Peptic Ulcer Disease
0025-7125/91 $0.00
+
.20
Psycho logic Factors Associated
with Peptic U leer Disease
Barbara A. Schindler, MD, * and Dilip Ramchandani, MDt It is not proper to cure the eyes without the head nor the head without the body, so neither is it proper to cure the body without the sou!. SOCRATES
Over the generations clinicians have been intrigued by the relationships between physical disorders and psychologic states. Observations of the role of psychologic processes in the pathogenesis and course of medical diseases may be found in the Bible. Some illnesses, recognized as the classic psychosomatic disorders in the 1930s, appear to be directly affected by the impact of psychosocial factors. Peptic ulcer disease is regarded as one of the psychosomatic disorders. Alexander's initial psychologic constructs, based on retrospective data, were elaborated by the prospective studies of Mirsky and Weiner. 2. 41. 59 The recent explosion in biologic research has produced a clearer understanding of the pathophysiology of peptic ulcer disease and has outpaced the more modest advances made in the psychosomatic arena. Revisions in psychiatric nomenclature and classification of "psychosomatic" disorders have magnified the apparent tenuousness of previously described psychiatric constructs. The focus in psychosomatic research has shifted from the examination of the role of personality factors to that of stressful life events. Separating the roles of premorbid personality traits, the effects of illness-acquired traits, and the impact of psychosocial stressors from the roles of pure biologic and genetic factors present serious methodologic challenges. Some even have questioned the validity of the psychosomatic model for peptic ulcer disease. 1 Yet, clinical experience with peptic ulcer disease patients indicates that a narrow biomedical approach does a disservice to both patient and physician. 16. 31. 66 This article explores how an individual's psychologic profile and mechanisms of coping with stress affect the predisposition, onset, course, and management of peptic ulcer disease. Psychosomatic, psychophysiologic, somatopsychic, and biopsychosocial models, along with the impact of stress,
*Associate
Professor of Psychiatry, and Chief, General Hospital Section, Department of Psychiatry, Medical College of Pennsylvania, Philadelphia, Pennsylvania tAssociate Professor of Psychiatry, Department of Psychiatry, Medical College of Pennsylvania, Philadelphia, Pennsylvania
Medical Clinics of North America-Vo!' 75, No. 4, July 1991
865
866
BARBARA
A.
SCllIJ\iDLER AND DILIP HA\ICIIAI\DA;\J1
will be examined. Methods of assessing the role of psyehologic f~lCtors and the management of these factors in individual patients with peptic ulcer disease are discussed.
PSYCHOSOMATIC MODEL
In 1934, Franz Alexander was the first to investigate carefully the role of psychologic factors in patients with peptic ulcer disease. 2 Before him, it was recognized that certain personality types were prone to developing ulcers, but there was no consensus about their characteristics. Alvarez, for instance, felt that the typical patient was an efficient, active businessmanthe go-getter type. 4 Hartman found the peptic ulcer type to be a man who felt compelled to overcome every obstacle. He believed that unambitious, apathetic, stoic men never had ulcers.26 In 1932, Draper and Touraine found in their peptic ulcer patients a rejection of "unconscious female tendencies" and classified them anatomically as asthenic or longitudinal in build. 13 Alexander and his colleagues found that peptic ulcers as well as nonspecific gastric symptoms developed more frequently in particular personality types, but encountered so many exceptions that they did not regard any generalization as valid. Alexander observed, based on psychoanalytic study of a self-selected group of male patients, that it was a typical psychologic conflict in individuals with many different personalities rather than specific personality types that characterized patients with peptic ulcer disease (specificity hypothesis). He found in his patients a wish to be dependent and to be cared for which clashed with their pride and aspiration for independence and accomplishment. These opposing tendencies created internal conflict, which became apparent in the following way. Overtly, many of these patients showed an exaggerated aggressive, ambitious, and confident attitude. They