GASTROENTEROLOGY 1986;91:1370-9
ALIMENTARY TRACT
Life Events Stress and Psychosocial
Factors in Men With Peptic Ulcer Disease
A Multidimensional
MARK FELDMAN, PAMELA WALKER, JANET L. GREEN, and
KATHY WEINGARDEN
University of Texas Health Science Center at Dallas and the Dallas Veterans Administration
Medical Center, Dallas, Texas
We carried out a case-controlled study of multiple
psychological and social factors in 49 men with
complicated or uncomplicated peptic ulcer disease.
Thirty-two men with renal stones or gallstones and
20 healthy men served as controls. Ulcer patients
and controls experienced a similar number of poten-
tially stressful life events. However, ulcer patients
perceived their events more negatively [p < 0.05j.
Ulcer patients also had significantly more personal-
ity disturbances than controls, although no one type
of “ulcer personality” was found consistently. Some
ulcer patients tended to be hypochondriacal com-
plainers, overly pessimistic, and excessively depen-
dent. Other personality disturbances were also more
common in ulcer patients [e.g., immaturity, impul-
sivity, and feelings of social isolation and alien-
ation). Ulcer patients had significantly lower ego
strength and they had fewer friends and relatives
whom they felt they could call upon in times of
crisis. Finally, ulcer patients exhibited significantly
more emotional distress in the form of depression
and anxiety. Hypochondriasis, a negative percep-
tion of their life events, dependency, and lowered
Received February 3, 1986. Accepted April 16, 1986.
Address requests for reprints to: Mark Feldman, M.D., Associate
Chief of Staff for Research and Development (151),Dallas Veter-
ans Administration Medical Center, 4500 South Lancaster Road,
Dallas, Texas 75216.
This work was supported in part by grants from the Research
Service of the Veterans Administration and the National Institutes
of Health (AM 16816).
Part of this work was presented at the 1984 meeting of the
American Gastroenterological Association and appeared in ab-
stract form (Gastroenterology 1984;86:1075).
The authors thank John Fordtran, Charles Richardson, Kenneth
Rylee, Dale Cannon, and Edward Feldman for their many useful
suggestions; Mary Ellen Matasso and Julie Oliver-Touchstone
excellent technical assistance; and Vicky Slagle for preparation of
the manuscript.
Case-Controlled Study
ego strength were the four variables that best dis-
criminated ulcer patients from controls. This con-
trolled study demonstrates a strong association be-
tween life events stress, psychosocial factors, and
peptic ulcer disease.
The importance of emotional disturbances in the
pathogenesis of peptic ulcer disease (PUD) and in
other “psychosomatic” illnesses was once widely
accepted (1,2). For example, at one time it was
believed that PUD patients had a distinct and pre-
dictable personality, characterized by a hard-
driving, “go-getter” stereotype (1).Furthermore, psy-
choanalytic studies by Alexander (2,3) suggested
that PUD patients consistently have an internal con-
flict resulting from strong dependency needs. How-
ever, early studies that claimed that psychosocial
factors were important in PUD were often uncon-
trolled and not designed in such a way as to elimi-
nate subjective bias (3-8). For example, the investi-
gator was usually aware that the patient he was
interviewing had PUD.
In the last decade, psychological research in PUD
has focused on stressful life events, rather than on
personality (9-12).Most studies have reported that
neither the frequency nor the apparent severity of
stressful life events differed between PUD patients
and controls. For this reason, many physicians have
come to believe that emotional factors may be unim-
portant in the pathogenesis of PUD, and research in
this area has increasingly emphasized physiologic
factors such as gastric acid secretion or mucosal
defense rather than psychological factors. In our
opinion, however, the relationship between life
for Abbreviations used in this paper: MMPI, Minnesota Multi-
phasic Personality Inventory; PAL-H, Profile of Adaptation to
Life-Holistic Scale; PUD, peptic ulcer disease.
December 1986
events stress, psychosocial factors, and PUD is not
clearly established at the present time and warrants
further study.
Whereas earlier psychosomatic research had fo-
cused primarily on either personality features or life
events as sources of stress, more recently stress has
been examined as a complex interaction between a
person and his environment. Accordingly, we exam-
ined both “internal” personality attributes and “ex-
ternal” environmental factors in a case-controlled
study of PUD. We used a multifactorial approach,
assessing several personality attributes (including
dependency), frequency of stressful life events and
the individual’s perception of these events, coping
ability, social support from friends and relatives, and
emotional state (e.g., level of depression and anxi-
ety). A series of psychological tests and question-
naires was administered to PUD patients and con-
trols, and tests were scored by standardized,
reproducible procedures to reduce the possibility of
subjective bias.
Methods
Study Population and Eligibility Criteria
Two acutely ill inpatient groups were studied:
