AN OVERVIEW OF PSYCHOSOMATIC DISORDERS: PEPTIC ULCERS & EMOTIONAL INTELLIGENCE
AN OVERVIEW OF PSYCHOSOMATIC DISORDERS
It is already clear that psychosomatic illness may take a bizarre form. In the
case of Steven, there is little doubt of the existence of a psychosomatic disorder.
But what about those cases where there is less dramatic evidence?
Many believe that some ulcers, high blood pressure, and other physical
problems are partly caused by an adverse psychological state. But how does
a clinician know this, and when there is evidence, how does he or she classify
it'?
The diagnosis of psychosomatic disorder is made if (I) there is a disorder
of known physical pathology present and (2) psychologically meaningful
events preceded and are judged to contribute to the onset or worsening of
the disorder. This diagnosis is contained in DSM's apt name for these
disorders "psychological factors affecting physical condition." The first criterion
distinguishes psychosomatic disorders from somatoform
disorders. Conversion. psychogenic amnesia, and the like have no
known physical basis, whereas psychosomatic disorders do. Bear's paralysis
was not accompanied by any physical damage to his nerves or spinal cord,
whereas an individual whose peptic ulcer flares up every time he is criticized
by his boss (which meets the second criterion) has actual physical damage 10
the lining of his gastrointestinal system. By these criteria, Steven's forearm
wells are a clear case of psychosomatic disorder, since symptoms of known
physical pathology are present-rope marks and bleeding-and a psychologically
traumatic incident-being bound while asleep c-preceded and was
demonstrated by the hypnotic reliving to have contributed to the wells and
bleeding.
These two defining criteria of psychosomatic disorder have been incorporated
into a particular model: the diathesis-stress model. "Diathesis"
refers to the constitutional weakness that underlies the physical pathology.
and "stress" to the psychological reaction to meaningful events. According
to this model, an individual develops a psychosomatic disorder when he
both has some physical vulnerability (diathesis) and experiences psychological
disturbance (stress). If an individual is extremely weak constitutionally,
very little stress will be needed to trigger the illness; if, on the other hand,
extreme stress occurs, even individuals who are constitutionally strong may
fall ill. In effect, the model suggests that individuals who develop peptic
ulcers are both constitutionally vulnerable to gastrointestinal problems and
experience sufficient stress to trigger the pathology.
Psychological factors can affect many physical conditions in a large
number of organ systems: the skin, the skeletal-musculature. the respiratory,
the cardiovascular, the blood and lymphatic, the gastrointestinal, the
genitourinary, the endocrine systems, or the sense organs (Looney. Lipp,
and Spitzer). Here is no evidence, however, that the process causing
psychosomatic effects is different for different organs. Although any given individual
may be especially vulnerable to psychosomatic influence in only
one organ system. Some of us react to stress with the stomach, others by
sweating, some by muscle tension, and still others with a racing heart.
PEPTIC ULCERS
A peptic ulcer is a circumscribed erosion of the mucous membrane of the
stomach or of the duodenum, the upper portion of the small intestine.
Such ulcers are called "peptic" because it is commonly thought that they arc at
least partially caused by pepsin, which is contained in the acidic juices normally secreted
by the stomach. There arc two sorts of peptic ulcers named by their location: a stomach
(gastric) ulcer and a duodenal ulcer.
Roughly two million people in the United States today have a peptic
ulcer, and about five thousand people die of peptic ulcer each year in the
United States (Center for Disease Control). We begin our discussion
of psychosomatic disorders with the peptic ulcers because they are so widespread
and because much is known, both about the physical pathology underlying
ulcers and about psychological influence on their development and course.
Carlos's gastrointestinal problems illustrate the ways in which environmental
stress influences peptic ulcers.
Carlos has had an ulcer for the last seventeen years. Until recently he had it
under control; for whenever he experienced gastric pain, drinking a quart of milk
or eating eggs would relieve it. Three years ago he was promoted to manager of a
major department store and moved from his home town to a distant city. Since he
took on this increased responsibility, he has experienced severe ulcer pain.
He had been born and raised in a small New England town. His father was
wealthy and the head of a chain of department stores. Although his father was in
general dominating and intolerant (and also had an ulcer), he was kind and generous to Carlos.
After graduation from college Carlos entered the department store business and even now,
at age forty-one, he feels incapable of holding a job without his father's intervention, influence, and support.
As soon as Carlos took over the management of the store, he became tense and
anxious and began to brood over trivial details. He was afraid the store would
catch fire; he was afraid that there would be bookkeeping errors that he might not
catch; he was afraid the store would not make a big profit. Convinced he was a
complete failure, and plagued with severe pains from his duodenal ulcer, he entered
psychotherapy. During these sessions, Carlos and his therapist learned how
much the psychological factors in his life contributed to the worsening of the
ulcer. The following three incidents particularly illustrate this.
First. on a day when the store was full of people a large ventilating fan broke.
The store began to shake as the customers rushed to the street, and Carlos went
into a panic. As soon as the excitement subsided and his panic diminished, severe
ulcer pains started.
Second, Carlos's mother had for many years complained of a "heart condition."
While his mother's physician had never isolated a physical cause, Carlos
nevertheless worried about it. One day Carlos saw a hearse pass in front of the
store. Immediately he thought that his mother had died and in panic ran several
miles to her home finding her quite alive. As he started to run the stomach pains
broke out, and these pains remained until he saw his mother was not ill.
Third, one night Carlos's store burned to the ground. He was highly anxious
that he would be found negligent during the ensuing insurance investigation. As
he awaited the results of the inquiry, his wife called and told him that his daughter
had broken a leg. He ran home and found his wife in tears, and he immediately
developed severe stomach pains.
Before he had become manager of the store he had occasionally had stomach
pains while on the job, but he had found a technique for reliably and immediately
alleviating them: he would go to an older person for comfort. Upon being reassured
by an authority figure, his ulcer pain would disappear. In his new job, however,
he was the authority figure, there was no one to turn to, and his ulcer pains
persisted, unrelieved, (Adapted from Weisman).
