Saudi Journal of Gastroenterology
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Year : 1999  |  Volume : 5  |  Issue : 1  |  Page : 18-22
The psychopathology of duodenal ulcer compared with functional dyspepsia: A case -control study


1 Department of Psychiatry, College of Medicine, Dammam, Saudi Arabia
2 Department of Internal Medicine, College of Medicine, Dammam, Saudi Arabia

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Date of Submission13-Oct-1997
Date of Acceptance09-Jun-1998
 

   Abstract 

This is a prospective study of the psychiatric morbidity in 80 patients with duodenal ulcer, 80 with functional dyspepsia and 80 healthy controls; matched for age, sex and marital status. A semi structured psychiatric interview and clinical mental state examination were used in the psychiatric assessment of the patients and controls. Psychiatric diagnoses were made according to DSM3-R. A modified version of Life Events Scale by Tennant and Andrews was used in the assessment of life events in relation to psychiatric illness. Psychiatric illness was significantly more in the patients than the controls. Anxiety and depressive disorders dominated the clinical picture and the symptoms were usually of mild nature. Other neurotic were rare and psychotic illness was absent. Though more psychiatric patients experienced life events than the controls, differences, however were not statistically significant. Further studies are needed, especially in relation to the causative association between the functional dyspepsia and psychiatric disturbances.

How to cite this article:
Abdel Hafeiz HB, Al-Quorain A, Karim AA, Al-Mangoor S. The psychopathology of duodenal ulcer compared with functional dyspepsia: A case -control study. Saudi J Gastroenterol 1999;5:18-22

How to cite this URL:
Abdel Hafeiz HB, Al-Quorain A, Karim AA, Al-Mangoor S. The psychopathology of duodenal ulcer compared with functional dyspepsia: A case -control study. Saudi J Gastroenterol [serial online] 1999 [cited 2019 Dec 16];5:18-22. Available from: http://www.saudijgastro.com/text.asp?1999/5/1/18/33521


Psychological factors have been held to be of significance for the development and onset of gastroduodenal disorders [1],[2] . The digestive tract is susceptible to stress-induced alterations of secretions, motility and vascularity [3] . Emotional disorders, such as anxiety and depression are presumed to influence gastrointestinal disorders and such patients seem to respond to anxiolytic and antidepressant drugs [4],[5] . The patients with gastrointestinal illness whether organic or non­organic are reported to be frequently suffering from psychiatric illness. It is thought that patients suffering from functional gastrointestinal illness are twice as likely as those with organic illness to be suffering from psychiatric illness [6],[7],[8] . Peptic and/or duodenal ulcer are reported frequently to be associated with psychiatric illness [9],[10],[11],[12],[13] and functional dyspepsia on the other hand was even more associated, perhaps more justifiably, with psychiatric morbidity [10],[14],[15] . However, the above mentioned reports and findings were not consistent and are not immune to criticism; in fact some of them were even conflicting. Thus, Talley et al showed in a prospective study that factors other than personality and psychopathology played an important role in functional gastrointestinal disorders [16] . Another problem is that it is always difficult to determine whether the accompanying psychopathology is a response to the gastrointestinal illness, a direct manifestation of it or merely a coincidence [14] . Psychiatric illness in the gastrointestinal disorders may be interpreted as indicating merely a nonspecific response to the presence of discomfort as this has been found in association with other organic diseases [17],[18] .

The aim of the present study is to investigate, in a prospective and controlled way the prevalence of psychiatric illness in duodenal ulcer and functional dyspeptic patients in comparison with a healthy group; perhaps for the first time in the Kingdom of Saudi Arabia.


   Patients and Methods Top


The diagnosis of patients with duodenal ulcer was established endoscopically, and patients were excluded if they had concomitant physical or mental illness. The diagnosis of patients with functional dyspepsia was based on exclusion of obvious organic cause for the dyspeptic symptoms, especially peptic ulceration, esophagitis and malignancy, through upper endoscopic examination and abdominal sonography. Patients with evidence of irritable bowel syndrome, gastro-esophageal reflux, gallstones and previous mental illness were also excluded from the study. The physical examination and investigations were carried out by the gastroenterologist in charge of the clinics at the hospital (one of the authors).

