Stress May Be an IBD Trigger

[David in Seattle]

Am J Gastroenterol 2010.

People with inflammatory bowel disease (IBD) commonly believe that stress can trigger their symptoms, and a new study suggests they may be right.

Canadian researchers found that among 552 patients with Crohn's disease or ulcerative colitis followed for a year, the risk of a symptom flare-up increased when patients were feeling particularly stressed.

The findings, reported online April 6th in the American Journal of Gastroenterology, lend support to what many people with IBD have believed to be true. Studies show that many people with IBD feel that stress worsens their symptoms, but there has been relatively little scientific evidence of that.

"This is among the first evidence to show that the perception of stress had a direct association with disease course," lead author Dr. Charles N. Bernstein told Reuters Health in by email.

"We are proposing that, based on this study and other emerging data, that clinicians make more of an effort to identify and manage psychological problems and stress that patients may have," said Dr. Bernstein, who directs the IBD Clinical and Research Center at the University of Manitoba in Winnipeg.

Patients in the study completed surveys every three months for one year, reporting on symptom flare-ups, stressful events, perceived stress, and other factors.

Overall, 174 patients reported a symptom flare-up during the study period.

The researchers found that patients' risk of a symptom flare-up increased more than two-fold when they had reported high levels of perceived stress in the preceding three-month period.

High stress in the previous 3 months was reported by 52% of patients who had flares, compared to 29% of those who remained symptom-free.

On the other hand, certain other factors suspected of triggering IBD symptoms showed no relationship to flare-ups, including use of antibiotics or non-steroidal anti-inflammatory drugs as well as colds, pneumonia and urinary tract infections.

There are biological reasons to believe that a person's response to stress would trigger or worsen IBD symptoms, Dr. Bernstein and his colleagues note.

The sympathetic nervous system acts on the lining of the colon and might exacerbate existing inflammation. There is also evidence that stress hormones may help harmful bacteria take up residence in the intestines, which might, in turn, affect symptoms.

If stress does trigger IBD symptoms in some people, then it's possible that learning better ways of managing stress would help stave off flare-ups, the researchers said.

 

[ameslouise]

I thought it was a "given" that stress triggers IBD -- I wonder if this is the first study ever done regarding stress specifically??

There sure are lots of people on this board that can pinpoint their flares to specific stress events. For me, when I had UC and now this current flare that got me re-diagnosed as Crohn's, ALL of my flares were triggered by my quitting smoking. Mental stress AND physical stress/traum caused by quitting cold turkey did me in everytime.

 

[David in Seattle]

They say "High stress in the previous 3 months was reported by 52% of patients who had flares, compared to 29% of those who remained symptom-free." One problem is "stress" is such a vague term, impossible to quantify. Who doesn't experience something describable as fairly significant stress in a given 3 month period? Assuming I did the math right, 40% of the sample, whether they had a flare or not, reported "stress" during the period. I'm surprised it's not higher. My main concern is it gives more ammunition to the doctors who want to maintain it's all (or mostly, significantly) psychological.

I'll bet an even higher percentage of the portion of the sample which had a flare was passed on the highway by a school bus during the period. You don't suppose... :eek2: Of course, that would probably be equally true of those who DIDN'T flare.

Another theory bites the dust...

 

[Hedgehog]

Hmmm..sometimes I think stress triggered my Crohn's and then I think...well...how do we know that psychological symptoms don't have a physiological rather than an environmental basis...maybe psychological symptoms are part of the Crohn's flare (eg related to wider systemic physiological changes)rather than being a cause of the Crohn's flare...

Ooooooo....it's all too bloody complicated.....

Know what you mean though David about docs too ready to pin everything on neurosis....

 

[David in Seattle]

Hmmm..sometimes I think stress triggered my Crohn's and then I think...well...how do we know that psychological symptoms don't have a physiological rather than an environmental basis...maybe psychological symptoms are part of the Crohn's flare (eg related to wider systemic physiological changes)rather than being a cause of the Crohn's flare...

