Keywords: Inflammatory Bowel Diseases, Crohn’s Disease, Ulcerative Colitis, Trauma, Dissociation, Integrated Psychotherapy.
Abstract: This paper proposes an assessment and intervention model aimed at providing adequate psychological support to patients diagnosed with inflammatory gastrointestinal diseases. Through an integrated psychotherapeutic approach, a clinical intervention is proposed that aims to reduce psychological symptoms, increase well-being, and enhance coping and problem-solving strategies in these patients. Quality of life and relapse risk related to psychiatric symptoms were monitored using scales such as SCL-90-R and CORE-OM.
Results: One year after the start of treatment, evaluation showed a reduction in psychiatric symptoms, improved quality of life, and greater acceptance of the disease.

Introduction
This work describes the clinical experience of psychological support provided over one year within a university psychotherapy service offering consultations and interventions in various hospital wards, both outpatient and inpatient. Specifically, through the report and study of the psychological-clinical assessment and intervention of a single case, a psychological support model for patients with inflammatory bowel diseases (IBD) is proposed. This is based on recent international literature highlighting the significant impact of stress on IBD and how psychological well-being, reduction of psychiatric symptoms, and the ability to develop adequate coping and problem-solving strategies can promote symptom remission and positive disease evolution despite its chronicity.

What Are IBD
Inflammatory Bowel Diseases (IBD) are a group of chronic conditions characterized by persistent inflammation of the gastrointestinal tract. The main forms are Crohn’s disease (CD) and ulcerative colitis (UC). Crohn’s disease can affect any part of the GI tract, from mouth to anus, involving deep layers of the intestinal wall, making it particularly complex to treat. In contrast, ulcerative colitis affects only the mucosa of the colon and extends continuously from the rectum. IBD symptoms vary and include persistent diarrhea, abdominal pain, weight loss, anemia, and fatigue. Both diseases have a relapsing-remitting course influenced by genetic, environmental, and immunological factors. Alterations in the gut microbiota combined with abnormal inflammatory responses are key in their pathogenesis.
The incidence of IBD is increasing, especially in Western countries, with a prevalence exceeding 0.5% of the population. These conditions significantly impact patients’ quality of life, not only due to physical symptoms but also psychological and social implications. Diagnosis and treatment require a multidisciplinary approach including immunosuppressants, biologics, and sometimes surgery for complications such as fistulas and strictures.

Psychopathological Disorders
IBD are not only organic diseases but also conditions profoundly affecting psychological health. Numerous studies show a strong correlation between IBD and psychopathological disorders, particularly anxiety and depression. This relationship can be explained through the “gut-brain axis,” a bidirectional communication system linking the central nervous system to the gastrointestinal tract. It involves complex mechanisms such as inflammatory immune responses, the autonomic nervous system, the gut microbiota, and its metabolites.
The prevalence of psychological disorders in IBD patients is significantly higher than in the general population. Recent studies report anxiety affects about 32% of patients, while depression is present in 25%. These disorders are more common during active disease phases but persist in many patients even during remission. Contributing factors include the psychological burden of chronic illness, chronic pain, social and occupational limitations, and fear of future complications. Socioeconomically disadvantaged patients or those with childhood trauma have an even higher risk. Women appear more vulnerable than men. Untreated anxiety and depression worsen disease management, increase relapse frequency, reduce treatment efficacy, and lower therapy adherence, leading to more hospitalizations and surgeries. Anxiety and depression also negatively affect the immune system, exacerbating the disease.
Managing anxiety and depression in IBD requires a multidisciplinary approach including pharmacotherapy (antidepressants, anxiolytics) and psychological support (psychotherapy). Early diagnosis and timely intervention are essential. Educating patients about the gut-brain axis can reduce stigma and improve long-term clinical outcomes.

