If you're living with a chronic illness, you're in the right place.

Monday, December 31, 2012

Friday, December 28, 2012

Research Roundup: Hat Tip to 2012 Edition

2:27 PM Posted by Tiffany Taft , , , , , ,
As we steadily march toward 2013, I'd like to take a few minutes to highlight some of the best studies of 2012 that advanced our knowledge of psychosocial issues for those living with chronic medical illness.  I might even include a few shameless self-plugs for my own research, but I promise to keep it under control.

Bullying experiences of obese children.  A great study in the journal Pediatrics highlights the struggles of overweight and obese children with bullying, with some startling statistics.  78% reported being bullied for at least 1 year, while 36% were bullied for 5 years.  Peers and friends were the most likely people to bully, but several adults were also identified including gym teachers/sports coaches (42%), parents (37%) and teachers (27%).  Yikes.

Cognitive-Behavioral Therapy (CBT) is effective in treating depression in teens with Inflammatory Bowel Disease.  The PASCET-PI study out of Children's Hospital of Pittsburgh found that adolescents who underwent CBT for depression related to Crohn's disease or Ulcerative Colitis continued to show improvement 1 year after treatment was completed, suggesting that CBT is an effective intervention for teens with IBD who are also depressed.

Qualitative experiences of mother's of children with food allergy.  I love qualitative research because it involves in-depth interviews with members of the group of interest.  In this case, mother's of kids with food allergies.  In this study, they found 3 common themes from moms:  living with food allergy risk is a big responsibility, making adjustments to keep life as stable as possible for themselves and their family, and changes to their identity as a mother of an allergic child while managing social relationships and obligations.

Caregiver stress in mothers of children with Eosinophilic GI disease.  This one is mine, and is the first study to evaluate parents of kids with EGIDs for stress.  We found that these moms reported significant anxiety and depression, and that the worse their mental health was the more severe their stress levels were.  The types of treatments their child was using, as well as their child's behavioral issues also contributed to stress.

The impact of a group self-management program for people living with chronic illness.  People living with a variety of chronic medical conditions reported significant positive impact from participating in a self-management program.  Main themes included:  increases in physical activities, improved coping skills, and reduced feelings of isolation.  There were barriers to these improvements, mostly related to patient-physician interactions and financial limitations.

Here's to a productive 2013 in the world of chronic illness research!
Just join us cos uh, no-one's gonna really be free until nerd persecution ends

Wednesday, December 26, 2012

Everyone Alive?

5:39 AM Posted by Tiffany Taft , ,
Another Hanukkah and Christmas season have passed us by.  So much preparation for what seems like a day that goes by in about 12 minutes.  I spent most of yesterday cooking, including a turkey marked by the 3 Bs:  Brine, Butter, and Bacon - because in this house, we're all about healthy eating at Christmas.

The holidays are a stressful time of year for many.  Running to crowded malls for last minute gifts, cooking extensive meals for 14 of your closest relatives, and mentally preparing for that one uncle who starts the political/religious/moral arguments while passing the stuffing.  It's no wonder that December has one of the highest suicide rates of the year.  Or does it?

I'm guessing that you've heard this factoid:  people are more likely to commit suicide around the holidays.  Well, researchers have studied this trend and found that this simply isn't true.  According to the Centers for Disease Control (CDC), suicide rates do not increase November-January but tend to rise in the spring (although they're not sure why).  One study out of the University of Pennsylvania found that suicide rates were actually lowest in this time frame when compared to the rest of the year.

You serious, Clark?
For those living with a chronic medical illness, the holidays can bring unique challenges.  Having to explain to your great Aunt Helen why you can't eat certain foods, or why "cleaning your plate" may result in hours in agony in the bathroom.  Finding the strength through overwhelming fatigue to sit and visit when your bed is screaming your name.  Answering questions about your health like "are you better yet?" or "when are you going to get over this?"  And my favorite, fielding suggestions like "my friend's sister's brother-in-law's uncle's wife is a physician and she says that eating lemon rinds is great for [insert name of your condition here]."

Thank you, Simone.
Knowing that even with all of the craziness of the holiday season, we're more likely to start to feel sad or blue after it's all over behooves us to check in with our mental well-being the next few months.  One of the reasons we suspect that suicide rates don't rise around the holidays is because of the increase in social support, for better or worse, that happens this time of year.  So keeping up with friends or family who are important to you, who make you feel good, and are healthy people to be around is key in the coming weeks.

