Saudi Journal of Gastroenterology
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Year : 2002  |  Volume : 8  |  Issue : 2  |  Page : 53-58
Life events stress in ulcerative colitis: A case-control study

1 Department of Psychiatry, College of Medicine, King Faisal University, Dammam, Saudi Arabia
2 Department of Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia

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Date of Submission17-Oct-2001
Date of Acceptance12-Mar-2002


Background: Ulcerative colitis (UC) is significantly associated with life events stress. Aim: To investigate the relationship between ulcerative colitis, and life events stress. Methods: A prospective study of 30 patients with ulcerative colitis and 30 healthy controls. A semi-structured psychiatric interview and clinical mental state examination were used in the psychiatric assessment of the patients and controls. Psychiatric diagnoses were made according to ICD-10. A modified version of Life Events Scale by Tennant and Andrews was used in the assessment of life events stress. Results: Life events stress were significantly experienced by more patients than the controls. The total number of life events, the number of individual significant life events and the total number of unpleasant events were all significantly more in patients than the controls. Conclusions: In this study the association between the ulcerative colitis and life events stress is substantiated at all levels. However, further more extensive studies are needed to elucidate the nature of this relationship.

Keywords: Life events stress, ulcerative colitis, case control, psychosomatic quality of life, exacerbation

How to cite this article:
Saed AM, Hafeiz H B, Abdulaziz AQ, Ismail YM, Mustafa AM. Life events stress in ulcerative colitis: A case-control study. Saudi J Gastroenterol 2002;8:53-8

How to cite this URL:
Saed AM, Hafeiz H B, Abdulaziz AQ, Ismail YM, Mustafa AM. Life events stress in ulcerative colitis: A case-control study. Saudi J Gastroenterol [serial online] 2002 [cited 2022 Aug 17];8:53-8. Available from:

Since the early thirties, an association was observed between emotional factors and ulcerative colitis [1] . In fact it was occasionally argued that the condition is in the essence of a psychosomatic disorder, caused by emotional factors [1],[2] . Others believed that ulcerative colitis has a multi-factorial etiology and that emotional aspects are partly responsible [3],[4],[5],[6],[7],[8] . Recent communications claimed that psychological stress has been positively correlated with exacerbation of UC [8],[9],[10] . Life events stress is also thought to be associated with both objective and subjective aspects of activity in UC [11] . To add to the controversy, some considered the psychological problem encountered in UC is to be the result of such severe and chronic illness, and not the cause [12],[13],[14] . Based on this presumed association between UC and emotional factors, various modalities of psychological treatments were found to be effective [15],[16] . On the other hand there are those who held the view that UC is a purely physiologic condition [17],[18],[19] . Serious flaws in the research design, in many of those studies advocating positive association of UC with psychiatric factors, are thought to be responsible [19] . Recall bias, distressing psychological consequences of the disease, psychogenic symptom exaggeration and irritable bowel component of UC are thought to complicate the problem further. The scarcity of prospective and controlled studies in this field is a further handicap for objective and replicable findings. Although ulcerative colitis had been reported frequently in Saudi Arabia and other countries in the Middle East [20],[21] , its association with stress has not been studied. The aim of the present study is to investigate the relationship between life events stress and ulcerative colitis in a prospective way. The psychopathology of ulcerative colitis is dealt with in a separate communication.

   Patient and Methods Top

Patient Selection: The study duration was for one year (1/11/99-31/10/2000). Ulcerative colitis is defined as recurrent abdominal pain, chronic diarrhea with or without rectal bleeding who had endoscopic features of hyperemia, contact bleeding, friability of mucosa with or without ulceration and biological features of chronic procto-colitis. The endoscopic (macroscopic) impression was confirmed hi stopatho logically. Colonic infections were excluded by repeated stool examinations and culture. Patients with evidence of irritable bowel syndrome and previous mental illness were also excluded from the study. Physical examination, lower gastrointestinal endoscopy and abdominal sonography were carried out by the gastroenterologists in charge of the two clinics at King Fahad Hospital of the University (KFHU). An equivalent number of healthy volunteers from the hospital and university staff, matched for age and sex were recruited randomly as normal controls. They had no past history of irritable bowel syndrome or severe medical or psychiatric illness.

Psychological Assessment: The psychiatric evaluation was carried out by the psychiatric team (the authors). They used a semi-structured psychiatric interview and a clinical mental state examination. Attention was focused on socio­-demographic data like age, sex, marital status and life events. The psychiatric diagnoses were made along the lines cited in 1CD-10 [22] . The severity of mental illness was graded as mild, moderate and severe according to ICD-10 mentioned above. Personality in our study has been assessed clinically in accordance with ICD-10 guidelines, which is a valid international research tool. Cognitive function was assessed clinically and the level of intelligence was judged by: general information, school and work records only. The measure of life events stress in the last six months before evaluation was carried out, using a modified version of the scale by Tennant and Andrews. This scale has been validated and extensively used internationally [23] . It has been translated in Arabic and also backtranslated in English [Table - 1]. In addition, this same scale has been used before by the same authors and items unsuitable to Saudi family culture (extramarital relationship, adoption) were omitted. Life events were not scaled and no numerical values were given for the degree of life change or stress, due to technical difficulties. Only life events experienced six months prior to the evaluation of the patients were included in the study. To render the results comparable to other studies, the findings in the present study were analyzed in a more or less similar way. Chi-square test, Fisher's exact test and Student's t test were used whenever relevant.

