Mental vulnerability, Helicobacter pylori, and incidence of hospital-diagnosed peptic ulcer over 28 years in a population-based cohort.

OBJECTIVE: To examine whether mental vulnerability, an enduring personality characteristic, predicts incident hospital-diagnosed ulcer over three decades. MATERIALS AND METHODS: A population-based cohort study enrolled 3365 subjects with no ulcer history, ages 30-60, in 1982-3. Mental vulnerability, Helicobacter pylori IgG antibodies, socioeconomic status, and sleep duration were determined at baseline; non-steroidal antiinflammatory drug use, smoking, leisure time physical activity, and alcohol consumption both at baseline and in 1993-4. Hospital diagnoses of incident ulcer through 2011 were detected using the Danish National Patient Registry. RESULTS: Ulcers were diagnosed in 166 subjects, including 83 complicated by bleeding or perforation. Age-, gender-, and socioeconomic status-adjusted associations were significant for mental vulnerability (Hazard Ratio (HR) 2.0, 95% Confidence Interval 1.4-2.8), Helicobacter pylori (HR 1.7, CI 1.2-2.3), smoking (HR 2.0, CI 1.3-3.1), heavy drinking (HR 1.6, CI 1.1-2.4), abstinence (HR 1.6, CI 1.1-2.5), non-steroidal antiinflammatory drugs (HR 2.1, CI 1.5-3.0), and sedentary lifestyle (HR 1.9, CI 1.4-2.7). Adjusted for all behavioral mediators, the HR for mental vulnerability was 1.5 (CI 1.0-2.2, p = .04). Mental vulnerability raised risk in Helicobacter pylori seropositive subjects and those exposed to neither Helicobacter pylori nor non-steroidal antiinflammatory drugs; its impact was virtually unchanged when analysis was limited to complicated ulcers. CONCLUSIONS: A vulnerable personality raises risk for hospital-diagnosed peptic ulcer, in part because of an association with health risk behaviors. Its impact is seen in 'idiopathic' and Helicobacter pylori-associated ulcers, and in acute surgical cases.

Hostility and the risk of peptic ulcer in the GAZEL cohort.

OBJECTIVE: Evidence for an association between hostility and peptic ulcer mainly relies on cross-sectional studies. Prospective studies are rare and have not used a validated measure of hostility. This prospective study aimed to examine the association between hostility and peptic ulcer in the large-scale French GAZEL cohort. METHOD: In 1993, 14,674 participants completed the Buss and Durkee Hostility Inventory. Participants were annually followed-up from 1994 to 2011. Diagnosis of peptic ulcer was self-reported. The association between hostility scores and ulcer incidence was measured by hazard ratios (HR) and 95% confidence intervals computed through Cox regression. RESULTS: Among 13,539 participants free of peptic ulcer history at baseline, 816 reported a peptic ulcer during a mean follow-up of 16.8 years. Adjusting for potential confounders, including smoking, occupational grade, and a proxy for nonsteroidal anti-inflammatory drug exposure, ulcer incidence was positively associated with total hostility (HR per SD: 1.23, confidence interval: 1.14-1.31), behavioral hostility (HR per SD: 1.13, confidence interval: 1.05-1.21), cognitive hostility (HR per SD: 1.26, confidence interval: 1.18-1.35), and irritability (HR per SD: 1.20, confidence interval: 1.12-1.29). The risk of peptic ulcer increased from the lowest to the highest quartile for all hostility measures (p for linear trend < .05). CONCLUSIONS: Hostility might be associated with an increased risk of peptic ulcer. Should these results be replicated, further studies would be needed to explore the underlying mechanisms.

Psychological stress increases risk for peptic ulcer, regardless of Helicobacter pylori infection or use of nonsteroidal anti-inflammatory drugs.