patients hospitalized because of an acute complication
PUD (bleeding or perforation) and patients hospitalized
with symptomatic kidney stones or gallstones (control
group). Patients hospitalized with renal or biliary colic
were selected as controls because (a) they usually present
with acute pain, with or without bleeding (hematuria); (b)
these conditions sometimes require surgical intervention;
and (c) stress is not considered important in their etiology.
Although acute illness and hospitalization themselves are
almost certainly stressful, we included this acutely ill,
hospitalized group to control for these factors. To reduce
effects of situational anxiety on testing, any patient who
manifested significant discomfort (e.g., grimacing, sweat-
ing, excess motor activity) or who was scheduled
surgery during the next 3 days was excluded.
We were notified by medical house officers of appropri-
ately diagnosed inpatient candidates for the study. Neither
referring house officers nor patients were informed of the
study’s specific purpose, which was described generally as
an examination of the incidence of stress in illness. We
first interviewed patients with regard to severity and
chronicity of symptoms during the year preceding their
hospitalization. Those who reported chronic discomfort
sufficient to interfere with normal daily activities and
overall quality of life were excluded because patients who
suffer from chronic pain or disability may be especially
likely to develop personality disturbance and emotional
distress (I 3). Patients were also excluded if they could not
clearly establish the date of onset of the acute symptoms
that led to hospitalization to within 7 days of hospital
admission or if psychological testing could not be com-
pleted within 17 days after admission. In the majority of
STRESS AND PEPTIC ULCER DISEASE 1371
cases, onset of symptoms was on the day of admission or
on the previous day. The length of time between the onset
of acute symptoms and completion of testing did not differ
significantly, averaging 7.6 days for PUD patients and 6.7
days for stone patients. Thus, we assumed that memory
errors in reporting past events and experiences would be
similar in these two groups of patients.
Patients were considered eligible if they (a) reported a
minimum of sixth grade education and could read and
write; (b) gave written informed consent; (c) had no previ-
ous ulcer surgery; (d) had no life-threatening illness (e.g.,
cancer, myocardial infarction); and (e) were male. We
excluded women because we anticipated a preponderance
of men in the PUD group. Two additional groups, outpa-
tients with uncomplicated PUD and healthy volunteers,
were also studied for comparison (see below). This study
was approved by a Human Studies Subcommittee at each
of four participating Dallas hospitals: the Veterans Admin-
istration Medical Center, Parkland Memorial Hospital (a
county hospital), Baylor University Medical Center (a
private hospital), and St. Paul Medical Center (a private
hospital). Patients were enrolled between 1982 and 1984.
Inpatients with acute complications from peptic
ulcer disease. Thirty-two patients ranging in age from 19
to 70 yr, admitted to the hospital for an acute complication
of PUD, were evaluated. Thirty presented with melena
with or without hematemesis, and ulcer was documented
at endoscopy, surgery, or both (24 duodenal, 2 duodenal
plus gastric, 4 gastric). Two presented with acute abdom-
of inal pain due to a perforated ulcer that was documented at
surgery (1 duodenal, 1 gastric). Surgery was performed to
treat the current ulcer complication in 7 patients. Sixteen
additional patients (33%) were considered but excluded
because they failed either to meet eligibility criteria or to
finish the testing procedure.
Inpatients with acute symptomatic kidney stones
or gallstones. This control group consisted of 32 patients
ranging in age from 22 to 70 yr, admitted to the hospital for
an acute episode of renal or biliary colic. Twenty-two had
kidney stones; 9 had gallstones; and 1 presented with
acute abdominal pain and hematuria and had a kidney
stone and gallstones. Kidney stones were documented by
for intravenous pyelography, spontaneous passage, surgery,
or any combination thereof. Gallstones were documented
by gallbladder sonography, oral cholecystography, or sur-
gery, alone or in combination. Patients reporting a history
of peptic ulcer within the past year were excluded. Sur-
gery was carried out to treat stones during the current
hospitalization in 15 patients. Twenty-four additional pa-
tients (43%) were considered but excluded (see above).
Outpatients with uncomplicated peptic ulcer dis-
ease. We evaluated 17 outpatients ranging in age from 27
to 66 yr with uncomplicated PUD, previously documented
by barium studies, endoscopy, or both (9 duodenal, 1
duodenal plus gastric, 7 gastric). Patients were recruited
during routine clinic visits and were either asymptomatic
or had mild dyspepsia well-controlled with medication at
time of study. Five additional patients (23%) were consid-
ered but excluded.
Healthy controls. Twenty healthy men ranging in
age from 25 to 71 yr with no history of PUD, kidney stones,
1372 FELDMANETAL. GASTROENTEROLOGYVol. 91,No.6