Trauma and Dissociation
Recent research focuses on more complex disorders such as post-traumatic stress disorder (PTSD) and dissociative symptoms, which appear particularly relevant in this population. While some studies link IBD and PTSD, data on IBD and dissociation are scarce despite both significantly impacting disease course and quality of life. A recent study (Ferrarese, 2022) assessed PTSD and dissociative symptoms in 112 IBD patients (55 CD, 57 UC) versus 114 healthy controls. Patients were grouped by disease activity (remission, mild, moderate). Standardized tools like the Impact of Event Scale-Revised (IES-R) and Dissociative Experience Scale (DES) were used.
Results showed IBD patients had significantly higher PTSD and dissociative symptoms than controls, confirming that managing a chronic disease like IBD can be traumatic and negatively affect mental health. In CD patients, PTSD and dissociative symptoms were more pronounced during mild to moderate/severe activity phases compared to remission; UC patients showed no significant symptom variation with disease activity. This suggests disease type and severity influence psychological impact, with Crohn’s more closely linked to trauma and dissociation than ulcerative colitis.
Dissociation, a psychological defense involving detachment from reality or emotional awareness, is frequent in patients experiencing stress and trauma related to their illness. Frequent hospitalizations, invasive surgeries, and disease impact on daily life can intensify these symptoms. PTSD and dissociation worsen quality of life and may exacerbate disease activity, creating a vicious cycle where psychological trauma aggravates physical condition and vice versa.
These findings highlight the importance of a multidisciplinary approach integrating medical treatment with psychological support. Psychodynamic psychotherapy, relaxation techniques, and psychoeducation programs can reduce trauma symptoms and improve emotional well-being. Monitoring psychological symptoms during follow-up provides valuable data to tailor therapy.
Further research is needed to fully understand trauma and dissociation roles in IBD progression. Future studies might explore early traumatic events or adverse childhood experiences influencing psychological symptoms and IBD onset. Longitudinal research could clarify whether treating PTSD and dissociation improves quality of life and clinical outcomes.
In conclusion, IBD affects both body and mind. The prevalence of trauma and dissociative disorders in IBD patients underscores the need for integrated treatment addressing physical and psychological aspects. A more comprehensive, personalized management could significantly improve quality of life and disease control.

Attachment in IBD Patients
Among psychological aspects related to IBD, recent attention has focused on attachment—the way people form significant emotional bonds and handle interpersonal stress.
Attachment styles, as defined by Bowlby’s theory, develop in childhood based on caregiver relationships and influence how individuals manage affective relationships and stress. Styles include:

• Secure: positive self and others perception, good emotional stress management, seeks support when needed;
• Anxious-Insecure: strong need for closeness and reassurance, fear of abandonment, high sensitivity to rejection;
• Avoidant-Insecure: tendency to avoid intimacy and emotional confrontation, negative view of relationships, strong emotional independence;
• Disorganized-Insecure: chaotic and ambivalent strategies to express needs for closeness and reassurance, inability to manage stress with stable strategies;

In IBD patients, the emotional burden from disease (symptom uncertainty, chronic pain, daily life limitations) can amplify relational dynamics typical of their attachment style.
Anxiously attached patients tend to be hypervigilant about symptoms and worry intensely about relationships, increasing perceived stress, which worsens inflammation and symptoms. Their constant need for reassurance can strain family relationships, increasing isolation and dissatisfaction.
Avoidantly attached patients may minimize symptoms or avoid emotional aspects, risking neglect of well-being and poor therapy adherence. Their self-sufficiency limits social and healthcare support, leading to less effective disease management.
Disorganized patients oscillate between these extremes, alternating hyperactivation and symptom minimization based on personal impressions and emotional states rather than medical reality.

Psychological and Relational Effects
IBD is often associated with higher anxiety, depression, and mood disorders, exacerbated by insecure attachment styles. Anxious attachment correlates with depressive symptoms due to amplified perception of difficulties and fear of rejection. Avoidant patients mask emotional distress, appearing detached but still suffering negative mental health impacts. Disorganized attachment leads to fluctuating behaviors, complicating disease management.
Family and social relationships also suffer. Caregivers, often overwhelmed, struggle to meet the emotional needs of patients with anxious, avoidant, or disorganized attachment, increasing relational tensions.