Agreed. When I was diagnosed with another red-herring disorder years ago - "fibromyalgia" - I was told it could be the result of depression, and I "seemed depressed". Yeah. I'm 22 years old, and you've just told me that for the rest of my life, every morning when I wake up I'm going to feel as though I've just spent the last 8 hours being pummeled with cricket bats. And I seem a bit DOWN, do I? Cart, horse, horse, cart, which way does this thing go ?!?!????? :ybatty:

 

[Hedgehog]

Barbara Erinreich has just written a book (called Bright Sided I think) about the down side of unbridled positivity that seems to have captured the Western imagination. Like...'if you have cancer then you should think positive because it will help you fight it'....or...'people who are happier live longer so you should try to be happy'....blah blah...

I think this must then also mean that if you feel rage or sadness because you've got a horrible illness then you deserve to die younger and be beaten by your illness because you didn't try hard enough to be positive....

But then...positive folk will just say Barbara is just being negative....ho hum!!!

When I feel physically crap, I usually feel mentally crap aswell. Cart AND horse maybe!

Gail

 

[kenny]

wasn't this disease classified as a Psychosomatic induced illness a few decades ago?

When I met the GI team for the first time during my initial hospitalization they were quite insistent that nothing outside of the unknown cause was responsible for my getting sick. I smiled, said thanks and filed that under "BS to make me feel better" I am pretty darn sure that three months of bounced paychecks and other associated turmoil from work put me in the doghouse. "My guts Where Tied In a Knot" over that.

 

[Entchen]

Kenny, a Crohn's book I was reading last night said that it was believed to be psychosomatic a few decades ago. Nowadays, there is zero consistent evidence for a causal link between stress and initial onset of Crohn's.

I saw Erinreich's book as an important step, when it came out recently. I still know little about Crohn's, but when I was a student I witnessed the incredible pressure women who have breast cancer are under to be positive at all times, to look inside themselves to get better, to go dragon-boating, and to do art therapy "because women with breast cancer are the personality type who benefit from art therapy." It's terrible. If she has had a crap day, if she wants to complain or stay at home alone for a while, if she doesn't want to paddle a stupid boat in October -- she is not taking emotional responsibility for her illness and is more likely to die. And please don't get me started on the "Type C (cancer) personality."
Stop blaming the person who already has enough to deal with, already. Sure being optimistic is great. Good belly laughter *can* promote healing. And stress can be a barrier to optimal wellness. That doesn't mean that people are always going to be able or willing to deal with illness by being practically perfect in every way.*

*with apologies to Mary Poppins

 

[David in Seattle]

Barbara Erinreich has just written a book (called Bright Sided I think) about the down side of unbridled positivity that seems to have captured the Western imagination.

Gail - I haven't read the book, but I have heard the author interviewed about it several times (a particularly good interview was on the excellent Pacifica news program Democracy Now!, and can be streamed HERE. I find her observations on the larger role of forced positivity in the culture at large (particularly in the US) especially interesting.

 

[David in Seattle]

Stop blaming the person who already has enough to deal with, already.

Kelly - I think the "Blame the victim mentality" is quite prevalent, not only in matters of illness, and makes it easier for those who have been more fortunate (so far) to look the other way.

If you want to see a good, in-depth video interview of Ehrenreich, click on the link in my previous message.

 

[Crohn's 35]

In my worst of times (before my dx) I was always sick and when I moved or left a relationship, I was always ill. I do believe stress is a trigger, everyone has a spot in their body that reacts some get headaches, we get intestinal cramps. In those times I kept saying it was a flu. I also think the medications we take react on us when we do get upset, I have had that too. Just my 2 cents.

 

[David in Seattle]

In my worst of times (before my dx) I was always sick and when I moved or left a relationship, I was always ill. I do believe stress is a trigger, everyone has a spot in their body that reacts some get headaches, we get intestinal cramps. In those times I kept saying it was a flu. I also think the medications we take react on us when we do get upset, I have had that too. Just my 2 cents.