SYMPTOMS OF PEPTIC ULCER
Carlos suffered the main symptom of peptic ulcer: abdominal pain. Such
abdominal pain can vary from mild discomfort to severe and penetrating,
extreme pain. Pain may be steady, aching, and gnawing, or it may be sharp
and cramp-like. Pain is usually not present before breakfast; it generally
starts from one to four hours after meals. Bland foods and antacids usually
alleviate the pain and peppery food, alcohol, and aspirin usually intensify it
(Lachman & Weiner). Peptic ulcers that become very serious
sometimes perforate or bleed. Without well-timed surgery, a perforated
ulcer can lead to death from internal bleeding.
PHYSIOLOGICAL DEVELOPMENT OF AN ULCER
In order to understand how these symptoms come to be, we must first take a
brief look at the actions of the digestive system. Digestion breaks down food
in the stomach so that when the food passes through the intestines, the appropriate
materials can be absorbed for use by the body. In order to digest
food, the stomach secretes two highly corrosive juices: hydrochloric acid,
which breaks food down, and pepsin, which decomposes protein. Why, you
might wonder, does the stomach not digest itself? Fortunately, the stomach
and the small intestine are lined with a mucous membrane that protects
them from corrosion by the hydrochloric acid they secrete. In addition, gastric
juices are normally secreted only when there is food in the stomach to
absorb most of the corrosive acid. But sometimes the system develops a
problem. A break may occur in the mucous coating of the stomach or duodenum.
Such a break may occur when some of the thin lining is worn away
in the normal course of digestion. It may also occur when an overdose of
aspirin, particularly in combination with alcohol, is ingested, or when naturally
secreted bile attacks the membrane. If a break occurs in the absence of
too much gastric juice, it will repair itself and no ulcer will form, since cell
growth completely renews the stomach lining every three days (Davenport).
If an excess of hydrochloric acid or pepsin is around, however, particularly
when food is not in the stomach, the abrasion will worsen and an
ulcer will form.
WHO Is SUSCEPTIBLE TO ULCERS?
The way an ulcer develops gives us clues about what diathesis, or constitutional
weakness, makes ulcers more likely. Individuals who secrete excess
hydrochloric acid or pepsin, individuals with an especially weak mucous
defense against acid, and individuals whose stomach lining regenerates
slowly may generally be more susceptible to ulcers. This condition may be
genetically inherited.
The prevalence of peptic ulcer varies widely from country to country, and
from decade to decade. Today, approximately 1percent of the adult American
population has an ulcer, and almost four hundred thousand Americans
are hospitalized yearly for peptic ulcers. The frequency of peptic ulcers has,
for unexplained reasons, declined by about 25 percent over the last decade
in the U.S. and Europe (McConnell, 1966; Lachman, 1972; Weiner, 1977;
Elashoffand Grossman, 1980).
The susceptibility of women versus men seems to have undergone a
major change over the past 100 years. Before 1900, peptic ulcers occurred
more frequently in women than in men, but in the beginning of the twentieth
century a shift occurred, with men becoming considerably more ulcer
prone. By the late 1950s, men had 3.5 times as many duodenal ulcers as
women (Watkins, 1960). In recent years the male/female ratio has been
changing (Elashoffand & Grossman). By 1990, men had only 1.2 times
as many peptic ulcers as women in America, as ulcers in men had become
less frequent and ulcers in women had either stayed the same or slightly increased.
Social class does not strongly influence the incidence of ulcers. For a time
it was commonly believed that highly pressured, upwardly mobile and
professionally successful individuals develop the most ulcers. But in fact many
patients with peptic ulcer are poor and wholly unsuccessful (Rennie and
Srole).
Age also does not make much of a difference beyond the age of twenty, although
children probably have ulcers less frequently than adults. Among
children, girls have peptic ulcers about twice as frequently as boys (Christodoulou,
Gergoulas, Paploukas, Marinopoulou, and Sideris; Medley).
Ulcers clearly run in families. The relatives of patients with duodenal and
gastric ulcers are about three times as likely to have an ulcer as those in the
general population (McConnell, 1966). Further, healthy individuals who
have relatives with peptic ulcers secrete more gastric juice than individuals
without relatives with ulcers (Fodor, Vestea, and Urcan). This increased
susceptibility in families could either be genetic or environmental,
since family members share many of the same stresses, as well as genes. But
twin data suggest it is genetic. If one of two identical twins has a peptic ulcer,
the chances are 54 out of 100 that the co-twin will also have a peptic ulcer;
whereas if one of two fraternal twins has a peptic ulcer, there is only a 17
percent chance that the co-twin will also have peptic ulcer (Eberhard).
Here then is the foundation of the diathesis, in the diathesis-stress model
of peptic ulcers. How much acid and pepsin the stomach secretes contributes
to the formation of an ulcer. High acid and pepsin secretion runs in
families and may be the constitutional weakness that makes individuals
more susceptible to ulcers (Mirsky).
PSYCHOLOGICAL FACTORS INFLUENCING PEPTIC ULCERS
To what extent does stress influence the development or worsening of peptic
ulcers? When individuals who have a constitutional weakness of the intestinal
system-such as hereditary over secretion of acid-encounter certain
kinds of stress, peptic ulcers may result. By "stress" researchers refer to the
reaction of an individual to disturbing events in the environment.
A stress reaction can either be a short-term emotional reaction induced by a specific
situation, or it can be a long-term pattern of such emotional reactions, adding
up to an ulcer-prone personality. We turn first to the evidence that
emotional states influence peptic ulcer, and then we examine the possibility
that individuals who have a certain personality pattern of reacting to stress are ulcer prone.
Gastric Secretion, Peptic Ulcer, and Emotional States
Let us now take a look at the evidence that emotional states affect gastric secretion.
Two researchers were afforded a rare opportunity to study directly
the effects of anxiety and depression on digestion when they discovered a
man who, because of a childhood experience, was forced to feed himself
through a hole in his stomach.
Tom was a fifty-seven-year-old workman who at age seven swallowed some
very hot soup, which so burnt his esophagus that it had to be surgically sealed off.
After many unsuccessful attempts at corrective surgery, Tom had to resort to
feeding himself by chewing his food (to satisfy his taste) and then depositing the
food directly into his stomach using a funnel and a rubber tube. He was secretive
about this for many years, but when he was in his fifties, Tom allowed himself to
be experimented upon. Investigators directly examined his gastric secretions
under different emotional conditions. When Tom was anxious, angry, or resentful,
gastric secretions increased. When he was sad, his gastric secretions decreased
(Wolff).