Targeted Therapeutic Approaches
Understanding attachment roles in IBD management is key to developing effective, personalized therapies. Psychotherapeutic approaches such as mentalization-based therapy (MBT) and attachment-focused therapy help patients recognize and modify dysfunctional stress regulation and coping patterns.
Raising awareness of mental-physical health links in IBD patients is important. Stress reduction via relaxation or psychological support improves emotional well-being and clinical outcomes. Involving caregivers in education and support programs enhances relationships and mutual support.

Perspectives
Attachment in IBD patients is crucial to understanding interactions between psychological health and chronic disease. Attachment styles affect emotional well-being, ability to face disease challenges, and build supportive relationships. Integrating psychological and relational strategies in IBD management can significantly improve quality of life and treatment effectiveness.

Clinical Case
A 42-year-old man with Crohn’s disease was referred to the Hospital Clinical Psychology Service from the Gastroenterology Unit for complex psychiatric symptoms including:

• Recurrent depressed mood and pervasive emptiness;
• Diffuse anxiety often with somatic activation;
• Outbursts of anger and impulsive behavior;
• Feelings of despair and existential worthlessness;
• Significant communication difficulties within the family, especially with wife and teenage daughter;

A multilayered psychodynamic intervention was implemented focusing on unconscious dynamics underlying symptoms, affect regulation, and trauma processing, with particular attention to relational and family context. Psychotherapy was conducted on three levels: individual (affect elaboration and internal relational patterns), dyadic (marital focus), and family (triadic dynamics and children involvement).

Anamnestic Notes and Context
Crohn’s diagnosis was made two years before psychotherapy. The disease had a traumatic impact on the patient’s bodily self and identity continuity, with repeated acute pain episodes, frequent diarrhea, weight loss, and surgeries deeply affecting body image.
Psychodynamically, the patient showed strong abandonment and depressive anxieties, disintegration feelings, and impaired mentalization of affective states. The unresolved loss of his mother in adolescence is a core trauma reactivating loss feelings and a fragile self. Dissociative experiences appeared in adolescence (post-bereavement amnesia) and recently (hospitalization identity confusion), indicating defenses like splitting and borderline personality organization.
Disorganized attachment dynamics stem from early maternal loss and lack of reliable emotional containment in adolescence. The patient developed relational patterns alternating emotional closeness seeking and abrupt withdrawal, with distrust and abandonment fears manifesting in therapy. Married 20 years with two children, his marital relationship is marked by emotional detachment, passive aggression, and poor mentalization, projecting anxiety and helplessness onto wife and children.

Assessment
Psychodiagnostic evaluation used projective and structured tests:

• Shedler Westen Assessment Procedure-200 (SWAP-200)
• Symptom Checklist 90-Revised (SCL-90-R)
• Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
• Rorschach Comprehensive System
• Adult Attachment Interview (AAI)
• Toronto Alexithymia Scale (TAS-20)
• Dissociative Experience Scale II (DES-II)

Profile indicated a neurotic-level personality organization with borderline-like dysfunctions during Crohn’s exacerbations (defensive integration, splitting, idealization, devaluation), identity regulation, and object relations quality.
Attachment interview revealed an “unresolved mourning” style with distancing aspects: difficulty processing losses, narrative inconsistencies, and dissociative content recalling mother.

Psychotherapy
Psychodynamic intervention focused on individual work accessing and processing affective states, interpreting defense mechanisms, strengthening reflective function, and building a more coherent, tolerant internal mental space. Key elements:

• Exploration of unresolved maternal grief via emotionally charged narrative recall;
• Interpretation of unconscious fantasies linking illness to punishment, atonement, or self-failure;
• Transference analysis, initially idealizing therapist, later devaluing during affective frustration;
• Work on primitive defenses (splitting, projection, projective identification);
• Exploration of attachment expectations toward therapist, oscillating between idealization and deep disappointment;

The setting was a potentially corrective space offering a secure base to observe, tolerate, and mentalize disorganized relational patterns. Developing secure attachment to therapist was transformative, allowing recognition of dependency needs without shame or impulsivity. Strengthening reflective function (Fonagy) was central. Couple work explored distorted relational patterns, unconscious collusions, and dependency-counterattack dynamics. Family sessions promoted mutual recognition and shifted defensive modes (accusations, silence, projections) toward empathetic listening.