   Results Top

The majority of the patients and controls were between the ages of 20 and 50 years. Only one patient was below 20 and one above 50 [Table - 2]. Twenty patients and 17 controls were males and ten patients and 13 controls were females. Twenty-two patients and 19 controls were married, seven patients and nine controls were single. 29 patients and all controls were employed. The differences between patients and controls in age, group, sex, marital status and employment were not statistically significant.

Distribution of number of events per person

All the patients and 21 controls experienced one or more life events [Table - 3]. Twelve patients and five controls experienced more than six life events. The mean numbers of life events for the patients and controls were 6.6 and 4.1 respectively; differences being statistically significant (p<0.001, 0.05, respectively).

Individual Events

Only events reported by ten or more patients or control were considered for comparison purposes. Five of the eight significant individual life events were experienced by more patients than the controls; of these four events were unpleasant ones; while only three life events were experienced by more controls; none of them was unpleasant. Events of "minor illness or injury", "difficulties with the police", "law suit" and "things lost" were reported significantly more patients than the controls (p<0.02, 0.02, 0.0003; respectively). The differences in life events experienced by more controls were not statistically significant [Table - 4]. More patients reported, desirable, "undesirable" and neutral (ambiguous) life events than the controls; differences between the first two groups were statistically significant (p< 0.0051,0.00006, respectively). It is also noticed that more patients than controls experienced more than two life events, in the undesirable group; differences being statistically significant, again (p<0.03).

   Discussion Top

The relationship of life events stress and gastrointestinal disorders is still controversial. While earlier reports [1],[2] and more recent ones confirm this relationship [3],[4],[5],[6],[7],[8],[9],[10] ; others were unable to prove [17],[18],[19] . Such controversy is most probably due to methodological problems and serious flaws in research design such as the non-quantitative methods used in evaluating stress and that most of the research published in this area was retrospective and not controlled [19] .

Although no scaling (intensity of life events) was carried out in this study, a degree of quantification was achieved by studying the frequency of the most common individual life events and the number of life events per person. In addition, desirability and undesirability of life events, which correlate with the magnitude of stress, i.e. objective, positive and negative impacts were also included in the study [24] . The six-month period for life events before the evaluation of the patient was selected to reduce recall bias. The prospective nature of the study and the selection of a control group are further attempts in the quantification process.

The association of life events stress and ulcerative colitis has been confirmed at all levels of investigation in the current study. First; there were significant differences between the patient and control groups in the total number and the mean numbers of life events experienced by each group [Table - 3]. Second; analysis of the significant individual life events between the patients and controls revealed significant differences between the two groups, i.e. significantly more patients than the controls experienced five of the total eight significant individual life events [Table - 4]. Third; the patients experienced significantly more unpleasant life events than the controls [Table - 5]. These last findings are indicative of the magnitude and impact of stress, as mentioned before [24] .

Our findings in the present studies confirm a strong relationship between life events stress and ulcerative colitis. There were significant differences between the patients and controls in the total number of life events experienced, significant events and the unpleasant nature of the events themselves. These findings are in accordance with others published abroad. Earlier studies advocated an etiological relationship between life events stress and ulcerative colitis [1],[2] . More recent studies showed that emotional factors are partly responsible for the condition (3-8) or that stress is positively correlated with exacerbation of ulcerative colitis [8],[9],[10] . Levenstein et al in a well-designed multidimensional cross-sectional study found that stress is associated with both objective and subjective aspects of activity in ulcerative colitis [11] . In another study the same author confirmed that high long-term stress tripled the risk of exacerbation of ulcerative colitis [10] . Mauner et al reported a high prevalence of insecure attachment in ulcerative colitis [7] . Casselas et al and others associated ulcerative colitis with poor quality of life [25],[26],[27],[28] . On the other hand, the above-mentioned findings supporting an association between stress and ulcerative colitis were criticized by others. Thus, Carol et al in an important comprehensive review of the findings and methods in the studies dealing with this problem came to the conclusion that serious flaws in research design were responsible for these positive results. Systematic investigation failed to find such an association [19] . Lack of control subjects, data collection problems and absence of diagnostic criteria are among these flaws. These rather negative views were carried further by claim that ulcerative colitis is a purely physiologic condition [17],[18],[19]. Feldman et al had seriously questioned the very concept psychosomatic in ulcerative colitis [2] . Murray observed that psychiatric factors in ulcerative colitis are rarely mentioned now [3] .

