Life Events Stress in Saudi Peptic Ulcer Patients of the Eastern Province

Introduction

Holmes and Rahe ^[1] defined life events as a complex of circumstances requiring or implying a change in the ongoing life-style of an individual. Psychological stress is defined as internal or external stimuli that are significant to the individual, and the emotions they arouse may induce psychological changes which threaten health ^[2].

Authors have reported an association of life events stress and onset or exacerbation of physical ^[3] and psychiatric disorders ^[4]. The influence of emotions on gastric motility, vascularity, and secretions is well documented ^[5].

Peptic ulcers (PU) develop in areas of the gastrointestinal tract exposed to acid and pepsin. They appear mostly in the stomach and duodenal bulb, though some may occur in the distal part of the esophagus. PU disease is a heterogenous disorder with a common clinical feature—a hole in the mucosa of the stomach or duodenum. Heredity, increased acidity and pepsin secretion, decreased mucosal defense, smoking, the use of steroidal and nonsteroidal antiinflammatory drugs, and emotional stress have been implied in the etiology of PU disease ^[6].

As early as 1937, Davies and Wilson ^[7] reported that 85% of 205 newly diagnosed duodenal ulcer patients had experienced stressful life events within a week of onset of their symptoms, as compared with 22 of 100 patients with hernia who served as controls. Myers ^[8] also reported that, in 86% of their PU patients, the majority were duodenal ulcer subjects who had experienced emotional stress at the onset of symptoms; however, the study was uncontrolled. Alpe et al ^[9] demonstrated that a group of hospitalized chronic gastric ulcer patients had experienced substantially more domestic and financial stresses before admission and were more prone to anxiety and depression than were matched controls. By contrast, several investigators in controlled studies of chronic gastric ^[10,11] and duodenal ulcer ^[12] patients found no significant differences between patients and controls regarding the number, nature, or stress of life events. Therefore, the role of stress in the etiology of PU remains controversial.

We carried out a preliminary study to investigate whether Saudi PU patients of the Eastern Province had experienced an excess of life events stress during the year preceding diagnosis of the disease or exacerbation of their illness, in comparison to a control group of subjects without ulcer. We ascertained the frequency and nature of psychiatric morbidity among the study participants.

MATERIAL AND METHODS

Fifty-one consecutive Saudi patients (42 males, 9 females) were diagnosed endoscopically to have PU. Patients were seen at the two endoscopy clinics of King Fahd Hospital of the University, Al-Khobar, Eastern Saudi Arabia, between March 1985 and July 1987. Forty-five of the patients were out-patients and six were in-patients (three medical, three surgical). Patients were excluded if they were suffering from a concomitant overwhelming physical disorder or they were not permanent residents of the Eastern Province. The outpatients were interviewed shortly after the endoscopy procedure and the inpatients were seen within one to two days. The patients’ occupations were: professionals (N = 2), army officer (N = 1), civil service (N = 14), private business (N = 4), soldiers (N = 7), and skilled, semiskilled, or unskilled laborers (N = 8). The 15 unemployed patients included: pensioners (N = 4), housewives (N = 6), students (N = 4), and jobless (N = 1). The control group included a consecutive series of 47 (42 males, five females) hospital or university civil servant Saudi employees and five unemployed Saudi housewives visiting normally confined female patients of the hospital on random days. Controls were excluded if they had a history of PU or dyspepsia or were not permanent residents in the Eastern Province.

Assessment of Events

A list of 34 life events was composed which was derived from Paykel et al's 61 life events schedule ^[13] (Table 1). Items believed to be inappropriate to the Saudi culture were deleted (e.g., going out with steady boyfriend, son drafted in forces, child marries without approval, and husband or wife unfaithful). However, the selected events were not scaled (i.e., numerical values given for the degree of life change or the amount of stress), as this would have entailed a validation study of the whole scale which was beyond the scope of our study, being a preliminary one. However, the selected events were categorized into areas of activities, according to Paykel et al ^[13], that included undesirability which correlates with the magnitude of stress.

Table 1. List of individual life events.

Data were collected during a semi-structured interview that sought information on sociodemographic data, mental state examination, physical health, and life events. The interview was conducted by the psychiatric team. The time span covered for any experienced life event was one year before the endoscopy for the patients and before the interview for the controls. Psychiatric diagnoses were based on the criteria recommended by the World Health Organization ^[14].

Student's t test (two-tailed) was used to test for the significance of difference between means. Chi-square test and Fisher's exact test were used to test for significance between proportions.

RESULTS

In the study group of 51 patients, the endoscopy diagnoses were as follows: 38 (74%), duodenal ulcer: five (10%), gastric ulcer; five (10%). gastric and duodenal ulcers; two (4%), esophageal ulcer; and one (2%), anastomotic ulcer.

The age range for patients was 21 to 78 years (mean age. standard deviation [SD], and standard error |SE] of the mean was36.34,16.49,2.31 years, respectively; values for controls were 35.81, 10.33, and 1.43 years, respectively). The difference between the mean age of the two groups was statistically insignificant. Student's t test (two-tailed) yielded t = 0.23, df = 101, P = 0.818.

Twelve patients were single, 3ft were married, and three were divorced or separated. The corresponding figures for the controls were 13, 35, and 4, respectively. There was no statistically significant difference between them. The chi-square test yielded P = 0.91, df = 2.

Thirty-six of the patients were employed and the remaining 15 were unemployed. Of the controls, 47 were employed and five were unemployed. The difference between patients and controls was statistically significant at P = 0.022.

