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Levenstein S, Jacobsen RK, Rosenstock S, Jørgensen T. Mental vulnerability, Helicobacter pylori, and incidence of hospital-diagnosed peptic ulcer over 28 years in a population-based cohort. Scand J Gastroenterol 2017; 52:954-961. [PMID: 28503971 DOI: 10.1080/00365521.2017.1324897] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Susan Levenstein
- a Aventino Medical Group , Rome , Italy.,b Research Centre for Prevention and Health, The Capital Region of Denmark , Glostrup , Denmark
| | - Rikke Kart Jacobsen
- b Research Centre for Prevention and Health, The Capital Region of Denmark , Glostrup , Denmark
| | - Steffen Rosenstock
- c Gastroenterology Department , Surgical Section, Hvidovre University Hospital , Copenhagen , Denmark
| | - Torben Jørgensen
- b Research Centre for Prevention and Health, The Capital Region of Denmark , Glostrup , Denmark.,d Department of Public Health, Faculty of Health Science , University of Copenhagen , Copenhagen , Denmark.,e Faculty of Medicine , Aalborg University , Aalborg , Denmark
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Deding U, Ejlskov L, Grabas MPK, Nielsen BJ, Torp-Pedersen C, Bøggild H. Perceived stress as a risk factor for peptic ulcers: a register-based cohort study. BMC Gastroenterol 2016; 16:140. [PMID: 27894275 PMCID: PMC5126869 DOI: 10.1186/s12876-016-0554-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 11/22/2016] [Indexed: 01/19/2023] Open
Abstract
Background The association between stress and peptic ulcers has been questioned since the discovery of helicobacter pylori. This study examined whether high perceived everyday life stress was associated with an increased risk of either receiving a triple treatment or being diagnosed with a peptic ulcer. Methods Cohen’s perceived stress scale measured the level of stress in a general health survey in 2010 of 17,525 residents of northern Jutland, Denmark, and was linked with National Danish registers on prescription drugs and hospital diagnoses. Cox proportional hazard regression was used to estimate the risk of either receiving a triple treatment or being diagnosed in a hospital with a peptic ulcer, in relation to quintiles of stress levels. Results A total of 121 peptic ulcer incidents were recorded within 33 months of follow-up. The lowest stress group had a cumulative incidence proportion of either receiving triple treatment or being diagnosed with peptic ulcer of approximately 0.4%, whereas the highest stress group had a cumulative incidence proportion of approximately 1.2%. Compared with that of the lowest stress group, those in the highest stress group had a 2.2-fold increase in risk of either receiving triple treatment or being diagnosed with peptic ulcer (HR 2.24; CI 95% 1.16:4.35) after adjustment for age, gender, socioeconomic status, non-steroid anti-inflammatory drug use, former ulcer and health behaviours. There was no difference in risk between the four least stressed quintiles. Subgroup analysis of diagnosed peptic ulcer patients revealed the same pattern as the main analysis, although the results were not significant. Conclusion The highest level of perceived everyday life stress raised the risk of either receiving triple treatment or being diagnosed with peptic ulcer during the following 33 months more than twice compared with that of the lowest level of perceived stress.
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Affiliation(s)
- Ulrik Deding
- Department of Health Science and Technology, Public Health and Epidemiology Group, Aalborg University, Niels Jernes Vej 14, Aalborg, Øst, 9220, Denmark.
| | - Linda Ejlskov
- Department of Health Science and Technology, Public Health and Epidemiology Group, Aalborg University, Niels Jernes Vej 14, Aalborg, Øst, 9220, Denmark
| | - Mads Phillip Kofoed Grabas
- Department of Health Science and Technology, Public Health and Epidemiology Group, Aalborg University, Niels Jernes Vej 14, Aalborg, Øst, 9220, Denmark
| | - Berit Jamie Nielsen
- Department of Clinical Epidemiology, Aalborg University Hospital, Sdr. Skovvej 15, Aalborg, DK-9000, Denmark
| | - Christian Torp-Pedersen
- Department of Health Science and Technology, Public Health and Epidemiology Group, Aalborg University, Niels Jernes Vej 14, Aalborg, Øst, 9220, Denmark.,Department of Clinical Epidemiology, Aalborg University Hospital, Sdr. Skovvej 15, Aalborg, DK-9000, Denmark
| | - Henrik Bøggild
- Department of Health Science and Technology, Public Health and Epidemiology Group, Aalborg University, Niels Jernes Vej 14, Aalborg, Øst, 9220, Denmark
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Levenstein S, Rosenstock S, Jacobsen RK, Jorgensen T. Psychological stress increases risk for peptic ulcer, regardless of Helicobacter pylori infection or use of nonsteroidal anti-inflammatory drugs. Clin Gastroenterol Hepatol 2015; 13:498-506.e1. [PMID: 25111233 DOI: 10.1016/j.cgh.2014.07.052] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/22/2014] [Accepted: 07/22/2014] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
| | - Steffen Rosenstock
- Gastroenterology Department, Surgical Section, Hvidovre University Hospital, Hvidovre, Denmark
| | - Rikke Kart Jacobsen
- Research Centre for Prevention and Health, Capital Region of Denmark, Glostrup, Denmark
| | - Torben Jorgensen
- Research Centre for Prevention and Health, Capital Region of Denmark, Glostrup, Denmark
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Stress-induced Physiologic Changes as a Basis for the Biopsychosocial Model of Chronic Musculoskeletal Pain. Clin J Pain 2008; 24:767-75. [DOI: 10.1097/ajp.0b013e3181790342] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kapfhammer HP. Depressive und Angststörungen bei somatischen Krankheiten. PSYCHIATRIE UND PSYCHOTHERAPIE 2008. [PMCID: PMC7122024 DOI: 10.1007/978-3-540-33129-2_57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Depressiv-ängstliche Störungen sind bei den unterschiedlichen somatischen Erkrankungen häufig. Sie sind nicht nur als Reaktion auf die Situation der Erkrankung zu verstehen, sondern in ein komplexes Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen, die das Zentralnervensystem oder endokrine Regulationssysteme direkt betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich.