did not like to accept help and, in fact, would burden themselves with too many responsibilities. However, on a deeper level, these patients longed for the passive, sheltered existence of a little child. Alexander attributed to this covert desire for dependence the often dramatic beneficial effect of "rest cures." Once severe ulcer symptoms developed, patients could acknowledge their wish to withdraw from their responsibilities. :J Alexander did not claim that all patients suffering from peptic ulcer overcompensate for their dependent desires. Some were overtly dependent, demanding, and disgruntled. However, in such patients, dependent wishes were frustrated not by internal self-imposed negation, but by external circumstances of deprivation extending to childhood, rejection, or, conversely, excessive spoiling. 3 Alexander further elaborated the mechanism by which the psyche finds a somatic, physiologic outlet in the form of peptic ulcer. He suggested that when patients find the wish to depend on others inherently unacceptable or are frustrated by external circumstances, they psychologically regress to cope with the resulting distress. Since all infants experience hunger that is eliminated by maternal feeding, a wish to be fed becomes a symbolic
PSYCHULOCIC FACTOHS ASSOCIATED WITll PEPTIC ULCEI\ DISEASE
867
substitute for the wish to be dependent and to be loved and produces the essential psychosomatic transformation. "Psychic" hunger mobilizes the innervations of the stomach and serves as a chronic stimulus to gastric function. The stomach responds continuously as if food were being taken in or about to be taken in. The greater the distress the patient feels, the greater this unconscious "hunger." Chronic hypersecretion of gastric acid and gastric hypermobility then may lead to ulcer formation. 3 Alexander based these postulations on the experimental work of his contemporaries. Silbermann found in his experimcnts that sham feeding of dogs led regularly to ulcer formation. 5l Winkelstein fcmnd evidence of increased nocturnal acid secretion and increased parasympathetic irritability with altered acid secretion in ulcer patients. G2 Wolf and \Voltf attributed the findings of hyperemia, hypermotility, and hypersecretion in a patient with a permanent gastric fistula to hostile feelings the patient was unable to express. G3 This patient returned to normal function when he regained his emotional balance. Mirsky postulated that urine pepsinogen concentrations paralleled gastric secretory activity. He studied ulcer patients and normal subjects for 2 years and kept a simultaneous record of significant daily events from interviews, diaries, and psychotherapy. He concluded that while overt anger did not aHect the rate of gastric secretion, there was a positive relationship between gastric secretion and dependent longings of which patients were not consciously aware. ~l
PSYCHOPHYSIOLOGIC MODEL Alexander's work and theories were, to varying degrees, supported by others. In a prospective hallmark study, Weiner and his colleagues examined 120 gastric acid hypersecretors and hyposecretors among 2073 draftees who underwent 16 weeks of basic training. They suhjected the selected draftees to extensive physical, psychologic, and psychiatric examinations, as well as radiologic studies. They concluded that it was indeed possible to classify a majority of hyper- and hyposecretors on the hasis of their psychologic profile. For hypersecretors, this profile was characterized by marked dependency in relationships, especially with authority figures. Other features included compliant, passive attitude, childish affect, greater need for tactile contact with others, and more immature body images on human drawing tests. Hypersecretors tended to he more depressed, and they somaticized less than hyposecretors who were more comfortable in expressing resentment and hostility. The draftees who developed ulcers were in the top 15% of hypersecretors. S~ This study seemed to provide experimental confirmation of Alexander's clinical findings. However, Weiner and his group did not find support for the theory that specific personality characteristics of the patients who develop peptic ulcer disease cause gastric acid hypersection. Indeed, Mirsky found that serum pepsinogen concentrations were genetically determined and thus unlikely to be caused by psychologic conflict as postulated by Alexander. "2
868
BAHBAHA
A.
