Stress and Microscopic Colitis

ByWayne Persky

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While certain foods, and in some cases, certain drugs, may be the primary continuing triggers for microscopic colitis (MC), most of us have found that stress can be just as troublesome, and in some cases, an even bigger problem than maintaining a safe diet, when attempting to maintain long-term remission. Sooner or later, virtually all of us have chronic stress episodes in our lives, and our relapse of MC symptoms usually catches us by surprise. We get distracted by the source of stress, and the symptom relapse blindsides us.

Stress causes inflammation.

As most of us are well aware, stress is a well known cause of inflammation (Sun, et al., 2019; Liu, Wang, and Jiang, 2017).1, 2 Additional research has shown that chronic stress triggers an immune system response by disturbing the gut microbiota (Gao, Cao, Cheng, and Yang, 2018).3​

And as we all know, stress is a major trigger for IBDs.

The data show that psychological stress uses the gut brain axis, (by way of the enteric nervous system), to regulate not only the activity status of IBDs, but also to regulates disease progression.4 And it appears to be likely that an often overlooked, yet much more common than realized, cause of chronic inflammation in a surprising number of cases, may be posttraumatic stress disorder (PTSD). Which, of course, implies that PTSD may be a common trigger for IBDs.​

PTSD can cause major immune system problems.

Based on an analysis of the results of 65 published studies, researchers determined that PTSD not only increases inflammatory agents, but it also reduces anti-inflammatory factors (Sun, Qu, and Zhu, 2021).5 The study also revealed that PTSD and immune system disorders share common genetics.​

Childhood trauma is associated with inflammation during adulthood.

A meta analysis that looked at C-reactive protein (CRP) levels of 16,870 individuals from 18 studies, interleukin-6 (IL-6) levels of 3,751 individuals from 15 studies, and tumor necrosis factor-α (TNF-α) levels of 881 individuals from 10 studies, showed that individuals who experienced childhood trauma, had significantly elevated levels of CRP, IL-6, and TNF-α, as adults (Baumeister, Akhtar, Ciufolini, Pariante, and Mondelli, 2016).6 Interestingly, the analysis also showed that different types of trauma, whether it be sexual, physical, or emotional abuse, resulted in the elevation of different inflammatory markers. In other words, each type of childhood abuse resulted in the elevation of a specific inflammatory agent in adulthood.​

Veterans show high rates of PTSD causing subsequent AI disease.

An analysis of data from the Millennium Cohort Study, which studied records of the Military Health System Data Repository (MDR), based on following participants for a mean of 5.2 years, showed that of 120,572 participants, those who had a history of PTSD had a 58% higher risk of developing one or more autoimmune (AI) diseases, compared with those who did not have PTSD (Bookwalter, et al., (2020).7​

PTSD even increases the health risks associated with viruses.

Analyzing data in the UK Biobank, researchers at the University of Pittsburgh, in Pittsburgh Pennsylvania, recently investigated a possible link between childhood trauma and adverse outcomes due to Covid 19 (Hanson, O’Connor, Adkins, and Kahhale, (2023).8 They considered data from 151,200 participants who had completed the Childhood Trauma Screen, and were alive at the start of the Covid 19 pandemic in January 2020. The researchers looked at hospitalization and mortality data between January 2020 and November 2021, and they found that the odds ratio associated with childhood trauma was 1.227 for hospitalization (due to Covid 19), and 1.25 for death (due to Covid 19).​

It appears that major surgery is also associated with PTSD.

A study that summarized the current medical literature regarding postoperative traumatic stress symptoms, found that approximately 20% of surgery patients showed symptoms of PTSD, with certain types of surgery resulting in higher rates (El-Gabalawy, et al., 2019).9 And, of course, surgery is performed in many cases of Crohn's disease and ulcerative colitis.​

PTSD is a major cause of gastrointestinal issues.

As might be expected, PTSD can have major adverse effects on the performance of the gastrointestinal system. An Australian study, based on the medical records of veterans, showed that veterans who had PTSD were 77 to 81% more likely to undergo upper GI endoscopy and abdominal ultrasound procedures, than those who did not have PTSD (Crawford, Mellor, Duenow, and Connelly, 2023).10​

And conversely, IBD can cause PTSD.

In a study of 797 IBD patients (452 who had Crohn's disease, and 345 who had ulcerative colitis — as usual, MC patients were not included), researchers found that approximately 1/4 to 1/3 of IBD patients reported significant posttraumatic stress symptoms (Taft, et al., 2022).11 The study also revealed that patients who had higher posttraumatic stress symptoms were less likely to be in remission, and were more likely to seek more help from outpatient gastrointestinal services.​

So how can we minimize stress in our own lives?

Several previous newsletters have dealt with stress issues, and the resolution of stress. One of them, which can be read or downloaded at the link below, offered some personal insights into the evolution of stress during our lifetimes, and dealing with increased stress.
​https://www.microscopiccolitisfoundation.org/uploads/5/8/3/2/58327395/2717c3cdf4c6623384733__1_.pdf

All the major healthcare institutions offer online advice for controlling stress.

The Cleveland Clinic,for example, recommends these methods (Wellness, 2022, May 26):12

1. Maintain a healthy diet.
2. Exercise.
3. Avoid tobacco and nicotine products.
4. Adopt relaxation techniques.
5. Reduce stress triggers.
6. Follow good lifestyle practices.
7. Learn to say no, when necessary.
8. Set realistic goals for yourself (don't require perfection).
9. Maintain a healthy state of self-esteem (don't beat yourself up when things go wrong).
10. Try biofeedback techniques.