In another study, thirteen patients with ulcers and thirteen normal subjects
were interviewed under emotion-provoking conditions. The patients
with ulcers showed a greater secretion of hydrochloric acid in the stomach
and more stomach motility than the patients without ulcers (Mittelmann,
Wolff, and Scharf). Findings with normal individuals under hypnosis
also confirmed that gastric secretions are influenced by emotion. Hypnotically
induced thoughts of anger and anxiety produced high gastric secretion,
while thoughts of depression, helplessness, and hopelessness produced low
secretion (Kehoe and Ironside).
High rates of peptic ulcer were also found in people in occupations that
produce high anxiety. For example, air traffic controllers have twice the
ulcer rate of matched control groups, and those controllers who work at
towers with much traffic have twice the ulcer rate of those who work at
towers with less traffic (Cobb and Rose). We must be cautious, however,
about this correlation between occupation and ulcers. It could be that
ulcer-prone individuals, for some reason, choose anxiety-provoking jobs. If
this is the case, it need not be the anxiety of the job that causes the ulcer.
The evidence presented above does suggest that emotional states like anxiety
and anger cause excess stomach acid; this in turn, contributes to the development
of peptic ulcers. Also, certain anxiety-producing occupations
may lead to more employees with stomach ulcers. Here again, greater anxiety
produces excess acid in the stomach. This latter point fits in with Carlos's
story narrated earlier. Like many individuals with ulcers, Carlos's ulcer
worsened and caused more pain after emotional crises. When he was anxious,
needed reassurance, and felt excessive demands for responsibility, his ulcer flared up.
When he allowed himself to be dependent, his ulcer was inactive.
Animal Models of Peptic Ulcer
Some investigators have shed light on the relation between emotional states
and ulcers by studying animals. In doing so, they have put animals in conditions
that change the emotional state of the animal. We will look at three
such situations: conflict, unpredictability, and uncontrollability. All of these
factors increase anxiety.
CONFLICT. Can "conflict" be aroused in a rat in order to find out
whether or not conflict produces ulcers? One way to bring about conflict is
to make a hungry rat run through shock in order to get food. This is called
an "avoidance-approach" conflict. In one experiment, one group of rats was
required to cross a shock grid in order to obtain food and water for forty seven
out of forty-eight hour cycles. During one hour, the grid was not electrified
so that the animals could have sufficient water and food. Six of nine
rats in this group developed ulcers, whereas none of the comparison group
rats did. Control groups with shock alone, food and water alone, or nothing
got fewer ulcers. So avoidance-approach conflict is more likely to produce
stomach ulcers than is electric shock, hunger, or thirst without conflict
(Sawrey, Conger, and Turrell; Sawrey and Weiss). Therefore
conflict, a psychological state that produces anxiety, can engender ulcers in
rats.
UNPREDICTABILITY. When noxious events are experienced by an individual,
they can either be signaled, and therefore predictable, or unsignaled,
and therefore unpredictable. For example, the rockets that fell on London
in World War II were signaled by an air raid siren. But when a concentration
camp guard arbitrarily singled out a prisoner for a beating, this was entirely
unsignaled. There is considerable evidence, both in rats and humans, that
when noxious events are signaled, individuals are terrified during the signal.
But they also learn that when the signal is not on, the noxious event docs not
occur, so they are safe and can relax. Also if something can be done, a signal
allows a person to prepare for the bad event. In contrast, when the identical
noxious event occurs without a signal, individuals are afraid all the time because
they have no signal of safety that tells them they can relax (Seligman
and Binik). Since over secretion of gastric juices occurs during anxiety
and more anxiety occurs with unpredictability, we might expect that more
ulcers would occur as well. It has been found that they do.
In one study, investigators took two groups of rats and deprived them of
food. Each group received occasional brief electric shocks. For one group,
the shocks were predictable: each shock was preceded by a tone or a light.
Another group of rats received exactly the same shocks and at the same
times, but they had no signal to tell them when shock would occur and
therefore no absence of signal to tell them when they were safe. More of the
rats who received unpredictable shock formed ulcers, and the ulcers they
formed were larger than those in the predictable shock group. Being in the
presence of chronic anxiety-as produced by unpredictable shock-causes
ulcers in rats (Seligman & Weiss).
UN CONTROLLABILITY. When noxious events occur, sometimes you can
do something about them, but at other times you are helpless. So, for example,
being a victim of lung cancer is at least partly controllable; you can take
action to avoid lung cancer by not smoking cigarettes. Losing your job during
a national depression, however, is quite uncontrollable. There is very
little you can do to protect your job once economic panic has set in and
most of your colleagues are being fired. More precisely, an event is uncontrollable
when no response an individual can make will change the probability
of the event. An event is controllable when at least one response the
individual has in his repertoire can change the probability of the event.
Which produces more ulcers, controllable or uncontrollable dangers? This
question has an intriguing twenty-year history, and it has only recently been
resolved.
In 1958, a study, now known as the "executive monkey" study was performed.
Eight monkeys were given occasional electric shocks. Four of them
could avoid the shocks by pressing a lever. The other four received exactly
the same shocks as their four executive partners, but they were helpless; no
response that they made would affect whether or not they were shocked;
only their executive partners' actions made any difference. The monkeys
could not see or hear each other. The executives in each of the four pairs developed
duodenal ulcers and died; their helpless partners remained healthy
(Brady, 1958). The conclusion from this study was that having control over
threat would cause ulcers. The moral was that executives, or others in a position
of great responsibility, would be more prone to ulcers than their employees.
This study was widely publicized, and for years many believed it was
valid. It is, however, an artifact. When experimenters in the 1960s had trouble
replicating it, the details of the procedure were scrutinized. As it turned
out, the eight monkeys had not been randomly assigned to the executive
group. The four monkeys who probably had been the most emotionally
reactive had become the executives and had developed the ulcers; but it
probably had been their preexisting high emotionality (which was indicated
by their readiness to lever press when shocked) and not the fact of having to
execute a controlling response, which had produced the ulcers.
