What the Freiburg Personality Inventory indicates about patients with IBD
The scores obtained with a sample of IBD patients were compared to the Romanian national reference standard, and a series of statistically significant differences were discovered. Other findings, both similar and dissimilar, are discussed below. It was assumed that the score level would exhibit some correlation. Consequently, Extraversion and Social Orientation scores were lower, whereas the Emotionality score was higher.
Higher scores on the Inhibitedness scale suggest a predisposition toward repressed feelings, insecurity, and avoidance of social engagement in the investigated group. Probst et al.  reported similar results in that patients were described as more tense, more inhibited, more reserved, less aggressive, and less friendly compared to the control group. These traits indicate a type D personality, often known as the "distressed" personality, which is characterized by negative affectivity and social inhibition. These individuals are at risk for a variety of health issues, including burnout, poor living standards, cardiovascular disease, and gastrointestinal dysfunction .
The Extraversion scale, which Eysenck conceptualized as a continuum from extraversion to introversion, was used to examine another important aspect of personality. Patients with IBD in this group had lower scores, which was be expected, given that the Inhibitedness scale score was higher. They were introverted, reserved, distant, self-controlled, and noncommittal. In a study conducted by Sajadinejad et al. , 58 patients with UC and 59 healthy control participants (selected from their family members) were assessed using the NEO Personality Inventory in Five Factors, the type D personality questionnaire, and the WHO quality of life questionnaire. Patients with UC scored lower on extraversion and higher on neuroticism and had a higher share of type D personality traits than the control group. Patients with UC who had a type D personality reported considerably lower average ratings on the Quality of Life Questionnaire than patients without a type D personality.
Within the group of patients with IBD, the highest scores on the Emotionality scale, defined as neuroticism by Eysenck and Eysenck  and McCrae and Costa  in the Big Five questionnaire, highlight the fact that they tend to be emotionally unstable and experience more internal conflicts. Their psychological condition was frequently unbalanced, with the patients acting excitable and easily provoked at times and asthenic, low energy, or uncommitted at other times. In terms of neuroticism, the findings were similar not only to those of the aforementioned study but also to those obtained by La Barbera et al. , who evaluated 100 people with IBD and a control group of 66 healthy people at a hospital in Palermo, Italy. Neuroticism, alexithymia (particularly external thinking), impulsive behaviors, and possibly traits perceived as feminine were discovered in a group predisposed to the development of IBD. The Romanian sample, unlike the Italian sample, showed no violent tendencies.
The low extraversion and strong emotionality revealed in the Romanian sample were likewise found in other groups who answered various questionnaires to measure similar characteristics. In addition, Tkalčić et al.  studied 34 patients with UC, 30 with CD, and 86 with IBD, as well as 122 healthy people and discovered that neuroticism was a strong predictor of both physical and mental aspects of quality of life.
The lower scores on the Social Orientation scale imply that patients with IBD from this study are less eager to care for sick people, are less warm and affective in interpersonal connections and are less supportive of others when compared to the national normative sample. Although no paper that referred to this scale was found, it is possible that patients’ lack of social and emotional involvement stemmed from their own need for care and emotional support. That is, this lack could be a protective or energy-saving mechanism.
Higher ratings on the Health Concerns scale suggest a fear of illness (infections, accidents), cautious conduct, and even hypochondria in the tested respondents. These people seek medical advice but are dubious of it, frequently seeking a second opinion. They examine medical treatments, alternatives, and other therapies in depth. This finding is similar to what Witges et al.  found. The researchers employed the Health Anxiety Inventory, which evaluates difficulties related to the magnitude of health problems and discovered that individuals with IBD had high scores when their symptoms were more severe. Health anxiety can range from mild to severe, and it can be a reaction to a chronic illness. Any symptom that was prevalent in people without digestive issues, such as bloating, abdominal embarrassment, or soft stools, could be perceived as a symptom of recurrence in patients with IBD and thus be associated with concern and distress. Health anxiety has been studied in patients with cancer who have shown fear of recurrence , as well as those with various chronic diseases . Lebel et al.  discuss health anxiety in the context of the removal of the diagnosis of hypochondria from the Diagnostic and Statistical Manual of Mental Disorders (DSM – 5) and the occurrence of the diagnosis. Somatic symptom disorder is frequently linked to medical conditions and according to the DSM-5, encompasses roughly three-quarters of people previously diagnosed with hypochondria. In the absence of somatic symptoms, a quarter of persons diagnosed with hypochondria had higher levels of health anxiety . Health concerns in the absence of disease are distinct from health concerns in the presence of disease, particularly chronic diseases such as IBD. Additional research is required in this area, as it is essential to determine how many of these patients with IBD develop anxiety disorder due to a medical condition  .
Patients with IBD in this sample were firmly oriented in their conduct according to social norms and conventional rules of behavior and coexistence, as evidenced by their low score on the Frankness scale. They were interested in actively managing their impact on individuals around them to make a positive impression. This scale, which was not designed as a binary truth-lie mechanism, does not examine the willingness to notice modest behavioral flaws at the edge of social desirability, such as being late for school, making awful remarks about others, finding joy in other people's misery, and expressing opinions having the necessary expertise. The low scores in this sample show that the respondents were not open people, that they were unable to identify such minor social deviations and that they were also conformists, rigid in their approach to breaking certain social conventions.