Here are a few other things you can do to beat the post-holiday blues:
  • Get up and get outside, even if it's for an hour. Fight the urge to stay in bed (or on the sofa) all day.
  • Schedule some time for yourself to do something you enjoy.  Put it on your calendar with a reminder, and treat it like you would any important meeting to prevent blowing it off.
  • Meet up with a good friend for lunch/coffee/just to chat and talk to them about what's going on.
  • Try to keep up with social activities even if you don't feel like it.  If you go and feel overwhelmed, you can always leave later.
  • Take the pressure off yourself for perfection (or near-perfection). 
  • Exercise regularly, whether it's going for a walk or hitting the gym for an hour. Both are effective in boosting your mood. A 10 minute walk can boost your mood for up to 2 hours!
  • Don't skip meals as the dips in blood sugar can make you irritable and tired. 
  • Check your self-talk.  What we tell ourselves has an enormous impact on our mood.  
And, my personal favorite:  Find something to laugh about.  Here's a good place to start.

Dr. T

Tuesday, December 18, 2012

Vicarious Trauma

12:29 PM Posted by Tiffany Taft ,
A lot has been said, and will continue to be said, about the tragic events in Newtown, CT on Friday.  The debate about gun control, mental health, violence, and the general pathology of our current society will hopefully rage for some time and lead to some meaningful changes in all of these areas.

Something needs to change.  I don't claim to have all of the answers.

This national tragedy has been particularly hard on me.  I'm not saying that previous mass shootings were any less ghastly, but they didn't penetrate my psyche like this one has.  Maybe it's because of the ages of the victims, and that I have a young daughter.  I really don't know.  But as has been said on the news, something's different about this one.

When I went through training to become a psychologist, we learn about something called vicarious trauma.  Basically hearing horrific stories from your clients wears on you, and it's vital to being a good therapist that you're aware of this and pay attention to symptoms of vicarious trauma.  Symptoms can parallel those associated with actual traumatic experiences, but are usually less intense and include:

Social withdrawal
Difficulty concentrating
Feeling numb
Mood swings
Sleep problems
Loss of meaning and hope

This type of trauma isn't unique to psychologists, and can happen to anyone who hears about traumatic events that happen to those you care about.  I'd bet there's a lot of vicarious trauma floating around in America right now.

So what can be done?  There are a few tricks of the trade that we use to ward of vicarious trauma that may be helpful if you're feeling some of the above, whether it's because of last Friday's shooting or other exposures to trauma toward loved ones in your life:

  • Stay connected with family and friends.  Social withdrawal is not your friend, here.
  • Slow down and focus on the little things. Sounds cliche, but the research on mindfulness supports this as an effective coping strategy in improving our mental well-being.
  • Take time to reflect, either through writing, reading, or conversation.  Talking about traumatic events helps our brains process them appropriately and reduces the risk of long-term conditions like PTSD.
  • Identify and challenge your cynical beliefs.  Do they hold any water?   Even if they do, do they serve any purpose?
  • Channel your energy into something positive, whether it's learning a new skill, volunteering, or giving back to the community some way.

Friday, December 14, 2012

There's Nothing To Say

1:47 PM Posted by Tiffany Taft
20 children.  Kindergarteners.  At least 6 adults.  Gone.

Thursday, December 13, 2012

Moving in the Wrong Direction

2:14 PM Posted by Tiffany Taft , , ,
It's been in the news recently, the upcoming 5 version to the Diagnostic and Statistical Manual for Mental Disorders - or DSM 5.  The DSM, published by the American Psychiatric Association, is the guidebook that every mental health professional is supposed to use to make a mental health diagnosis.  It contains the symptoms, timeframes, and exclusions for every condition from acute stress disorder to voyeurism.

Where the magic happens.
Version 5 has been worked on for years and is due out in 2013.  Much of the news reports about this version have to do with the elimination of Asperger's in lieu of creating an Autism spectrum on which people with Asperger's will now fall on the mild end.  Other concerns are that normal bereavement will now be considered major depression due to loosening of the depression diagnostic criteria.  But my concern lies with the changes to an existing diagnostic category - Somatoform Disorders.

