Effects of Transpersonal Brief Psychotherapy on general state of health and quality of life in patients with Crohn's disease

Efeitos da Psicoterapia Breve Transpessoal sobre o estado de saúde geral e a qualidade de vida em pacientes com doença de Crohn

ABSTRACT

Introduction:  Crohn's disease (CD) is a chronic illness with continuous and longstanding treatment, which affects general state of health and life quality of patients.

Objectives:  Evaluating the effects of Transpersonal Brief Psychotherapy (TBP) on general state of health and life quality of patients with CD.

Methods:  Eleven people diagnosed with CD of both sexes and aged between 25 and 50 years old have been evaluated. The clinical method was used and the procedure consisted of treatment with TBP and data collection before and after psychotherapy. In data collection, the following instruments were used: Sociodemographic Questionnaire (SDQ), Crohn's Disease Activity Index (CDAI), Inflammatory Bowel Disease Questionnaire (IBDQ) and General Health Questionnaire (GHQ), with descriptive analysis of results and the statistical methodology with Wilcoxon test.

Results:  The procedure turned out to be effective to all instruments (p< 0.05) and the most significant result was in relation to general state of health (-40.4%) and life quality (35.3%). The disease activity has decreased by 38.1% on CDAI.

Conclusion:  TBP has brought meaningful benefits to patients with CD, influencing the clinical picture, with reduction of the severity of the disease and, consequently, it has improved their general state of health and life quality.

Keywords: Inflammatory bowel disease; Quality of life; Brief psychotherapy; Crohn's disease

RESUMO

Introdução:  A doença de Crohn (DC) é uma enfermidade crônica que exige tratamento contínuo e prolongado, afetando a qualidade de vida e a saúde geral dos pacientes. Além do tratamento clínico, recomenda-se o acompanhamento psicológico para o desenvolvimento de estratégias adaptativas.

Objetivo:  Avaliar os efeitos da Psicoterapia Breve Transpessoal (PBT) sobre a qualidade de vida e estado geral de saúde de pacientes com DC, e possível correlação com a atividade da doença.

Métodos:  Foram avaliados 11 pacientes com diagnóstico de DC, de ambos os sexos, com idade entre 25 anos e 55 anos. Utilizou-se o método clínico e o procedimento consistiu no atendimento em PBT, com coleta de dados antes e depois da psicoterapia. Na coleta de dados foi utilizado o Questionário Sociodemográfico (QSD), Índice de Atividade da Doença de Crohn (IADC), Inflammatory Bowel Disease Questionnaire (IBDQ), Questionário de Saúde Geral de Goldberg (QSG), com análise descritiva para os resultados e estatística com o teste de Wilcoxon.

Resultados:  A intervenção mostrou-se significativamente eficaz para todos os instrumentos avaliados (p < 0,05), com melhor resultado para o estado de saúde geral (-40,4%) e qualidade de vida (35,3%). A atividade da doença apresentou uma redução de 38,1% no IADC.

Conclusão:  A PBT trouxe benefícios aos pacientes com DC, influenciando seu quadro clínico, com redução da severidade da doença, e consequentemente, melhorando o estado de saúde geral e a qualidade de vida destes doentes.

Palavras-chave: Doenças inflamatórias intestinais; Qualidade de vida; Psicoterapia breve; Doença de Crohn

Introduction

Crohn's disease (CD) is an Inflammatory Bowel Disease (IBD), which is a chronic illness that affects life quality and life expectation of patients. At the same time, the disease activity is intimately related to impoverishment of life quality of these patients.^{1 3}

Norton et al.,⁴ assessing the impact of CD over patients life, have reported the following repercussions: (a) large physical impact due to abdominal and joint pain, diarrhea and flatulence; (b) impact on the diet due the removal of certain foods or food groups; (c) psychological impact with embarrassing, awkward and silent aspects of CD; (d) minusculo routine in the course of the disease, with difficulty to share fears and insecurities; (e) great concern regarding the bathroom; (f) social impact and social avoidance and withdrawal; change in circle of friends, traveling, leisure activities with children and sports activities; (g) impact on professional life with reduction of worked hours and career change; (h) impact on sexual life.