SCIIINDLJ1 40. McMillan MA, Ambis D, Siegel JH: Cimetidine and mental confusion . .\I Engl J Med 298:284-285, 1978 41. Mirsky lA, Futtennan P, Kaplan S: Blood plasma pepsinogen n. The activity of the plasma /i'om "normal" subjects, patients with duodenal ulcer, and patients with pernicious anelllia. J Lab Clin .'vIed 40:188, 19.52 42 . .'vlirsky lA: Physiologic, psychologic and social determinants in the etiology of duodenal ulcer. Am J Dig Dis :3:28.5-314, 19.51> 43 . .\Iasiry R, Piper DW: Social aspects of chronic duodenal ulcer. Digestion 27:196-202, 191>3 44. Nellliah JC, Sifneos PE: Affect and hmtasy in patients with psychosomatic disorders. In Hill 0 (ed): Modern Trends in Psychosomatic Medicine, vol 2. London, Butterworth, 1970 4.5. l\yren 0, Adami H, Gustavsson S, et al: Excess sick-listing in non-ulcer dyspepsia. J Clin Gastroenterol 8:339-34.5, 1986 46. Paulley JW, Pelser HE (eds): Psychological Managements for Psychosomatic Disorders. Berlin, Springer-Verlag, 1989, p .53 47. Piper DW, McIntosh JH, Ariotti DE, et a1: Life events and chronic duodenal ulcer: A case control studv. Gut 22:1011-1017, 1981 48. Powel JH, Donn KH: Histamine H,-antagonist drug interactions in perspective: .'vlechanistic concepts and clinical implications. Am J Med 77(suppl .58):.57-83, 1984 49. Hose HM, Jenkins CD, Hurst MW, et al: Air Traffic Controller Health Change Studv: A Prospective Investigation of Physical, Psychological and Work-rE'lated Changes. Washington, DC, USA Dept of Transportation, Federal Aviation Admin, Office of Aviation Medicine, 1978 .50. Sifneos PE: Clinical observations on some patients suffering from a variety of psychosomatic diseases. Proceedings of the 7th European Conference on Psychosomatic Hesearch, Rome. Acta Med Psychosom 1:4,52--4.59, 1967 .51. Silberlllann IS: Experimentelle Magen-Duodenal Ulcer Serzeugung durch scheinfuttern nach Pavlov. Zentralbl f Chir 54:2385-2392, 1927 .52. Schindler BA: Stress, affective disorders, and immune hmction. Med Clin l\orth Am 69(3):.585, 198.5 .53. Sjodin I, Svedlnnd J, Ottosson J, et a1: Controlled study of psychotherapy in chronic peptic ulcer disease. Psychosomatics 27(3):187-196, 1986 ,54. Soli AH: Pathogenesis of peptic ulcer and implications for therapy. N Engl J Med 822:909916, 1990 .5.5. Talley NJ, Fung LB, Gilligan IJ, et al: Association of anxiety, neuroticism and depression with dyspepsia of unknown cause: A case control study. Gastroenterology 90:886-892, 1986 ,56. Tennant C, GOlllston K, Langeluddecke P: Psychological correlates of gastric and duodenal ulcer disease. Psych Med 16:36.5-371, 1986 .57. Thompson DG, Richelson E, Malagelada JR: Perturbation of gastric emptying and duodenal motility through the central nervous system. Gastroenterology 83: 1200-1206, 1983 .58. Walker P, Luther J, SamlofI' ~I, et al: Life events, stress and psychosocial factors in men with peptic ulcer disease. Gastroenterology 94:323-330, 1988 .59. Weiner H, Thaler M, Heiser M, et a1: Etiology of duodenal ulcer I: Helation of specific psychological characteristics to rate of gastric secretion (serum pepsinogen). Psychosom Med 19:1-10, 1957 60. \Veiner H: The prospects for psychosomatic medicine: Selected topics. Psychosom .'vIed 44:491-517, 1982 61. \Veiss Jl\-\: Influence of psychological variables on stress-induced pathology. In Porter R, Knight J (eds): Physiology, Emotions, and Psychosomatic lllness. (Ciba Foundation Symposium 8.) New York, Associated Scientific Publishers, 1972 62. Winkelstein A: A new therapy of peptic ulcer. Am J >..Ied Sci 18.5:69.5, 1933
876
BAl\BARA
A.