In another study, the methodological problems of the executive monkey
study were avoided and the opposite results were obtained. Rats were divided
into six groups. Two of the groups received escapable shock, shock
they could turn off by rotating a wheel in front of them. Two of the groups
were "yoked." They received exactly the same pattern of shock, but it was
inescapable-no response they made affected the shock; it went on and off
for them at the same time as for their "executive" partners in the "escapable"
group. Two of the groups received no shock. Within each of these
groups, shock was either signaled or unsignaled. In this experiment, then,
both the controllability and predictability of the shock were varied. The rats
were assigned to these six groups randomly, thereby distributing any preexisting
emotionality equally among the groups (Weiss).
As can be seen, two basic findings emerged. First, unpredictability
leads to ulcers-the rats developed more ulcers when they were
subjected to unsignaled than to signaled shock, whether or not they could
escape it. Second, uncontrollability leads to ulcers-rats who received inescapable
shock developed more ulcers than rats who could escape shock,
whether or not the shock was signaled.
What are we to conclude from this and other animal studies? First of all, it
seems clear that the "executives" were actually less likely to develop ulcers.
Second, this and other studies set up three conditions: conflict, unpredictability,
and uncontrollability-that produce anxiety, and eventually a
greater number of ulcers. Research on how humans react in parallel situations
continues. Indeed our environment may well be constructed in a way
to produce ulcers in some individuals. Other researchers, however, have
looked elsewhere for the cause of ulcers. Specifically, they have looked into
the dynamics of personality.
Personality and Susceptibility to Peptic Ulcer
In 1950, the psychoanalyst Franz Alexander formulated the most influential
statement of the ulcer-prone personality (Alexander). Based on
his observations of his ulcer patients, mostly men from upper-middle-class
backgrounds, Alexander postulated that an unconscious conflict of dependence
versus independence predisposes an individual to ulcers. He claimed
that the ulcer patient has a deep-seated wish to be loved and nurtured like an
infant. But at the same time, these motives give rise to shame and guilt and
are rejected by the adult ego. To avoid displaying the oral motives of an infant,
which he considers shameful, the ulcer-prone person puts on a mask of
exaggerated self-sufficiency and "pseudo independence." He is characterized
by driving ambition and inappropriate displays of strength. When his
dependency wishes are re-aroused, the conflict is intensified with gastric hyper
secretion worsening the symptoms. For example, Alexander would consider
Carlos, from our earlier case study, as having an ulcer-prone
personality, for when the fire breaks out in Carlos's store, his need for nurturance
by his father is evoked and his ulcer pain is exacerbated.
Alexander's formulation contains three parts: (1) the predisposition pseudo independent
defenses against the need to be dependent, (2) the conditions
for exacerbation-the re-arousal of the oral-dependency conflict, and
(3) a physiological mechanism-gastric hyper secretion brought on by this
conflict (Alexander, 1950; Weiner, 1977).
This formulation has received some experimental support. A group of
specialists in internal medicine and a group of psychoanalysts were asked to
diagnose which psychosomatic illnesses were suffered by a group of patients.
The judges had to do this on the basis only of edited interviews that omitted
all reference to the patients' psychosomatic symptoms. Each of the eighty three
patients had one of the seven "classic" psychosomatic illnesses (arthritis,
ulcer, high blood pressure, dermatitis, ulcerative colitis, asthma, and
thyroid over secretion). The judges were asked to pick out which ones had
the ulcers using Alexander's characterization of the ulcer-prone personality.
Eighteen of the patients actually had ulcers. The group of psychoanalysts
correctly picked out 50 percent of the men but only 16 percent of the
women who had ulcers. The group specializing in internal medicine made a
successful diagnosis of 40 percent of the men and 10 percent of the women.
Chance guessing would have gotten 14 percent (one out of seven) right. This
indicates that Alexander's formulations may separate the ulcer-prone
man from men who have other psychosomatic disorders but that his theory
does not work for women (Alexander, French, and Pollack, 1968). So far,
these remain tentative findings, for more studies are needed to clarify exactly
what might he an ulcer-prone personality.
TREATMENT OF PEPTIC ULCERS
In times past, peptic ulcers were treated primarily by giving patients antacid
drugs in an attempt to lower stomach acidity. In addition, bland diets that
restricted intake of foods that stimulate hydrochloric acid secretion were
recommended to patients. Smoking, drinking alcohol, and drinking coffee
or tea were also restricted. About half of the ulcers usually healed under such
a regimen. In the late 1970s, a new drug---cimetidine-came into use. Cirnetidine
reduces stomach acid by about two-thirds, and it produces healing
in 70 to 9S percent of patients with peptic ulcers in a few months. It is now
clearly the treatment of choice for peptic ulcer (Bardhan, 1980).
Psychological treatments of ulcers are less well charted. Rest, relaxation,
anxiety management, and removal from the external sources of psychological
stress are often prescribed for ulcer patients, and there is at least strong
clinical evidence that these are effective. Psychoanalytic therapy has been
reported to be effective with ulcer patients, but the appropriate controlled
studies have yet to be done (Orgel, 1958). Finally, some individuals without
ulcers can learn to control their level of gastric acid secretion voluntarily by
using biofeedback about their gastric acid secretion (Welgan, 1974). But it
has yet to be demonstrated that patients who actually have ulcers can learn
voluntary control over gastric acid secretion or that this will alleviate their
peptic ulcers.
To summarize, peptic ulcers are best viewed within a diathesis-stress
model. A peptic ulcer is caused when gastric juice that is naturally secreted
in the stomach eats a hole into the protective mucous membrane of the
stomach or the duodenum, This erosion is the ulcer. Three kinds of constitutional
weaknesses or "diatheses," can make an individual prone to ulcers:
(1) an over secretion of gastric juices. and there is evidence that this can be
genetically inherited; (2) a weak mucous membrane. and (3) a stomach lining
that regenerates slowly. Psychological factors can also influence the formation
of a peptic ulcer in individuals who have such a diathesis, There is evidence that
emotional states, particularly anxiety, cause over secretion of
acid in the stomach. In addition, there is further experimental evidence that
rats who experience anxiety when placed in conflict, in the presence of unpredictable
stressors, or in the presence of uncontrollable stressors develop
peptic ulcers. This suggests that chronic or frequent anxiety may cause
over secretion of stomach acid which, in turn, may produce ulcers in individuals
whose gastrointestinal system is genetically vulnerable.