The psychosocial consequences and life quality of patients must be considered therapeutic.⁵ Besides medical accompaniment, there must be psychological, social and educational support.^{3 4 6 11} Psychotherapy is recommended even for periods of disease remission.^{12 13}

Recently, the brief psychotherapies have presented great expansion as well as alternatives and techniques to attend different diseases, with themes regarding health and life quality. They allow good therapeutic results within few sessions; it focuses on symptoms, crisis, personality characteristics or some kind of comprehension. It provides continence, comprehension of the sickening process and possible psychosomatic interactions involved; this is accompanied by relief of anxiety and symptomatic aspects.^{14 16}

The therapist role is broader, free and responsible; it requires experience as well as combination of procedures to make the therapeutic sessions catalyzing agents that accelerate and make possible the relations and healthier experiences.¹⁵

The Transpersonal Integrative Approach (TIA), in its structural and dynamical aspects, presents theoretical and practical principles that are methodologically structured to orient and sustain psychotherapeutic process in Transpersonal Brief Psychotherapy (TBP).^{16 17}

The main objective of this study was to evaluate the effects of TBP over the general state of health and life quality of CD patients. The secondary objective was to observe possible correlations between general state of health and life quality of patients along with disease activity. In this study, there was the participation of 11 patients with CD, who were followed in the process of TBP for 14 weeks, in individual sessions of 50 min.

Methods

Eleven patients, of both sexes, diagnosed with CD and aged between 25 and 55 years old, followed up at the Inflammatory Bowel Diseases Unit "Prof. Dr. Juvenal Ricardo Navarro Góes", at the University of Campinas (UNICAMP), were studied. Patients bearing intestinal stomas, women who were pregnant or lactating, patients with surgical treatment indication, previous or evident diagnosis of psychosis, those who were under an individual or group psychotherapy process or alternative treatments such as acupuncture and those who had lost the segment were excluded. The project was approved by Research Ethical Committee of the University of Campinas, under protocol number 953/2010, and with volunteer adhesion of the participants. All of them were clarified about the research procedures and its phases and they have signed the Informed Consent.

The clinical method was used, with evaluation of the results before and after psychotherapy. For evaluating, the following instruments were used:

1. (a) Sociodemographic Questionnaire (SDQ): elaborated in order to get sociodemographic information from patients regarding their identifying data, school level, professional situation and clinical data.

2. (b) General Health Questionnaire (GHQ): questionnaire developed and validated by Goldberg in 1972; it is composed of 60 items, distributed randomly, that measure the state of general health (general factor) and five specific factors: psychic stress, death wish, distrusting in own performance, sleep disorders and psychosomatic disorders.¹⁸

3. (c) Inflammatory Bowel Disease Questionnaire (IBDQ): developed and validated in the United States in 1988, by Mitchell e cols. from McMaster University; it has been translated and adapted to Brazilian culture as a specific instrument to evaluate life quality of Brazilian patients with IBD. It has 32 items that evaluate four dimensions: intestinal symptoms, systemic symptoms, social aspects and emotional aspects. On the questionnaire these items are distributed randomly in order to avoid bias in answers.¹⁹

4. (d) Crohn's Disease Activity Index (CDAI): instrument developed and validated for characterizing the severity of CD, allowing classifying patients according to intensity of the inflammatory activity: disease in remission, with mild, moderate, and severe fulminant disease.²⁰

The TBP process took place for 14 weekly meetings, in individual sessions of 50 min. The process included: (a) Sign of Informed Consent; (b) screening interview along with filling out of SDQ, exploration on the history of the disorder and mean complaint; (c) initial evaluation, in which the patient filled out the following questionnaires: GHQ and IBDQ; therefore, the patient was forwarded to see a doctor from the clinic in order to fill out the CDAI; (d) evolution of life history and self-evaluation, contextualizing the present moment; (e) session in TBP with weekly accompaniment; (f) final evaluation, in which the patient answered GHQ and IBDQ, once again, and the CDAI was filled out by a doctor from the group; (g) feedback interview.