The mean number, SD, and SE of ascertained life events in patients was 1.65, 1.21, and 0.17, and in controls, 1.75, 1.3. and 0.18. respectively. The difference between the mean number of life events in the patients and controls was statistically insignificant. Student's t test (two-tailed) yielded t = 0.42, df = 101, and P = 0.678. The distribution of the number of life events in patients and controls is shown in Table 2. The majority of patients and contols had experienced between one and three events, but the chi-square test revealed no significant difference between patients and controls.

Table 2. Distribution of number of events: peptic ulcer patients and controls.

Individual Events

As many events were reported by only a few subjects, the difference between events frequency in patients and controls was examined only for those events reported by at least five subjects in either group (Table 3). Serious arguments with inlaws or relatives (Event No. 9) were significantly more frequent in patients while minor personal illness (Event No. 20) and moderate financial problems (Event No. 29) were significantly more frequent in controls.

Table 3. Frequency of individual life events: peptic ulcer patients and controls.^a

Categorization of Life Events

The life events shown in Table 1 were categorized into the following areas of activity, according to the scheme of Paykel et al ^[13]: bereavement (Events Nos. 1, 2, 3, 4), health (Events Nos. 14,18,19, 20), marital (Events Nos. 7, 8, 10), finance (Events No. 28, 29), work (Events Nos. 21, 22, 23, 24, 25, 26, 27, 30, 31), children (Events Nos. 2, 11, 13, 14, 17), legal (Events Nos. 33, 34), exit (Events Nos. 1, 2, 3, 4, 6, 10, 16), entrance (Events Nos. 5, 7, 12, 13), undesirable (Events Nos. 1, 2, 3, 4, 6, 8, 9, 10, 14, 17, 18, 19, 20, 24, 25, 26, 28, 29, 31, 33, 34), uncontrolled (Events Nos. 1, 2, 3, 4, 14, 15, 16, 17, 18, 19, 20, 25, 26, 28, 30, 34), and controlled (Events Nos. 5, 7, 11, 12,13, 21). Only those subjects who were employed—both patients and controls—were included in the work, undesirable, and controlled categories. The undesirable and controlled categories involve events related to work. There was no statistical difference between patients and controls in the twelve areas of activities, either in the number included in a particular category or the frequency distribution of events, i.e., one, two, or more events (Table 4).

Table 4. Analysis of categorized events.

Psychiatric diagnostic categories encountered in both patients and controls are shown in Table 5. Significantly more PU patients (N = 21) than controls (N = 10) had recognizable psychiatric morbidity. Fisher's exact test yielded P = 0.013. Anxiety and/or depression was significantly more frequent in PU patients (N = 16) than in controls (N = 7). Fisher's exact test yielded P = 0.025.

Table 5. Percentage of psychiatric morbidity in peptic ulcer patients and controls.

DISCUSSION

Research on life events stress and subsequent illness are beset with several problems: data are collected retrospectively (i.e., after the onset of the illness with the recognizable drawbacks of fall-off of reporting of events due to poor recall as increased time elapses before the interview), exact onset of the disease is difficult to ascertain, and accurate quantification of stress is hampered ^[3,15]. Though stress was not quantified in our study, events were grouped into categories that included undesirability, which is documented to correlate significantly with the magnitude of life events stress (i.e., “objective negative impact”) ^[15].

Our study revealed that only three of the 34 events studied showed a statistically significant difference between PU patients and controls, and of these, only one event (No. 9, serious arguments with in-laws) was more-common in patients, whereas the other two events (No. 20, minor personal illness, and No. 29, moderate financial problems) were more common in controls. Furthermore, neither the mean number of life events nor the aggregation of the events into various categories was significantly different between PU patients and controls. Thus, the presence of significant stress in our PU patients was not substantiated.

Studies relating stress to PU disease have been criticized on various grounds. In Davies and Wilson's study ^[7], patients were asked to give an account of events which occurred before their illness, rather than being asked systematically about a list of events. Meyer's study ^[8] did not include controls, while data on the patients in Alpe et al's study ^[9] were collected from case notes several years after admission for their illness.

Our negative findings are supported by those from other studies that found no excess stress in chronic gastric ^[10,11] or duodenal ulcer ^[12] patients over that seen in controls. Furthermore, the incidence of PU in air-traffic controllers, a group exposed to high stress, was reported to be similar to its incidence in the general population ^[16]. Other authors have also concluded that there was no evidence of a relationship between life events stress and chronic organic diseases ^[17], and the association accounts for less than 10% of the variance ^[18]. However, failure to demonstrate excess stress in our PU group does not preclude the possibility that these patients might have reacted differently to stress. This is supported by findings in a recent study of PU patients ^[19], in which there was no significant difference in the frequency of life events between patients and controls, but the patients perceived more events as threatening and reacted more intensely to them than did the controls.

Anxiety and depressive symptoms are the most common mood changes associated with physical illness ^[20]. The prevalence of depression in the medically ill ranges from 13 to 27%, according to the severity of the condition ^[21]. However, it is frequently difficult to determine whether depression is a response to the illness, a direct manifestation of it, or part of a co-existing psychological disorder ^[22].

Anxiety and/or depression were significantly noted in nearly one third of our PU patients (31%). This agrees with the findings of Feldman et al ^[19] and Sjodin et al ^[23], who reported that their PU patients were significantly more depressed as well as more anxious than were the control subjects.

Concomitant psychological morbidity needs to be taken into consideration in the therapeutic management of PU patients receiving treatment in the Eastern Province.