Stress, but not Helicobacter pylori, is associated with peptic ulcer disease in a Thai population.

The purpose of this study was to clarify the relation between psychological and other risk factors, notably helicobacter pylori (H. pylori) infection, in contributing to the occurrence of peptic ulcer (PU) disease. A retrospective case-control study was conducted at Siriraj Hospital, Bangkok from March to December 2000. Seventy endoscopically diagnosed patients with new PU or peptic perforation were compared with 70 patients with other diseases as well as blood donors control matched for age and sex. Historical risk factors, H. pylori Immunoglobulin G antibody (H. pylori IgG Ab), stress (Perceived Stress Questionnaire) and hostility (MMPI Hostility Scale) were assessed. Data were analyzed using logistic regression analysis. The results showed that PU was associated with chronic stress (aOR 2.9, p = 0.01; 95% CI, 1.3-6.5) and family history of PU (aOR 2.4, p < 0.03; 95% CI, 1.1-5.1), with an interaction effect between stress and irregular mealtimes (aOR 4.8, p = 0.01; 95% CI, 1.3-16.9). The incidence rate of H. pylori infection in PU patients was similar to the control group (61.4% and 50.0%, respectively, OR 1.2). The authors conclude that stress and family history, not H. pylori infection, are important risk factors for PU in this population. This finding supports previous studies in Thailand, showing a high prevalence of H. pylori in the population but a low association with PU, in contrast to developed countries. It remains to be seen whether the impact of a family history is due to genetic factors or shared life-style patterns.

Cross-cultural variation in disease-related concerns among patients with inflammatory bowel disease.

OBJECTIVE: The aim of this work was to study cross-cultural variations in the impact of inflammatory bowel disease (IBD) on health-related quality of life by an international comparison of disease-related concerns. METHODS: Item and factor scores on the Rating Form of Inflammatory Bowel Disease Patient Concerns and overall mean concern levels were compared by analysis of variance among 2002 IBD patients in eight countries. RESULTS: The overall level of concern varied from 51 out of 100 in Portugal to 19 in Sweden, with intermediate scores for Italy (43), Canada (40), United States (39), France (39), Austria (33), and Israel (25). Having surgery, an ostomy, the uncertain nature of the disease, and medication side effects were each rated among the first five in importance in six countries. Other items varied considerably. For example, concern regarding pain and suffering was high in Israel and low in Portugal, whereas concern over developing cancer was low in Italy. Concern over financial issues and access to high-quality health care were inversely associated with measures of national economic prosperity. CONCLUSIONS: 1) Cross-cultural comparisons of patient concerns related to IBD are feasible using translated scales. 2) Reporting tendencies vary greatly; within Europe, patients from southern countries report greater overall concern. 3) The complications and the variable evolution of disease elicit general concern, but the importance of specific issues varies among countries. 4) The reasons for national differences may have social, cultural, and/or economic determinants with relevance to the patient-physician relationship, patient education, and therapeutic decision making.

Psychosocial predictors of hypertension in men and women.

BACKGROUND: Psychosocial stressors have been shown to predict hypertension in several cohort studies; patterns of importance, sex differences, and interactions with standard risk factors have not been fully characterized. METHODS: Among 2357 adults in a population sample of Alameda County, California, free of hypertension in 1974, 637 reported in 1994 having ever used antihypertensive medication (27.9% of the men and 26.3% of the women). The effects of baseline psychosocial, behavioral, and sociodemographic factors on the incidence of treated hypertension were examined using multiple logistic regression. RESULTS: Low education, African American race, low occupational prestige, worry about job stability, feeling less than very good at one's job, social alienation, and depressive symptoms each had significant (P<.05) age-adjusted associations with incident hypertension. Associations were weakened by adjustment for body mass index, alcohol consumption, smoking status, and leisure time physical activity, especially the associations of anomy and depression, which persisted in women but not in men. In multivariate models, job insecurity (odds ratio, 1.6), unemployment (odds ratio, 2.7), and low self-reported job performance (odds ratio, 2.1) remained independent predictors of hypertension in men, whereas low-status work (odds ratio, 1.3) was an independent predictor of hypertension in women. CONCLUSIONS: In the general population, low occupational status and performance and the threat or reality of unemployment increase the likelihood of developing hypertension, especially among men, independent of demographic and behavioral risk factors. Psychological distress and social alienation may also increase hypertension incidence, especially in women, chiefly through an association with health risk behaviors.

