Psychosomatics 48:448-450, September-October 2007
doi: 10.1176/appi.psy.48.5.448
© 2007 Academy of Psychosomatic Medicine
Bowel Obsession Syndrome in a Patient With Ulcerative Colitis
Piero Porcelli, Ph.D., and
Gioacchino Leandro, M.D.
Received December 12, 2006; accepted January 4, 2007. From the Psychosomatic Unit and Department of Gastroenterology, IRCCS De Bellis Hospital, Castellana Grotte, Italy. Send correspondence and reprint requests to Piero Porcelli, Ph.D., Unità di Psicosomatica, IRCCS Ospedale De Bellis Via della Resistenza, 70013 Castellana Grotte, Bari, Italy. e-mail: porcellip{at}media.it
© 2007 The Academy of Psychosomatic Medicine
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ABSTRACT
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Gastroenterologists are often faced with the diagnostic problem of differentiating acute symptoms of ulcerative colitis from functional intestinal disorders. Bowel obsession syndrome (BOS) is an OCD-like, functional syndrome characterized by fear of fecal incontinence and compulsive behaviors of evacuation-checking. Only sparse case studies on treatment of BOS with antidepressants have been published. This is the first study on successful psychotherapy of a male patient with ulcerative colitis overlapping functional bowel symptoms and marked symptoms of BOS. Clinical recognition of BOS may help clinicians in differential diagnosis, prevent unnecessary investigations, and give patients the most appropriate treatment.
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INTRODUCTION
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Ulcerative colitis (UC) is an inflammatory bowel disease (IBD), a chronic intestinal disease likely due to a combination of genetic vulnerability and immune factors producing inflammation of the intestinal wall in different segments of the colon and the rectum, characterized by intermittent phases of acute relapses and symptom-free periods. Although UC is no longer seen as a psychosomatic illness, psychological factors play an important role in its clinical course and in patients’ quality of life.1 Classic signs that reflect the inflammatory process are rectal bleeding, diarrhea, fever, and weight loss, occasionally associated with extra-intestinal manifestations. Gastroenterologists are often faced with the diagnostic problem of differentiating UC’s acute symptoms from functional bowel disorders, particularly, irritable bowel syndrome (IBS). IBS is one of the functional gastrointestinal disorders (FGID) currently diagnosed on the basis of a cluster of symptoms in the absence of detectable structural abnormalities.2 However, many symptoms are common to both conditions, including abdominal pain, bloating, excessive flatus, and altered bowel habits, as evidenced in recent large population studies.3,4 Because the clinical manifestations remain problematic, many patients might be exposed to invasive investigations and hazardous drugs with little prospect of benefit and significant implications on healthcare costs. Here, we report the case of a patient with UC and overlapping symptoms of functional bowel disorder. In particular, the patient showed symptoms of bowel obsession syndrome (BOS), a rarely-diagnosed condition that is not currently included in the Rome criteria for FGID2 and that was fully described about 10 years ago.5 The clinical characteristics of BOS (Table 1) are similar to those of obsessive-compulsive disorder (OCD), although they do not fit well into the diagnostic criteria of OCD and other anxiety-related disorders.
Case Report
"Mr. GB" was a 33-year-old man who had been diagnosed with UC 6 years ago. He was a street-sweeper with 8 years of education, and he had a stable conjugal relationship.
At the onset of UC, he was referred to a gastroenterologist who told him he had a severe disease that could possibly lead to death, prescribed 5-aminosalycilate and steroid treatment, and "commanded" a series of behavioral rules, including rigid diet (only very few foods were allowed), no alcohol or cigarette consumption, complete abstinence from sexual activity, and avoidance of physical activity (including exercise and sports) and psychological stress. Because of the fear induced by this physician, in the following years, he changed his lifestyle dramatically and became socially isolated. His life was totally restricted to his home. He went out only for work, and, when he had to go somewhere, he always needed his girlfriend with him. UC activity was always at a mild-to-moderate level, and the patient began to develop a deeper fear of leaving home and compulsive rituals of defecation-checking. He woke up at 3 A.M., 2 hours before going to work, and strained to evacuate 2 to 3 times in order to be calm enough to leave home, thus avoiding the fear of fecal incontinence he experienced when on the street with no bathroom at his disposal. He could go only to places he was familiar with, and he had to know where the bathroom was located.
Because of the persistence of abdominal pain and problems with bowel habits, he was referred to another gastroenterologist, who ordered a colonoscopy (which revealed, however, no sign of inflammation) and who treated him with mesalazine 3.2 g daily, with no substantial benefit. Because of his persistent depressive mood, the patient was referred to a psychiatrist, who treated him with paroxetine 20 mg daily for 3 months, again without any beneficial effects on the intestinal or psychological symptoms. At a later psychological consultation, he scored in the higher range for anxiety, depression, alexithymia, poor emotional control, dependency traits, and vulnerability to affect-dysregulation under stress to a battery of screening and personality scales, and he was diagnosed with BOS.