It is already clear that psychosomatic illness may take a bizarre form. In the
case of Steven, there is little doubt of the existence of a psychosomatic disorder.
But what about those cases where there is less dramatic evidence?
Many believe that some ulcers, high blood pressure, and other physical
problems are partly caused by an adverse psychological state. But how does
a clinician know this, and when there is evidence, how does he or she classify
it'?
The diagnosis of psychosomatic disorder is made if (I) there is a disorder
of known physical pathology present and (2) psychologically meaningful
events preceded and are judged to contribute to the onset or worsening of
the disorder. This diagnosis is contained in DSM's apt name for these
disorders "psychological factors affecting physical condition." The first criterion
distinguishes psychosomatic disorders from somatoform
disorders. Conversion. psychogenic amnesia, and the like have no
known physical basis, whereas psychosomatic disorders do. Bear's paralysis
was not accompanied by any physical damage to his nerves or spinal cord,
whereas an individual whose peptic ulcer flares up every time he is criticized
by his boss (which meets the second criterion) has actual physical damage 10
the lining of his gastrointestinal system. By these criteria, Steven's forearm
wells are a clear case of psychosomatic disorder, since symptoms of known
physical pathology are present-rope marks and bleeding-and a psychologically
traumatic incident-being bound while asleep c-preceded and was
demonstrated by the hypnotic reliving to have contributed to the wells and
bleeding.
These two defining criteria of psychosomatic disorder have been incorporated
into a particular model: the diathesis-stress model. "Diathesis"
refers to the constitutional weakness that underlies the physical pathology.
and "stress" to the psychological reaction to meaningful events. According
to this model, an individual develops a psychosomatic disorder when he
both has some physical vulnerability (diathesis) and experiences psychological
disturbance (stress). If an individual is extremely weak constitutionally,
very little stress will be needed to trigger the illness; if, on the other hand,
extreme stress occurs, even individuals who are constitutionally strong may
fall ill. In effect, the model suggests that individuals who develop peptic
ulcers are both constitutionally vulnerable to gastrointestinal problems and
experience sufficient stress to trigger the pathology.
Psychological factors can affect many physical conditions in a large
number of organ systems: the skin, the skeletal-musculature. the respiratory,
the cardiovascular, the blood and lymphatic, the gastrointestinal, the
genitourinary, the endocrine systems, or the sense organs (Looney. Lipp,
and Spitzer). Here is no evidence, however, that the process causing
psychosomatic effects is different for different organs. Although any given individual
may be especially vulnerable to psychosomatic influence in only
one organ system. Some of us react to stress with the stomach, others by
sweating, some by muscle tension, and still others with a racing heart.
PEPTIC ULCERS
A peptic ulcer is a circumscribed erosion of the mucous membrane of the
stomach or of the duodenum, the upper portion of the small intestine.
Such ulcers are called "peptic" because it is commonly thought that they arc at
least partially caused by pepsin, which is contained in the acidic juices normally secreted
by the stomach. There arc two sorts of peptic ulcers named by their location: a stomach
(gastric) ulcer and a duodenal ulcer.
Roughly two million people in the United States today have a peptic
ulcer, and about five thousand people die of peptic ulcer each year in the
United States (Center for Disease Control). We begin our discussion
of psychosomatic disorders with the peptic ulcers because they are so widespread
and because much is known, both about the physical pathology underlying
ulcers and about psychological influence on their development and course.
Carlos's gastrointestinal problems illustrate the ways in which environmental
stress influences peptic ulcers.
Carlos has had an ulcer for the last seventeen years. Until recently he had it
under control; for whenever he experienced gastric pain, drinking a quart of milk
or eating eggs would relieve it. Three years ago he was promoted to manager of a
major department store and moved from his home town to a distant city. Since he
took on this increased responsibility, he has experienced severe ulcer pain.
He had been born and raised in a small New England town. His father was
wealthy and the head of a chain of department stores. Although his father was in
general dominating and intolerant (and also had an ulcer), he was kind and generous to Carlos.
After graduation from college Carlos entered the department store business and even now,
at age forty-one, he feels incapable of holding a job without his father's intervention, influence, and support.
As soon as Carlos took over the management of the store, he became tense and
anxious and began to brood over trivial details. He was afraid the store would
catch fire; he was afraid that there would be bookkeeping errors that he might not
catch; he was afraid the store would not make a big profit. Convinced he was a
complete failure, and plagued with severe pains from his duodenal ulcer, he entered
psychotherapy. During these sessions, Carlos and his therapist learned how
much the psychological factors in his life contributed to the worsening of the
ulcer. The following three incidents particularly illustrate this.
First. on a day when the store was full of people a large ventilating fan broke.
The store began to shake as the customers rushed to the street, and Carlos went
into a panic. As soon as the excitement subsided and his panic diminished, severe
ulcer pains started.
Second, Carlos's mother had for many years complained of a "heart condition."
While his mother's physician had never isolated a physical cause, Carlos
nevertheless worried about it. One day Carlos saw a hearse pass in front of the
store. Immediately he thought that his mother had died and in panic ran several
miles to her home finding her quite alive. As he started to run the stomach pains
broke out, and these pains remained until he saw his mother was not ill.
Third, one night Carlos's store burned to the ground. He was highly anxious
that he would be found negligent during the ensuing insurance investigation. As
he awaited the results of the inquiry, his wife called and told him that his daughter
had broken a leg. He ran home and found his wife in tears, and he immediately
developed severe stomach pains.
Before he had become manager of the store he had occasionally had stomach
pains while on the job, but he had found a technique for reliably and immediately
alleviating them: he would go to an older person for comfort. Upon being reassured
by an authority figure, his ulcer pain would disappear. In his new job, however,
he was the authority figure, there was no one to turn to, and his ulcer pains
persisted, unrelieved, (Adapted from Weisman).
SYMPTOMS OF PEPTIC ULCER
Carlos suffered the main symptom of peptic ulcer: abdominal pain. Such
abdominal pain can vary from mild discomfort to severe and penetrating,
extreme pain. Pain may be steady, aching, and gnawing, or it may be sharp
and cramp-like. Pain is usually not present before breakfast; it generally
starts from one to four hours after meals. Bland foods and antacids usually
alleviate the pain and peppery food, alcohol, and aspirin usually intensify it
(Lachman & Weiner). Peptic ulcers that become very serious
sometimes perforate or bleed. Without well-timed surgery, a perforated
ulcer can lead to death from internal bleeding.