Stress and exacerbation in ulcerative colitis: a prospective study of patients enrolled in remission.

OBJECTIVE: We sought to determine whether psychosocial factors influence the course of ulcerative colitis, hypothesizing that high perceived stress among patients with inactive disease will increase the risk of subsequent exacerbation. METHODS: Sixty-two patients with known ulcerative colitis were enrolled into a prospective cohort study while in clinical remission. Their perceived stress, depressive symptoms, and stressful life events were followed, along with potential confounders, for up to 45 months; exacerbation status was monitored for up to 68 months. RESULTS: The 27 patients who experienced an exacerbation were compared with those who remained in remission. Having a score in the upper tertile on the long-term (past 2 yr) baseline Perceived Stress Questionnaire significantly increased the actuarial risk of exacerbation (hazards ratio = 2.8, 95% confidence interval 1.1-7.2). At any given study visit, high long-term stress tripled the risk of exacerbation during the next 8 months (risk for the three tertiles, 8.3%, 16.7%, and 26.2%, p = 0.02). Shorter sleep time, briefer remission, histological activity, and use of nonsteroidal antiinflammatory drugs, antibiotics, or oral contraceptives also increased the medium- and/or long-term risk of exacerbation, but adjustment for these variables did not eliminate the associations with stress. Exacerbation was not associated with stressful life events, depressive symptoms, short-term (past month) perceived stress, smoking, disease extent or duration, or severity of recent course. CONCLUSIONS: Short-term stress does not trigger exacerbation in ulcerative colitis, but long-term perceived stress increases the risk of exacerbation over a period of months to years.

The very model of a modern etiology: a biopsychosocial view of peptic ulcer.

OBJECTIVE: Research on ulcer psychosomatics has plummeted since the early 1970s, to the applause of many who argue that ulcer is simply an infectious disease. The purpose of this article is to discuss the relevance of ulcer psychogenesis in the age of Helicobacter pylori. METHODS: A critical literature review was conducted. RESULTS: There is a substantial and methodologically sound body of prospective studies linking stress with the onset and course of peptic ulcer. Psychosocial factors can be estimated to contribute to 30% to 65% of ulcers, whether related to nonsteroidal antiinflammatory drugs, H. pylori, or neither. The observed association between stress and ulcer is accounted for, in part, by recall bias, misreported diagnoses, and confounding by low socioeconomic status (a source of stress and of ulcer risk factors, such as H. pylori and on-the-job exertion) and by distressing medical conditions (which lead to use of nonsteroidal antiinflammatory drugs). Of the residual, true association, a substantial proportion is accounted for by mediation by health risk behaviors, such as smoking, sleeplessness, irregular meals, heavy drinking, and, again, nonsteroidal antiinflammatory drugs. The remainder results from psychophysiologic mechanisms that probably include increased duodenal acid load, the effects of hypothalamic-pituitary-adrenal axis activation on healing, altered blood flow, and impairment of gastroduodenal mucosal defenses. CONCLUSIONS: Peptic ulcer is a valuable model for understanding the interactions among psychosocial, socioeconomic, behavioral, and infectious factors in causing disease. The discovery of H. pylori may serve, paradoxically, as a stimulus to researchers for whom the concepts of psychology and infection are not necessarily a contradiction in terms.

Peptic ulcer at the end of the 20th century: biological and psychological risk factors.