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Abstract
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.
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Affiliation(s)
- Susan Levenstein
- Gastroenterology Department, San Camillo-Forlanini Hospital, Rome, Italy.
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Abstract
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.
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Affiliation(s)
- S Levenstein
- Gastroenterology Department, San Camillo-Forlanini Hospital, Rome, Italy.
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Levenstein S, Kaplan GA, Smith MW. Psychological predictors of peptic ulcer incidence in the Alameda County Study. J Clin Gastroenterol 1997; 24:140-6. [PMID: 9179731 DOI: 10.1097/00004836-199704000-00004] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
It has often been suggested that mood and personality predispose to peptic ulcer, but little prospective evidence exists. We used longitudinal data from the Alameda County Study to seek associations of psychological characteristics with later ulcer development, taking into account the possible confounding or mediating, taking into account the possible confounding or mediating roles of nonpsychological factors. Among 4,595 Alameda County Study subjects ulcer-free in 1965, we studied five baseline psychological measures (depression, hostility, ego resiliency, social alienation or anomy, and personal uncertainty) with respect to reported ulcer in 1973-1974. All five measures had significant age-adjusted associations with incident ulcer [odds ratio (O.R.) 1.8-2.6]. After adjustment for smoking, drinking, skipping breakfast, lack of sleep, painful medical conditions, and liver disease, three measures remained significant: depression, anomy, and hostility. The age-adjusted O.R. of 2.8 [95% confidence interval (C.I.) 1.6, 4.8] for an upper versus a lower tertile index of independently predictive psychological factors fell to 2.1 with adjustment for health-related behaviors and medical conditions, and reached 1.7 (C.I. 1.0, 3.1) after addition of education to the model. We conclude that depression, maladjustment, and hostility are prospectively associated with peptic ulcer. These associations are partially accounted for by confounding or mediation by standard risk factors, and are to some extent related to socioeconomic status.
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Affiliation(s)
- S Levenstein
- Human Population Laboratory, Berkeley, California, USA
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Levenstein S, Prantera C, Varvo V, Arca M, Scribano ML, Spinella S, Berto E. Long-term symptom patterns in duodenal ulcer: psychosocial factors. J Psychosom Res 1996; 41:465-72. [PMID: 9032710 DOI: 10.1016/s0022-3999(96)00196-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Seventy-five patients with recent-onset dyspepsia and endoscopically visible duodenal ulcer underwent psychological evaluation. Following ranitidine treatment, they were reinterviewed periodically for 12 to 76 months (mean 38.6). Ulcer symptoms were present during a mean of 14.9% of follow-up months. Patients did significantly worse if they had a low-status occupation, low education, depression, stressful life events, or abnormal Minnesota Multiphasic Personality Inventory at baseline. Of patients recalling premorbid life stress, those with a normal MMPI had a particularly benign course, whereas those with an abnormal MMPI did particularly poorly (6% versus 29% of months symptomatic: p < 0.04). Age, gender, smoking, drinking, antiinflammatory drugs, pepsinogen, Helicobacter pylori titers, and initial healing had no prognostic effect. Low socioeconomic status, life stress, depression, and psychopathology each predict a relatively poor symptom outcome for duodenal ulcer treated with antisecretory therapy, but psychologically stable individuals who develop an ulcer under stress have an excellent long-term prognosis.
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Affiliation(s)
- S Levenstein
- Gastroenterology Division, Nuovo Regina Margherita Hospital, Rome, Italy
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Friedman EH. Neurobiology of psychologic predictors of duodenal ulcer healing. J Clin Gastroenterol 1996; 23:81. [PMID: 8835914 DOI: 10.1097/00004836-199607000-00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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