SCIIINDLER AND DILIP RA~1CHANDANI
6:3. \\folcott DL. \Vellis DK. Rohertson CR, et al: Serum gastrin and the family environment in duodenal ulcer disease. Psvchosom Med 4:3:501-507, 1981 64. Wolf S, Almy TP, Bachrach WH, et al: The role of stress in peptic ulcer disease. J Hum Stress S:27 -:37, 1979 6.5. Wolf S, Wolf1:' HG: Human Gastric Function. New York, Oxford University Press, 194:3 66. Zola I: Sociocultural factors in the seeking of medical aid. A progress report. Trans Psych Res 14:62-6.5, 196:3
Address reprint requests to Barhara A. Schindler, MD Department of Psychiatry The :-'Iedical College of Pennsylvania 3300 Henrv Avenue Philadelphia, PA 19129
0025-7125/91 $0.00
+
.20
Psycho logic Factors Associated
with Peptic U leer Disease
Barbara A. Schindler, MD, * and Dilip Ramchandani, MDt It is not proper to cure the eyes without the head nor the head without the body, so neither is it proper to cure the body without the sou!. SOCRATES
Over the generations clinicians have been intrigued by the relationships between physical disorders and psychologic states. Observations of the role of psychologic processes in the pathogenesis and course of medical diseases may be found in the Bible. Some illnesses, recognized as the classic psychosomatic disorders in the 1930s, appear to be directly affected by the impact of psychosocial factors. Peptic ulcer disease is regarded as one of the psychosomatic disorders. Alexander's initial psychologic constructs, based on retrospective data, were elaborated by the prospective studies of Mirsky and Weiner. 2. 41. 59 The recent explosion in biologic research has produced a clearer understanding of the pathophysiology of peptic ulcer disease and has outpaced the more modest advances made in the psychosomatic arena. Revisions in psychiatric nomenclature and classification of "psychosomatic" disorders have magnified the apparent tenuousness of previously described psychiatric constructs. The focus in psychosomatic research has shifted from the examination of the role of personality factors to that of stressful life events. Separating the roles of premorbid personality traits, the effects of illness-acquired traits, and the impact of psychosocial stressors from the roles of pure biologic and genetic factors present serious methodologic challenges. Some even have questioned the validity of the psychosomatic model for peptic ulcer disease. 1 Yet, clinical experience with peptic ulcer disease patients indicates that a narrow biomedical approach does a disservice to both patient and physician. 16. 31. 66 This article explores how an individual's psychologic profile and mechanisms of coping with stress affect the predisposition, onset, course, and management of peptic ulcer disease. Psychosomatic, psychophysiologic, somatopsychic, and biopsychosocial models, along with the impact of stress,
*Associate
Professor of Psychiatry, and Chief, General Hospital Section, Department of Psychiatry, Medical College of Pennsylvania, Philadelphia, Pennsylvania tAssociate Professor of Psychiatry, Department of Psychiatry, Medical College of Pennsylvania, Philadelphia, Pennsylvania
Medical Clinics of North America-Vo!' 75, No. 4, July 1991
865
866
BARBARA
A.
SCllIJ\iDLER AND DILIP HA\ICIIAI\DA;\J1
will be examined. Methods of assessing the role of psyehologic f~lCtors and the management of these factors in individual patients with peptic ulcer disease are discussed.
PSYCHOSOMATIC MODEL
In 1934, Franz Alexander was the first to investigate carefully the role of psychologic factors in patients with peptic ulcer disease. 2 Before him, it was recognized that certain personality types were prone to developing ulcers, but there was no consensus about their characteristics. Alvarez, for instance, felt that the typical patient was an efficient, active businessmanthe go-getter type. 4 Hartman found the peptic ulcer type to be a man who felt compelled to overcome every obstacle. He believed that unambitious, apathetic, stoic men never had ulcers.26 In 1932, Draper and Touraine found in their peptic ulcer patients a rejection of "unconscious female tendencies" and classified them anatomically as asthenic or longitudinal in build. 