The prevailing concept of peptic ulcer etiology has swung over entirely in just a few years from the psychological to the infectious, yet the rich literature documenting an association between psychosocial factors and ulcer is not invalidated by the discovery of Helicobacter pylori. Physical and psychological stressors interact to induce ulcers in animal models, concrete life difficulties and subjective distress predict the development of ulcers in prospective cohorts, shared catastrophes such as war and earthquakes lead to surges in hospitalizations for complicated ulcers, and stress or anxiety can worsen ulcer course. Many known ulcer risk factors, including smoking, nonsteroidal anti-inflammatory drug use, heavy drinking, loss of sleep and skipping breakfast, can increase under stress; the association of low socioeconomic status with ulcer is also accounted for in part by psychosocial factors. Among possible physiological mechanisms, stress may induce gastric hypersecretion, reduce acid buffering in the stomach and the duodenum, impair gastroduodenal blood flow, and affect healing or inflammation through psychoneuroimmunological mechanisms. Psychosocial factors seem to be particularly prominent among idiopathic or complicated ulcers, but they are probably operative in run of the mill H pylori disease as well, either through additive effects or by facilitating the spread of the organism across the pylorus, while gastrointestinal damage by nonsteroidal anti-inflammatory drugs can also be potentiated by stress. Although the clinical importance of peptic ulcer is fading along with the millennium, due to secular trends and new therapies, it remains worthy of study as a splendid example of the biopsychosocial model.

Socioeconomic status and ulcer. A prospective study of contributory risk factors.

Peptic ulcer is associated with low socioeconomic status. In this study we used longitudinal population-based data to investigate factors other than Helicobacter pylori that might contribute to this association. Of 4597 Alameda County Study participants, 104 developed ulcers between 1965 and 1974. We examined the impact of baseline risk factors on the association between education and incident ulcer. Among women, high school dropouts had a higher risk of incident ulcer than those who attended college (age-adjusted odds ratio [OR], 3.3; 95% confidence interval [CI], 1.5, 7.3). Adjustment for smoking, alcohol, lack of sleep, skipping breakfast, chronic pain, and liver disease eliminated 21.7% of this excess risk, whereas adjustment for psychological characteristics and life stress eliminated 56.5% of the risk; adjusted for all risk factors, the OR was 1.9. Among men, the risk associated with low education was weaker (OR, 1.9; 95% CI, 0.9, 3.9). Health risk behaviors and poor health had a greater impact (55.5% drop in excess risk with adjustment) and psychosocial factors a lesser impact (33.3% drop) in men than in women. Adjustment for heavy on-the-job labor decreased the risk by 77.8%, whereas the fully adjusted OR was 1.0. We conclude that psychological stress, health risk behaviors, analgesic use, and hard physical labor may contribute to the increased risk of ulcer in low socioeconomic populations.

Socioeconomic status, number of siblings, and respiratory infections in early life as determinants of atopy in children.

Asthma and allergic disorders have been on the increase in recent decades, especially among children living in affluent countries; some aspects of the "Western" way of life may explain this trend. We evaluated the relation of aeroallergen skin test reactivity with socioeconomic status, number of siblings, and respiratory infections in early life. We examined a total of 2,226 schoolchildren, ages 7-11 years, in three areas of Lazio, Italy. Skin prick tests were performed to assess atopic status, and self-administered questionnaires were completed by the parents. The prevalence of prick test positivity was greater among children whose fathers were in the highest educational level than among those in the lowest [prevalence ratio (PR) = 1.58; 95% confidence interval (CI) = 1.21-2.06]. There was also a lower prevalence of atopy among larger sibships (PR = 0.38 for subjects with four or more siblings vs those without siblings; 95% CI = 0.14-0.99). A history of bronchitis or bronchiolitis before age 2 years was weakly associated with an increased risk of atopy, whereas a history of pertussis or pneumonia was not. Both the effect of father's education and the influence of larger sibship size remained when we adjusted for several potential confounding factors, including respiratory infections in early life. We infer that higher socioeconomic status and lower sibling number are determinants of atopy in this Italian population. Protection arising from early severe respiratory infections does not explain this association, although we cannot exclude a role for other viral infections.

Psychological predictors of peptic ulcer incidence in the Alameda County Study.

It has often been suggested that mood and personality predispose to peptic ulcer, but little prospective evidence exists. We used longitudinal data from the Alameda County Study to seek associations of psychological characteristics with later ulcer development, taking into account the possible confounding or mediating, taking into account the possible confounding or mediating roles of nonpsychological factors. Among 4,595 Alameda County Study subjects ulcer-free in 1965, we studied five baseline psychological measures (depression, hostility, ego resiliency, social alienation or anomy, and personal uncertainty) with respect to reported ulcer in 1973-1974. All five measures had significant age-adjusted associations with incident ulcer [odds ratio (O.R.) 1.8-2.6]. After adjustment for smoking, drinking, skipping breakfast, lack of sleep, painful medical conditions, and liver disease, three measures remained significant: depression, anomy, and hostility. The age-adjusted O.R. of 2.8 [95% confidence interval (C.I.) 1.6, 4.8] for an upper versus a lower tertile index of independently predictive psychological factors fell to 2.1 with adjustment for health-related behaviors and medical conditions, and reached 1.7 (C.I. 1.0, 3.1) after addition of education to the model. We conclude that depression, maladjustment, and hostility are prospectively associated with peptic ulcer. These associations are partially accounted for by confounding or mediation by standard risk factors, and are to some extent related to socioeconomic status.