The data were collected by the some investigator (A.S.A.) and data registration was performed by the patient or the researcher, which was a transcription of the spontaneous speech of the patient. The study was done with previous planning and the established methodology to TBP was based on TIA principles.¹⁷ In order to articulate the interactive dynamics with the seven steps of TIA in the TBP process, in planning, an instrument to each step was elected (Table 1).

Table 1
Planning of the sessions with seven stages of TIA.

Stage	Instrument	Technical procedure
Recognition	Exercise of excellence	Symbolic reorganization
Identification	Heuristics of emotion and graphics	Interactive dynamics
Disidentification	Exercise of source	Active imagination
Transmutation	Internal dialogs	Symbolic reorganization
Transformation	The seven selves	Interactive dynamics
Elaboration	The four doors	Interactive dynamics
Integration	Exercise of loving own body	Active imagination

To ensure scientific character to therapeutic process, some criteria have been established: (a) use of treatment protocol in all interviews; (b) the duration of individual psychotherapeutic process in 14 sessions of 50 min once a week; (c) more active position by the therapist than in traditional psychotherapies, sustaining the focus on current questions, stimulating active position for patients in relation to their difficulties, conflicts and needs, encouraging pro-activeness; (d) no interpretation and employ of interventions to promote consciousness, comprehension, clarification and perception of unconscious components by the patient himself; (e) use of patterned verbal interventions, which intended to identify, qualify, quantify and localize the purpose of situations; for what and to whom it was addressed, with goal and objective to be achieved.

Statistical analysis

Descriptive analysis with presentation of frequency tables for categorical variables was applied and also measures of position and dispersion for numeric variables. Wilcoxon test for related samples was used for comparison of numeric measures that resulted in initial and final evaluations. The level of significance is p < 0.05.

Results

The female gender (72.7%), married individuals (63.6%), with children (72.7%) and those who completed High School (45.4%) predominated among the patients. Majority (72.3%) had exercised any of the activities, paid or unpaid.

Mean age was 40 (maximum of 50 and minimum of 29) years old. The first symptoms had appeared at the mean age of 27 (maximum of 41 and minimum of 7) years old and the average time for CD diagnosis was 9.7 (maximum of 20 and minimum of 0.5) years.

The best results obtained were from GHQ, with improvement of -40.4% in patients' general state of health (Table 2).

Table 2
GHQ.

GHQ		Average	Standard deviation	Minimum	Median	Maximum	Variation %	p-value
Psychosocial disorders	Initial Final Difference	2.9 1.8 -1.1	0.7 0.4 0.7	1.5 1.2 -2.1	3.1 1.8 -1.3	3.7 2.2 -0.2
							-39.0	0.001a
Distrust of own performance	Initial Final Difference	2.9 1.7 -1.2	0.5 0.4 0.6	1.8 1.1 -2.4	2.8 1.8 -1.1	3.7 2.2 -0.2	-40.1	0.001a
Sleep disorders	Initial Final Difference	3.2 1.7 -1.5	0.6 0.5 0.7	1.7 1.0 -2.5	3.2 1.7 -1.7	3.8 2.7 -0.3	-46.5	0.001a
Psychic stress	Initial Final Difference	3.2 1.8 -1.4	0.6 0.4 0.7	1.9 1.1 -2.3	3.4 1.8 -1.6	3.9 2.6 -0.1	-44.8	0.001a
Death wish	Initial Final Difference	2.0 1.2 -0.9	0.7 0.3 0.6	1.0 1.0 -1.6	2.0 1.1 -1.0	2.9 1.9 0.0	-42.9	0.004b
Total	Initial Final Difference	2.8 1.7 -1.2	0.5 0.3 0.6	1.6 1.2 -2.2	3.0 1.6 -1.1	3.5 2.2 -0.2	-40.4	0.001a

• ^a Significant at 0.1%. ^b Significant at 1% for Wilcoxon test.