gallstones, extensive psychiatric treatment, drug or alco-
hol abuse, or chronically disabling medical conditions
were studied. Eleven additional subjects (35%) were con-
sidered but excluded because they did not meet these
criteria or did not finish the testing procedure.
Testing Procedure
Subjects were tested using measures described be-
low under controlled conditions. The testing procedure
typically lasted 2-3 h.
Demographic questionnaire. An inventory devised
by the authors was used to record age, race, marital status,
education, employment status, and occupational level.
Life experiences survey. This 47-item survey as-
sessed the frequency of potentially stressful life events
(stressors) during the past year, as well as the subject’s
own perception of these events (14). Inpatients were in-
structed to consider events that had occurred during the
year before the onset of their current acute symptoms and
to exclude those events that had occurred after the onset of
their current illness. Subjects rated the impact of each
event they had experienced using a seven-point scale
ranging from extremely positive (+ 3) through neutral (0)to
extremely negative (- 3). The Life Experiences Survey was
scored to yield the four separate measures described in
Table 1.
Minnesota Multiphasic Personality Inventory.
Minnesota Multiphasic Personality Inventory (MMPI) (15)
provided infomation related to personality, coping ability,
and emotional state, as described in Table 1. Scores of 370
on a particular scale are typically used for diagnostic
purposes, with the exception of ego strength, on which
high scores are considered healthy.
Profile of Adaptation to Life-Holistic Scale. The
Profile of Adaptation to Life-Holistic Scale (PAL-H) con-
sists of 52 items on which the subject rated his behavior
and emotions during the prior month, using a four-point
frequency scale ranging from “never” to “often” (16).
Inpatients rated themselves for the month before the onset
of current acute symptoms. In Table 1 are described PAL-H
measures related to coping ability and social activity, with
higher scores indicating better adjustment.
Crisis Support Questionnaire. We used a modifi-
cation of the Crisis Support Questionnaire, described in
Table 1,as a second measure of social support (17). Higher
scores reflect a higher degree of support, rather than the
actual number of persons available for support per se.
Statistical Methods
tween duodenal and gastric ulcer patients. Therefore, all
49 PUD patients were combined and then compared with
stone patients and healthy subjects. A multivariate analy-
sis of variance comparing the PUD, stone, and healthy
groups on all 20 psychological variables described in
Table 1 was significant (p < 0.001). Separate comparisons
of these three groups were then conducted for each vari-
able by univariate analysis of variance. Because of the
relatively large number of variables examined, when sig-
nificant differences were found by analysis of variance, the
highly conservative Scheffe post hoc test was then used for
the three pairwise comparisons to minimize the possibility
of type I errors (19). The a-level for these pairwise com-
parisons was 0.05.
Results
Demographics
Patients with PUD, stone patients, and healthy
subjects did not differ significantly with regard to
age, racial composition, marital status, or level of
education. All three groups were predominantly
white (71% 91% and 80%, respectively) and fairly
well-educated (13, 13, and 14 mean years of educa-
tion, respectively). Despite similar educational at-
The tainment and mean ages (45, 45, and 43 yr, respec-
tively), occupational level was significantly different
in the three groups, due to less high status occupa-
tions and to more unemployment in PUD patients
(Table 2).
Life Events (Stressors)
As shown in Table 1, total frequency of life
events experienced during the past year did not
differ significantly among the study groups. How-
ever, the frequency of events perceived as negative
was significantly higher in PUD patients than in
healthy subjects. Patients with PUD also perceived a
much greater negative impact of life events than both
control groups. As shown in Figure 1, there was
considerable overlap in the negative impact of
events in PUD patients and controls. Six PUD pa-
tients, however, had very high negative impact
scores, whereas a large number of controls had very
low scores.