13 Alexander and his colleagues found that peptic ulcers as well as nonspecific gastric symptoms developed more frequently in particular personality types, but encountered so many exceptions that they did not regard any generalization as valid. Alexander observed, based on psychoanalytic study of a self-selected group of male patients, that it was a typical psychologic conflict in individuals with many different personalities rather than specific personality types that characterized patients with peptic ulcer disease (specificity hypothesis). He found in his patients a wish to be dependent and to be cared for which clashed with their pride and aspiration for independence and accomplishment. These opposing tendencies created internal conflict, which became apparent in the following way. Overtly, many of these patients showed an exaggerated aggressive, ambitious, and confident attitude. They did not like to accept help and, in fact, would burden themselves with too many responsibilities. However, on a deeper level, these patients longed for the passive, sheltered existence of a little child. Alexander attributed to this covert desire for dependence the often dramatic beneficial effect of "rest cures." Once severe ulcer symptoms developed, patients could acknowledge their wish to withdraw from their responsibilities. :J Alexander did not claim that all patients suffering from peptic ulcer overcompensate for their dependent desires. Some were overtly dependent, demanding, and disgruntled. However, in such patients, dependent wishes were frustrated not by internal self-imposed negation, but by external circumstances of deprivation extending to childhood, rejection, or, conversely, excessive spoiling. 3 Alexander further elaborated the mechanism by which the psyche finds a somatic, physiologic outlet in the form of peptic ulcer. He suggested that when patients find the wish to depend on others inherently unacceptable or are frustrated by external circumstances, they psychologically regress to cope with the resulting distress. Since all infants experience hunger that is eliminated by maternal feeding, a wish to be fed becomes a symbolic
PSYCHULOCIC FACTOHS ASSOCIATED WITll PEPTIC ULCEI\ DISEASE
867
substitute for the wish to be dependent and to be loved and produces the essential psychosomatic transformation. "Psychic" hunger mobilizes the innervations of the stomach and serves as a chronic stimulus to gastric function. The stomach responds continuously as if food were being taken in or about to be taken in. The greater the distress the patient feels, the greater this unconscious "hunger." Chronic hypersecretion of gastric acid and gastric hypermobility then may lead to ulcer formation. 3 Alexander based these postulations on the experimental work of his contemporaries. Silbermann found in his experimcnts that sham feeding of dogs led regularly to ulcer formation. 5l Winkelstein fcmnd evidence of increased nocturnal acid secretion and increased parasympathetic irritability with altered acid secretion in ulcer patients. G2 Wolf and \Voltf attributed the findings of hyperemia, hypermotility, and hypersecretion in a patient with a permanent gastric fistula to hostile feelings the patient was unable to express. G3 This patient returned to normal function when he regained his emotional balance. Mirsky postulated that urine pepsinogen concentrations paralleled gastric secretory activity. He studied ulcer patients and normal subjects for 2 years and kept a simultaneous record of significant daily events from interviews, diaries, and psychotherapy. He concluded that while overt anger did not aHect the rate of gastric secretion, there was a positive relationship between gastric secretion and dependent longings of which patients were not consciously aware. ~l
PSYCHOPHYSIOLOGIC MODEL Alexander's work and theories were, to varying degrees, supported by others. In a prospective hallmark study, Weiner and his colleagues examined 120 gastric acid hypersecretors and hyposecretors among 2073 draftees who underwent 16 weeks of basic training. They suhjected the selected draftees to extensive physical, psychologic, and psychiatric examinations, as well as radiologic studies. They concluded that it was indeed possible to classify a majority of hyper- and hyposecretors on the hasis of their psychologic profile. For hypersecretors, this profile was characterized by marked dependency in relationships, especially with authority figures. Other features included compliant, passive attitude, childish affect, greater need for tactile contact with others, and more immature body images on human drawing tests. Hypersecretors tended to he more depressed, and they somaticized less than hyposecretors who were more comfortable in expressing resentment and hostility. The draftees who developed ulcers were in the top 15% of hypersecretors. S~ This study seemed to provide experimental confirmation of Alexander's clinical findings. However, Weiner and his group did not find support for the theory that specific personality characteristics of the patients who develop peptic ulcer disease cause gastric acid hypersection. Indeed, Mirsky found that serum pepsinogen concentrations were genetically determined and thus unlikely to be caused by psychologic conflict as postulated by Alexander. "2
868
BAHBAHA
A.
