Brit. 3. Psychial. (1976), 128, 446—50

Crohn's Disease: A Psychosomatic Illness? By B. F. SHEFFIELD

and M. W. P. CARNEY

Summary.

We investigated

because 10 department between the be one case

such patients had been referred to our psychiatric over a period of six years, whereas if there were no disease and psychiatric morbidity, the expected referral in 20 to ioo years. We found an association between

psychiatric

and

physical

the psychological

symptoms

status of Crohn's

in the case histories.

disease

patients

out-patient association rate would episodes of

We administered

the

Eysenck Personality Inventory and the Manifest Anxiety Scale to 28 out-patients with Crohn's disease (8 psychiatrically and 20 non-psychiatrically referred), I7 with chronic non-psychosomatic

medical

diseases, 43 with psychosomatic

diseases and ioo with neurosis. Crohn's disease patients were significantly more anxious, neurotic and introverted than both the test norms and the non psychosomatic medical out-patients and did not differ appreciably from the psychosomatic patients in these respects.

IN'rRoDucnoN

Despite case reports that psychological stresses and emotional disturbance may provoke and maintain 1949;

episodes

Crocket,

of Crohn's

1952;

Grace,

disease 1953;

(Stewart, Mersereau,

1963; Ford, Glober and Castelnuovo-Tedesco, 1969;

Paulley,

1971),

a psychogenesis

for the

disorder is doubted (Crohn and Yarnis, 1958; British Medical Journal, 1970) or ignored (Pro ceedings of the Royal Society of Medicine, i@@i).

Indeed, while concluding that Crohn's disease was in no sense psychosomatic, Feldman, Carton,

Soll and Bacharach

(1967)

mentioned

4 cases of depression among their 17 patients; they failed to use standard interview techniques and fallaciously assumed that abnormal pheno mena were normally distributed in the general population. Attempts to describe a particular pre-morbidpersonality orpsychopathology have failed, but inability to express anger and obsessional features are mentioned (Goldberg, 1970). Ford et al (1969) found immaturity

and

excessive dependence to be common, and attacks of enteritis apparently frequently modified the original

stress situation

by changing

equilibrium. The possibly increasing

the family

(Lance!, 1972) mci

dence of Crohn's in the general population apparentlyvariesfrom o'8 per 100,000 in Oxfordshire 3@I

per

(Evans i oo,ooo

in

and Sweden

Acheson, (Norlen,

1965)

to

Krause

and Bergman, 1970). We suspected an associa tion between Crohn's disease and psychiatric disorder on the following grounds. Within six years, io patients were referred to our psychia tric out-patient department in Blackpool, where as, assuming a population for the Fylde district of Lancashire of 310,000, an annual new psychiatric out-patient referral rate of 1,500 and an incidence of o •¿8 to 3@I per 100,000, we might have expected to see one every 20 to ioo years. Furthermore, the case histories of these patients suggested that certain personality traits were common and that there were associa tions between the occurrence physical symptoms.

of psychiatric

and

Accordingly, the group of patients with Crohn's disease who had been psychiatrically referred were compared with those patients not so referred, and also with groups of neurotic out-patients and psychosomatic medical out patients, in terms of objective measures of anxiety and neuroticism. To attempt to control for the possibility that any vulnerability found

BY B. F. SHEFFIELD AND M. W. P. CARNEY

was merely a reaction physical

condition,

to the stress of a chronic a group

of non-psychoso

matic medical out-patients of similar chronicity were also included. METHODS

AND RESULTS

447

turity (7), obsessionality (6) and inability to express emotion (6). Six patients had had courses of ECT. During bouts of psychiatric illness there were only single instances of steroid therapy and low serum folate concentration (i .@

ng/ml)

and

none

of

serum

B 12

below

of

serious

mal

Crohn's disease patients

100

In order to carry out a psychometric investi gation of a representative sample of Crohn's

absorption.