Psychotherapy Effects on Gastrointestinal Symptoms
Affect regulation visibly impacted somatic symptoms. Reduced anger and depressive crises coincided with improved intestinal function, confirming affect-body interconnection (psychosomatic-dynamic approach). The patient better tolerated anxiety without immediate visceral pain or dissociation. Affectively meaningful interpretations of flare-ups (often linked to unmentalized conflicts) increased awareness of internal-external symptom links. Greater relational stability and therapeutic security correlated with significant intestinal symptom reduction, suggesting attachment system rebalancing positively influenced somatic functioning.

Stress Management and Psychosomatic Functioning
Intestinal inflammation reduction was supported not only by medical therapy but also by gradual symbolization work. The body, initially perceived as hostile and persecutory, was progressively reintegrated into self-representation. Specifically:

• Imaginative techniques and focus on interoceptive states fostered body reappropriation;
• Processing anger and guilt decreased somatic self-punitive attacks;
• Verbalized loss and pain reduced symbolic bodily distress expression.

Work on Disease Acceptance
Initially, the disease was experienced as injustice or punishment; therapy weakened these fantasies rooted in rigid or devaluing internalized parental representations. The disease progressively gained new meaning as part of the patient’s biography, no longer persecutory or narcissistically intolerable. The patient integrated his chronic condition without compromising self-worth, achieving greater existential acceptance.

Emotional Regulation and Reflective Function
Affect regulation, especially anger and shame, was central. Verbalizing emotions and interpreting unconscious determinants enhanced mentalization of internal states. Transference was a container to observe and modify impulsive reactive patterns. “Holding” techniques and preconscious conflict interpretation reduced affective disorganization. Over time, the patient better recognized and mentalized original affective needs previously dissociated or somatically acted out. This promoted progressive reorganization of internal attachment models, increasing trust in others and internal containment of intense emotions without somatic evacuation.

Family Support and Relational Dynamics
Family work uncovered rigid roles, dysfunctional triangulations, and unspoken mutual expectations. Joint sessions were transformative: the wife expressed frustration and loneliness; children found space to share emotional experiences. Psychotherapy’s systemic effect increased affective cohesion, reduced hostility, and improved family containment function.

Technique Theory
– Personality Structure and Primitive Defenses.

Kernberg’s model guided understanding of patient’s oscillation between neurotic and borderline functioning. Recurrent primitive defenses (splitting, projective identification, idealization) and unstable self/object representations indicated difficulty maintaining cohesive identity under stress. Transference work and internal object relation clarification were central.
– Adaptive Function of Symptoms and Intrapsychic Conflicts.

According to Gabbard, illness can have deeply defensive and symbolic meanings. In this patient, Crohn’s initially somatized depressive and aggressive anxiety, using the body as unconscious conflict expression. Treatment made preconscious conscious and symbolized enacted conflicts.
– Mentalization and Attachment.

Fonagy’s mentalization-based approach restored compromised reflective function, enabling understanding of self and others’ mental states. Unresolved attachment found a secure base in therapy to develop new emotional regulation and psychic integration capacities. “Epistemic trust” was key: the patient learned to trust the relationship and consider the other a reliable source of emotional knowledge and validation. This process facilitated profound transformation of reflective function and psychosomatic balance, visibly improving disease course.

Table 1 – SCL-90-R

Tabele 2 – CORE-OM

Conclusions
The patient’s psychotherapeutic journey demonstrated that an integrated approach based on psychodynamic and attachment theory can significantly impact Crohn’s disease management. Combining mentalization-based interventions, containment of bodily experiences, traumatic grief processing, and family therapy reduced stress, enhanced disease acceptance, improved emotional regulation, and supported family dynamics. This therapeutic path substantially improved quality of life and reduced gastrointestinal symptoms.
This clinical case shows psychotherapy is not merely psychological support for a medical condition but a complementary therapeutic tool in chronic intestinal disease treatment. Equipping gastroenterology departments with professionals dedicated to psychological support for these patients could be a challenge worth considering by the National Health System, given the disease prevalence, chronicity, and associated costs.

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