Rather than repeating what's in store in DSM 5, this article provides an excellent summary of the proposed changes.  It's really worth taking the time to read, whether you have diabetes, irritable bowel syndrome, lupus, or fibromyalgia.  The bottom line is, regardless of the etiology of your chronic illness you are a candidate for the Somatic Symptom Disorder (SDD) diagnosis.  If you're a parent caregiver, your reactions to your child's illness may be deemed pathological as well.

So what does this mean?

Like most things in the DSM, there's ambiguity and room for interpretation from the mental health provider about if a symptom or behavior meets the diagnosis criteria.  Terms like "excessive," "disproportionate," and "exceedingly high" are used to describe worry or time/attention dedicated to one's health.  My opinion on what's excessive health-related worry may differ from the next therapist and from the next.  What happens when people living with chronic illness are experiencing relatively normal reactions to a flare up or new diagnosis and are labeled with SDD?  So now they not only have Rheumatoid Arthritis but have RA and SDD.

Will their symptoms be taken as seriously or will they be seen as people who blow things out of proportion and be blown off?

Actual someecard.
Will a diagnosis of SDD be given in haste to a person with as-yet medically unexplained symptoms, who will then be denied testing to ensure there really isn't something wrong?

Will the SDD diagnosis become the diagnosis du jour for women experiencing physical complaints?  Notice the task force for SDD is a bunch of men.  The only woman on the panel "was withdrawn" in 2011.

You demand answers?  You must be excessively anxious.
Are there people who have "excessive" or "disproportionate" concerns about their health or medical diagnosis?  Yes.  I think of people who cut themselves off from their friends and family, who can't go to work for fear of having symptoms in public, or who cannot think of much else other than their illness.  In my experience, this is not the norm but a relatively small percentage of the hundreds of people I've seen living with a chronic medical condition.  And I'm not sure what giving them an SDD diagnosis will do for them, even if they met the "official criteria."

The most concerning thing is there is no published research to back up any of this.

As someone who has spent the last 9 years trying to advance the understanding and integration of physical and mental health, and de-stigmatize normal human reactions to illness, especially for those with "functional" conditions like Irritable Bowel Syndrome, I see this reclassification as an enormous step in the wrong direction.  Rather than acknowledging that with a chronic illness comes normal feelings of worry, sadness, frustration, curiosity, anger, or *gasp* anxiety or depression, the DSM 5 is pathologizing them.  And only one of these "excessive" feelings need be present, only for 6 months.

Are the members of the committee responsible for this change really trying to say that someone who was diagnosed with stage 3 breast cancer a month ago best get their emotions under control because the statute of limitations on worry is 182 days?

Clock's tickin' people.
Or the person living with severe Irritable Bowel Syndrome, a still relatively poorly-understood condition with few medical treatment options, shouldn't spend more than an hour or 2 on the internet looking for remedies or connecting with others via online support communities?  People living with IBS already face considerable stigma and implication that their symptoms are "all in their head."  Consider what an additional diagnosis of SDD would do to their status in both the medical and lay community.

Or the mother of a child with multiple, severe food allergies who is worried about contamination and its subsequent anaphylaxis?  Is her vigilance in keeping her child safe from a potentially lethal event "excessive" or the normal reaction to something that could prematurely end her child's life?  Is it something I should recommend some Valium for or validate as normal and help her cope with?

What are your thoughts on these changes?  Will SDD be a help or hindrance to those living with a chronic medical condition?

Wednesday, December 5, 2012

IBD Awareness Week: IBD and BCP

6:09 AM Posted by Tiffany Taft , , ,
I came across this question this morning on Crohnology:

Has anyone had difficulty with any types of birth control during a flare?

It got me thinking about if there's a relationship between IBD and birth control pills.  I've read research articles on how female hormones and monthly menstrual cycles can affect digestive symptoms, but that was mostly in people with IBS.  Before I continue, I want to preface my post that I'm not trying to cause any alarm, rather discuss my personal experience in this area and go over a few research studies on the topic.

I've been living a bit of a confused life as a person with Crohn's disease the past year and a half or so.  See, I had my first child in April of 2011.  Before getting pregnant I was in a minor flare up and got back together with my old friends "the biologics," this time in the form of Cimzia.  

Syringe courtesy of the OXO corporation, makers of fine kitchen spatulas.
I stayed on Cimzia until week 30 of my pregnancy, when I and my GI doc decided it was worth the risk of a flare to ensure the drug would be out of my baby's system at birth (see recent study on that idea).  I was prescribed a lower dose of budesonide to ride out the remaining 10 weeks.  I stopped taking it while in the hospital.

