w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Effects
of
Transpersonal
Brief
Psychotherapy
on
general
state
of
health
and
quality
of
life
in
patients
with
Crohn’s
disease
Arlete
Silva
Acciari
a,∗,
Frederico
Camelo
Leão
b,
Cláudio
Saddy
Rodrigues
Coy
c,
Raquel
Franco
Leal
c,
Cristiana
Corrrêa
Dias
a,
Vera
Saldanha
d,
Maria
de
Lourdes
Setsuko
Ayrizono
caSurgeryDepartment,UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,Brazil
bInstituteofPsychiatry,UniversityofSãoPaulo(USP),SãoPaulo,SP,Brazil
cColoproctologyUnit,SurgeryDepartment,UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,Brazil
dBrazilianPortugueseTranspersonalAssociation,Campinas,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received24May2015 Accepted8June2015 Availableonline2July2015
Keywords:
Inflammatoryboweldisease Qualityoflife
Briefpsychotherapy Crohn’sdisease
a
b
s
t
r
a
c
t
Introduction:Crohn’sdisease(CD)isa chronicillness withcontinuousandlongstanding treatment,whichaffectsgeneralstateofhealthandlifequalityofpatients.
Objectives:EvaluatingtheeffectsofTranspersonalBriefPsychotherapy(TBP)ongeneralstate ofhealthandlifequalityofpatientswithCD.
Methods:ElevenpeoplediagnosedwithCDofbothsexesandagedbetween25and50years oldhavebeenevaluated.Theclinicalmethodwasusedandtheprocedureconsistedof treat-mentwithTBPanddatacollectionbeforeandafterpsychotherapy.Indatacollection,the followinginstrumentswereused:SociodemographicQuestionnaire(SDQ),Crohn’sDisease ActivityIndex(CDAI),InflammatoryBowelDiseaseQuestionnaire(IBDQ)andGeneralHealth Questionnaire(GHQ),withdescriptiveanalysisofresultsandthestatisticalmethodology withWilcoxontest.
Results:Theprocedureturnedouttobeeffectivetoallinstruments(p<0.05)andthemost significantresultwasinrelationtogeneralstateofhealth(−40.4%)andlifequality(35.3%). Thediseaseactivityhasdecreasedby38.1%onCDAI.
Conclusion:TBPhasbroughtmeaningfulbenefitstopatientswithCD,influencingtheclinical picture,withreductionoftheseverityofthediseaseand,consequently,ithasimprovedtheir generalstateofhealthandlifequality.
©2015SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.
∗ Correspondingauthor.
E-mail:arletesilvapsi@gmail.com(A.S.Acciari). http://dx.doi.org/10.1016/j.jcol.2015.06.001
Efeitos
da
Psicoterapia
Breve
Transpessoal
sobre
o
estado
de
saúde
geral
e
a
qualidade
de
vida
em
pacientes
com
doenc¸a
de
Crohn
Palavras-chave: Doenc¸asinflamatórias intestinais
Qualidadedevida Psicoterapiabreve Doenc¸adeCrohn
r
e
s
u
m
o
Introduc¸ão: Adoenc¸adeCrohn(DC)éumaenfermidadecrônicaqueexigetratamento con-tínuoeprolongado,afetandoaqualidadedevidaeasaúdegeraldospacientes.Alémdo tratamentoclínico,recomenda-seoacompanhamentopsicológicoparaodesenvolvimento deestratégiasadaptativas.
Objetivo: AvaliarosefeitosdaPsicoterapiaBreveTranspessoal(PBT)sobreaqualidadede vidaeestadogeraldesaúdedepacientescomDC,epossívelcorrelac¸ãocomaatividadeda doenc¸a.
Métodos: Foramavaliados11pacientescomdiagnósticodeDC,deambosossexos,com idadeentre25anose55anos.Utilizou-seométodoclínicoeoprocedimentoconsistiuno atendimentoemPBT,comcoletadedadosantesedepoisdapsicoterapia.Nacoletade dadosfoiutilizadooQuestionárioSociodemográfico(QSD),ÍndicedeAtividadedaDoenc¸a deCrohn(IADC),InflammatoryBowelDiseaseQuestionnaire(IBDQ),QuestionáriodeSaúde GeraldeGoldberg(QSG),comanálisedescritivaparaosresultadoseestatísticacomoteste deWilcoxon.