PHYSIOLOGICAL DEVELOPMENT OF AN ULCER
In order to understand how these symptoms come to be, we must first take a
brief look at the actions of the digestive system. Digestion breaks down food
in the stomach so that when the food passes through the intestines, the appropriate
materials can be absorbed for use by the body. In order to digest
food, the stomach secretes two highly corrosive juices: hydrochloric acid,
which breaks food down, and pepsin, which decomposes protein. Why, you
might wonder, does the stomach not digest itself? Fortunately, the stomach
and the small intestine are lined with a mucous membrane that protects
them from corrosion by the hydrochloric acid they secrete. In addition, gastric
juices are normally secreted only when there is food in the stomach to
absorb most of the corrosive acid. But sometimes the system develops a
problem. A break may occur in the mucous coating of the stomach or duodenum.
Such a break may occur when some of the thin lining is worn away
in the normal course of digestion. It may also occur when an overdose of
aspirin, particularly in combination with alcohol, is ingested, or when naturally
secreted bile attacks the membrane. If a break occurs in the absence of
too much gastric juice, it will repair itself and no ulcer will form, since cell
growth completely renews the stomach lining every three days (Davenport).
If an excess of hydrochloric acid or pepsin is around, however, particularly
when food is not in the stomach, the abrasion will worsen and an
ulcer will form.
WHO Is SUSCEPTIBLE TO ULCERS?
The way an ulcer develops gives us clues about what diathesis, or constitutional
weakness, makes ulcers more likely. Individuals who secrete excess
hydrochloric acid or pepsin, individuals with an especially weak mucous
defense against acid, and individuals whose stomach lining regenerates
slowly may generally be more susceptible to ulcers. This condition may be
genetically inherited.
The prevalence of peptic ulcer varies widely from country to country, and
from decade to decade. Today, approximately 1percent of the adult American
population has an ulcer, and almost four hundred thousand Americans
are hospitalized yearly for peptic ulcers. The frequency of peptic ulcers has,
for unexplained reasons, declined by about 25 percent over the last decade
in the U.S. and Europe (McConnell, 1966; Lachman, 1972; Weiner, 1977;
Elashoffand Grossman, 1980).
The susceptibility of women versus men seems to have undergone a
major change over the past 100 years. Before 1900, peptic ulcers occurred
more frequently in women than in men, but in the beginning of the twentieth
century a shift occurred, with men becoming considerably more ulcer
prone. By the late 1950s, men had 3.5 times as many duodenal ulcers as
women (Watkins, 1960). In recent years the male/female ratio has been
changing (Elashoffand & Grossman). By 1990, men had only 1.2 times
as many peptic ulcers as women in America, as ulcers in men had become
less frequent and ulcers in women had either stayed the same or slightly increased.
Social class does not strongly influence the incidence of ulcers. For a time
it was commonly believed that highly pressured, upwardly mobile and
professionally successful individuals develop the most ulcers. But in fact many
patients with peptic ulcer are poor and wholly unsuccessful (Rennie and
Srole).
Age also does not make much of a difference beyond the age of twenty, although
children probably have ulcers less frequently than adults. Among
children, girls have peptic ulcers about twice as frequently as boys (Christodoulou,
Gergoulas, Paploukas, Marinopoulou, and Sideris; Medley).
Ulcers clearly run in families. The relatives of patients with duodenal and
gastric ulcers are about three times as likely to have an ulcer as those in the
general population (McConnell, 1966). Further, healthy individuals who
have relatives with peptic ulcers secrete more gastric juice than individuals
without relatives with ulcers (Fodor, Vestea, and Urcan). This increased
susceptibility in families could either be genetic or environmental,
since family members share many of the same stresses, as well as genes. But
twin data suggest it is genetic. If one of two identical twins has a peptic ulcer,
the chances are 54 out of 100 that the co-twin will also have a peptic ulcer;
whereas if one of two fraternal twins has a peptic ulcer, there is only a 17
percent chance that the co-twin will also have peptic ulcer (Eberhard).
Here then is the foundation of the diathesis, in the diathesis-stress model
of peptic ulcers. How much acid and pepsin the stomach secretes contributes
to the formation of an ulcer. High acid and pepsin secretion runs in
families and may be the constitutional weakness that makes individuals
more susceptible to ulcers (Mirsky).
PSYCHOLOGICAL FACTORS INFLUENCING PEPTIC ULCERS
To what extent does stress influence the development or worsening of peptic
ulcers? When individuals who have a constitutional weakness of the intestinal
system-such as hereditary over secretion of acid-encounter certain
kinds of stress, peptic ulcers may result. By "stress" researchers refer to the
reaction of an individual to disturbing events in the environment.
A stress reaction can either be a short-term emotional reaction induced by a specific
situation, or it can be a long-term pattern of such emotional reactions, adding
up to an ulcer-prone personality. We turn first to the evidence that
emotional states influence peptic ulcer, and then we examine the possibility
that individuals who have a certain personality pattern of reacting to stress are ulcer prone.
Gastric Secretion, Peptic Ulcer, and Emotional States
Let us now take a look at the evidence that emotional states affect gastric secretion.
Two researchers were afforded a rare opportunity to study directly
the effects of anxiety and depression on digestion when they discovered a
man who, because of a childhood experience, was forced to feed himself
through a hole in his stomach.
Tom was a fifty-seven-year-old workman who at age seven swallowed some
very hot soup, which so burnt his esophagus that it had to be surgically sealed off.
After many unsuccessful attempts at corrective surgery, Tom had to resort to
feeding himself by chewing his food (to satisfy his taste) and then depositing the
food directly into his stomach using a funnel and a rubber tube. He was secretive
about this for many years, but when he was in his fifties, Tom allowed himself to
be experimented upon. Investigators directly examined his gastric secretions
under different emotional conditions. When Tom was anxious, angry, or resentful,
gastric secretions increased. When he was sad, his gastric secretions decreased
(Wolff).