I certainly wouldn't say stress has no impact. It's very hard to tell, one way or the other. An interesting aspect of this is that certain areas of globe, especially the impoverished 3rd world, have a very low incidence of these conditions. Surely these people are under greater stress, materially at the very least, than most of us are in the wealthier parts of the population. Various explanations have been suggested for this, such as the prevalence of certain parasites (as implemented in helminthic therapy), but it's still an interesting phenomenon as regards IBD and stress.

 

[ameslouise]

I'm Suzie friggin Sunshine over here, tons of positive attitude and I still can't catch a break.

I think it's tremendously interesting about the low incidence of IBD in third world countries. I would like to read more about that if anyone has a link to an article.

Thanks - Amy

 

[dreamintwilight]

Agreed. When I was diagnosed with another red-herring disorder years ago - "fibromyalgia" - I was told it could be the result of depression, and I "seemed depressed". Yeah. I'm 22 years old, and you've just told me that for the rest of my life, every morning when I wake up I'm going to feel as though I've just spent the last 8 hours being pummeled with cricket bats. And I seem a bit DOWN, do I? Cart, horse, horse, cart, which way does this thing go ?!?!????? :ybatty:

Haha, this made me laugh. So true.

 

[D Bergy]

Impoverished nations have a more survival of the fittest type environment. In another words the sick and weak die early and do not reproduce more generations of the same.

They also have lifestyles quite different than ours in other ways that could lead to different results. They do not eat what we eat. Most probably have never had a vaccination of any kind, and many other variables that would be hard to quantify.

I do not believe stress causes Crohn's any more than it causes Cancer, but both are a factor in how the immune system works, and can trigger a flare, or worsen symptoms or progression of a disease.

I know of several dogs and people that die when someone close to them dies.
When someone loses there will to live or is severely stressed, it does have a physical impact.

My take on it.

Dan

 

[David in Seattle]

I'm Suzie friggin Sunshine over here, tons of positive attitude and I still can't catch a break.

I think it's tremendously interesting about the low incidence of IBD in third world countries. I would like to read more about that if anyone has a link to an article.

Thanks - Amy

Amy - If it's any consolation to you, I'm probably pretty much your opposite in terms of "outlook", and it hasn't done much for my health, either

Below are a few abstracts you might find interesting. The Wikipedia articles on Helminthic therapy and the Hygiene hypothesis and their associated links are also informative.

Have fun reading (because what could be more fun than reading about worms and diarrhea??? :ylol2: )

Environmental Influences on Inflammatory Bowel Disease Manifestations
Lessons from Epidemiology
Antje Timmer
Department of Internal Medicine I, University Hospital of Regensburg, Regensburg, Germany

Dig Dis 2003;21:91-104 (DOI: 10.1159/000073242)

Environmental factors play an important role in the disease manifestation, course and prognosis of inflammatory bowel disease. Observations on temporal trends and geographical distribution point at risk factors associated with a Western lifestyle. A large number of studies have been performed on various factors such as diet, smoking, and several infectious agents. Childhood exposures modifying immune responses in later life form a particularly interesting field. However, so far, only smoking in Crohn's disease, and smoking cessation in ulcerative colitis can be considered established as risk factors for the manifestation of the disease. Smoking is also associated with a poor prognosis in Crohn's disease. A strong negative association of appendectomy with ulcerative colitis has been very consistent across many studies; however, the implications of this finding are still obscure.

Copyright © 2003 S. Karger AG, Basel

_____________________________________________________

World J Gastroenterol. 2008 Jan 14;14(2):165-73.
Hygiene hypothesis in inflammatory bowel disease: a critical review of the literature.