The study comprised 80 patients with duodenal ulcer (DU), and 80 patients with functional dyspepsia (FD) who attended the gastroenterology clinics at King Fahd Hospital of the University (KFHU) during the study period of one year. Eighty healthy controls were also selected randomly from the hospital and the university staff, as a comparison group. They were matched with the patients for age, sex and marital status. They had no past history of peptic ulcer, gallstones, severe medical or psychiatric illness.

Psychiatric assessment was carried out by two psychiatrists (the authors), using a semi-structured psychiatric interview and a clinical mental state examination. Attention in the present communication was focused on the sociodemographic data of the DU and FD patients, in comparison with the healthy controls and psychiatric diagnoses which were made along the lines cited in DSM-111R [19] . The severity of the psychiatric illness was graded as mild, moderate and severe. Personality was assessed only in descriptive teens (as mentioned above) and no personality inventories were used due to technical difficulties. Intellingence also was judged only by general information, school and work records of the patients. Life event stress is dealt with in a separate communication.

Various tests for statistical significance (Chi­square, Fisher's exact and Student's t-tests) were applied whenever relevant.


   Results Top


Age distribution is shown in [Table - 1]. The differences between the mean ages of the DU patients (35.75 years), FD patients (38.1) and controls (34.6) were not statistically significant. The female to male ratio for DU, FD patients and controls were 32:48, 46:34, 45:35, respectively. Fifty DU patients, 43 FD patients and 70 controls were employed; 55 DU patients, 60 FD patients and 57 controls were married. The differences in gender, employment and marital status were not statistically significant.

Twenty out of the 80 DU patients had psychiatric illness; an incidence of 25%, compared with 25 patients of FD group (31.2%) and 14 patients of the control group (17.5%), differences being statistically significant between FD patients and healthy controls (p<0.04). Differences between FD and DU patients on one hand and DU patients and controls were not statistically significant [Table - 2]. Anxiety and depressive symptoms dominated the clinical picture of the DU, FD patients and controls. Seven DU patients (30%) suffered from anxiety neurosis, mostly generalised anxiety disorder, compared wtih 11 FD patients (44%) and nine patients of the control group (64%); differences were not statistically significant. Five DU patients were rated as having mild anxiety symptoms and two as moderate, compared with nine and two patients of the FD group, while all the patients in the control group had only mild anxiety symptoms. In addition, two DU patients had social phobia while two FD patients suffered from panic disorder without agoraphobia. Ten DU patients, 11 FD patients and four controls suffered from depressive illness, mostly dysthymia; differences were statistically significant between FD patients and controls (p<0.05). Eight DU patients and seven FD patients were rated as having mild; two DU and four FD patients as moderate depressive illness, while all the four patients in the control group suffered from mild symptoms. Overlaps between anxiety and depressive symptoms were frequent, and the diagnoses were made according to the dominant symptoms only. Other neurotic conditions were rare: two cases of social phobia and two adjustment disorder and one patient migraine. Psychotic illness was absent in the present study.

Life events were substantially more in DU and FD patients with psychiatric illness than the controls, but differences were not statistically significant [Table - 3].


   Discussion Top


Psyche and gastrointestinal disorders have been linked since the early writings of William Beaumont in 1830 and others [1],[2],[21] . Emotional disorders in particular have been shown to affect gut disturbances in various ways [4],[5] , though a causative relationship has never been easy to prove beyond doubt [13] .

Twenty-five percent of the DU patients reported psychiatric illness, compared with 31.2% FD patients and 17.5% of the control group, differences being statistically significant between FD patients and controls only. Similar findings to ours were reported before in patients with peptic ulcer [10],[14]. In fact Mahgoub et al [22] , in a more or less similar study to the present one reported an even higher prevalence of psychiatric illness in duodenal and gastric ulceration (31%). On the other hand, Mackdonal et al [7] found that non-organic gastrointestinal disorders are twice as likely as those with organic illness to be suffering from psychiatric disturbances. Kingham et al [8] reported that nearly half of those with severe functional bowel disorder have been shown to have moderate or severe depressive illness. Creed et al [10] reported a 34% of 79 patients with functional gastrointestinal disorder as having psychiatric disorders that definitely occurred before the onset of abdominal pain. Ford et al [23] found that the prevalence of psychiatric illness in functional gastrointestinal disorders fell from 48% to 31%, when the psychiatric disorder preceded the onset of the bowel symptoms.