BACKGROUND & AIMS: There is controversy over whether psychological stress contributes to development of peptic ulcers. We collected data on features of life stress and ulcer risk factors from a defined population in Denmark and compared these with findings of confirmed ulcers during the next 11-12 years. METHODS: We collected blood samples and psychological, social, behavioral, and medical data in 1982-1983 from a population-based sample of 3379 Danish adults without a history of ulcer participating in the World Health Organization's MONICA study. A 0- to 10-point stress index scale was used to measure stress on the basis of concrete life stressors and perceived distress. Surviving eligible participants were reinterviewed in 1987-1988 (n = 2809) and 1993-1994 (n = 2410). Ulcer was diagnosed only for patients with a distinct breach in the mucosa. All diagnoses were confirmed by review of radiologic and endoscopic reports. Additional cases of ulcer were detected in a search of all 3379 subjects in the Danish National Patient Register. RESULTS: Seventy-six subjects were diagnosed with ulcer. On the basis of the stress index scale, ulcer incidence was significantly higher among subjects in the highest tertile of stress scores (3.5%) than the lowest tertile (1.6%) (adjusted odds ratio, 2.2; 95% confidence interval [CI], 1.2-3.9; P < .01). The per-point odds ratio for the stress index (1.19; 95% CI, 1.09-1.31; P < .001) was unaffected after adjusting for the presence of immunoglobulin G antibodies against Helicobacter pylori in stored sera, alcohol consumption, or sleep duration but lower after adjusting for socioeconomic status (1.17; 95% CI, 1.07-1.29; P < .001) and still lower after further adjustments for smoking, use of nonsteroidal anti-inflammatory drugs, and lack of exercise (1.11; 95% CI, 1.01-1.23; P = .04). The risk for ulcer related to stress was similar among subjects who were H pylori seropositive, those who were H pylori seronegative, and those exposed to neither H pylori nor nonsteroidal anti-inflammatory drugs. On multivariable analysis, stress, socioeconomic status, smoking, H pylori infection, and use of nonsteroidal anti-inflammatory drugs were independent predictors of ulcer. CONCLUSIONS: In a prospective study of a population-based Danish cohort, psychological stress increased the incidence of peptic ulcer, in part by influencing health risk behaviors. Stress had similar effects on ulcers associated with H pylori infection and those unrelated to either H pylori or use of nonsteroidal anti-inflammatory drugs.

Association between peptic ulcer and personality disorders in a nationally representative US sample.

OBJECTIVE: To assess the association between peptic ulcer and a wide range of personality disorders in a large sample representative of the general population in the United States. METHODS: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, on the basis of a face-to-face interview of more than 43,000 adults. Univariate and multivariate logistic regression were used to examine the relationship between self-reported "stomach ulcer" and personality disorders. RESULTS: All seven personality disorders assessed in the National Epidemiologic Survey on Alcohol and Related Conditions (i.e., avoidant, dependent, obsessive-compulsive, paranoid, schizoid, histrionic, and antisocial personality disorders) were associated with stomach ulcer, with odds ratio ranging from 2.26 (obsessive compulsive personality disorder) to 5.54 (dependent personality disorder). Participants with ulcer were five times more likely to have more than three personality disorders than participants without ulcer. The relationship between ulcer and personality disorders was only slightly attenuated after adjusting for sociodemographic conditions, physical and psychiatric disorders, and addictions. CONCLUSIONS: Self-reported peptic ulcer is associated with increased rates of personality disorders, beyond the influence of psychiatric disorders or addictions.

The role of stress in the development and clinical course of inflammatory bowel disease: epidemiological evidence.

BACKGROUND: It is unclear whether psychological stress contributes to the inflammatory process in the inflammatory bowel diseases (IBD), ulcerative colitis (UC) and Crohn's disease (CD). This review assesses the epidemiological evidence regarding a causal link between stress and gut inflammation in IBD. METHODS: A Medline search identified prospective studies of the effects of stress on subsequent disease activity and randomized controlled studies of the effects of psychological interventions on disease course in IBD. Controlled retrospective studies were included in the review of aspects of the stress-inflammatory relationship for which few prospective studies are available (e.g. the link between stress and disease onset). Studies were assessed qualitatively. RESULTS: Among 9 longitudinal studies of stress or depression and disease course, a significant stress-inflammation relationship has been found when UC and CD are studied independently (4 of 4 studies positive) but studies of mixed samples of CD and UC have mostly had negative results (1 of 5 studies positive). Evidence of a contribution of stress to disease onset is very weak. The results of 5 studies of psychological interventions in IBD have been negative or modestly supportive of benefit. Confidence in therapeutic benefits of psychological interventions results is limited by methodological weaknesses in these studies. DISCUSSION: There is consistent evidence for a contribution of psychological factors to IBD disease course, especially stress in UC and depressive symptoms in CD. More rigorous tests of psychological interventions in IBD are needed.

Psychosomatic medicine: the scientific foundation of the biopsychosocial model.