Before I decided to reproduce, I was on "the pill" since I was roughly 19 years old.  I was diagnosed with Crohn's at 26.  I'll be 37 in 25 days (but who's counting).

Since my daughter was born, I've been in remission and have not resumed any medications.  My GI doc wanted me to go back on Cimzia as a maintenance medication, but I balked at that idea and said I wanted to see how things went before I went back to the big guns. Plus, I was breastfeeding. The research says that roughly 50% of women will experience an IBD flare either during or shortly after pregnancy.  Anecdotally, I've heard from a few others on various Facebook IBD groups that there are other people who share my story of post-pregnancy remission. Even though being a new mom can be incredibly stressful.

Because I'm a research dork, I went to PubMed after reading the above Crohnology question and I searched for "oral contraceptive IBD" and found a 2008 meta-analysis published in the American Journal of Gastroenterology, which is a pretty high ranking GI journal, on this very topic.  For those of you who don't share in my geekdom, a meta-analysis is a review of all of the studies on a specific topic to date.  So the authors of this study went over 14 studies that included almost 76,000 women with IBD, roughly half having taken oral contraceptives and half not. So what did they find?
  1. Women who took oral contraceptives were 1.5 times more likely to develop IBD than those who did not.
  2. The relative risk of developing Crohn's Disease increased the longer the woman took oral contraceptives.
  3. The risk for developing IBD was no longer statistically significant once the oral contraceptive was stopped.

Conclusion?  There is a small, but significant, increase in risk of developing IBD in women who use oral contraceptives.  A similar meta-analysis performed in 1995 reported similar findings.

All is well!
I want to reiterate that this post isn't meant to cause alarm, and as with any research studies just because a relationship exists doesn't mean it is going to apply to you, personally.  I haven't gone back on "the pill" and I'm curious if this is contributing to my prolonged, med-free remission.  A 2010 review article reports that there's no risk of relapse from oral contraceptive use, so who knows. 

So, as with a lot of research out there, there is conflicting evidence.  This happens for a variety of reasons, including the way studies are designed, the size of the study's sample, and the quality of the research methods used.  It's enough to drive you to drink sometimes.

Until today, I was assuming pregnancy did something to reboot my immune system.  There is 1 study that reports that the relapse rate 3 years after pregnancy in people with Crohn's is lower than 3 years prior.  So that could be it. I thought maybe the hormonal changes from breastfeeding for 14 months did something, but I stopped that almost 6 months ago and except for a few minor bumps in the road, my remission is still going strong.  Except now I've jinxed myself with this post.  Time to go knock on some wood.

What do you think about these findings?  What has your experience been with IBD and hormones, either via contraceptives or monthly cycle?

Tuesday, December 4, 2012

IBD Awareness Week: The Role of Stress, Part 2

8:41 AM Posted by Tiffany Taft , ,
Today I'm going to talk about the brain-gut connection and how it may play a role in IBD symptoms.  Yesterday I gave an overview of the HPA Axis, which recent research is implicating in the presence of inflammation and other changes in the digestive tract.  The brain-gut connection has some overlap to what I went over, so I'll try not to be repetitive.

Historically, the brain-gut connection has been connected with more "functional" conditions, such as Irritable Bowel Syndrome or Functional Dyspepsia.  Functional conditions are a class of disorders that are caused by problems with how the digestion system functions (see, medicine isn't all convoluted all the time), typically at the neurological or muscular level.

When a person with IBS has a colonoscopy, there is no evidence of inflammation either visibly or under the microscope when biopsies are taken and analyzed.  Their colon looks like that of a healthy person, even though they may have chronic abdominal pain, bloating, diarrhea, or constipation.

Isn't that pretty?
Don't let the lack of inflammation fool you. IBS is a very debilitating disease and costs billions of dollars every year in medical costs and lost productivity.  It affects between 25 and 45 million people in the US, can take on average 7 years to diagnose, and has limited medical treatments.  Many medications that have come to market for IBS have been pulled because of fatal side effects (e.g. Zelnorm, Lotronex).  Those that remain have about a 25-30% success rate, which isn't much better than placebo.