Resultados: Aintervenc¸ãomostrou-sesignificativamenteeficazparatodososinstrumentos avaliados(p<0,05),commelhorresultadoparaoestadodesaúdegeral(−40,4%)equalidade devida(35,3%).Aatividadedadoenc¸aapresentouumareduc¸ãode38,1%noIADC. Conclusão:APBTtrouxebenefíciosaospacientescomDC,influenciandoseuquadroclínico, comreduc¸ãodaseveridadedadoenc¸a,econsequentemente,melhorandooestadodesaúde geraleaqualidadedevidadestesdoentes.
©2015SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.
Introduction
Crohn’sdisease(CD)isanInflammatoryBowelDisease(IBD), which is achronic illness that affects lifequality and life expectationofpatients.Atthesametime,thediseaseactivity isintimatelyrelatedtoimpoverishmentoflifequalityofthese patients.1–3
Nortonetal.,4assessingtheimpactofCDoverpatientslife, havereportedthefollowingrepercussions:(a)largephysical
impactduetoabdominalandjointpain,diarrheaand
flatu-lence;(b)impactonthedietduetheremovalofcertainfoods
orfoodgroups;(c)psychologicalimpactwithembarrassing,
awkwardandsilentaspectsofCD;(d)minusculoroutineinthe courseofthedisease,withdifficultytosharefearsand inse-curities;(e)greatconcernregardingthebathroom;(f)social
impactandsocialavoidanceandwithdrawal;changein
cir-cleoffriends,traveling,leisureactivitieswithchildrenand sportsactivities;(g)impactonprofessionallifewithreduction ofworkedhoursandcareerchange;(h)impactonsexuallife. Thepsychosocialconsequencesandlifequalityofpatients
mustbeconsideredtherapeutic.5Besidesmedical
accompa-niment,theremustbepsychological,socialandeducational
support.3,4,6–11 Psychotherapy is recommended even for
periodsofdiseaseremission.12,13
Recently,thebriefpsychotherapieshavepresentedgreat
expansionaswellasalternatives andtechniquestoattend
differentdiseases,withthemesregardinghealthandlife qual-ity.Theyallowgoodtherapeuticresultswithinfewsessions;
itfocusesonsymptoms,crisis,personalitycharacteristicsor
somekindofcomprehension.Itprovidescontinence,
compre-hensionofthesickeningprocessandpossiblepsychosomatic
interactionsinvolved;thisisaccompaniedbyreliefofanxiety andsymptomaticaspects.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
practicalprinciples that are methodologicallystructuredto
orient and sustain psychotherapeutic process in
Transper-sonalBriefPsychotherapy(TBP).16,17
Themainobjectiveofthisstudywastoevaluatetheeffects ofTBPoverthegeneralstateofhealthandlifequalityofCD patients.Thesecondaryobjectivewastoobservepossible cor-relationsbetweengeneralstateofhealthandlifequalityof patientsalongwithdiseaseactivity.Inthisstudy,therewas
theparticipationof11patientswithCD,whowerefollowed
intheprocessofTBPfor14weeks,inindividualsessionsof
50min.
Methods
Elevenpatients,ofbothsexes,diagnosedwithCDandaged
BowelDiseasesUnit“Prof.Dr.JuvenalRicardoNavarroGóes”,
at the University of Campinas (UNICAMP), were studied.
Patientsbearingintestinalstomas,womenwhowerepregnant
orlactating,patientswithsurgicaltreatmentindication,
previ-ousorevidentdiagnosisofpsychosis,thosewhowereunder
anindividualorgrouppsychotherapyprocessoralternative
treatmentssuchasacupunctureandthosewhohadlostthe
segmentwereexcluded.TheprojectwasapprovedbyResearch
EthicalCommitteeoftheUniversityofCampinas,under
pro-tocolnumber953/2010,andwithvolunteeradhesionofthe
participants.Allofthemwereclarifiedabouttheresearch
pro-ceduresandits phasesand theyhavesignedthe Informed
Consent.
The clinical method was used, with evaluation of the
resultsbeforeandafterpsychotherapy.Forevaluating,the
fol-lowinginstrumentswereused:
(a) Sociodemographic Questionnaire (SDQ): elaborated in
ordertogetsociodemographicinformationfrompatients
regardingtheiridentifyingdata,schoollevel,professional situationandclinicaldata.