SCIIINDLJ1 40. McMillan MA, Ambis D, Siegel JH: Cimetidine and mental confusion . .\I Engl J Med 298:284-285, 1978 41. Mirsky lA, Futtennan P, Kaplan S: Blood plasma pepsinogen n. The activity of the plasma /i'om "normal" subjects, patients with duodenal ulcer, and patients with pernicious anelllia. J Lab Clin .'vIed 40:188, 19.52 42 . .'vlirsky lA: Physiologic, psychologic and social determinants in the etiology of duodenal ulcer. Am J Dig Dis :3:28.5-314, 19.51> 43 . .\Iasiry R, Piper DW: Social aspects of chronic duodenal ulcer. Digestion 27:196-202, 191>3 44. Nellliah JC, Sifneos PE: Affect and hmtasy in patients with psychosomatic disorders. In Hill 0 (ed): Modern Trends in Psychosomatic Medicine, vol 2. London, Butterworth, 1970 4.5. l\yren 0, Adami H, Gustavsson S, et al: Excess sick-listing in non-ulcer dyspepsia. J Clin Gastroenterol 8:339-34.5, 1986 46. Paulley JW, Pelser HE (eds): Psychological Managements for Psychosomatic Disorders. Berlin, Springer-Verlag, 1989, p .53 47. Piper DW, McIntosh JH, Ariotti DE, et a1: Life events and chronic duodenal ulcer: A case control studv. Gut 22:1011-1017, 1981 48. Powel JH, Donn KH: Histamine H,-antagonist drug interactions in perspective: .'vlechanistic concepts and clinical implications. Am J Med 77(suppl .58):.57-83, 1984 49. Hose HM, Jenkins CD, Hurst MW, et al: Air Traffic Controller Health Change Studv: A Prospective Investigation of Physical, Psychological and Work-rE'lated Changes. Washington, DC, USA Dept of Transportation, Federal Aviation Admin, Office of Aviation Medicine, 1978 .50. Sifneos PE: Clinical observations on some patients suffering from a variety of psychosomatic diseases. Proceedings of the 7th European Conference on Psychosomatic Hesearch, Rome. Acta Med Psychosom 1:4,52--4.59, 1967 .51. Silberlllann IS: Experimentelle Magen-Duodenal Ulcer Serzeugung durch scheinfuttern nach Pavlov. Zentralbl f Chir 54:2385-2392, 1927 .52. Schindler BA: Stress, affective disorders, and immune hmction. Med Clin l\orth Am 69(3):.585, 198.5 .53. Sjodin I, Svedlnnd J, Ottosson J, et a1: Controlled study of psychotherapy in chronic peptic ulcer disease. Psychosomatics 27(3):187-196, 1986 ,54. Soli AH: Pathogenesis of peptic ulcer and implications for therapy. N Engl J Med 822:909916, 1990 .5.5. Talley NJ, Fung LB, Gilligan IJ, et al: Association of anxiety, neuroticism and depression with dyspepsia of unknown cause: A case control study. Gastroenterology 90:886-892, 1986 ,56. Tennant C, GOlllston K, Langeluddecke P: Psychological correlates of gastric and duodenal ulcer disease. Psych Med 16:36.5-371, 1986 .57. Thompson DG, Richelson E, Malagelada JR: Perturbation of gastric emptying and duodenal motility through the central nervous system. Gastroenterology 83: 1200-1206, 1983 .58. Walker P, Luther J, SamlofI' ~I, et al: Life events, stress and psychosocial factors in men with peptic ulcer disease. Gastroenterology 94:323-330, 1988 .59. Weiner H, Thaler M, Heiser M, et a1: Etiology of duodenal ulcer I: Helation of specific psychological characteristics to rate of gastric secretion (serum pepsinogen). Psychosom Med 19:1-10, 1957 60. \Veiner H: The prospects for psychosomatic medicine: Selected topics. Psychosom .'vIed 44:491-517, 1982 61. \Veiss Jl\-\: Influence of psychological variables on stress-induced pathology. In Porter R, Knight J (eds): Physiology, Emotions, and Psychosomatic lllness. (Ciba Foundation Symposium 8.) New York, Associated Scientific Publishers, 1972 62. Winkelstein A: A new therapy of peptic ulcer. Am J >..Ied Sci 18.5:69.5, 1933
876
BAl\BARA
A.
SCIIINDLER AND DILIP RA~1CHANDANI
6:3. \\folcott DL. \Vellis DK. Rohertson CR, et al: Serum gastrin and the family environment in duodenal ulcer disease. Psvchosom Med 4:3:501-507, 1981 64. Wolf S, Almy TP, Bachrach WH, et al: The role of stress in peptic ulcer disease. J Hum Stress S:27 -:37, 1979 6.5. Wolf S, Wolf1:' HG: Human Gastric Function. New York, Oxford University Press, 194:3 66. Zola I: Sociocultural factors in the seeking of medical aid. A progress report. Trans Psych Res 14:62-6.5, 196:3
Address reprint requests to Barhara A. Schindler, MD Department of Psychiatry The :-'Iedical College of Pennsylvania 3300 Henrv Avenue Philadelphia, PA 19129