Remember these ads?  
So what is the prevailing theory behind IBS?  The brain-gut connection.  Although more recent studies are finding that there is some sort of inflammatory process in IBS, and some researchers are theorizing that IBS and IBD are related and lie on a continuum.  Others don't agree, and believe that IBS and IBD are distinct diseases that may overlap.  More on this later.

If you think about it, the brain-gut connection is part of our everyday language.  "Gut feelings." "Gut-wrenching." "Butterflies in my stomach."  Stress and emotions have a direct, and considerable, effect on our digestive system.  The gut has been called our second brain and is run by something called the enteric nervous system.  This system contains over 100 million neurons (more than are in your spinal cord or peripheral nervous system).  It also contains more of a chemical called serotonin than your brain (95% of it is in your gut, not your head).  You may have heard of serotonin as a chemical that's too low in people with depression.

Schematic of the BGC
Wired into the enteric nervous system is the autonomic nervous system, which I mentioned briefly yesterday. This system does a lot, but what's important for this post is that a sub-part of it (the sympathetic nervous system) drives the fight-or-flight response (aka, the stress response).  A lot of physical changes happen when we're perceiving a threat - our heart rate goes up, our breathing increases, blood is diverted to larger muscles (that's why cold hands and feet are a sign of chronic stress), we start sweating.  This system also tells the gut to stop digestion - because when you're about to get eaten by the saber tooth tiger, digesting your mammoth burger is a low priority.

Captain Caveman had to have had digestive problems.
I want to make clear that the fight-or-flight response isn't an all-or-nothing phenomenon.  Meaning, it's engaged whenever we experience stress.  Whether it's that irritating co-worker, an upcoming deadline, or almost being hit by a bus.  We don't have to feel the full effects of an adrenaline rush to know that the stress response is happening inside of us.  I often use the tachometer in your car as a way to think about this.  When your car is in neutral and you push on the gas pedal, the needle goes up.  You can do this gradually or you can stomp on the gas, sending it into the red.  The needle moves up and down according to how much pressure is on the pedal.  The same is true of the stress-response.

Who is Margret, and why are we always telling her to "punch it!"?
In conditions like IBS, the communication between the enteric nervous system and the brain is thrown off.  Unfortunately, researchers don't know why or how this happens.  Often times, the nerves in the gut become hypersensitive so people with a kooky (technical term) brain-gut interaction feel sensations in their bowels that they shouldn't, and are more likely to experience these sensations as painful.  Something called visceral hypersensitivity.

As I previously mentioned, there's some debate among gastroenterologists if a person with IBD can go on to develop IBS so they have both conditions.  Typically this idea is floated when an IBD patient comes to the doctor's office with symptoms but their bloodwork and colonoscopies are clear.  How frustrating, right?

At first I thought this was a silly idea, but as I thought about it and read the research, it makes some sense.  Chronic inflammation from IBD causes damage that you would think would affect the enteric nervous system, somehow.  Also, if stress has a direct effect on the functioning of the digestive system it would make sense that symptoms like diarrhea, pain, or bloating could be from this brain-gut connection and not an IBD flare.  It's tricky for patients and physicians to tease this out when the typical "red-flag" IBD symptoms aren't present.

I hope my 2 posts on stress and IBD have been informative.  For Part 3, I'd like to get reactions from people about these stress theories.  Do you agree?  Disagree?  What has your experience been with stress and your IBD symptoms?  It'll probably take me a few days to get feedback, so Part 3 will hopefully happen in the next week or so.

Monday, December 3, 2012

IBD Awareness Week: The Role of Stress, Part 1

5:32 AM Posted by Tiffany Taft , ,
Yesterday I tweeted the statistic that 75% of people with IBD report that they believe stress was a contributing factor to their developing Crohn's disease or Ulcerative Colitis.  That stat came from a 2012 review article of psychological issues in IBD, published in the journal Gastroenterology Research & Practice.  It prompted an exchange with one of our followers about a common misconception that stress causes IBD, and how this belief can lead to stigma in that the person with IBD has done something to bring the disease on themselves.

This is a tricky topic because, as I tell every person that I see, stress doesn't necessarily cause your condition but stress isn't good for any chronic illness - whether it's hypertension, ulcerative colitis, lupus, or migraine headaches.  Some people readily endorse the connection between stress and symptoms, while others deny any connection whatsoever.  So what's the deal?