All tests were scored using reproducible, standard-

ized procedures that eliminated subjective bias. The data Personality
obtained were analyzed using the following procedures: The PUD patients scored significantly higher
analysis of variance, x2 test, Student’s t-test, stepwise
than both control groups on MMPI scale 1 (hypo-
multiple discriminant analysis, and Pearson’s linear
chondriasis) and on the dependency supplemental
bivariate correlation (18).
The two PUD groups (complicated inpatient, n = 32; scale [Table 1).Nevertheless, as shown in Figure 2,
and uncomplicated outpatient, n = 17) did not differ there was considerable overlap in hypochondriasis
significantly with respect to any psychological variable and dependency scores between PUD patients and
(Table 1) or with respect to any demographic variable. controls. The PUD patients also scored significantly
Furthermore, there were no significant differences be- higher than stone patients on MMPI scales 4 (psy-
December 1986 STRESS AND PEPTIC ULCER DISEASE 1373

Table 1. Description of 20 Psychological Variables Examined and Mean [+- SE) Scores for Study Groups

PUD PUD All PUD Stone Healthy

inpatients outpatients patients patients subjects
Variable name Description (n = 32) (n = 17) (n = 49) (n = 32) (n = 20)

Life events
Total frequency Number of events regardless of 9.6 k 1.0 10.0-c2.1 9.7 ir 1.0 7.5+ 1.0 7.5r 1.5
positive, negative, or neutral
perception
Negative Number of events perceived as 5.9? 0.8 6.8t 1.8 6.2+-0.8 3.52 0.7 2.7t 0.8"
frequency negative
Total impact Total impact of events regardless 17.8k 2.0 18.9f 4.8 18.2z!z
2.1 11.6L 1.6 10.7? 2.4
of positive or negative
perception
Negative impact Total impact of events perceived 12.2-c1.7 13.92 4.2 12.8-c1.8 5.9t 1.2O 3.62 1.1"
as negative
Personality
MMPI scale 1 Somatic preoccupation, 68.8-c2.5 77.1t 4.0 71.7k 2.2 60.22 2.5' 55.8k 2.8"
(hypochondriasis) pessimism, complaining attitude
MMPI scale 3 Somatization, repression and 63.8xi2.0 66.4* 2.9 64.7+ 1.6 61.1rf:
2.0 57.92 2.0
(hysteria] denial
MMPI scale 4 Immaturity, impulsivity, authority 67.3k 2.1 64.6?I1.9 66.3!I1.5 60.0t 1.9' 61.1Ifr
2.8
(psychopathic and family problems
deviate)
MMPI scale 5 Aesthetic or passive interests 57.9+ 1.7 58.9t 2.4 58.32 1.4 57.12 1.4 62.2zh3.0
(masculinity/
femininity]
MMPI scale 6 Sensitivity, resentment, cynicism, 59.0I!2.1 60.3f 3.8 59.5+ 1.9 54.4? 1.5 54.3t 2.4
(paranoia] irritability
MMPI scale 8 Social isolation, alienation, 63.6f 3.2 66.8+ 4.2 64.7t 2.5 56.4+ 1.9' 56.22 2.2
(schizophrenia] withdrawal
MMPI scale 9 High energy level, restlessness, 63.3k 2.2 62.42 2.9 63.0Z!I
1.7 56.6? 1.9" 63.6k 1.6
(hypomania) overactivity
MMPI scale 0 Social discomfort, shyness, 54.0f 1.7 55.6k 2.3 54.62 1.3 53.7-t-
1.6 48.02 2.2"
(social aloofness
introversion)
MMPI dependency Excessive reliance on others 56.3k 1.9 56.5f.2.9 56.32 1.6 49.8-t1.4" 47.42 2.1"

Coping ability
MMPI ego strength Confidence, resourcefulness, 44.6f 1.9 40.1t 3.5 43.1t 1.7 49.4? 1.6" 54.22 2.1"
coping ability, stability
PAL-H adjustment Physical and emotional symptoms, 44.12 1.4 46.22 1.4 44.8k 1.0 47.9r 1.0 51.4k 1.3"
and functioning well-being, drug and alcohol
use, income management, and
family relationships
PAL-H life-style Social activity, time spent alone, 46.4t 1.1 49.6-t1.7 47.5t 0.9 48.32 0.9 49.9f 1.2
diet and exercise, personal ar
psychological growth activities
Social support
PAL-H social Involvement with friends and 49.3f 1.9 53.9+ 2.4 50.92 1.5 50.72 1.8 56.4t 1.9
activity acquaintances and within the
community
Crisis support Degree of support from relatives, 7.8-+0.6 8.62 0.6 8.1k 0.4 8.82 0.6 10.1Ifr
0.5"
friends, and neighbors during
emergencies
Emotional state
MMPI scale 2 Depression, emotional discomfort 67.82 2.0 69.5?I3.7 68.42 1.8 58.92 2.1" 55.2t 2.4'
(depression]
MMPI scale 7 Anxiety, obsessive worry, 62.12 2.2 65.2k 3.6 63.22 1.9 55.54 1.6" 54.62 2.1"
fearfulness

MMPI, Minnesota Multiphasic Personality Inventory; PAL-H, Profile of Adaptation to Life-Holistic Scale; PUD, peptic ulcer disease.
a p < 0.05vs.all PUD patients by analysis of variance with Scheffe’s post hoc correction.
1374 FELDMAN ET AL. GASTROENTEROLOGY Vol. 91, No. 6

Table 2. Occupational Categories of the Three Study

GTOUDS’

Peptic ulcer Stone Healthy

patients patients subjects
(n = 49) (n = 32) (n = 20) .
(%) (%I (%I
Professional, white 28.6 59.4 60.0 NEGATIVE 3”; 0.

collar, skilled IMPACT .