The present study attempted to overcome some of the mentioned above flaws by the selection of a control group, prospective nature of the study and some _degree of quantification of life events, as described earlier. Nevertheless, the present study is definitely not immune to criticism, in spite of the attempts made for quantification. There are limitations; mainly that the number of patients under investigation is small and there was no scaling for life events. What was actually achieved in the present study is definitely not enough to reach a final decision on such a complex matter as the relationship between life events stress and ulcerative colitis. The response of a patient to stress depends on many other variables than those studied here, such as personality and cognition. The impact of life events is a complex interaction of stress, availability of social support, individual ability to cope with stress and personality.

   Conclusion Top

The significance of life events stress in ulcerative colitis compared with a control group was strongly substantiated in the present study. However, further extensive studies that address the various aspects of the problem, as mentioned above are no doubt needed before a final conclusion is reached.

   Acknowledgement Top

We are indebted to the Deanship of Scientific Research (KFU) for their invaluable financial help and support for the project.

   References Top

1.Murray CD: Psychological Factors in Ethiology of Ulcerative Colitis and Bloody Diarrhea. Am J Med Sci 1930,180:239-48  Back to cited text no. 1    
2.Feldman F, Cantor D, Soll S, et al: Psychiatric Study of 34 consecutive series of 34 Patients with Ulcerative Colitis. Brit Med J 1967; 3:14-7  Back to cited text no. 2    
3.Murray JB: Psychological Factors in Ulcerative Colitis. J Gen Psychol 1984; 110:201-21  Back to cited text no. 3    
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7.Maunder RG, Lancee WJ, Greenberg GR, Hunter JJ, Femandes BJ: Insecure attachment in a Subgroup with Ulcerative Colitis defined by ANCA status. Dig Dis Sci 2000; 45: 2127-32  Back to cited text no. 7    
8.Anton PA. Stress and Mind-body Impact on the Course of Inflammatory Bowel Diseases. Semin Gastrointest Dis 1999; 10:14-9  Back to cited text no. 8  [PUBMED]  
9.Levenstein S, Prantera C, Varvo V, Scribano ML, Andreoli A, Luzi C, Area M, Berto E, Milite G, Marcheggiano A: Stress and Exacerbation in Ulcerative Colitis: A Prospective Study of Patients enrolled in Remission. Am J Gastroenterol 2000 ; 95:1213-20  Back to cited text no. 9    
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16.Maunder R, Esplen MJ Facilitating Adjustment to Inflammatory Bowel Disease: A model of Psychosocial Intervention in Non-Psychiatric Patients. Psychother Psychosom 1999; 68: 230-40  Back to cited text no. 16    
17.Drossman DA: The Psychosocial Aspects of Inflammatory Bowel Disease. Stress Med 1986,2:119-­28  Back to cited text no. 17    
18.Engel GI: Psychological Factors and Ulcerative Colitis Brit med J 1967, 4:56  Back to cited text no. 18    
19.North C. Clouse R, Spitznagel E. Alpers D: The Relation of Ulcerative Colitis to Psychiatric Factors A Review of Findings and Methods Am J Psychiatry 1990, 147: 974-81  Back to cited text no. 19    
20.Satti MB, AI-Quorain A, Al-Gindan Y, et- al : Chronic idiopathic ulcerative colitis in Saudi Arabia A clinicopathological study of 76 cases. Annals of Sad. Med 1996; 16:637-40  Back to cited text no. 20    
21.Hossain J, Al-Faleh FZ, AI-Motleh I, et al . Does ulcerative colitis exist in Saudi Arabia? Analysis of 37 cases. Saudi Med J 1989; 10:360-2  Back to cited text no. 21    
22.World Health Organization: The ICDIO Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. World Health Organization, 1993, Geneva  Back to cited text no. 22    
23.Tennant C, Andrews G: A Scale to Measure the Stress of Life Events. Aust & New Zealand J Psychiat 1987; 10:27-32  Back to cited text no. 23    
24.Paykel ES: Methodological Aspects of Life Events Research. Psychosom res 1983, 27: 341-52  Back to cited text no. 24    
25.Casella F, Lopez-Vivancos J, Badia X, Vilaseca J, Malagelada JR: Influence if Inflammatory Bowel Disease on Different Dimensions of Quality of Life. Fur J Gastroenterol Hepatol 2001;13: 567-72  Back to cited text no. 25    
26.Helzer JE: Psychiatric Aspects of Inflammatory Bowel Disease, in Colon, Rectal, and Anal Surgery: Current Techniques and Controversies. Ed. Kodner IJ, Fry RD, Roe JP. St. Louis, CV Mosby, 1985  Back to cited text no. 26    
27.Turnbull G, Vallis TM: Quality of Life in Inflammatory Bowel Disease: The Interaction of Disease Activity with Psychosocial Function. AJG 1995, 90:1450-4  Back to cited text no. 27    
28.Irvine EJ: A Quality of Life Index for Inflammatory Bowel Disease. Can 3 Gastroenterol 1993: 7: 155-9  Back to cited text no. 28    

Correspondence Address:
AL-Quorain Abdulaziz
P. O. Box 40001, Al Khobar, 31952
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 19861791

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  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]


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