In another study, thirteen patients with ulcers and thirteen normal subjects
were interviewed under emotion-provoking conditions. The patients
with ulcers showed a greater secretion of hydrochloric acid in the stomach
and more stomach motility than the patients without ulcers (Mittelmann,
Wolff, and Scharf). Findings with normal individuals under hypnosis
also confirmed that gastric secretions are influenced by emotion. Hypnotically
induced thoughts of anger and anxiety produced high gastric secretion,
while thoughts of depression, helplessness, and hopelessness produced low
secretion (Kehoe and Ironside).
High rates of peptic ulcer were also found in people in occupations that
produce high anxiety. For example, air traffic controllers have twice the
ulcer rate of matched control groups, and those controllers who work at
towers with much traffic have twice the ulcer rate of those who work at
towers with less traffic (Cobb and Rose). We must be cautious, however,
about this correlation between occupation and ulcers. It could be that
ulcer-prone individuals, for some reason, choose anxiety-provoking jobs. If
this is the case, it need not be the anxiety of the job that causes the ulcer.
The evidence presented above does suggest that emotional states like anxiety
and anger cause excess stomach acid; this in turn, contributes to the development
of peptic ulcers. Also, certain anxiety-producing occupations
may lead to more employees with stomach ulcers. Here again, greater anxiety
produces excess acid in the stomach. This latter point fits in with Carlos's
story narrated earlier. Like many individuals with ulcers, Carlos's ulcer
worsened and caused more pain after emotional crises. When he was anxious,
needed reassurance, and felt excessive demands for responsibility, his ulcer flared up.
When he allowed himself to be dependent, his ulcer was inactive.
Animal Models of Peptic Ulcer
Some investigators have shed light on the relation between emotional states
and ulcers by studying animals. In doing so, they have put animals in conditions
that change the emotional state of the animal. We will look at three
such situations: conflict, unpredictability, and uncontrollability. All of these
factors increase anxiety.
CONFLICT. Can "conflict" be aroused in a rat in order to find out
whether or not conflict produces ulcers? One way to bring about conflict is
to make a hungry rat run through shock in order to get food. This is called
an "avoidance-approach" conflict. In one experiment, one group of rats was
required to cross a shock grid in order to obtain food and water for forty seven
out of forty-eight hour cycles. During one hour, the grid was not electrified
so that the animals could have sufficient water and food. Six of nine
rats in this group developed ulcers, whereas none of the comparison group
rats did. Control groups with shock alone, food and water alone, or nothing
got fewer ulcers. So avoidance-approach conflict is more likely to produce
stomach ulcers than is electric shock, hunger, or thirst without conflict
(Sawrey, Conger, and Turrell; Sawrey and Weiss). Therefore
conflict, a psychological state that produces anxiety, can engender ulcers in
rats.
UNPREDICTABILITY. When noxious events are experienced by an individual,
they can either be signaled, and therefore predictable, or unsignaled,
and therefore unpredictable. For example, the rockets that fell on London
in World War II were signaled by an air raid siren. But when a concentration
camp guard arbitrarily singled out a prisoner for a beating, this was entirely
unsignaled. There is considerable evidence, both in rats and humans, that
when noxious events are signaled, individuals are terrified during the signal.
But they also learn that when the signal is not on, the noxious event docs not
occur, so they are safe and can relax. Also if something can be done, a signal
allows a person to prepare for the bad event. In contrast, when the identical
noxious event occurs without a signal, individuals are afraid all the time because
they have no signal of safety that tells them they can relax (Seligman
and Binik). Since over secretion of gastric juices occurs during anxiety
and more anxiety occurs with unpredictability, we might expect that more
ulcers would occur as well. It has been found that they do.
In one study, investigators took two groups of rats and deprived them of
food. Each group received occasional brief electric shocks. For one group,
the shocks were predictable: each shock was preceded by a tone or a light.
Another group of rats received exactly the same shocks and at the same
times, but they had no signal to tell them when shock would occur and
therefore no absence of signal to tell them when they were safe. More of the
rats who received unpredictable shock formed ulcers, and the ulcers they
formed were larger than those in the predictable shock group. Being in the
presence of chronic anxiety-as produced by unpredictable shock-causes
ulcers in rats (Seligman & Weiss).
UN CONTROLLABILITY. When noxious events occur, sometimes you can
do something about them, but at other times you are helpless. So, for example,
being a victim of lung cancer is at least partly controllable; you can take
action to avoid lung cancer by not smoking cigarettes. Losing your job during
a national depression, however, is quite uncontrollable. There is very
little you can do to protect your job once economic panic has set in and
most of your colleagues are being fired. More precisely, an event is uncontrollable
when no response an individual can make will change the probability
of the event. An event is controllable when at least one response the
individual has in his repertoire can change the probability of the event.
Which produces more ulcers, controllable or uncontrollable dangers? This
question has an intriguing twenty-year history, and it has only recently been
resolved.
In 1958, a study, now known as the "executive monkey" study was performed.
Eight monkeys were given occasional electric shocks. Four of them
could avoid the shocks by pressing a lever. The other four received exactly
the same shocks as their four executive partners, but they were helpless; no
response that they made would affect whether or not they were shocked;
only their executive partners' actions made any difference. The monkeys
could not see or hear each other. The executives in each of the four pairs developed
duodenal ulcers and died; their helpless partners remained healthy
(Brady, 1958). The conclusion from this study was that having control over
threat would cause ulcers. The moral was that executives, or others in a position
of great responsibility, would be more prone to ulcers than their employees.
This study was widely publicized, and for years many believed it was
valid. It is, however, an artifact. When experimenters in the 1960s had trouble
replicating it, the details of the procedure were scrutinized. As it turned
out, the eight monkeys had not been randomly assigned to the executive
group. The four monkeys who probably had been the most emotionally
reactive had become the executives and had developed the ulcers; but it
probably had been their preexisting high emotionality (which was indicated
by their readiness to lever press when shocked) and not the fact of having to
execute a controlling response, which had produced the ulcers.
In another study, the methodological problems of the executive monkey
study were avoided and the opposite results were obtained. Rats were divided
into six groups. Two of the groups received escapable shock, shock
they could turn off by rotating a wheel in front of them. Two of the groups
were "yoked." They received exactly the same pattern of shock, but it was
inescapable-no response they made affected the shock; it went on and off
for them at the same time as for their "executive" partners in the "escapable"
group. Two of the groups received no shock. Within each of these
groups, shock was either signaled or unsignaled. In this experiment, then,
both the controllability and predictability of the shock were varied. The rats
were assigned to these six groups randomly, thereby distributing any preexisting
emotionality equally among the groups (Weiss).