(b) GeneralHealthQuestionnaire(GHQ):questionnaire
devel-opedand validatedbyGoldbergin1972;it iscomposed
of60items,distributedrandomly,thatmeasurethestate ofgeneralhealth(generalfactor)andfivespecificfactors:
psychic stress, death wish, distrusting in own
perfor-mance,sleepdisordersandpsychosomaticdisorders.18
(c) InflammatoryBowelDiseaseQuestionnaire(IBDQ):
devel-opedandvalidatedintheUnitedStatesin1988,byMitchell
ecols.fromMcMasterUniversity;ithasbeentranslated
andadaptedtoBraziliancultureasaspecificinstrument toevaluatelifequalityofBrazilianpatientswithIBD.Ithas 32itemsthatevaluatefourdimensions:intestinal
symp-toms,systemicsymptoms,socialaspectsandemotional
aspects.Onthequestionnairetheseitemsaredistributed randomlyinordertoavoidbiasinanswers.19
(d) Crohn’sDiseaseActivityIndex(CDAI):instrument
devel-opedandvalidatedforcharacterizingtheseverityofCD, allowingclassifyingpatientsaccordingtointensityofthe
inflammatoryactivity: disease inremission, withmild,
moderate,andseverefulminantdisease.20
TheTBPprocesstookplacefor14weeklymeetings,in
indi-vidualsessions of50min.Theprocessincluded: (a)Sign of
InformedConsent;(b)screeninginterview alongwithfilling
out ofSDQ,explorationon the historyofthe disorder and
meancomplaint;(c)initialevaluation,inwhichthepatient filledoutthefollowingquestionnaires:GHQandIBDQ; there-fore,thepatientwasforwardedtoseeadoctorfromtheclinic inordertofillouttheCDAI;(d)evolutionoflifehistoryand
self-evaluation,contextualizingthepresentmoment;(e)session
inTBP withweeklyaccompaniment; (f)finalevaluation, in
whichthepatientansweredGHQandIBDQ,onceagain,and
theCDAIwasfilledoutbyadoctorfromthegroup;(g)feedback interview.
Thedatawerecollectedbythesomeinvestigator(A.S.A.)
and dataregistration was performedby the patientor the
researcher, which was a transcription of the spontaneous
speechofthepatient.Thestudywasdonewithprevious
plan-ningandtheestablishedmethodologytoTBPwasbasedon
Table1–Planningofthesessionswithsevenstagesof TIA.
Stage Instrument Technical
procedure
Recognition Exerciseof excellence
Symbolic reorganization Identification Heuristicsof
emotionand graphics
Interactive dynamics
Disidentification Exerciseof source
Active imagination Transmutation Internaldialogs Symbolic
reorganization Transformation Thesevenselves Interactive
dynamics Elaboration Thefourdoors Interactive
dynamics Integration Exerciseofloving
ownbody
Active imagination
TIAprinciples.17Inordertoarticulatetheinteractive dynam-icswiththesevenstepsofTIAintheTBPprocess,inplanning, aninstrumenttoeachstepwaselected(Table1).
Toensurescientificcharactertotherapeuticprocess,some criteriahavebeenestablished:(a)useoftreatmentprotocolin allinterviews;(b)thedurationofindividualpsychotherapeutic processin14sessionsof50minonceaweek;(c)moreactive positionbythetherapistthanintraditionalpsychotherapies, sustainingthefocusoncurrentquestions,stimulatingactive positionforpatientsinrelationtotheirdifficulties,conflicts
and needs, encouraging pro-activeness; (d) no
interpreta-tionandemployofinterventionstopromoteconsciousness,
comprehension,clarificationandperceptionofunconscious
componentsbythepatienthimself;(e)useofpatterned
ver-balinterventions,whichintendedtoidentify,qualify,quantify
andlocalizethepurposeofsituations;forwhatandtowhom
itwasaddressed,withgoalandobjectivetobeachieved.
Statisticalanalysis
Descriptiveanalysiswithpresentationoffrequencytablesfor
categoricalvariableswasappliedandalsomeasuresof
posi-tionanddispersionfornumericvariables.Wilcoxontestfor
relatedsampleswasusedforcomparisonofnumeric
meas-uresthatresultedininitialandfinalevaluations.Thelevelof significanceisp<0.05.
Results
Thefemalegender(72.7%),marriedindividuals(63.6%),with
children(72.7%)andthosewhocompletedHighSchool(45.4%)
predominatedamongthepatients.Majority(72.3%)had
exer-cisedanyoftheactivities,paidorunpaid.
