What role do emotions play in inflammatory bowel disease (IBD)? How do emotions affect symptoms? And what are the implications for treatment?
Inflammatory bowel disease (IBD) is an umbrella term for a group of conditions that cause swelling and inflammation of the tissues in the digestive tract.
The most common types of IBD include:
Ulcerative colitis: This condition involves inflammation and sores, called ulcers, along the lining of the colon and rectum.
Crohn's disease: In this type of IBD, the lining of the digestive tract becomes inflamed. This condition often affects the deeper layers of the digestive system. Crohn's disease most often affects the small intestine, but it can also affect the large intestine and, rarely, the upper digestive tract.
Symptoms of both ulcerative colitis and Crohn's disease typically include abdominal pain, diarrhea, rectal bleeding, extreme fatigue, and weight loss, according to the Mayo Clinic.
For some people, IBD is only a mild illness. For others, it is a debilitating condition that can lead to life-threatening complications.
Dr. Hanna Ullmann, from the Center for Medical Psychology and Translational Neuroscience at Ruhr University Bochum in Germany, says, "The fact that patients with inflammatory bowel disease often experience symptoms like abdominal pain even during periods of remission suggests that mechanisms other than acute inflammatory processes contribute to the persistence of pain. One possibility is that the emotional processing of pain is altered," as reported by EurekAlert.
Fear is a crucial emotion in the context of pain. Abdominal pain signals the possibility of tissue damage or impending digestive symptoms, so we quickly learn when events or stimuli occur in close proximity to the abdominal pain.
We then begin to fear and avoid these stimuli, a response that usually protects us. However, studies of other chronic pain conditions, such as irritable bowel syndrome (IBS), show that individuals with IBS tend to develop a stronger fear associated with pain than healthy individuals. Ullmann says, "Along with persistent avoidance behavior, this may lead to the perception of abdominal pain as an increasing threat, which can prolong the pain."
Learning to Fear Pain
To investigate whether this also applies to patients with inflammatory bowel disease (IBD), researchers recruited 43 participants for their pilot study. Twenty-one of these participants were diagnosed with ulcerative colitis, a subtype of IBD that primarily affects the colon. The remaining participants served as a control group of healthy individuals.
On the first day of the study, participants were shown different symbols on a screen. One symbol was repeatedly associated with painful heating applied to the lower abdomen, while another symbol was never associated with pain. In this way, participants learned to fear pain. This was followed by an extinction phase, during which all the symbols were shown without any painful stimuli, resulting in a decrease in the fear associated with pain.
On the second day of the study, the extinction phase was repeated. Then, participants were unexpectedly exposed to painful heating again without any visual cues. “We wanted to test whether IBD patients perceive pain differently than healthy individuals, and whether this was related to the strength of fear learning,” explains Ullman.
Patients perceive pain as more bothersome and intense.
The results show that patients with inflammatory bowel disease (IBD) perceived pain as more bothersome and intense upon re-exposure compared to healthy participants. Increased fear associated with learned pain on the first day of the study was associated with a more bothersome and intense pain perception on the second day, but only in the group with IBD. Further analysis revealed that learning the fear was the primary driver of the perceived discomfort of pain, and only indirectly influenced pain intensity. The emotional aspect of pain played a significant role.
Ullman notes, "Interestingly, IBD patients did not acquire a greater fear of pain on the first day of the study compared to healthy participants. So, the difference was not in the learning process itself, but in how fear was associated with pain perception." This suggests that acute and recurrent episodes of inflammation may, over time, alter how pain is processed centrally in relation to fear. Thus, pain may be perceived more intensely even if the fear itself is not very strong. This idea is supported by previous studies showing structural and functional changes in the brains of inflammatory bowel disease (IBD) patients, particularly in brain regions responsible for processing fear and pain.
Implications for Treatment: Treatment for IBD has so far focused primarily on controlling inflammation in the digestive tract. However, psychological factors—such as stress, persistent avoidance, or fear associated with pain—may also play a crucial role.
“For this reason, chronic abdominal pain should be recognized as an important disease marker and treated accordingly,” says Ullman. She adds that patients who continue to experience abdominal pain despite successful inflammation control may particularly benefit from a holistic approach, as data suggest the need to systematically study psychological approaches—such as cognitive behavioral therapy (CBT) specifically addressing fear and avoidance—including in other chronic inflammatory diseases associated with pain, such as rheumatoid arthritis or endometriosis.