.

occupations .
LIFE ~&VENTS 25
Semiskilled and
unskilled
30.6 18.8 25.0 ni a
occupations
Unemployed 40.8 21.9 15.0

a Professional occupations included jobs usually requiring college

or postgraduate training, e.g., doctor, lawyer, teacher, accountant,
PEPTIC ULCER CONTROLS
police officer, nurse, engineer. White collar occupations would PATIENTS
include jobs such as secretary, contra@or, small business owner, (n=49) (n=52)
bookkeeper, teller. Skilled occupations were exemplified by Figure 1. Scores for negative impact of life events in 49 peptic
foreman, carpenter, plumber, mechanic, electrician. Semiskilled ulcer patients (inpatients, closed circles; outpatients,
occupations included jobs such as truck driver, factory worker, open circles) and in 52 controls (stone patients, closed
repair person, cook, barber, mailman. Unskilled jobs included circles; healthy subjects, open circles). Mean values are
farm or day laborer, janitor, nurse’s aide, service station worker. shown as horizontal lines. Differences between the
Unemployed category included homemakers, students, and re- ulcer patients and both control groups were significant
tired or otherwise not gainfully employed individuals. Differ- (see Table 1).
ences among groups were significant (p < 0.05) by x2 test.

ported slightly, but significantly, fewer friends and

chopathic deviate), 8 (schizophrenia), and 9 (hypo- relatives whom they felt they could call upon in
mania) and significantly higher than healthy con- emergency situations than did healthy subjects.
trols on MMPI scale 0 (social introversion). Thus, on
six of nine MMPI scales chosen as personality mea- HYPOCHONDRIA%3 DEPENDENCY
sures, PUD patients differed significantly, and in an 110 ilO-
adverse direction, from one or both control groups, r 8 ??

whereas the two control groups were not signifi- go-

cantly different on any personality scale.* L

8 70-
L
Coping Ability 50-

As shown in Table 1 and in Figure 2, mean --2-

3oL -+ 30-
ego strength, an MMPI measure of self-confidence, PUD CONTROL PUD CONTROL

resourcefulness, and coping ability, was signifi-

cantly lower in the PUD group than in both control
EGO STRENGTH DEPRESSION
groups. The PUD group also had significantly lower 110-
mean scores than healthy subjects on PAL-H adjust-
ment and functioning (Table l), whereas the three QO-
groups did not differ significantly on PAL-H life- e
style. g 70-

:
50-
Social Support
IOL - - 30- A
Social activity during the past month, as mea- PUD CONTROL PUD CONTROL
sured by the PAL-H, was not significantly different
Figure 2. MMPI T-scores for hypochondriasis (scale l), depen-
among the three groups (Table 1). On the Crisis dency, ego strength, and depression (scale 2) in 49
Support Questionnaire, however, PUD patients re- patients with peptic ulcer disease (PUD) and in 52
controls. Inpatients with PUD and stone patients are
* The PUD patients also scored significantly higher on MMPI shown as closed circles; FUD outpatients and healthy
validity scale F than both control groups. Scale F is a general subjects are shown as open circles. Mean values are
indicator of emotional disturbance and tends to rise with in- shown as horizontal lines. Differences between PUD
creased psychopathology (15). Mean scores on MMPI validity patients and both control groups were significant for
scales L and K did not differ significantly among the three groups. each variable examined (see Table 1).
December 1986 STRESS AND PEPTIC ULCER DISEASE 1375

PEPTIC ULCER PATIENTS STONE PATIENTS HEALTHY SUBJECTS

(n=49) fn=32) In=201

Figure 3. Percentage of peptic ulcer patients, stone patients, and healthy subjects blindly classified into four general psychological
categories based on their overall MMPI profiles. Fewer normal profiles and a greater percentage of severely disturbed profiles
were found in ulcer patients than controls (p < 0.001, ulcer patients vs. combined controls by x2 test). Percentages for peptic
ulcer inpatients and outpatients, respectively, were 16% and 24% (normal); 34% and 29% (neurotic]; 31% and 6% (personality
disorder): and 19% and 41% (severely disturbed).