Long-term symptom patterns in duodenal ulcer: psychosocial factors.

Seventy-five patients with recent-onset dyspepsia and endoscopically visible duodenal ulcer underwent psychological evaluation. Following ranitidine treatment, they were reinterviewed periodically for 12 to 76 months (mean 38.6). Ulcer symptoms were present during a mean of 14.9% of follow-up months. Patients did significantly worse if they had a low-status occupation, low education, depression, stressful life events, or abnormal Minnesota Multiphasic Personality Inventory at baseline. Of patients recalling premorbid life stress, those with a normal MMPI had a particularly benign course, whereas those with an abnormal MMPI did particularly poorly (6% versus 29% of months symptomatic: p < 0.04). Age, gender, smoking, drinking, antiinflammatory drugs, pepsinogen, Helicobacter pylori titers, and initial healing had no prognostic effect. Low socioeconomic status, life stress, depression, and psychopathology each predict a relatively poor symptom outcome for duodenal ulcer treated with antisecretory therapy, but psychologically stable individuals who develop an ulcer under stress have an excellent long-term prognosis.

Is there health in wellness?

In the last 20 years, patient autonomy has vastly increased and a "well-being" movement has flourished, with great benefits but with definite drawbacks as well. Exaggeration of the individual's potential for prevention and self-healing can foster a crude psychological reductionism that hampers potential for subtle etiologic understanding and may weaken research, as well as creating a tendency to blame the victim. Probing of the health effects of any activity before engaging in it can lead to healthier-than-thouness and a fear of living. The well-being movement tends to ignore social causes of disease in favor of individual ones and therefore to disregard a need for social remedies. Both theory and practice can be contaminated by economic motives: Medicine is expensive, meditation is cheap. The chasm between the "mind-body" school and the dominant medical model may have widened as some holistically minded individuals, finding a haven in the well-being movement, give up on affecting the medical mainstream. Thus, the advance of holistic medicine has aided in conceptualizing the health-illness continuum, in understanding pathogenesis, and in discovering new preventive and therapeutic tools, but its emphasis on internal causes and therapies should not be allowed to detract resources from the equally important ones lying outside the realm of lifestyle.

Psychologic predictors of duodenal ulcer healing.

We investigated psychologic influences on duodenal ulcer by examining the effect of personality, stress, and mood, measured at diagnosis, on subsequent ulcer healing. Stressful life events, psychopathology (assessed using the Minnesota Multiphasic Personality Inventory), anxiety, depression, smoking, alcohol consumption, nonsteroidal antiinflammatory drug use, and serum pepsinogen I levels were determined immediately after endoscopy showed duodenal ulcer craters in 70 patients with recent onset of symptoms. Endoscopy was repeated following 6 weeks of ranitidine therapy. Six ulcers (8.6%) persisted, and the duodenum remained inflamed in an additional five cases, for a total of 16% with incomplete healing. The only baseline characteristic significantly associated with poor healing was anxiety (p = 0.03 for ulcer persistence, p = 0.02 for incomplete healing). Being in the highest anxiety tertile was associated with a more than fourfold elevation in the risk of incomplete healing (p = 0.02). The association between anxiety and poor healing was not changed by modification of the anxiety score to eliminate gastrointestinal symptom items or by adjustment for serum pepsinogen, sex, or cigarette smoking. Anxiety inhibits the healing of duodenal ulcers treated with adequate antisecretory therapy.

Sociodemographic characteristics, life stressors, and peptic ulcer. A prospective study.