disease

Controlpatients Consultant physicians selected patients ill for

patients,

we asked

the general

practi

tioners of the Fyle and interested hospital consultants for the names of such patients. Because these doctors worked within a peninsula served by one district general hospital we assumed

that

few would

escape

notice

or be

treated elsewhere (only one patient was so treated). All the diagnoses had been confirmed at laparotomy and histologically. Of 30 patients we contacted, 28 (8 ‘¿psychiatric' and 20 ‘¿non psychiatric') co-operated; 2 (non-psychiatric) patients refused. A further psychiatric patient was judged to be incapable because of brain damage, and another had left the area and could not be traced. The mean duration of symptoms

was 9 years

patients, studied.

so only

(@ to 27). All were

out-patient

controls

out

were

at

pg/mi

least

Crohn's

symptoms

of 12 @8(i to 27) years

two

other

evidence

years

(mean

duration

of illness

8 years; range 2 to 22) from consecutive medical out-patients, having rejected those over 6o years. The two groups did not differ on length of illness (t = o'4; P > 0@5; not significant). These were then sorted

by a psychiatrist

(M.W.P.C.),

ignorant of the test results, into those with psychosomatic (Henderson and Gillespie, 1962) and those with non-psychosomatic diagnoses. The former comprised asthma, diabetes mellitus, essential hypertension, coronary thrombosis, duodenal ulcer, rheumatoid arthritis, thyro toxicosis and ulcerative colitis; the latter valvular and other chronic heart disease, aplastic anaemia, polycythaemia, biliary cir rhosis, chronic epistaxis, Raynaud's disease and various

Patients psychiatrically referred (Table I) Seven female and 3 male patients (mean age 47, range 26-68 years) had a mean duration of

or

chronic

gastrointestinal

and

renal

dis

orders. Psychiatric

controls were consecutive

first attenders

neurosis

with

at our psychiatric

out-patient department.

and

of psychiatric symptoms of 8 4 (i@to i6) years. In 3 cases psychiatric preceded abdominal symptoms, and in 2 there had been psycho somatic disorders (hay fever, urticaria, asthma); in the remainder, abdominal symptoms appeared first. In 7 cases bouts of psychiatric and abdo minal complaints alternated and both seemed to be ways of manipulating domestic situations; in 3 they coincided and appeared to be more directly related to stress. Psychiatric diagnoses were: neurotic depression (8), psychotic de pression (i) and mania (i). Other features

non-psychiatric patients in the medical out patient department and to the psychiatric patients in the psychiatric out-patient depart ment. They were: the Manifest Anxiety Scale (MAS) (Taylor, 1953) and the Eysenck Per sonality Inventory (EPI) (Eyscnck and Eysenck, 1964)—from which are derived neurotic (N),

were

extraversion

hysterical

symptoms

(7)—eg

‘¿bellein

difference', manipulative behaviour and neuras thenia—one or more psychiatric admissions (7), self-poisoning attempts (4), self-mutilation (i) and drug addiction (i); there were also per sonality traits of undue dependence (7), imma

Psychometric investigations All patients

were invited

by their

doctors

to

complete questionnaires to further psychological understanding of their cases. These were administered

by a trained

(E)

and

staff nurse

‘¿Lie'(to

assess

to the

self

misrepresentation) scores. As psychiatric and non-psychiatric Crohn's disease patients did not differ significantly with respect to mean N (13.0 (24-0

and and

14.0), 21.6)

E and

(9.0 Lie

and (4.0

and

Io'2), 4.5)

MAS sco@

CRORN'S DISEASE: A PSYCHOSOMATICILLNESS? 448 the two groups were combined for comparison neuroticism and anxiety. However, in no case with 17 medical, 43 psychosomatic and 100 did the mean difference between males and neurotic out-patients (Table II). females reach significance, and accordingly the For all three groups, female patients showed scores of the sexes were combined (Table II). a tendency to score more highly on extraversion, On the mean N, the Crohn's disease patients, TABLE I

Clinicalfeatures of psychiatrically-referred patients with Cro/in'sdisease Duration of symptoms

Personality traits

02

(years)

I

U

@ @

Ce

c@

U

cn

I

2

&‘o 2

.5

-