Anxiety and depressive disorders dominated the clinical picture of the DU and FD patients in the present study [Table - 2]. Though the control group patients reported a more or less similar incidence of anxiety, they reported significantly less incidence of depressive disorders (p<0.05). Anxiety and depression were reported to be frequent in peptic ulceration [9],[22] . Thus Mahgoub et al [22] reported 31% incidence rate and Sjoidin et al [9] reported that peptic ulcer patients were significantly more depressed and anxious than the controls. Huag et al [15] reported similar results but with significantly more anxiety and depression in FD patients than DU patients. Talley et al [14] , reported initial baseline but significant differences on a number of mood measures in essential dyspepsia, compared with community controls, though the numerical differences observed were not large. The authors went to argue that the association of anxiety, neuroticism and depression with essential dyspepsia cannot be accepted as a causal association, as this has to satisfy other criteria [24] . In addition, these results could also be interpreted as merely indicating a non-specific response to the presence of discomfort [17] , as reported in a number of organic diseases [17],[18] . Anxiety and depression were reported to be frequent in peptic ulceration [9],[22] . On the other hand, Creed et al [10] in a well-designed study reported similiar findings to ours, on the prevalence of psychiatric illness that definitely preceded the onset of abdominal complaints. He argued that the associated psychiatric disorder was not simply a reaction to prolonged abdominal disorders. However he did not rule the possibility that the depressive and anxiety symptoms may lead to a lowered pain threshold and that this may contribute to the experience of abdominal pain. Kingham et al [8] reported a 50% of patients with severe functional bowel disorder to be moderately or severely depressed, but he did not show whether the psychiatric illness or the bowel disturbance occurred first. Hafeiz and Al Quorain reported a significantly higher psychiatric morbidity with irritable bowel syndrome than in the healthy controls [25] . No abnormal personality traits were noticed in the DU and FD patients in the present study. Talley et a1 [14] did not find any distinct personality profile in non­ulcer dyspepsia, though significant differences were observed on the personality clinical scales. No psychotic disorders were noticed in the present study and, in addition the anxiety and depressive symptoms reported were mostly mild ones, a finding common to most of the studies mentioned above [10],[14],[26] .

The relationship of stress to DU and FD in the present study is dealt with in a separate communication [27] . Life events were substantially more in DU and FD patients with psychiatric illness than the controls, though differences were not statistically significant [Table - 3], a finding common to most of the studies abroad [10],[15] . Differences in experiencing life events between DU and FD psychiatric patients were insignificant. It is, no doubt, difficult to draw conclusions on the relationship between stress and gastrointestinal disorders, as the above mentioned differences in experiencing life events are not consistant, sometimes even conflicting.

In conclusion, the study shows a significant association between ulcer and non-ulcer dyspepsia and psychiatric disturbances in comparison with a control group. Further studies are needed to elucidate the nature and causes that underlie this relationship.