The role of psychosocial factors in peptic ulcer remains controversial. We have investigated the relationship between socioeconomic status, concrete stressors, and ulcers in a longitudinally followed, population-based cohort, taking confounding risk factors into account. A total of 6,928 adults completed the Alameda County Study's baseline questionnaire in 1965; 4,595 ulcer-free on enrollment responded again in 1973-1974. Reported cases of ¿stomach or duodenal¿ ulcer during the year before each of the two surveys were examined with relation to 1965 characteristics: 288 subjects reported ulcers at baseline, and 104 reported new ulcers on follow-up. Sociodemographic characteristics associated with incident ulcers (age-adjusted) were, in women, low education, a blue-collar household, overcrowding, unemployment, marital strain, and children's problems; in men, nonwhite race. Prevalent ulcers were associated in women with sociability and children's problems; in men, with blue-collar occupation, low education, financial difficulties, marital strain, children's problems, and a sense of failure. Adjustment for smoking, alcohol, chronic bronchitis, arthritis, liver disease, and skipping breakfast weakened but did not eliminate these associations; adjustment for socioeconomic status further attenuated the associations of specific problems. Low socioeconomic status and concrete life difficulties are associated with peptic ulcer in the general population cross-sectionally and prospectively after adjustment for major physical risk factors, lending credence to a relationship between psychological stress and peptic ulcer.

Patterns of biologic and psychologic risk factors in duodenal ulcer patients.

To clarify whether and how psychologic factors might contribute to peptic ulcer, in this study we addressed the relations between psychologic characteristics and known biologic risk factors among ulcer patients. In 75 patients with recent-onset, symptomatic duodenal ulcer, an index of three potential psychologic risk factors (stressful life events, abnormal Minnesota Multiphasic Personality Inventory, mood disturbance) was examined in relation to historical risk factors (sex, age, seasonality, family history, smoking, alcohol use, coffee consumption, nonsteroidal antiinflammatory drug use), and to blood type, serum pepsinogen I, and Helicobacter pylori antibody titers. The more risk factors in a patient's history, the less likely he or she was to have psychopathology or stress (r = -0.45, p = 0.0007). The mean number of conventional risk factors was 2.7 in patients with all three psychologic risk factors and 4.4 in patients with none; conversely, the mean number of psychologic factors was 0.9 among patients with five or more biologic risk factors and 2.1 among patients with fewer than three risk factors. This negative association was strongest among patients with no previous ulcer history. The psychologic factors also tended to vary inversely with H. pylori antibody titers but not with blood type O or pepsinogen. Duodenal ulcer patients who are atypical in terms of their conventional risk factors are likely to be emotionally fragile, under stress, or both, especially at the time of their first ulcer symptoms. A clinician diagnosing an ulcer in an individual who does not match the usual patient profile should be on the lookout for psychologic factors.

Psychological stress and disease activity in ulcerative colitis: a multidimensional cross-sectional study.

OBJECTIVES: It is not known whether any link exists between life stress and disease activity in ulcerative colitis; attempts to demonstrate one have been complicated by recall bias, distressing psychological consequences of disease, psychogenic symptom exaggeration, and an irritable bowel component of inflammatory bowel disease symptoms. We therefore studied the relationship between psychological measures and two different aspects of ulcerative colitis activity. METHODS: The relation of perceived stress, depression, state anxiety, trait anxiety, and life events with endoscopic appearance of the rectal mucosa was studied "blind" in 46 asymptomatic outpatients with known ulcerative colitis. The same measures were then examined in relation to subjective activity, comparing the group in clinical remission with 32 ulcerative colitis outpatients who reported symptoms. RESULTS: Among asymptomatic patients, the level of stress over the past 2 yr on the General Perceived Stress Questionnaire was higher in the 11 with mucosal abnormalities than in the 35 with a normal rectal mucosa (p = 0.004). Among the entire population, symptomatic patients were more likely to recall major life events in the previous 6 months than the asymptomatic group (p = .02). Adjustment for smoking and for duration of remission did not substantially alter these findings. CONCLUSIONS: Life stress is associated with both objective and subjective aspects of activity in ulcerative colitis. Although the association of life events with reported symptoms may be subject to recall bias, the association of perceived stress with rectal mucosal abnormalities in asymptomatic patients is strongly suggestive of a true link between psychological factors and ulcerative colitis activity.