Predictors of clinical outcomes and quality of life in patients with inflammatory bowel disease: a longitudinal study

Psychosomatic medicine is a wide interdisciplinary field that is concerned with the interaction of biological, psychological, and social factors in regulating the balance between health and disease (Lipowski, 1986). It provides an important conceptual framework for the scientific investigations on the role of psychosocial factors affecting individual vulnerability, course, and outcome of any type of medical disease. Current health care is conceived as acute care, while 80% of health expenses are for chronic diseases. Almost all of health care spending is directed at biomedically oriented care. However, unhealthy behavior is responsible for over half of morbidity. Medically unexplained symptoms occur in up to 30-40% of medical patients and increase medical utilization and costs (Fava & Sonino, 2010). Tinetti and Fried (2004) suggested that time has come to abandon disease as the primary focus of medical care. In this regard, disease-specific guidelines provide very limited indications for patients with chronic diseases. The main aim of treatment should be the attainment of individual goals and the identification and treatment of all modifiable biological and non-biological factors, according to Engel’s model. The application of psychological understanding to the management of the individual patient, which includes establishing a therapeutic relationship, helping the patient to identify his/her current problems, and working with family and significant others, results to be essential in all medical settings (Porcelli, 2008). In this context, the aim of the current thesis is to investigate the clinical role of psychological factors in patients with Inflammatory Bowel Disease (IBD). IBD is a chronic disease whose course is characterized by exacerbations and remissions that primarily affect the gastrointestinal tract. Its main clinical forms are Crohn’s disease (CD) and ulcerative colitis (UC) that sharing clinical, epidemiologic, and pathogenetic features. The prevalence of IBD is around 150-200 cases per 100,000 in Western countries (Kappelman et al., 2007). Acute episodes of IBD are characterized by clinical symptoms of severe abdominal pain and diarrhea, bloody stools, and endoscopic and histological signs of inflammation and lesions of the gut mucosa. These symptoms strongly affect various life domains (e.g., job, social and intimate relationship, hobbies) of IBD patients. IBD patients with long-standing disease have an increased risk of developing fistulas, intestinal perforation, bowel obstruction, and colorectal cancer. Furthermore, the unpredictable course of IBD can involve a lot of complications leading to the escalation of therapy, hospitalization, and surgery (Loftus, 2004; Conley et al., 2017). The current standard of care in IBD treatment is aimed essentially at managing the inflammatory response during relapses and maintaining remission with a focus on the treatment adherence (Mowat et al., 2011; Jordan et al., 2016). Current evidence highlights that psychological factors play a central role both in the pathophysiology and course of IBD (i.e., clinical outcome, number of relapses, pain severity) and in how patients deal with this disabling disease (adherence to the treatment, coping strategies). Moreover, some patients experience symptoms in the absence of objective evidence of disease activity, with occult inflammation, visceral hypersensitivity altered mucosal permeability, and co-existent functional disease (Gracie et al., 2016). The first part of my Ph.D thesis aimed at analyzing the main features of this chronic medical condition. It is an overview on etiology, epidemiology, classifications, and more common medical treatments for IBD patients. The second chapter is a comprehensive review presenting “the state of the art” on the relationship between psychological factors and IBD. Finally, third and last chapter is focused on my research project. The research is a longitudinal study aimed at investigating psychological factors (i.e., anxiety, depression, somatization, perceived stress, and alexithymia) predicting/contributing to clinical outcomes (i.e. disease activity, relapse, and severity of gastrointestinal symptoms), including quality of life, of IBD patients