And, of course, by clicking on the reference link, a detailed explanation of each item on the list can be reviewed on the Cleveland Clinic website. Because we all tend to have different needs, most of us only need to concentrate on two or three of these issues (the ones that are the most relevant for us), in order to bring our stress levels way down. A few of us may need to consider more of the items on this list, or even some items that are not on the list, in special cases.​

Summary

Obviously, it shouldn't be surprising that so many of us have serious problems caused by stress triggering MC symptoms. And stress (particularly PTSD) is surely a primary factor in the original onset of the disease, for many of us, possibly most of us. All this provides further evidence that the gut brain axis, and psychological issues in general, may be much more important in the etiology (and treatment) of MC , and other IBDs, than most gastroenterologists realize.

As most of us have found, controlling stress is not easy.

Unfortunately, for many of us, stress may be the most difficult aspect of our lives to manage. But although we may have no control over many of the sources of stress, fortunately, we do have ways to mitigate the potential damage that stress can cause, so that we can choose not to let stress dominate our mood, and wreck our recovery, or our remission. There are many online sources that can provide help, and professional help is always available, if needed

Clinicians desperately need to adopt a multidisciplinary approach.

If the medical community hopes to ever be able to understand and successfully treat MC, they will almost surely have to abandon the outdated practice of studying each system of the body as if it operates independently of the others , and adopt a multidisciplinary approach, so that they can consider the interaction of multiple systems in the body, and how they are associated with disease. A multidisciplinary approach is not just important, but it's probably essential to the understanding and proper treatment of virtually every known AI disease, not just IBD.

References

1. Sun, Y., Li, L., Xie, R., Wang, B., Jiang, K,, and Cao, H. (2019). Stress Triggers Flare of Inflammatory Bowel Disease in Children and Adults. Frontiers in Pediatrics, 7, 432. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6821654/

2. Liu, Y. Z., Wang, Y. X., and Jiang, C. L. (2017). Inflammation: The Common Pathway of Stress-Related Diseases. Frontiers in Human Neuroscience, 11, 316. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5476783/

3. Gao, X., Cao, Q., Cheng, Y., and Yang, Y. (2018). Chronic stress promotes colitis by disturbing the gut microbiota and triggering immune system response. PNAS, Retrieved from https://www.pnas.org/doi/10.1073/pnas.1720696115

4. Ge, L., Liu, S., Li, S., Yang, J., Hu, G., Xu, C., and Song, W. (2022). Psychological stress in inflammatory bowel disease: Psychoneuroimmunological insights into bidirectional gut-brain communications. Frontiers in Immunology, 13, 1016578. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9583867/

5. Sun, Y., Qu, Y., and Zhu, J. (2021). The Relationship Between Inflammation and Post-traumatic Stress Disorder. Frontiers in Psychiatry, 12(1). Retrieved from https://www.frontiersin.org/articles/10.3389/fpsyt.2021.707543/full

6. Baumeister, D., Akhtar, R., Ciufolini, S., Pariante, C. M., and Mondelli, V. (2016). Childhood trauma and adulthood inflammation: a meta-analysis of peripheral C-reactive protein, interleukin-6 and tumour necrosis factor-α. Molecular Psychiatry, 21(5), pp 642–649. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26033244/

7. Bookwalter, D. B., Roenfeldt, K. A., LeardMann, C., A., Kong, S. Y., Riddle, M. S., and Rull, R. P. (2020). Posttraumatic stress disorder and risk of selected autoimmune diseases among US military personnel. BMC Psychiatry, 20(1), 23. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964079/

8. Hanson, J. L., O’Connor, K., Adkins, D. J., and Kahhale, I. (2023).Childhood adversity and COVID-19 outcomes in the UK Biobank. Journal of Epidemiological & Community Health, Published Online First, Retrieved from https://jech.bmj.com/content/early/2023/11/01/jech-2023-221147

9. El-Gabalawy, R., Sommer, J. L., Pietrzak. R., Edmondson, D., Sareen, J., Avidan, M. S., . . . Jacobsohn, E. (2019). Post-traumatic stress in the postoperative period: current status and future directions. Canadian Journal of anesthesia, 66(11), pp 1385–1395. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31190143/

10. Crawford, D. H. G., Mellor, R., Duenow, P., and Connelly, L. B. (2023). The impact of posttraumatic stress disorder on upper gastrointestinal investigations in Australian Defence Force veterans: a retrospective review. Internal Medicine Journal, 53(5), pp 841–844. Retrieved from https://pubmed.ncbi.nlm.nih.gov/37145886/

11. Taft, T. H., Quinton, S., Jedel, S., Simons, M., Mutlu, E. A., and Hanauer, S. B. (2022). Posttraumatic Stress in Patients With Inflammatory Bowel Disease: Prevalence and Relationships to Patient-Reported Outcomes. Inflammatory Bowel Disease, 28(5), pp 710–719. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344426/

12. Wellness, (2022, May 26). 10 Ways You Can Relieve Stress Right Now. Cleveland Clinic, Retrieved from https://health.clevelandclinic.org/how-to-relieve-stress/