As can be seen, two basic findings emerged. First, unpredictability
leads to ulcers-the rats developed more ulcers when they were
subjected to unsignaled than to signaled shock, whether or not they could
escape it. Second, uncontrollability leads to ulcers-rats who received inescapable
shock developed more ulcers than rats who could escape shock,
whether or not the shock was signaled.
What are we to conclude from this and other animal studies? First of all, it
seems clear that the "executives" were actually less likely to develop ulcers.
Second, this and other studies set up three conditions: conflict, unpredictability,
and uncontrollability-that produce anxiety, and eventually a
greater number of ulcers. Research on how humans react in parallel situations
continues. Indeed our environment may well be constructed in a way
to produce ulcers in some individuals. Other researchers, however, have
looked elsewhere for the cause of ulcers. Specifically, they have looked into
the dynamics of personality.
Personality and Susceptibility to Peptic Ulcer
In 1950, the psychoanalyst Franz Alexander formulated the most influential
statement of the ulcer-prone personality (Alexander). Based on
his observations of his ulcer patients, mostly men from upper-middle-class
backgrounds, Alexander postulated that an unconscious conflict of dependence
versus independence predisposes an individual to ulcers. He claimed
that the ulcer patient has a deep-seated wish to be loved and nurtured like an
infant. But at the same time, these motives give rise to shame and guilt and
are rejected by the adult ego. To avoid displaying the oral motives of an infant,
which he considers shameful, the ulcer-prone person puts on a mask of
exaggerated self-sufficiency and "pseudo independence." He is characterized
by driving ambition and inappropriate displays of strength. When his
dependency wishes are re-aroused, the conflict is intensified with gastric hyper
secretion worsening the symptoms. For example, Alexander would consider
Carlos, from our earlier case study, as having an ulcer-prone
personality, for when the fire breaks out in Carlos's store, his need for nurturance
by his father is evoked and his ulcer pain is exacerbated.
Alexander's formulation contains three parts: (1) the predisposition pseudo independent
defenses against the need to be dependent, (2) the conditions
for exacerbation-the re-arousal of the oral-dependency conflict, and
(3) a physiological mechanism-gastric hyper secretion brought on by this
conflict (Alexander, 1950; Weiner, 1977).
This formulation has received some experimental support. A group of
specialists in internal medicine and a group of psychoanalysts were asked to
diagnose which psychosomatic illnesses were suffered by a group of patients.
The judges had to do this on the basis only of edited interviews that omitted
all reference to the patients' psychosomatic symptoms. Each of the eighty three
patients had one of the seven "classic" psychosomatic illnesses (arthritis,
ulcer, high blood pressure, dermatitis, ulcerative colitis, asthma, and
thyroid over secretion). The judges were asked to pick out which ones had
the ulcers using Alexander's characterization of the ulcer-prone personality.
Eighteen of the patients actually had ulcers. The group of psychoanalysts
correctly picked out 50 percent of the men but only 16 percent of the
women who had ulcers. The group specializing in internal medicine made a
successful diagnosis of 40 percent of the men and 10 percent of the women.
Chance guessing would have gotten 14 percent (one out of seven) right. This
indicates that Alexander's formulations may separate the ulcer-prone
man from men who have other psychosomatic disorders but that his theory
does not work for women (Alexander, French, and Pollack, 1968). So far,
these remain tentative findings, for more studies are needed to clarify exactly
what might he an ulcer-prone personality.
TREATMENT OF PEPTIC ULCERS
In times past, peptic ulcers were treated primarily by giving patients antacid
drugs in an attempt to lower stomach acidity. In addition, bland diets that
restricted intake of foods that stimulate hydrochloric acid secretion were
recommended to patients. Smoking, drinking alcohol, and drinking coffee
or tea were also restricted. About half of the ulcers usually healed under such
a regimen. In the late 1970s, a new drug---cimetidine-came into use. Cirnetidine
reduces stomach acid by about two-thirds, and it produces healing
in 70 to 9S percent of patients with peptic ulcers in a few months. It is now
clearly the treatment of choice for peptic ulcer (Bardhan, 1980).
Psychological treatments of ulcers are less well charted. Rest, relaxation,
anxiety management, and removal from the external sources of psychological
stress are often prescribed for ulcer patients, and there is at least strong
clinical evidence that these are effective. Psychoanalytic therapy has been
reported to be effective with ulcer patients, but the appropriate controlled
studies have yet to be done (Orgel, 1958). Finally, some individuals without
ulcers can learn to control their level of gastric acid secretion voluntarily by
using biofeedback about their gastric acid secretion (Welgan, 1974). But it
has yet to be demonstrated that patients who actually have ulcers can learn
voluntary control over gastric acid secretion or that this will alleviate their
peptic ulcers.
To summarize, peptic ulcers are best viewed within a diathesis-stress
model. A peptic ulcer is caused when gastric juice that is naturally secreted
in the stomach eats a hole into the protective mucous membrane of the
stomach or the duodenum, This erosion is the ulcer. Three kinds of constitutional
weaknesses or "diatheses," can make an individual prone to ulcers:
(1) an over secretion of gastric juices. and there is evidence that this can be
genetically inherited; (2) a weak mucous membrane. and (3) a stomach lining
that regenerates slowly. Psychological factors can also influence the formation
of a peptic ulcer in individuals who have such a diathesis, There is evidence that
emotional states, particularly anxiety, cause over secretion of
acid in the stomach. In addition, there is further experimental evidence that
rats who experience anxiety when placed in conflict, in the presence of unpredictable
stressors, or in the presence of uncontrollable stressors develop
peptic ulcers. This suggests that chronic or frequent anxiety may cause
over secretion of stomach acid which, in turn, may produce ulcers in individuals
whose gastrointestinal system is genetically vulnerable.
EMOTIONAL INTELLIGENCE THERAPY APPLIED TO PSYCHOSOMATIC DISORDERS HAS BEEN PROVEN SUCCESSFUL.
For the Treatment method I recommend click here:
http://theliberatormethod.com/Welcome.html
For the Treatment method I recommend click here:
http://theliberatormethod.com/Welcome.html