Psychosomatic Considerations in Peptic Ulcer

The concept of peptic ulcer as a psychosomatic disorder affects considerations in etiology, pathology, clinical pathology, symptomatology, diagnosis, management, therapy, and prognosis. In the usual case of chronic peptic ulcer, an underlying conflict exists in which the individual feels compelled to function in a certain manner despite anticipation of failure. The origins and significance of this conflict are presented and discussed. The peptic-ulcer conflict situation involves both fear and resentment, each of which has opposing effects on the stomach and duodenum. When fear and resentment are experienced simultaneously, the reactions in the stomach are dissociated, often resulting in increased acid, motility, and vascularity, with decreased mucin (H. G. Wolff). It is postulated that during such dissociation other protective substances and mechanisms are likewise deficient in the presence of increased acid and pepsin. Such physiologic concomitants to this conflict situation are highly conducive to the development of ulceration. The adjustments of the patient to his underlying conflict may be infinitely varied so that the outward appearance of these patients differs markedly. The ulcer diathesis resides in the basic character structure which readily thrusts the patient into the peptic-ulcer type of conflict situation. If the situation is of short duration, the symptoms will also be brief; if sustained, they will be prolonged. Chronic, indolent peptic ulcers heal as rapidly as acute ulcers when the conflict situation is removed. The variations in gastroscopic findings, which are described, are best integrated by the psychosomatic concept, which assumes both that the emotions affect the color and appearances of the stomach, and that changing emotions are accompanied by prompt changes in the appearance of the stomach. Varying gastric juice and acid levels during the day and night are explained by the changing emotions experienced. Seasonal recurrence, frequent association of symptoms with infections, and frequency of recurrence are all related to the character structure of the patient. The diagnosis of peptic ulcer is supported by NOVEMBER, 1947 finding a character structure which readily thrusts the patient into the peptic-ulcer conflict situation. Some of the character traits commonly found in ulcer patients are described. The psychosomatic effect of treatment, including diet, rest, hospitalization, and exercise, is discussed. The emotional reaction of the patient is held to be of greater significance than the particular diet or drugs utilized in treatment. This does not preclude the possibility of developing measures to correct the autonomic imbalance in the stomach and duodenum associated with the ulcer type of conflict. The evaluation of the character structure, the psychosomatic history, and the changes possible in the environment afford the best means of determining the prognosis in a particular case. The likelihood that the patient will become involved in the peptic-ulcer conflict situation is the basis for such prognosis. The best prognosis exists for patients with the longest intervals between attacks, implying as it does, adequate adjustment during the intervals. Patients with pseudo-ulcer syndrome (pyloroduodenal irritability) may develop demonstrable ulceration in later years if the conflict situation becomes sufficiently intense and sustained. The patient's concern with his diet and pain may in turn result in tension which gives rise to more pain.