Home > International Dictionary of Psychoanalysis > Ulcerative Colitis

Organic in its etiology, ulcerative colitis remains an enigmatic disease, although current understanding puts it in the group of autoimmune disorders, thus increasing its interest for those involved in psychosomatic medicine.

It involves continuous damage to the mucous lining of the colon but can also affect the rectal mucosa. The latter are eroded, sometimes abscessed, and can rupture, making this a serious condition. It progresses through a series of attacks of varying degrees of severity and can occasionally necessitate a colectomy with a colostomy.

Its main symptom, bleeding (the mucosa "weep" blood), the psychological profile often associated with it (depression, regression), and its evolution, which is variable and unpredictable but is often correlated with a psychoaffective trauma, have put this disease under the spotlight among psychoanalysts specializing in psychosomatic disorders.

The circumstances that trigger the onset of the disease or attacks have been identified by the majority of authors. These appear to be fortuitous during the early stages of investigation but may become more defined in the course of psychotherapy with the gradual emergence of latent content. Often, although not always, the following are found: experiences of object-loss, experiences of wounded narcissism with feelings of worthlessness, self-depreciation, and a sense of the impossibility of taking on new responsibilities. These experiences may result from new real-life situations (with a traumatic valence) or situations that are fantasized and retroactively reconstructed. In "Étude psychosomatique de dix-huit cas de recto-colite hémorragique" (Psychoanalytic study of eighteen cases of ulcerative colitis; 1958), Michel de M'Uzan and his collaborators wrote: "The common element in these factors is their ability to provoke in the patient a loss of self-esteem, along with the belief that he is unloved or incapable of overcoming a difficulty."

Thus, to a greater degree than with other organic pathologies, these causes point toward a narcissistic destabilization along with a certain degree of melancholia. Inspired by the bleeding mucosa, certain authors have speculated a "melancholia of the organ"—a theoretical fantasy on the part of the analyst or a structural reality?

The fact remains that a somewhat mechanistic approach would posit the existence of: an affective block or immaturity; strong ambivalence (the depressive pole of which is deeply repressed) toward persons close to the patient as well as toward the therapist; and a depressive tendency different from the reactive depression of the disorder. This depression, sometimes carried along on the tide of a massive regression, has even led to indications for treatment with antidepressants (see Guy Besançon's article "Le corps présent, réflexions sur une série de recto-colites hémorragiques" [The body as presence; reflections on a series of cases of ulcerative colitis]; 1977).

This correlation between ulcerative colitis and a narcissistic axis of depression remains a pivotal element in attempts at a psychoanalytic interpretation. Some authors have thus invoked the idea of a somatic dramatization of melancholia and have sought its source in the mother-child relationship, thereby suggesting that this disorder may be part of a psychogenetic given. Kleinians see this disease in terms of incorporation of a bad maternal imago: According to Melitta Sperling (1946), "As the object is incorporated sadistically, it is a hostile inner danger and has to be eliminated immediately. The faeces and blood (in severe attacks, only blood and mucus) represent the devaluated and dangerous objects. . . . The severe form of ulcerative colitis shows a great resemblance in behavior, personality structure and dynamics to melancholia, and seems to represent the somatic dramatization of the same conflict, with relatively little mental pain, that in depression is expressed psychologically" (p. 326).

There is no consensus on this approach. However, it seems probable that these patients have been unable to constitute and develop a mental space wherein they could find themselves by finding objects other than the primary object to which they felt and feel extremely bound, in an inexorable and often conflicted way.

See also: Psychosomatics.