Emotional State Additional Analyses

The PUD patients were significantly more MMPI profile analysis. Anonymous MMPI
depressed as well as more anxious and worried profiles of PUD patients and controls were randomly
(psychasthenia] than both control groups, which did combined and number-coded by a technician. Two
not differ significantly from each other (Table 1). clinical psychologists blinded to medical diagnosis
Depression was particularly pronounced in the PUD consensually sorted each profile into one of four
group, with a mean T-score of 68.4 (Table 1 and predetermined, primary psychological diagnostic
Figure 2). categories: “normal,” “neurotic,” “personality disor-
der,” or “severely disturbed.” As shown in Figure 3,
the 49 PUD patients were underrepresented in the
normal category and overrepresented in the severely
Stepwise Multiple Discriminant Analysis
disturbed category relative to controls (p < 0.001,
Eleven of our 20 psychological variables en- PUD vs. combined controls by x2 test).
tered the stepwise multiple discriminant equation, Veterans Administration vs. county vs. pri-
with a canonical correlation of 0.68 (p < 0.001) and vate inpatients. To determine whether psychologi-
an overall correct classification rate of 80%. cal differences between PUD patients and controls
were present in each type of hospital, we calculated
Hypochondriasis and negative impact of life events
test scores in Veterans Administration, county, and
were the most important variables distinguishinig
private inpatients for six selected psychological vari-
PUD patients from controls, followed by depen-
ables Four of these variables (hypochondriasis, neg-
dency and ego strength. The other seven variables
ative impact of life events, dependency, and ego
were crisis support, total frequency of life events,
strength) were selected because they were the best
hysteria, total impact of life events, depression,+ discriminators between PUD patients and controls,
social introversion, and masculinity/femininity. whereas the others (depression and psychasthenia)
Once these 11 variables had entered the equation, were chosen as measures of emotional distress. Al-
the other nine variables contributed no new addi- though statistical tests were not performed because
tional information and thus were not included in the of relatively small numbers, mean scores of PUD
discriminant function. A subsequent analysis using inpatients tended to differ from those of stone pa-
only the first four variables revealed that these vari- tients in the adverse direction in each type of hospi-
ables were capable of distinguishing PUD patients tal (Table 3).
from controls with a 78% correct classification rate. Employment vs. unemployment. When we
compared all employed to all unemployed subjects
’ Although depression entered the discriminant function fairly with respect to the six selected variables described
late (step 9), it nevertheless correlated highly with the discrimin-
ant function (r = 0.61, p < 0.001). Late entry of depression into
above using a two-way analysis of variance, unem-
the equation was due to its high correlation with several previ- ployed subjects reported significantly more hypo-
ously entered variables. chondriasis (p < O.OOl), depression (p < O.Ol), and
1376 FELDMAN ET AL. GASTROENTEROLOGY Vol. 91, No. 6

Table 3. Comparison of Six Selected Psychological Variables in Inpatients With Peptic Ulcer Disease or With Stones
by Type of Hospital
Veterans Administration
Hospital County Private
Ulcer Stone Ulcer Stone Ulcer Stone
(n = 17) (n = 19) (n = 10) (n = 5) (n = 5) (n = 8)
Hypochondriasis 74.1 f 3.7 61.5 f 3.9 64.6 f 3.8 56.8 f 1.3 65.4 t 3.2 59.2 2 4.3
Negative impact of 11.6 2 2.4 5.3 k 1.5 14.3 + 3.5 9.6 k 4.7 9.8 f 2.5 5.0 f 1.6
life events
Dependency 55.7 k 2.6 50.3 2 1.8 58.7 2 3.9 50.2 2 3.3 53.4 k 4.2 48.5 + 2.9
Ego strength 43.6 f 2.7 48.6 2 2.1 46.0 k 2.7 48.6 * 3.7 45.4 2 7.0 51.8 t 3.7
Depression 67.5 ? 3.3 59.9 ?I 2.8 68.8 * 3.1 61.8 2 3.2 66.4 2 4.1 55.4 k 4.7
Psychasthenia 61.2 2 3.4 53.3 " 1.6 64.4 2 4.2 57.0 2 3.9 60.2 t 3.7 59.8 t 4.2

Values are mean f SE.