First off, we ALL experience stress.  Every day.  Unless you perpetually live in a Corona commercial.  And this isn't necessarily a bad thing.  Stress is a motivator - to a point.  Because I like pretty graphs, here's a common representation of stress's effect on our ability to get things done:

The "Stress Curve"
As you can see from the graph, too little and too much stress each have their own negative effects.  However, the red area on the right side is when stress levels begin to exceed our internal resources and is when we start to see detrimental effects including changes to our immune system functioning.  There's an entire field that studies this, called psychoneuroimmunology.

Before I get into that, which do you think is harder on your body?  Chronic daily hassles or big-time stressful life events like a death of a loved one or losing your job?  Most people to whom I've asked this question say big events, because we always hear about Uncle Ralph having a heart attack after something major happened in his life.  When actually it's the chronic daily hassles that produce the most wear and tear.  Things that are enough to get you agitated - being stuck in traffic when you're running late as it is; an annoying co-worker; getting an unexpected medical bill; a cranky toddler.
Be glad you don't live here...
It's the cumulative effect of chronic daily hassles that leads to the greatest wear and tear on your body from stress; things that some people may not really consider stress, per say, because they're not one of the bigger problems we could experience in life.

So what happens to your immune system when you're experiencing stress?  Well, a lot of things.  Some recent studies, including one published in the past month in the journal Gastroenterology (which is one of the highest ranked GI journals), talk about the role of the stress response and the hypothalamic-pituitary-adrenal (HPA) axis.  There is mounting evidence that stress can affect systemic and mucosal inflammation in the digestive system.

Wait, what the heck is the HPA axis?  Some of you may have heard about the mind-body connection, or even the brain-gut connection.  The gist is that our nervous system is intricately wired into the rest of our body (duh), and when chemicals are released in response to stressful situations this sends shockwaves through various pathways between the brain and the body, resulting in a myriad of physical symptoms.  Let's break down HPA:

Hypothalamic:  In every one of our brains is a structure called the hypothalamus.  It's remarkable what this relatively small area of the brain does, including controlling:  body temperature, sleep, hunger, thirst, sexual behavior, and emotional responses.  Whew.  The hypothalamus serves as a relay station for its neighbor, and the next part of the HPA...

Pituitary (Gland):  Remember 9th grade biology?  The "master" gland.  This thing does everything.  Well, almost.  It manages the release of 9 major hormones that control growth, blood pressure, temperature, pain regulation, water absorption, and energy conversion.  It also releases a hormone that's associated with levels of cortisol (the stress hormone) in the body.  This leaves the last part of the HPA...

Adrenal (Glands):  One sitting on top of each kidney.  The adrenal glands release adrenaline,  which controls blood pressure and metabolism.  But is more commonly known as being part of the fight-or-flight response.  The "adrenaline rush."  You've experienced it so I don't need to go into it in more detail.  If you're rusty, think of something you're afraid of and then go try and do it.

These 3 areas of your body are all wired together to create the HPA axis.

Think of it as your body's stress superhighway.
Researchers are identifying through both basic science experiments with mice and clinical studies with people that the HPA axis is somehow involved in the inflammatory process in the colon.  Yes, there are mice running around in labs with Ulcerative Colitis.

Quite possibly the cutest thing you'll see this week.
One theory is that the HPA axis in people with IBD doesn't work properly, which  may be the result of chronic inflammation derailing the feedback loop between the immune system and the HPA axis. So hormones released by the pituitary gland that would normally be anti-inflammatory don't result in this response. Another theory is that the autonomic nervous system, which is involved in the fight-or-flight response (among other things), is hyperactive in people with IBD. Yet another theory is that changes in receptors in the intestines that respond to a chemical released by the pituitary gland result in reduced water absorption and increased mucus production.

Conclusions?  The jury is still out in the research community what the role of stress is in IBD, but the trend is toward an understanding that it does play a role, at least in disease flare-ups.  Anecdotally, up to 90% of people with IBD endorse this idea.  But it's difficult to say if stress plays any role in the onset of IBD in people who are predisposed to developing it.  And if research does, one day, find that stress is indeed one of the several triggers of the start of IBD (and other autoimmune conditions for that matter), what might that mean for the way IBD is perceived by others?  Will it increase the stigma that already exists?

In Part 2 I'll talk about the Brain-Gut connection and the role stress plays there.

source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774724/