The sleep disorder factor presented the most significant improvement, with decrease of 46.5% in difficulties related to sleep, followed by psychic stress (-44.8%), death wish (-42.9%), distrusting in own performance (-40.1%) and psychosocial disorders (-39.0%).

The IBDQ presented an improvement of 35.3% in quality of life, whereas the systematic symptoms had the higher improvement (50.3%), followed by emotional aspects (42.6%), social aspects (33.9%) and intestinal aspects (28.4%), as we can observe in Table 3.

Table 3
IBDQ.

IBDQ		Average	Standard deviation	Minimum	Median	Maximum	Variation %	p-value
Intestinal aspects	Initial Final Difference	44.5 57.1 12.6	7.1 7.8 6.7	32.0 41.0 5.0	45.0 59.0 11.0	53.0 67.0 23.0
							28.4	0.001a
Systemic symptoms	Initial Final Difference	17.0 25.6 8.6	4.7 6.0 5.5	10.0 17.0 2.0	16.0 26.0 8.0	27.0 35 18.0
							50.3	0.001a
Social aspects	Initial Final Difference	21.7 29.1 7.4	5.9 5.5 4.6	15.0 19.0 2.0	23.0 32.0 6.0	33.0 35.0 18.0
							33.9	0.001a
Emotional aspects	Initial Final Difference	11.7 16.7 5.0	3.8 4.2 2.8	5.0 9.0 1.0	13.0 19.0 5.0	16.0 21.0 11.0
							42.6	0.001a
Total	Initial Final Difference	94.9 128.5 33.6	17.8 21.8 13.4	71.0 89.0 18.0	94.0 134.0 33.0	129.0 155.0 63.0
							35.3	0.001a

• ^a Significant at 0.1% for Wilcoxon test.

The results of CDAI evidenciate a decrease of -38.1% in disease activity (Table 4).

Table 4
CDAI.

CDAI	Average	Standard deviation	Minimum	Median	Maximum	Variation %	p-value
Initial	187.4	92.9	84.0	161.0	356.0
Final	116.0	93.7	25.0	80.0	315.0
Difference	-71.4	46.5	-181.0	-65.0	-20.0	-38.1	0.001a

• ^a Significant at 0.1% for Wilcoxon test.

Discussion

CD represents a global public health matter at the present moment^{3 11 21}; it is a chronic infirmity, with prolonged and continuous treatment seeking adequate life quality.^{6 9 20 22}

It is possible that, due to multiplicity of clinical presentations and similitude to other disorders, the diagnosis of CD might be difficult, making the adequate control of the disease, especially at early stages, impossible, and implying in long periods of suffering, with physical and psychic discomfort.^{7 9 22 23} Just as it has been demonstrated by several epidemiological studies, the majority of patients in this casuistry had the first symptoms of the disease in their second decade of life, and it took an average time of 10 years for definitive diagnostic counting from the appearance of clinical picture.^{6 9 20 22}

Many studies have assessed the psychological issue and recommend psychotherapy as part of the treatment for better control of the disease and to improve patients' life quality.^{10 13 24 25} However, few studies have been conducted to evaluate the results of psychotherapy in these patients.^{25 26}

In the present study, the patients went through TBP process, under the referential from TIA. It has been considered that the systemic and transdisciplinary approach, viewing humans as bio-psycho-socio-spiritual beings, favors the comprehension of psychosomatic manifestations.^{16 17}

Through the methodology used in this research, an improvement of -40.4% in general state of heath of patients and 35% in quality of life was observed, and a lower difference for intestinal aspects, with reduction of 28.4%. This factor might be a reflection of the chronic aspects of CD, as described by other authors.^{6 9 20 22}

Deter et al.²⁶ have also demonstrated that CD course is influenced by psychotherapy; this study has observed a reduction of -38.1% in illness activity, what could be associated to improvement in general state of health and quality of life of the patients.