OBJECTIVE: This article presents major concepts and research findings from the field of psychosomatic medicine that the authors believe should be taught to all medical students. METHOD: The authors asked senior scholars involved in psychosomatic medicine to summarize key findings in their respective fields. RESULTS: The authors provide an overview of the field and summarize core research in basic psychophysiological mechanisms-central nervous system/autonomic nervous system, psychoneuroimmunology, and psychoendocrinology-in three major disease states-cardiovascular, gastrointestinal, and HIV virus infections. CONCLUSIONS: Understanding the core scientific concepts and research findings of psychosomatic medicine should provide medical trainees with a scientific foundation for practicing medicine within a biopsychosocial model of care.

Contribution to the construct validity of the Perceived Stress Questionnaire from a population-based survey.

OBJECTIVE: Detailed evidence for the construct validity of stress questionnaires has been repeatedly demanded. This study aimed to investigate the construct validity of the Perceived Stress Questionnaire (PSQ) in the context of a transactional view of stress. METHODS: The examination was based on the PSQ and on standardized quality of life and personality questionnaires. The analyses focused on structural equation modeling. A total of 2552 subjects from a population-based survey were studied. RESULTS: A transactional model fitted the data. Personality aspects and resources contribute to the total perceived stress. Yet the physical aspects of quality of life receive a comparatively low weighting. The prevalence of perceived stress at a moderate level was estimated to be 14.5%, lowest in the age group>75 years and highest in the 35- to 54-year age group. The prevalence of high stress was 3.1%. The total PSQ-30 score of the general population was 0.30 (S.D.=0.15), slightly higher in women than in men. CONCLUSION: We consider the PSQ as a valid instrument for recording subjective perceived stress in the context of a transactional view of stress. The present broad and international database suggests that it needs further investigation in terms of transcultural studies.

Embracing complexity: what determines quality of life in inflammatory bowel disease?

A subset of patients with inflammatory bowel disease have markedly impaired quality of life. In this issue, Mussell et al. report that patients' self-rated health status and disease-related concerns were determined at least as strongly by their habitual use of depressive coping patterns as by their disease activity. Although past disease severity may have confounded these results, the finding that quality of life is better for patients armed with a positive approach to problem-handling suggests that psychologically oriented interventions could have far-reaching benefits for selected patients. Since evidence is accumulating that stress and distress can worsen tissue inflammation and clinical course in animal models and in clinical populations with inflammatory bowel disease, we may dare to hope that interventions aimed at improving patients' stress tolerance, depressive symptoms, and coping capacities might not only improve perceived quality of life but could potentially decrease bowel inflammation and reduce some patients' need for toxic medications or surgery. Designing, applying, and evaluating such interventions should be a major item on the agenda of psychosomatic medicine in gastroenterology, and biological reductionism should be replaced by the biopsychosocial model.

Bellyaching in these pages: upper gastrointestinal disorders in Psychosomatic medicine.

OBJECTIVE: The evolution of views regarding the impact of psychosocial factors on peptic ulcer was traced by examining all articles related to the upper gastrointestinal tract published in Psychosomatic Medicine since its inception. METHODS: Titles were retrieved using MEDLINE and by manually searching tables of contents for the years 1939 through 2000. The articles were classified by type and reviewed for gastrointestinal topic, broad biopsychosocial themes, methodology, and hypotheses. RESULTS: One hundred seven articles were found, peaking in the 1960s. Of these, 73.8% reported large-sample research, 10.3% were case reports or series (all before 1965), and 15.9% were review articles or commentaries (most frequent before 1950 and after 1990). The chief topic was peptic ulcer in 47.7%, ulcer related in 29.9%, nonulcer dyspepsia or motility in 15.0% (dominating research since 1990), and miscellaneous in 7.5%. Original investigations related to peptic ulcer dropped off steadily after 1970. Attention was consistently paid to interactions of psychological factors with gastric acid secretion but not with several other important ulcer risk factors: Helicobacter pylori, smoking, and nonsteroidal antiinflammatory drugs. Interest in personality, stress, and laboratory methodology remained steady over time, whereas psychoanalysis and the specificity hypothesis declined, and statistical comparisons and quantitative approaches to psychological assessment rose. CONCLUSIONS: Psychosomatic Medicine articles reflect the life history of the stress-acid theory of peptic ulcer: hypothesis generation through case studies; a boom of experimental research; and retrenchment into literature reviews with a falloff in original investigations when new views of etiology and effective medical therapies appeared.