 
   References Top

1.Beaumount W. Experiments and observations on the gastric juice and the physiology of digestion. Plattsburg: Allen, 1833.  Back to cited text no. 1    
2.Cannon WB. Bodily changes in pain, hunger, fear and rage. New York: Appleton, 1929.  Back to cited text no. 2    
3.Davenport HW. Physiology of the digestive tract, 5th ed. Chicago, London: Year Book Medical Publishers, 1982;52-69.  Back to cited text no. 3    
4.Baume P, Tracey M, Dawson L. Efficacy of two minor tranquilizers in relieving symptoms of functional gastrointestinal distress. Aust NZ J Med 1975;5:503-6.  Back to cited text no. 4    
5.Terris G. Amitriptyline in functional digestive disorders. Gaz Med Fr 1971;78:7192-5.  Back to cited text no. 5    
6.Creed F, Guthrie E. Psychological factors in the irritable bowel syndrome. Gut 1987;28:1307-18.  Back to cited text no. 6    
7.Mackdonald A.J, Boushier PAD. Non-organic gastrointestinal illness: a medical and psychiatric study. Br J Psychol 1980;136:276-83.  Back to cited text no. 7    
8.Kingham JGC, Dawson AM. Origin of chronic right upper quadrant pain. Gut 1985;26:783-8.  Back to cited text no. 8    
9.Sjodin I. Svedlund J, Dotevall G, Gilberg R. Symptom profiles in chronic peptic ulcer disease. Scand J Gastroenterol 1985;20:419-27.  Back to cited text no. 9    
10.Creed F, Craig T, Farmer R. Functional abdominal pain, psychiatric illness, and life events. Gut 1988;29:235-42.  Back to cited text no. 10    
11.Piper DW, Ariotti D, Creig M, Brown R. Chronic duodenal ulcer and depression. Scand J Gastroenterol 1980,15:201-3.  Back to cited text no. 11    
12.Piper DW, Creig M, Thomas J, Shinners J. Personality pattern of patients with chronic gastric ulcer. Gastroenterol 1977;73:444-6.  Back to cited text no. 12    
13.McIntosh JH, Nasiry RW, Frydman M, Waller SL, Piper DW. The personality pattern of patients with chronic peptic ulcer: a case control study. Scand J Gastroenterol 1983;18:945-50.  Back to cited text no. 13    
14.Talley NJ, Fung LH, Gilligan IJ, McNeil D, Piper DW. Association of anxiety, neuroticism, and depression with dyspepsia of unknown cause: a case-contol study. Gastroenterol 1986;90:886-92.  Back to cited text no. 14    
15.Haugh TT, Wilhelmsen 1, Berstad A, Ursin H. Life events and stress in patients with functional dyspepsia compared with patients with duodenal ulcer and healthy controls. Scand J Gastroenterol 1995;30:524-30.  Back to cited text no. 15    
16.Talley NJ, Piper DW. A prospective study of social factors and major life event stress in patients with dyspepsia of unknown cause. Scand J Gastroenterol 1987;22:268-72.  Back to cited text no. 16    
17.Merskey H. The role of the psychiatrist in the investigation and treatment of pain. In: Bonica JJ, ed. Pain. New York: Raven, 1980;249-60.  Back to cited text no. 17    
18.Mandelbrote BM, Wittkower ED. Emotional factors in Graves disease. Psychosom Med 1955;17:109-23.  Back to cited text no. 18    
19.American Psychiatric Association. DSM-11l-R 1987.  Back to cited text no. 19    
20.Tennant C, Andrews G. A scale to measure the stress of life events. Aust & New Zealand J Psychiat 1987;10:27-32.  Back to cited text no. 20    
21.Wolf F, Wolff HG. Human gastric function. An experimental study of a man and his stomach. New York: Oxford University Press, 1943.  Back to cited text no. 21    
22.Mahgoub OM, Hafeiz HB, Al-Quorain A, et al. Life events stress in Saudi peptic ulcer patients of the Eastern Province. Annals of Saudi Medicine 1991;11:669-74.  Back to cited text no. 22    
23.Ford MJ, Miller PMcC, Eastwood J, Eastwood MA. Life events, psychiatric illness and the irritable syndrome. Gut 1987;28:160-5.  Back to cited text no. 23    
24.Hill AB. Environment and disease: association or causation. Proc R Soc Med 1965;58:295-300.  Back to cited text no. 24    
25.Hafeiz HB, Al-Quorain A. The psychopathology of irritable bowel syndrome. J Bahrain Med Soc 1994;6:117-21.  Back to cited text no. 25    
26.Talley NJ, Philips SF, Bruce B, Twomey CK, Zinsmeister AR, Melton Ill MJ. Relation among personality and symptoms in non-ulcer dyspepsia and the irritable bowel syndrome. Gastroenterol 1990;99:327-33.  Back to cited text no. 26    
27.Hafeiz HB, Al-Quorain A, Karim AA, Al-Mangoor S. Life event stress in duodenal ulcer compared with functional dyspepsia: a case-control study. The Saudi J of Gastroenterol 1997;3:84-9.  Back to cited text no. 27    

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Correspondence Address:
Hassan B Abdel Hafeiz
Department of Psychiatry, College of Medicine, P.O. Box 2114, Dammam 31451
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864755

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