Meanagewas 40(maximumof50 andminimumof29)
yearsold.Thefirstsymptomshadappearedatthemeanage
of27(maximumof41andminimumof7)yearsoldandthe
averagetimeforCDdiagnosiswas9.7(maximumof20and
minimumof0.5)years.
ThebestresultsobtainedwerefromGHQ,with
Table2–GHQ.
GHQ Average Standarddeviation Minimum Median Maximum Variation% p-value
Psychosocial disorders
Initial 2.9 0.7 1.5 3.1 3.7
Final 1.8 0.4 1.2 1.8 2.2
Difference −1.1 0.7 −2.1 −1.3 −0.2 −39.0 0.001a
Distrustof
own performance
Initial 2.9 0.5 1.8 2.8 3.7
Final 1.7 0.4 1.1 1.8 2.2
Difference −1.2 0.6 −2.4 −1.1 −0.2 −40.1 0.001a
Sleep disorders
Initial 3.2 0.6 1.7 3.2 3.8
Final 1.7 0.5 1.0 1.7 2.7
Difference −1.5 0.7 −2.5 −1.7 −0.3 −46.5 0.001a
Psychic stress
Initial 3.2 0.6 1.9 3.4 3.9
Final 1.8 0.4 1.1 1.8 2.6
Difference −1.4 0.7 −2.3 −1.6 −0.1 −44.8 0.001a
Deathwish Initial 2.0 0.7 1.0 2.0 2.9
Final 1.2 0.3 1.0 1.1 1.9
Difference −0.9 0.6 −1.6 −1.0 0.0 −42.9 0.004b
Total Initial 2.8 0.5 1.6 3.0 3.5
Final 1.7 0.3 1.2 1.6 2.2
Difference −1.2 0.6 −2.2 −1.1 −0.2 −40.4 0.001a
a Significantat0.1%.
b Significantat1%forWilcoxontest.
Table3–IBDQ.
IBDQ Average Standarddeviation Minimum Median Maximum Variation% p-value
Intestinal aspects
Initial 44.5 7.1 32.0 45.0 53.0
Final 57.1 7.8 41.0 59.0 67.0
Difference 12.6 6.7 5.0 11.0 23.0 28.4 0.001a
Systemic symptoms
Initial 17.0 4.7 10.0 16.0 27.0
Final 25.6 6.0 17.0 26.0 35
Difference 8.6 5.5 2.0 8.0 18.0 50.3 0.001a
Social aspects
Initial 21.7 5.9 15.0 23.0 33.0
Final 29.1 5.5 19.0 32.0 35.0
Difference 7.4 4.6 2.0 6.0 18.0 33.9 0.001a
Emotional aspects
Initial 11.7 3.8 5.0 13.0 16.0
Final 16.7 4.2 9.0 19.0 21.0
Difference 5.0 2.8 1.0 5.0 11.0 42.6 0.001a
Total Initial 94.9 17.8 71.0 94.0 129.0
Final 128.5 21.8 89.0 134.0 155.0
Difference 33.6 13.4 18.0 33.0 63.0 35.3 0.001a
a Significantat0.1%forWilcoxontest.
The sleep disorder factor presented the most significant
improvement,withdecrease of46.5% indifficultiesrelated
to sleep, followed by psychic stress (−44.8%), death wish
(−42.9%),distrustinginownperformance(−40.1%)and psy-chosocialdisorders(−39.0%).
TheIBDQ presented animprovement of 35.3% in
qual-ityoflife,whereasthesystematicsymptomshadthehigher
improvement(50.3%),followedbyemotionalaspects(42.6%),
socialaspects(33.9%)andintestinalaspects(28.4%),aswecan observeinTable3.
TheresultsofCDAIevidenciate adecreaseof−38.1% in
diseaseactivity(Table4).
Discussion
CDrepresents aglobal publichealthmatteratthe present
moment3,11,21;it isa chronicinfirmity,withprolonged and continuoustreatmentseekingadequatelifequality.6–9,20–22
Itispossiblethat, duetomultiplicityofclinical
presen-tations and similitudeto other disorders, the diagnosis of
CD might be difficult, making the adequate controlof the
disease, especially at early stages, impossible, and
imply-ing inlong periods ofsuffering,with physicaland psychic
discomfort.7–9,22,23 Justasithasbeendemonstratedby sev-eralepidemiologicalstudies,themajorityofpatientsinthis casuistryhadthefirstsymptomsofthediseaseintheir sec-onddecadeoflife,andittookanaveragetimeof10yearsfor definitivediagnosticcountingfromtheappearanceofclinical picture.6–9,20–22
Many studieshaveassessedthe psychologicalissue and
recommendpsychotherapyaspartofthetreatmentfor
bet-ter control of the disease and to improve patients’ life
quality.10–13,24,25 However,fewstudieshavebeenconducted toevaluatetheresultsofpsychotherapyinthesepatients.25,26
Inthepresentstudy,thepatientswentthroughTBP
Table4–CDAI.