psychasthenia (p < o.o~), as well as significantly
lower ego strength (p < 0.001). However, when the
six variables were examined with respect to both
employment status (i.e., employed vs. unemployed)
and diagnosis (PUD vs. controls), psychasthenia was
the only variable in which there was a significant
interaction (i.e., the higher anxiety of the PUD pa-
tients was significantly related to unemployment].
For the other five variables, PUD patients were more
disturbed than controls regardless of employment
status.
Discussion
The only significant demographic difference
between PUD patients and controls was that more
PUD patients were unemployed and fewer had high
status occupations, even though they had received a
similar level of education. Other investigators have
similarly found lower status occupations in PUD
patients relative to controls (20). We considered the
possibility that underemployment per se, which may
be a major chronic stressor, may have accounted for
some of the psychological differences we observed
between PUD patients and controls. With the excep-
tion of anxiety, however, unemployment did not
contribute to psychological differences between PUD
patients and controls in the selected variables exam-
ined, suggesting that regardless of employment sta-
tus, PUD patients are more psychologically dis-
turbed than controls.
One of our major findings was that PUD patients
and controls differed not in the number of life events
they had experienced, but in the way they perceived
and responded to those events. Other authors have
similarly found no differences between PUD patients
and controls in number of life events Experienced
(g-11). Investigators have also attempted to examine
impact of life events using scales in which events
were preweighted for desirability or undesirability,
amount of distress produced, or degree of adaptation
required, and with one exception (12), have found
negative results (9-11). Identifying a methodologic
problem in this approach, Fordtran (21) has noted
that although ulcer patients may experience no more
than the average number of life events, they may
respond differently to events that occur, for example,
with more anxiety, fear, or frustration. Other inves-
tigators have similarly emphasized the importance
of individual differences in perceptions of life
events, and have encouraged researchers to obtain
stress ratings of events directly from the subjects
being studied, rather than using predetermined,
weighted ratings (22, 23). In the life events measure
we utilized, respondents determined both the desir-
ability and impact of their own life events. The PUD
patients not only perceived more events as negative
than did our healthy controls, they also reacted more
intensely to negative events than did either control
group. Thus, for our ulcer patients, events were not
just negative, they tended to be very negative (Figure
1). Our study contrasts with a recent study by Piper
and colleagues in which duodenal ulcer patients and
controls perceived life events similarly. In that
study, however, subjects were asked to rate hypo-
thetical events, as well as events they had actually
experienced (24).
Certain personality features may have predisposed
our PUD patients to perceive and react to their life
events more negatively than controls. Results of the
MMPI suggest that PUD patients were, on the aver-
age, more hypochondriacal, pessimistic, dependent,
immature, impulsive, socially alienated, introverted,
and restless than one or both control groups. Other
authors (12,25) similarly have found increased intro-
version and neuroticism in male ulcer patients.
Increased dependency needs have long been postu-
lated to be present in patients with duodenal ulcer
(3) or in men likely to develop duodenal ulcer during
a period of intense stress (26). Seven of our 49 PUD
patients (14%) had a T-score of 270 on the MMPI
dependency scale, whereas none of the 52 control
subjects was this highly dependent (Figure 2). It is
perhaps especially stressful when both increased
dependency needs and social discomfort and alien-
ation occur together. For such people, intimate so-
cial involvement may represent a stressful conflict
involving simultaneous, but incompatible, tenden-
cies to approach and avoid close social relation-
ships.
It is not surprising that the aforementioned per-
sonality features would be associated with problems
in coping with stressors. Our PLJD patients had
significantly lower ego strength than either of our
control groups, suggesting fewer psychological re-
sources, less confidence in their ability to cope, and
greater feelings of vulnerability to stress (15). In fact,
7 of the 49 PUD patients had extremely low T-scores
on ego strength (524), whereas none of our controls
scored in this range (Figure 2).
Several investigators have found that lack of social
support or loneliness correlate with depression, anx-
iety, tension, anger, or general psychological malad-
justment (27-29). Social support has similarly been
related to (a) long-term mortality rates (30); (b) com-
plications of pregnancy in highly stressed women
(31); (c) physical symptoms and serum cholesterol in
men involuntarily terminated from work (32);and
(d) angina pectoris among highly anxious men (33).
It is also of interest that rats stressed in isolation
developed gastric ulcers at a higher rate than rats
stressed in the presence of littermates (34). Despite
its intriguing role in modifying stress outcomes,
social support has been assessed inconsistently in
the literature because of a paucity of adequate mea-
sures of this variable. Furthermore, as recently as
1983, Weiner (35) noted that no study of ulcer
patients had examined social support in conjunction
with individual perception of life events. Our PUD
patients had slightly but significantly fewer social
resources in a crisis situation than healthy subjects
and significantly more social isolation and alien-
ation than stone patients. Given their greater de-
pendency needs and reduced coping ability, this
perceived lack of crisis support may be quite threat-
ening to PUD patients, perhaps contributing to their
tendency to evaluate life events negatively.
The outcome of life events in a stress-vulnerable
person may be emotional distress, in the form of
depression or anxiety, or both. For example, Sarason
et al. (14) found that life events perceived as negative
correlated significantly with depression and anxiety.
Other researchers have identified dependency as a
significant independent dimension of depression,
noting that dependency can result in a sense of
personal helplessness, weakness, and failure (36).
Along these lines, we found a significant correlation
between dependency and depression (r = 0.49, p <
0.001). Thus, a stressful life event, such as a change
in residence, may lead to depression or anxiety if
one perceives the event very negatively, is depen-
dent, and has reduced coping ability and minimal
social support. On the other hand, the same event in
another, less vulnerable individual may not result in
any emotional distress.
Close to 50% of our PUD patients had an MMPI
T-score of ~70 on scale 2 (depression), whereas this
was true for only 19% of stone patients and 15% of
healthy subjects. Depression scores in PUD patients
were as elevated in private patients as in veterans or
county patients (Table 3). We did not distinguish
between depressive symptoms occurring in response
to life events (reactive depression) and primary,
endogenous depression. Nevertheless, a higher fre-
quency of depressive symptoms in PUD patients is of
interest in light of increasing evaluation of tricyclic
antidepressant drugs in the therapy of PUD (37,38).
These drugs, however, also reduce gastric acid secre-
tion (39), probably as a result of their anticholinergic
properties, and so a beneficial effect of these drugs
on peptic ulcer healing may be unrelated to their
antidepressant effect.
As might be expected when examining closely
interrelated concepts such as personality, perception
of life events, coping ability, and emotional state,
we found that many of these variables correlated
with each other. Stepwise multiple discriminant
analysis allowed us to determine which subset of
variables best discriminated PUD patients from con-
trols. The first and most discriminating variable,
hypochondriasis, has been associated with somati-
zation defenses, i.e., the expression of emotional
conflicts through somatic channels, as well as a
pessimistic, complaining outlook on life (14). The
relatively higher ranking of negative impact of life
events, compared to total frequency of events, fur-
ther emphasizes the importance of one’s unique and
subjective interpretation of one’s environment. High
dependency scores and low ego strength also helped
in discriminating PUD patients from controls. These
results therefore suggest that internal attributes such
as a pessimistic, negative outlook, certain personal-
ity features, and impaired coping ability may be
more significant than external environmental events
in separating PUD patients from controls. They also
suggest that future psychological research in PUD
should employ a multidimensional stress model,
encompassing both environmental variables (stres-
sors) and person-specific psychological and social
variables.
Although our PUD patients as one large group
1378 FELDMAN ET AL. GASTROENTEROLOGY Vol. 91, No. 6

