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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. [ABSTRACT FROM AUTHOR]

Seventy patients with non-stenosing Crohn's disease were randomly assigned to follow a low residue diet or a normal Italian diet for a mean of 29 months. The two groups were comparable at the onset in various measures of disease severity and diet. Patients complied well with the diet prescriptions, the low residue group eating a mean of 8.1 portions a week of fibre containing foods and the liberalized group a mean of 26.6 portions (p less than 0.005). There was no difference in outcome between the two groups, including symptoms, need for hospitalisation, need for surgery, new complications, nutritional status, or postoperative recurrence. Eighty six per cent of patients eating ad libitum and 65% of patients who avoided roughage eliminated one or more permitted foods because of subjective intolerance. Lifting of dietary restrictions, which results in a more appetizing and nutritious diet, does not cause symptomatic deterioration or precipitate intestinal obstruction in Crohn's disease. [ABSTRACT FROM PUBLISHER]

Asserts that life stress can contribute to the development of peptic ulcer disease. Prior dominant etiologic model for ulcers; Role of Helicobacter pylori; H. pylori's inability to explain ulcers completely; Stress a factor in ulcers in animal models; Known behavioral risk factors; Impact of stimulation of gastric acid secretion; Therapy less effective in distressed individuals; Healing of wounds impaired by stress; Limitations of monocausal thinking.

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.

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., (Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.)

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.

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.

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.

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.

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.

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.

Over the past decade, while gastroenterologists' interest in mind-body interactions in organic disorders dwindled, stronger evidence has linked psychosocial factors with the incidence and recurrence of peptic ulcer and with the course of inflammatory bowel disease. Psychological-behavioral approaches to treatment continue to be disappointing. Psychosocial factors may affect ulcer by increasing duodenal acid load, altering local circulation or motility, intensifying Helicobacter pylori infection, stimulating corticosteroid secretion, and affecting health risk behaviors; possible mechanisms for inflammatory bowel disease include immune deregulation, gut permeability changes, and poor medication adherence. Both belong to the growing category of diseases thought to have an infectious component: for peptic ulcer the bacterium Helicobacter pylori, for inflammatory bowel disease an exaggerated immune response to gut bacteria. Peptic ulcer and inflammatory bowel disease, which present unique interactions among psychological, immunologic, endocrine, infectious, and behavioral factors, are splendid paradigms of the biopsychosocial model.

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.

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.

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 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.