CDAI Average Standarddeviation 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 Significantat0.1%forWilcoxontest.
that the systemic and transdisciplinary approach, viewing
humansasbio-psycho-socio-spiritualbeings,favorsthe com-prehensionofpsychosomaticmanifestations.16,17
Through the methodology used in this research, an
improvementof−40.4%ingeneralstateofheathofpatients and35%inqualityoflifewasobserved,andalower differ-enceforintestinalaspects,withreductionof28.4%.Thisfactor mightbeareflectionofthechronicaspectsofCD,asdescribed byotherauthors.6–9,20–22
Deteret al.26 havealsodemonstrated that CD courseis
influencedbypsychotherapy;thisstudyhasobserveda reduc-tionof−38.1%inillnessactivity,whatcouldbeassociatedto improvementingeneralstateofhealthandqualityoflifeof thepatients.
Although this paper may differ in means of
meth-ods, criteria of inclusion, and evaluation of results, its
findings are in consonance to other studies that
eval-uate the results of psychotherapy in patients with IBD,
among them CD, as well as other studies that have
rec-ognized the benefits of psychotherapy, regardless of the
approachused.15,25,26Theseresultsarealsosimilartoother 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
percep-tions,makesanevaluationofthemselvesalsoand chooses
the alternatives that best fit the state observed in
self-evaluation.
Conclusion
TBP has brought meaningful benefits topatients withCD,
influencingthe clinicalpicturewithreductionofthe sever-ityofthedisease,and,consequently,ithasimprovedtheir generalstateofhealthandlifequality.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgments
TotheStatisticalOfficeoftheMedicalSciencesFacultyfrom
UNICAMPfordesigningthestatisticalanalysisandVera
Sal-danha,offeredvolunteersupervisioninpreparingtheproject.
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1.Kleinubing-JuniorH,PinhoMSL,FerreiraLC,BachtoldGA, MerkiA.Profileofpatientsfromboweldiseasesambulatory. ArqBrasCirDig.2011;24:200–3.
2.GuthrieE,JacksonJ,ShafferJMRCP,ThompsonD,Tomenson B,CreedF.Psychologicaldisorderandseverityof
inflammatoryboweldiseasepredicthealth-relatedqualityof lifeinulcerativecolitisandCrohn’sdisease.AmJ
Gastroenterol.2002;97:1994–9.
3.SouzaMM,BarbosaDA,EspinosaMM,BelascoAGS.Life qualityofpatientswithbowelinflammatorydiseases.Acta PaulEnferm.2011;24:479–84.
4.NortonBA,ThomasR,LomaxKG,Dudley-BrownS.Patient perspectivesontheimpactofCrohn’sdisease:resultsfrom groupinterviews.PatientPreferAdher.2012;2:509–20. 5.CaprilliR,GassullMA,EscherJC,MoserG,MunkholmP,
ForbesA,etal.Europeanevidencebasedconsensusonthe diagnosisandmanagementofCrohn’sdisease:special situations.Gut.2006;55:36–58.
6.JonesFA,GummerJW,JonesJEL.Clinicalgastroenterology. 2nded.México:Interamericana;1971.p.685.
7.LaudannaAA.Clinicalgastroenterology.SãoPaulo:Santos; 1990.p.550.
8.MoraesFilhoJPP.Gastroenterologymanual.SãoPaulo:Rocca; 1993.p.617.
9.SteinwurzF.Crohn’sdiseaseinmedicalpractice.Riode Janeiro:Elsevier;2009.p.112.
10.BennebroekEvertsz’F,ThijssensNA,StokkersPC, GrootenhuisMA,BocktingCL,NieuwkerkPT,etal.Do inflammatoryboweldiseasepatientswithanxietyand depressivesymptomsreceivethecaretheyneed?JCrohn’s Colitis.2012;6:68–76.