Although this paper may differ in means of methods, criteria of inclusion, and evaluation of results, its findings are in consonance to other studies that evaluate the results of psychotherapy in patients with IBD, among them CD, as well as other studies that have recognized the benefits of psychotherapy, regardless of the approach used.^{15 25 26} These results are also similar to other studies that have evaluated IBD.^{5 10 12 13 24 30} However, it is necessary to bring out the limitations of the study as the casuistry is small and the subjectivity of evaluation, once each individual interpret his own internal perceptions, makes an evaluation of themselves also and chooses the alternatives that best fit the state observed in self-evaluation.

Conclusion

TBP has brought meaningful benefits to patients with CD, influencing the clinical picture with reduction of the severity of the disease, and, consequently, it has improved their general state of health and life quality.

Acknowledgments

To the Statistical Office of the Medical Sciences Faculty from UNICAMP for designing the statistical analysis and Vera Saldanha, offered volunteer supervision in preparing the project.

REFERENCES

• ¹ Kleinubing-Junior H, Pinho MSL, Ferreira LC, Bachtold GA, Merki A. Pro?le of patients from bowel diseases ambulatory. Arq Bras Cir Dig. 2011;24:200-3.
• ² Guthrie E, Jackson J, Shaffer JMRCP, Thompson D, Tomenson B, Creed F. Psychological disorder and severity of in?ammatory bowel disease predict health-related quality of life in ulcerative colitis and Crohn&apos;s disease. Am J Gastroenterol. 2002;97:1994-9.
• ³ Souza MM, Barbosa DA, Espinosa MM, Belasco AGS. Life quality of patients with bowel in?ammatory diseases. Acta Paul Enferm. 2011;24:479-84.
• ⁴ Norton BA, Thomas R, Lomax KG, Dudley-Brown S. Patient perspectives on the impact of Crohn&apos;s disease: results from group interviews. Patient Prefer Adher. 2012;2:509-20.
• ⁵ Caprilli R, Gassull MA, Escher JC, Moser G, Munkholm P, Forbes A, et al. European evidence based consensus on the diagnosis and management of Crohn&apos;s disease: special situations. Gut. 2006;55:36-58.
• ⁶ Jones FA, Gummer JW, Jones JEL. Clinical gastroenterology. 2nd ed. México: Interamericana; 1971. p. 685.
• ⁷ Laudanna AA. Clinical gastroenterology. São Paulo: Santos; 1990. p. 550.
• ⁸ Moraes Filho JPP. Gastroenterology manual. São Paulo: Rocca; 1993. p. 617.
• ⁹ Steinwurz F. Crohn&apos;s disease in medical practice. Rio de Janeiro: Elsevier; 2009. p. 112.
• ¹⁰ Bennebroek Evertsz&apos; F, Thijssens NA, Stokkers PC, Grootenhuis MA, Bockting CL, Nieuwkerk PT, et al. Do in?ammatory bowel disease patients with anxiety and depressive symptoms receive the care they need? J Crohn&apos;s Colitis. 2012;6:68-76.
• ¹¹ Sajadinejad MS, Asgari K, Molavi H, Kalantari M, Adibi P. Psychological issues in in?ammatory bowel disease: an overview. Gastroenterol Res Pract. 2012:1-11. ID 106502.
• ¹² Iglesias M, Barreiro De Acosta M, Vázquez I, Figueiras A, Nieto L, Lorenzo A, et al. Psychological impact of Crohn&apos;s disease in remission: anxiety and depression risk. Rev Esp Enferm Dig. 2009;101:249-57.
• ¹³ Vidal A, Gómez-Gil E, Sans M, Portellad MJ, Salamero M, Piqué JM, et al. The impact of anxiety and depression on relapse in patients with in?ammatory bowel disease. Med Clin. 2009;132:298-3012.
