duodenum, we see emphasis on the emotional aspect and considerable will involvement in a patient whose self-experience goes beyond the normal level with the inner space strongly developed and differentiated, but easily broached, and indeed almost paralyzed, by outside influences. The power of particular elements of consciousness will, of course, vary from individual to individual, so that the overall picture will differ. These patients have problems with their perception of the outside world; their imaginations are relatively well developed and they depend a great deal on their inner world, clearly having gone consciously through the process of isolation and growing solitude in childhood, or having been pushed into this role at too early an age. Their biographies indicate beyond-normal development in the second seven-year period, which is when the whole or at least the major part of the process of becoming a separate individual normally takes place. There has been obvious failure to establish a natural relationship not only to the world of sensory perception but also to the world of physical substances, two worlds to which a similar "basis of trust" is normally developed in childhood.

Mueller-Wiedemann 38 writes that this process of separation and the experience of being different from the outside world essentially are part of development between the ages of 8 and 11. Our attempt to represent the extent to which crucial experiences at that time of life played a contributory role is shown in Figure 13.

The hypothesis, then, is that the patients with Crohn's disease who have been in our care had not been able to make the right transition from the first to the second seven-year period. The fundamental experience, to which these individuals adhere rather strongly, is to feel themselves estranged from the outside world. Their own solitary state becomes physical. The Thou does not primarily inspire trust but becomes hurtful. Sensitivity towards other people is much greater than we are inclined to think.

Negative experiences in the second seven-year period also showed high incidence with colitis patients, but they were more diffuse than those described by patients with Crohn's disease.

The psychological situation of colitis patients is typically different, and it is possible that this correlates with the degree of colonic involvement.

These patients are more governed by their ideas. Intellectually they usually do well, and there are normally no problems with professional training and in coping with external demands. The main desire is to adapt, sometimes even putting opportunities for self-development in secondary place. Memory and ideas are well developed but much affected by the demands of tradition and of society in a collective sense. Thus we have form again, with loss of distance, judgment and critical faculties. Thinking is predominantly associative. Kuhlewind connects this with powers of will and emotion which may also be dominant in the sphere of ideas.37

As to psychological development, it appears that the main problem of colitis patients is that they have not definitely grown out of the reconciliation space that is part of the first seven-year period. Marked dependence on their mothers or a life partner who may be considerably older indicates the need to continue under protection and the inability to develop independence. Cognitive faculties develop normally, though there may be a strong bias.

If we consider the character of the one type of patient, which is more determined from inside, and that of the other type, which is more determined from the outside — the terms "introversion" and "extroversion" only partly cover the aspects under discussion — it is evident that both may become pathological, with wide intermediate zones before they are definitely pathological and, what is more, require psychiatric treatment. Once again these are two opposite extremes of one and the same thing.

Table 14.
Notable differences in behavior seen in patients with
Crohn's disease and colitis patients included in the present study


5.1       Summary

Summing up, we'd like to present the following for discussion:

1. In patients with chronic intestinal disease, not only the morphology but also the psychic sphere show much that is similar both in essence and in biographical terms. This suggests that similar changes occur due to the disease.

2. There is some probability that the common features we observed in colitis patients were due to involvement of the colon. In particular we would connect the distribution of superficial morphological changes due to inflammation with the typical psychological situation.

Similarly, we have to consider that the similarities in psychological features and structure shown by patients with Crohn's disease are connected with the fact that the duodenum is primarily involved.

3. The fact that there were a number of instances where patients with Crohn's disease showed the psychological features of colitis patients, may be connected with the observation that the colon was also involved in these patients.

4. The encounter with these patients reveals characteristic features which indicate that developmentally it had not been possible for them to make the right transition from the first to the second seven-year period. On the one hand the result is that, in colitis patients, the kind of attitude persists which is normally found in the first seven-year period. In the case of patients with Crohn's disease, a crisis caused the transition from the maternal reconciliation space to the individual's own inner space to go beyond normal limits. Alienation from the world is considerable, and goes hand in hand with increased sensitivity.

5. Patients with either of the two diseases may show specific basic moods. The severity of the mood appears to be connected with the acuteness of the inflammatory process. The tendency is either to be depressive or more sanguine. This basic mood is not always easy to perceive but merits particular attention.

6. Reactive behavior which also comes to expression at the organic level may mask the above phenomena. They will only be perceived by someone familiar with the situation. This in turn may be connected with processes occurring in the rest of the organism, which may have to do with concomitant diseases. It appears that the organ systems particularly affected are gall-bladder and pancreas, or the liver. The question is in how far the involvement of other parts of the body may be regarded as a sign of the organism being involved as a whole. All separate phenomena relating to this would therefore have to be interpreted in the light of the whole.

7. The connection between onset, acute episodes and general deterioration on the one hand and outside events on the other is much more direct with colitis patients than with those suffering from Crohn's disease. It appears that with Crohn's disease patients there is a much longer time interval (inwardly coming to terms?) before the threshold is reached that leads to physical manifestation.

8. In establishing the prognosis it is not enough to develop ideas on the patient's active involvement and prospects for the future. Both with the patients included in the present study and with cancer patients it proved impossible to get observations of this type to show agreement with the subsequent prognosis. The question that was much more to the fore was the extent to which the individual was capable of change. In the few instances where this capacity was found, we could see that it was a factor in the prognostic trend.

9. Observations like these have specific therapeutic consequences, some of which will be reported in due course. Observations made with eurythmy, painting therapy and music therapy have been collected and collated.

10. In our view it is important to put the way these patients relate to their past on a different basis. This either is not taken sufficiently seriously or it has such a powerful determining role that in either case patients are not able to be really open to the future. As a first step, we have made this a part of our therapeutic interviews with patients.

One aspect of this is, in our opinion, acceptance of one's own biography.) Both groups of patients clearly are unable to let the real past be a supportive element in the present. In the encounter with these patients, it is therefore always necessary to remove a veil.

 

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