The three healthcare professionals involved in the case (gastroenterologist, psychiatrist, and psychologist) decided to stop psychiatric therapy, and the patient was treated for 16 sessions with cognitive-behavior therapy (CBT). His CBT focused on three major areas of functioning: First, the fear of leaving home was addressed with techniques of gradual exposure and response prevention. Second, the alexithymia component was explored with the patient. Because of the difficulty in the cognitive processing of feelings, he experienced high emotional arousal when exposed to the perceived danger (leaving home) that led to automatic thoughts ("I do not feel anxiety if I completely evacuate before leaving."), compulsive symptoms (multiple defecation), and misinterpretation of signs of distress as acute UC symptoms. Third, the hopelessness/helplessness attitude ("I am not able to cope with the fear of urgent defecation.") was addressed with cognitive restructuring aimed at improving autonomy and ego strength.
At the end of psychotherapy, the patient was able to leave home with no OCD-like symptoms, had no IBS-like symptoms, and scored in the normal range on anxiety and depression scales. After 3 years, the patient reported no BOS symptoms and had had two flare-ups of UC that were managed appropriately, with no further psychological problems.
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Discussion
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Although the prevalence of BOS is not known, the syndrome is not frequently diagnosed, and it is not actually included in the diagnostic criteria for FGID,2 there is reason to believe it is more common than may be thought. Some sparse studies have previously documented successful treatment of BOS with antidepressants,6 but, to our knowledge, no psychotherapy study has been published, and this is the first case report on successful psychological treatment of a patient with bowel obsessions.
BOS, particularly in patients with organic intestinal disease, is a diagnostic challenge for gastroenterologists and a good example of a real psychosomatic disorder. From the medical perspective, it does not completely fulfill the diagnostic criteria for IBS, and it adds confusion to the overlap of symptoms between IBS and UC. For instance, altered bowel habits are a result of this patient’s ideational focus and related compulsive behaviors; they are neither a core clinical feature typical of IBS nor a cause of anxiety, as in UC. From the psychopathological perspective, BOS includes symptoms of OCD and, to a lesser extent, social phobia, but symptoms are strictly related only to one limited area of functioning (daily consequences of disordered bowel habits) that, in turn, might be a clinical manifestation of a motility or inflammatory illness, as well. BOS symptoms remain, therefore, at the intersection of somatic and psychological domains, without being completely either somatic or psychiatric.
The intertwining link between UC, IBS, and BOS may occur as a result of several putative mechanisms. The inflammatory process may leave the bowel irritable and hypersensitive after the inflammatory infiltrate has regressed because of failure to down-regulate the immune response.7 Also, subclinical inflammation could alter motility and sensation through serotonergic pathways.3 Finally, subclinical psychopathology and alexithymia may lead to somatosensory amplification and misinterpretation of emotional arousal as symptoms of organic illness.8 Therefore, psychological treatments have been shown to be highly effective in reducing IBS symptoms.9
Medically unexplained symptoms generally pose a special challenge to healthcare providers. However, a clear understanding of the symptom history, along with appropriate liaison between specialists, could help avoid delays in diagnosis and prevent unnecessary investigations. This case report shows the need for integrative, multidisciplinary assessment and treatment of medical patients not only because of comorbid psychiatric disorders but also because psychopathology may present under the appearance of somatic symptoms that are plausible with the underlying organic condition of the patient.
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REFERENCES
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- Mawdsley JE, Rampton DS: Psychological stress in IBD: new insights into pathogenetic and therapeutic implications. Gut 2005; 54:1481–1491[Free Full Text]
- Drossman DA (ed): Rome III: The Functional Gastrointestinal Disorders, 3rd Ed. McLean, VA, Degnon Associates, 2006
- Farrokhyar F, Marshall JK, Easterbrook B, et al: Functional gastrointestinal disorders and mood disorders in patients with inactive inflammatory bowel disease: prevalence and impact on health. Inflamm Bowel Dis 2006; 12:38–46[CrossRef][Medline]
- Barratt HS, Kalantzis C, Polymerost D, et al: Functional symptoms in inflammatory bowel disease and their potential influence in misclassification of clinical status. Aliment Pharmacol Ther 2005; 21:141–147[CrossRef][Medline]
- Hatch ML: Conceptualization and treatment of bowel obsessions: two case reports. Behavior Res Ther 1997; 35:253–257[CrossRef]
- Jenike MA, Vitagliano HL, Rabinowitz J, et al: Bowel obsessions responsive to tricyclic antidepressants. Am J Psychiatry 1987; 144:1347–1348[Abstract/Free Full Text]
- Bradesi S, McRoberts JA, Anton PA, et al: Inflammatory bowel disease and irritable bowel syndrome: separate or unified? Curr Opin Gastroenterol 2003; 9:336–342
- Porcelli P, De Carne M, Todarello O: The prediction of treatment outcome of patients with functional gastrointestinal disorders by the diagnostic criteria for psychosomatic research (DCPR). Psychother Psychosom 2004; 73:166–173[CrossRef][Medline]
- Lackner JM, Morley S, Dowzer C, et al: Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis. J Consult Clin Psychol 2004; 72:1100–1113[CrossRef][Medline]
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ABSTRACT
INTRODUCTION