11.SajadinejadMS,AsgariK,MolaviH,KalantariM,AdibiP. Psychologicalissuesininflammatoryboweldisease:an overview.GastroenterolResPract.2012:1–11.ID106502. 12.IglesiasM,BarreiroDeAcostaM,VázquezI,FigueirasA,Nieto
L,LorenzoA,etal.PsychologicalimpactofCrohn’sdiseasein remission:anxietyanddepressionrisk.RevEspEnfermDig. 2009;101:249–57.
13.VidalA,Gómez-GilE,SansM,PortelladMJ,SalameroM,Piqué JM,etal.Theimpactofanxietyanddepressiononrelapsein patientswithinflammatoryboweldisease.MedClin. 2009;132:298–3012.
14.YoshidaEMP,SanteiroTV,SanteiroFRM,RochaGMA.Brief psychodynamicpsychotherapies:characteristicsofnational andforeignscientificproduction(1980/2003).Psico-USF. 2005;10:51–9.
15.Ferreira-SantosE.Briefpsychotherapy:systematicapproach tocrisissituation.2nded.SãoPaulo:EditoraÁgora;1997.p. 122.
17.SimãoMJP,SaldanhaV.Resilienceandtranspersonal psychotherapy:straighteningofvalues,actionsand spirituality.MundoSaúde.2012;36:291–302.
18.GoldbergDP.GeneralHealthQuestionnaire:technicalmanual GHQ:Brazilianadaptation.SãoPaulo:CasadoPsicólogo;1996. p.45.
19.PontesRMA,MiszputenSJ,FerreiraFilhoOF,MirandaCF, MarcosB.Qualityoflivewithinflammatoryboweldiseases: translationtoPortugueselanguageandvalidationofthe InflammatoryBowelDiseaseQuestionnaire(IBDQ).Arq Gastroenterol.2004;41:137–43.
20.Brasil.PortariaSAS/MSn◦858,4denovembro,2002.Clinical
protocolsandtherapeuticguidelines:exceptional medicaments–Crohn’sdisease.MinistériodaSaúde, SecretariadeAssistênciaàSaúde.
21.GordonPH.Principlesandpracticeofsurgeryforthecolon, rectum,andanus.3rded.NewYork;London:Informa Healthcare;2006.p.1370.
22.Gonc¸alvesCCM,HernandesL,OliveiraNLB,NataliMRM. Therapeuticalternativesinexperimentalmodelsofbowel inflammatorydisease.CiencCuidSaúde.2008;7:107–11. 23.Mikocka-WalusAA.Treatmentofpsychological
co-morbiditiesincommongastrointestinalandhepatological disorders.WorldJGastrointestPharmacolTher.2010;1: 64–71.
24.KnowlesSR,WilsonJL,ConnellWR,KammMA.Preliminary examinationoftherelationsbetweendiseaseactivity,illness
perceptions,copingstrategies,andpsychologicalmorbidityin Crohn’sdiseaseguidedbythecommonsensemodelof illness.InflammBowelDis.2011;17:2551–7.
25.KellerW,PritschM,vonWietersheimJ,ScheibP,OsborneW, etal.,TheGermanStudyGrouponPsychosocialIntervention inCrohn’sDisease.Effectofpsychotherapyandrelaxationon thepsychosocialandsomaticcourseofCrohn’sdisease:Main resultsoftheGermanProspectiveMulticenterPsychotherapy TreatmentStudyonCrohn’sDisease.JPsychosomRes. 2004;56:687–96.
26.DeterH-C,vonWietersheimJ,JantschekG,BurgdorfF,BlumB, KellerW,etal.High-utilizingCrohn’sdiseasepatientsunder psychosomatictherapy.BiopsychosocialMed.2008;2:18. 27.HäuserW,JankeKH,KlumpB,HinzA.Anxietyand
depressioninpatientswithinflammatoryboweldisease: comparisonswithchronicliverdiseasepatientsandthe generalpopulation.InflammBowelDis.2011;17:621–32. 28.WietersheimJV,KesslerHP.Psychotherapywithchronic inflammatoryboweldiseasepatients:areview.Inflamm BowelDis.2006;12:1175–84.
29.BrandiMT,RibeiroMS,ChebliLA,FrancoMB,PintoAL, GaburriPD,etal.PsychologicaldistressinBrazilianCrohn’s diseasepatients:screening,prevalence,andriskfactors.Med SciMonit.2009;15:101–8.