Koloski NA, Bret L, Radford-Smith G.
Abstract

The hygiene hypothesis is thought to be a significant contributor to the growing incidence of inflammatory bowel disease (IBD) around the world, although the evidence for specific factors that underlie the hygiene hypothesis in IBD is unclear. We aimed to systematically review the literature to determine which hygiene-related factors are associated with the development of IBD. Publications identified from a broad based MEDLINE and Current Contents search between 1966 and 2007 on key terms relevant to the 'hygiene hypothesis' and IBD including H pylori exposure, helminths, cold chain hypothesis, measles infection and vaccination, antibiotic use, breastfeeding, family size, sibship, urban upbringing, day care attendance and domestic hygiene were reviewed. The literature suggests that the hygiene hypothesis and its association with decreased microbial exposure in childhood probably plays an important role in the development of IBD, although the strength of the supporting data for each of the factors varies considerably. The most promising factors that may potentially be associated with development of IBD include H pylori exposure, helminths, breastfeeding and sibship. However, the vast majority of studies in this area are plagued by serious methodological shortcomings, particularly the reliance on retrospective recall of information making it difficult to truly ascertain the importance of a 'hygiene hypothesis' in IBD. The 'hygiene hypothesis' in IBD is an important area of research that may give clues to the aetiology of this disease. Directions for future research are recommended.

__________________________________________________

Aliment Pharmacol Ther. 2004 Jan 15;19(2):167-77.
Review article: helminths as therapeutic agents for inflammatory bowel disease.

Hunter MM, McKay DM.

Intestinal Disease Research Programme, McMaster University, Hamilton, Ontario, Canada.
Abstract

Over the last decade major advances have been made in our understanding of the mechanisms and mediators of inflammation that hold the promise of the development of new therapies for inflammatory disease. While much is to be gleaned from the application of new technologies, assessment of the age-old host-parasite relationship may also provide insights on how to counter pathological inflammatory events. In the case of inflammatory bowel disease [particularly Crohn's disease, which is associated with T helper 1 (Th1) events] it is proposed that infection with parasitic helminths would be beneficial: the paradigm being that of immune deviation, where Th2 cytokines mobilized in response to the helminth will prevent or antagonize the disease-promoting Th1 events in the gut. The situation is unlikely to be this simple. Here we review and critique the data in support of helminth therapy for inflammatory bowel disease, drawing attention to the gaps in knowledge and presenting a view on how the field may be advanced. While the concept of helminth therapy may be superficially unappealing, this review may convince the reader of the value of more extensive analyses of the impact of helminth infection on enteric inflammation.

_______________________________________________________

Trends Parasitol. 2009 Mar;25(3):109-14. Epub 2009 Jan 23.
The therapeutic helminth?

McKay DM.

Gastrointestinal Research Group, Department of Physiology and Biophysics, The Calvin, Phoebe and Joan Snyder Institute of Infection, Inflammation and Immunology, University of Calgary, Calgary, Alberta, Canada. [email protected]
Abstract

By definition, parasites harm their hosts. Yet substantial evidence from animal models of human disease support the hypothesis that infection with helminths can suppress the development of other maladies. Here, the view is presented that assessment of the immunophysiological response to helminths could identify that infection with specific parasites would be therapeutically useful (although many helminths could not fulfil this role) and lead to precise knowledge of the immune events following infection, to identify ways to intervene in disease processes (in the absence of infection per se) that can be used to treat, and eventually cure, inflammatory and autoimmune disease.

_______________________________________________________


Int J Parasitol. 2007 Apr;37(5):457-64. Epub 2006 Dec 28.
Helminths as governors of immune-mediated inflammation.

Elliott DE, Summers RW, Weinstock JV.

Department of Internal Medicine, University of Iowa, Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242-1009, USA. [email protected]
Abstract

Immune-mediated diseases (e.g. inflammatory bowel disease, asthma, multiple sclerosis and autoimmune diabetes) are increasing in prevalence and emerge as populations adopt meticulously hygienic lifestyles. This change in lifestyles precludes exposure to helminths (parasitic worms). Loss of natural helminth exposure removes a previously universal Th2 and regulatory immune biasing imparted by these organisms. Helminths protect animals from developing immune-mediated diseases (colitis, reactive airway disease, encephalitis and diabetes). Clinical trials show that exposure to helminths can reduce disease activity in patients with ulcerative colitis or Crohn's disease. This paper summarises work by multiple groups demonstrating that colonization with helminths alters immune reactivity and protects against disease from dysregulated inflammation.