• ¹⁴ Yoshida EMP, Santeiro TV, Santeiro FRM, Rocha GMA. Brief psychodynamic psychotherapies: characteristics of national and foreign scienti?c production (1980/2003). Psico-USF. 2005;10:51-9.
• ¹⁵ Ferreira-Santos E. Brief psychotherapy: systematic approach to crisis situation. 2nd ed. São Paulo: Editora Ágora; 1997. p. 122.
• ¹⁶ Saldanha V. Transpersonal psychology: an emerging knowledge in psychology of consciousness. Ijuí: Ed. Unijuí; 2008. p. 344.
• ¹⁷ Simão MJP, Saldanha V. Resilience and transpersonal psychotherapy: straightening of values, actions and spirituality. Mundo Saúde. 2012;36:291-302.
• ¹⁸ Goldberg DP. General Health Questionnaire: technical manual GHQ: Brazilian adaptation. São Paulo: Casa do Psicólogo; 1996. p. 45.
• ¹⁹ Pontes RMA, Miszputen SJ, Ferreira Filho OF, Miranda CF, Marcos B. Quality of live with in?ammatory bowel diseases: translation to Portuguese language and validation of the In?ammatory Bowel Disease Questionnaire (IBDQ). Arq Gastroenterol. 2004;41:137-43.
• ²⁰ Brasil. Portaria SAS/MS n? 858, 4 de novembro, 2002. Clinical protocols and therapeutic guidelines: exceptional medicaments - Crohn's disease. Ministério da Saúde, Secretaria de Assistência à Saúde.
• ²¹ Gordon PH. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New York; London: Informa Healthcare; 2006. p. 1370.
• ²² Gonçalves CCM, Hernandes L, Oliveira NLB, Natali MRM. Therapeutic alternatives in experimental models of bowel in?ammatory disease. Cienc Cuid Saúde. 2008;7:107-11.
• ²³ Mikocka-Walus AA. Treatment of psychological co-morbidities in common gastrointestinal and hepatological disorders. World J Gastrointest Pharmacol Ther. 2010;1:64-71.
• ²⁴ Knowles SR, Wilson JL, Connell WR, Kamm MA. Preliminary examination of the relations between disease activity, illness perceptions, coping strategies, and psychological morbidity in Crohn&apos;s disease guided by the common sense model of illness. In?amm Bowel Dis. 2011;17:2551-7.
• ²⁵ Keller W, Pritsch M, von Wietersheim J, Scheib P, Osborne W, et al., The German Study Group on Psychosocial Intervention in Crohn&apos;s Disease. Effect of psychotherapy and relaxation on the psychosocial and somatic course of Crohn&apos;s disease: Main results of the German Prospective Multicenter Psychotherapy Treatment Study on Crohn&apos;s Disease. J Psychosom Res. 2004;56:687-96.
• ²⁶ Deter H-C, von Wietersheim J, Jantschek G, Burgdorf F, Blum B, Keller W, et al. High-utilizing Crohn&apos;s disease patients under psychosomatic therapy. Biopsychosocial Med. 2008;2:18.
• ²⁷ Häuser W, Janke KH, Klump B, Hinz A. Anxiety and depression in patients with in?ammatory bowel disease: comparisons with chronic liver disease patients and the general population. In?amm Bowel Dis. 2011;17:621-32.
• ²⁸ Wietersheim JV, Kessler HP. Psychotherapy with chronic in?ammatory bowel disease patients: a review. In?amm Bowel Dis. 2006;12:1175-84.
• ²⁹ Brandi MT, Ribeiro MS, Chebli LA, Franco MB, Pinto AL, Gaburri PD, et al. Psychological distress in Brazilian Crohn&apos;s disease patients: screening, prevalence, and risk factors. Med Sci Monit. 2009;15:101-8.
• ³⁰ Thabet JB, Char? N, Mnif L, Yaïch S, Zouari L, Zouari N, et al. Emotional disorders and in?ammatory bowel disease. Tunis Med. 2012;90:557-63.

Publication Dates

• Publication in this collection
  July-Sep 2015

History

• Received
  24 May 2015
• Reviewed
  08 June 2015
• Accepted
  02 July 2015