could be described generally in unidimensional 11. Thomas J, Greig M, Piper DW. Chronic gastric ulcer and life
terms, such as more depressed or dependent than events. Gastroenterology 1980;78:905-11.
12. Christodoulou GN, Alevizos BH, Konstantakakis E. Peptic
controls, it is important to note that, in fact, there
ulcer in adults. Psychopathological, environmental, char-
was considerable overlap in test results between acterological and hereditary factors. Psychother Psych-
PUD patients and controls. For instance, some ulcer osom 1983;39:55-62.
patients were highly dependent, whereas many oth- 13. Pinsky JJ. The behavioral consequences of chronic intractable
ers were no more dependent than controls (Figure 2). benign pain. Behav Med 1980;7:12-20.
14. Sarason IG, Johnson JH, Siegel JM. Assessing the impact of
Considerable heterogeneity of PUD patients was also life changes: development of the life experiences survey. J
apparent when complete MMPI profiles, rather than Consult Clin Psycho1 1978;46:932-46.
individual scales, were examined (Figure 3). Thus, 15. Graham JR. The MMPI: a practical guide. New York: Oxford
although our findings cannot be applied to every University Press, 1981.
PUD patient, they indicate that a variety of emo- 16. Ellsworth RB. PAL-H scale. Profile of adaptation to life
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these emotional disturbances would have a benefi- stress, social support, coping style, and risk of psychological
cial effect on the course of PUD is an intriguing impairment. J Nerv Ment Dis 1978;166:307-16,
question, and merits further study. 18. Nie NH, Hull CH, Jenkins JG, Steinbrenner K, Bent DH. SPSS:
statistical package for the social sciences. 2nd ed. New York:
We wish to emphasize that our findings may not McGraw-Hill, 1975.
be specific for PUD as opposed to other illnesses 19. Spence JT, Underwood BJ, Duncan CP, Cotton JW. Elemen-
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association between life events stress, psychosocial 20. Nasiry R, Piper DW. Social aspects of chronic duodenal ulcer.
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Gastroenterol 1979;3:24-31.
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