___________________________________________________


Inflamm Bowel Dis. 2009 Jan;15(1):128-33.

Helminths and the IBD hygiene hypothesis.
Weinstock JV, Elliott DE.

Tufts New England Medical Center, Boston, Massachusetts 02111, USA. [email protected]

Abstract
Helminths are parasitic animals that have evolved over 100,000,000 years to live in the intestinal track or other locations of their hosts. Colonization of humans with these organisms was nearly universal until the early 20th century. More than 1,000,000,000 people in less developed countries carry helminths even today. Helminths must quell their host's immune system to successfully colonize. It is likely that helminths sense hostile changes in the local host environment and take action to control such responses. Inflammatory bowel disease (IBD) probably results from an inappropriately vigorous immune response to contents of the intestinal lumen. Environmental factors strongly affect the risk for IBD. People living in less developed countries are protected from IBD. The "IBD hygiene hypothesis" states that raising children in extremely hygienic environments negatively affects immune development, which predisposes them to immunological diseases like IBD later in life. Modern day absence of exposure to intestinal helminths appears to be an important environmental factor contributing to development of these illnesses. Helminths interact with both host innate and adoptive immunity to stimulate immune regulatory circuitry and to dampen effector pathways that drive aberrant inflammation. The first prototype worm therapies directed against immunological diseases are now under study in the United States and various countries around the world. Additional studies are in the advanced planning stage.

 

[David in Seattle]

Impoverished nations have a more survival of the fittest type environment. In another words the sick and weak die early and do not reproduce more generations of the same.

They also have lifestyles quite different than ours in other ways that could lead to different results. They do not eat what we eat. Most probably have never had a vaccination of any kind, and many other variables that would be hard to quantify.

I agree, the differences are considerable. it's not likely to be as simple as one variable.

 

[Mayflower537]

The most promising factors that may potentially be associated with development of IBD include H pylori exposure, helminths, breastfeeding and sibship.

Would this mean being breastfed, or breastfeeding your own kids?

I know correlation doesn't necessarily indicate causation but either way, that's interesting!

 

[David in Seattle]

Would this mean being breastfed, or breastfeeding your own kids?

I know correlation doesn't necessarily indicate causation but either way, that's interesting!

I would assume they mean the advantage is for the infant. Breastfeeding passes the mother's immunity on to the infant via various antibodies, as well as lactoferrin, certain enzymes, etc.

 

[Hedgehog]

Kelly - I think the "Blame the victim mentality" is quite prevalent, not only in matters of illness, and makes it easier for those who have been more fortunate (so far) to look the other way.

The stress and disease link is so complex and I find it difficult to know for sure. One thing I do know though is that people who are ill don't need the extra burden of being positive all the time or the worry that if they aren't always able to be cheery or calm that others might see that as a failing.
I find the accepting attitude on this forum really comforting. People can vent, rage, whine and stress and those having better days will support them. Some days I feel positive; other days I'm a cumudgeonly old bag. It's good to know that people will stick around whatever!

 

[kenny]

I'm trying to stay positive and relaxed as much as possible these days. it is not as hard as it sounds once you get that initial couple of months to think about nothing but your health. I had a break from life from July to January with the circumstances I presented under until I was fully recovered from surgery. It was easy to put off anything that didn't fit with talking care of ME.

Now that I learned how to do that I can manage my days and situations with a new set of tools. I don't start running about in frenzy when too much comes flowing down the pipe at me. I just deal with what I can and let the rest slide. I finally realized that my health and happiness is all that is important and that comes first.

 

[dreamintwilight]

That's great, Kenny. I tend to be a worry wart, so I could use a mentality like that. It's just difficult because my husband and I are planning a move in the next 2 months (still aren't 100% sure where we're going to live though we have a very good option), he's up for a possible promotion at work, and I'm in the middle of looking for a job (in a field that's new to me, but I'd be fully capable doing) to keep me busy as well as trying to decide what I want to do about school (took a break from it to figure out what was going on with my health). Lots of transitions going on in my life, so it can be hard sometimes.