Presenting a positive self-image to the public to make a positive impression is a common human phenomenon with both positive consequences (e.g., growth, modeling, self-identity, relationships, personal branding)and negative consequences (e.g., manipulation) [49, 50]. To cope, people with IBD may exhibit sensitivity to how they are regarded by others and a fixation on value aspects, such as the need to fit into desirable groups. Additional research is required to fully understand this issue.
The Freiburg Personality Inventory based on medical factors in patients with IBD
The current study found that the activity of the disease and comorbidities influenced several psychological aspects, including the patient's quality of life, an aspect that has also been confirmed by other studies.
Patients with lesions and comorbidities scored higher on the Somatic Complaints scale, as expected. Patients with comorbidities also had higher sores on the Excitability scale. Patients with IBD who had lesions and comorbidities exhibited physical symptoms and were asthenic, anxious about how they would cope with problems and generally pessimistic. Roy et al.  examined data from the Multi-Ethnic Study of Atherosclerosis (MESA), which included 6,814 people aged 45 to 84 with no history of clinical cardiovascular disease. The researchers wanted to see how optimism and pessimism were linked to a variety of medical markers, such as interleukin-6, C-reactive protein, fibrinogen, and homocysteine, and discovered that pessimism was associated with greater levels of inflammatory markers. The high scores on the Somatic Complaints scale indicated pessimism in Romanian patients with IBD who participated in this study, suggesting the need for psychotherapy, personal development (for a more positive outlook), and trust that the generated chemical processes could reduce inflammation.
Many studies have focused on fatigue in individuals with IBD, a disease that has been shown to have severe effects on the quality of life and professional activity . Additionally, the role of bidirectional communication between the intestine and the central nervous system was explored (the bowel-brain axis) in mediating fatigue . High scores on the Somatic Complaints scale revealed asthenia, or fatigue, in patients with IBD in this study, reflecting both the need for enhanced attention to treat anemia, monitoring of how they feed, and the utility of psychological interventions to manage fatigue. Furthermore, psychological and antidepressant therapy could help IBD patients with disrupted brain-intestinal activity. Additional research is required in this area .
The Excitability scale scores were higher in patients with IBD who also had comorbidities, indicating that they had reactive behavior, poor self-control, prolonged bouts of anger, and overly emotional reactions to life situations. It should be highlighted that the scores were greater only in patients with comorbidities, not in the control group. However, Rada et al. , Rada et al. , Rada and Andrei , in addition to using questionnaires and anamneses, employed in-depth interviews in the form of a "life story" or "personal biography notes" and found that patients with IBD tend to hyperbolize unpleasant life events. Given that no higher score was detected on the Aggressiveness scale compared to the control group (normative sample), which would have suggested aggressive imposition of one's own beliefs and a level of hostility toward others, it is plausible that this feature was rather internal. Certainly, in addition to the features specific to IBD, the presence of comorbidities that include suffering and therapies could explain this loss of patience and emotional self-control. In the present study, there were inconsistencies between patients in remission and those in relapse on some psychological parameters. The findings are comparable to those of Küchenhoff , who studied 119 CD patients and 89 patients in remission; life satisfaction was much higher in those in remission, i.e., in relatively good health than in those in the acute phase. However, Mancina et al. , in a cross-sectional study on 109 IBD patients in clinical and endoscopic remission, found that the patient's quality of life was influenced by gastrointestinal symptoms.
Over the course of two years, Osborn  separated CD patients into several categories based on standardized questionnaires, clinical interviews, and thorough disease progression data. The variability of the factors of gender, education level, and marital status was found to be minimal, whereas the activity status of the disease showed fairly large variability depending on the duration and severity of the disease. Similarly, in this study of Romanian patients, no significant difference was detected based on sociodemographic variables, but the disease activity status revealed disparities on the Somatic Complaints and Excitability scales. This finding must be considered because Regev et al.  found that somatization was the only predictor of disease activity beyond depression and anxiety.
Surprisingly, patients in remission scored higher on the Strain scale. Being in remission and thus in reasonable health, it was expected that they would not feel overworked, tense, or as if they were being burdened by demanding requests. It is likely that people in remission seek to reclaim the time when they were in the midst of an active disease and could not keep up with the responsibilities of work or family life. To understand this issue, additional research, particularly qualitative research, is required.
In this study with a Romanian sample, patients with CD scored higher on the Strain scale than those with UC. This finding suggests that although the two conditions have similar symptoms and require similar pharmacological treatment, they should also be treated psychologically to some extent because, in contrast to patients with UC, social adjustment in patients with CD was more dependent on disease activity and was lower when stools and abdominal pain were more common. These results are consistent with those of Probst et al. , who used the FPI-R questionnaire and a semistandardized interview to examine the activity evolution and symptoms of 63 patients with CD and 58 patients with UC. FPI-R scores in CD patients were found to be more impacted by disease activity and somatic signs than in patients with UC. Differences between patients with CD and UC in a state of active disease regarding the impact of psychosocial variables were also found by Sarid et al. , which suggests the need for a relatively specific psychotherapeutic approach to the two conditions.