Saudi Journal of Gastroenterology
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Year : 1997  |  Volume : 3  |  Issue : 2  |  Page : 84-89
Life event stress in duodenal ulcer compared with functional dyspepsia: A case-control study

Department of Psychiatry, College of Medicine, Dammam, Saudi Arabia

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Date of Submission23-Jun-1996
Date of Acceptance19-Nov-1996


This is a prospective study of life event stress in 80 duodenal ulcer patients compared with 80 patients with functional dyspepsia and 80 healthy controls; matched for age, sex and marital status. A semi structured psychiatric interview was used in the psychiatric assessment of the dyspeptic patients and controls. A modified version of Life Events Scale by Tennant and Andrews was used in the assessment of life event stress. More dyspeptic patients reported life events than the controls, but, on the whole, the differences were not statistically significant. On the other hand, more patients with functional dyspepsia experienced life events than the patients with duodenal ulcer, but again the results were not consistent. Life event stress as measured by the experience of undesirable life events was significantly reported by more patients with functional dyspepsia. The significance of the presence of life events in duodenal ulcer and functional dyspepsia patients is not substantiated in the present study, as the positive findings were few and sometimes inconsistent. More quantitative studies are needed, taking into consideration the other aspects of the problem like personality, cognition and the complex interaction of stressors and personality.

How to cite this article:
Abdel Hafeiz HB, Al Quorain A, Karim AA, Al-Mangoor S. Life event stress in duodenal ulcer compared with functional dyspepsia: A case-control study. Saudi J Gastroenterol 1997;3:84-9

How to cite this URL:
Abdel Hafeiz HB, Al Quorain A, Karim AA, Al-Mangoor S. Life event stress in duodenal ulcer compared with functional dyspepsia: A case-control study. Saudi J Gastroenterol [serial online] 1997 [cited 2022 Aug 17];3:84-9. Available from:

The association of life events stress and the onset or exacerbation of physical illness is well documented [1],[2],[3] . Rabkin and Struening reported significant relationship between life change and various physical illnesses like myocardial infarction, accidents, diabetes, leukemia, and other medical ailments [4] . Similarly, close associations of emotional states with changes in the gastric motility, vascularity and secretions has been known for a long time [5],[6] . Hypersecretion of gastric acid and the bacterium  Helicobacter pylori Scientific Name Search  be major etiologic factors in duodenal ulcer while in functional dyspepsia abnormalities of the gastric motor activity are usually incriminated [7],[8],[9] . It is generally thought that patients with non-organic gastrointestinal complaints are more exposed to major life events stress than those with physical illness [7],[10],[11] . The relationship between major life events and duodenal ulcer and functional dyspepsia are well documented [12],[13],[14],[15] . By contrast, several investigators found no significant differences between patients and controls in life events stress in functional and ulcer dyspepsia [16],[17],[18],[­19].

The aim of the present study is to investigate the relationship between life events and duodenal ulcer (as an organic gastrointestinal disorder), in comparison with functional dyspepsia and healthy controls. Unfortunately, comparable studies are not available in this part of the world, and this preliminary study seems to be the first one in the Kingdom of Saudi Arabia.

   Patients and method Top

The study comprised 80 patients with duodenal ulcer (DU), and 80 patients with functional dyspepsia (FD) who attended the gastroenterology clinics at King Fahd Hospital of the University (KFHU) during the study period of one year. Eighty healthy controls were also selected randomly from the hospital and the university staff, as a comparison group. They were matched with the patients for age, sex and marital status.

The diagnosis of patients with duodenal ulcer was established endoscopically, and patients were excluded if they had concomitant physical or mental illness. The diagnosis of patients with functional dyspepsia was based on exclusion of obvious organic cause for the dyspeptic symptoms, especially peptic ulceration, esophagitis and malignancy, through upper endoscopic examination and abdominal sonography. Patients with evidence of irritable bowel syndrome, gastroesophageal reflux, gallstones and previous mental illness were also excluded from the study. The 80 healthy controls had no past history of peptic ulcer, gallstones, severe medical or psychiatric illness.

Psychiatric assessment was carried out by us using a semi-structured psychiatric interview and a clinical mental state examination. Attention in the present communication was focused on the sociodemographic data of the DU and FD patients, in comparison with healthy controls. Personality assessment and psychiatric diagnoses and their relationship to life events were dealt within a separate communication.

   Assessment of life events Top

This was done by using a modified version of the scale by Tennant and Andrews [20] . Items on extra­marital relationship and adoption were omitted to suit the Saudi family setting and culture [Table l]a. Life events were not scaled in the present study and no numerical values were given for the degree of life change or stress, due to technical difficulties. The life events were analyzed in terms of their number, significance of individual events (only those reported by more than 10 patients or controls) and categorisation into seven areas of activities [Table - 2],[Table - 3],[Table - 4] a & b respectively. Furthermore, life events were grouped into desirable, undesirable and ambiguous (neutral) events [Table - 4]b, which in a way correlate with the magnitude of stress [21] . Only life events experienced six months prior to the diagnosis of DU and FD were included in the study. To render the results comaprable to other studies, the findings in the present study were analyzed in a more or less similar way. Chi square test and Fisher's exact test were used to find out the significance between proportion and Student's T-test to test for significance between the means.

   Results Top

Age distribution is shown in [Table l]b. The differences between the mean age of the DU patients (35.75 years), FD (38.1 years) patients and controls (34.6 years) were not statistically significant. The female to male ratio for DU, FD patients and healthy controls were 32:48, 46:34, 45:35, respectively. Fifty DU patients, 43 FD patients and 70 controls were employed. Fifty-five DU patients, 60 FD patients and 57 controls were married. The differences in gender, employment and marital status between the patients and controls were not statistically significant. There were no significant changes in the number of life events between DU, FD patients and controls in raltion to age, sex and marital status in the present study.

   Distribution of number of events per person Top
[Table - 2]

The majority of the patients in the DU and FD groups and controls experienced between 1-6 life events: 84%, 84%, 67%, respectively. Though more FD patients experienced life events than DU patients and control, the differences were not statistically significant. The difference between the mean number of life events between the DU, FD patients and control was also not significant (3.7., 3.8, 3.5 respectively).

   Individual Events Top
[Table - 3]

Only events reported by more than 10 DU, FD patients or control were considered for comparison purposes. More DU and FD patients reported the life events of "minor illness or injury", "did a course or exam" and "better off financially" (p<0.05, 0.003, 0.04 respectively). Events of "serious arguments", "separation" and "increase in problems" were reported by more FD than DU patients (P<0.04, 0.03, 0.02 respectively). Events of "promotion", "change in work hours", "change in duties" were reported more by DU than FD patients and controls (p<0.005, 0.01, 0.006 respectively). Events of "separation", "completed a program" and "major financial crisis" were reported by more controls than both DU and FD patients; the separation event being highly significant in the controls (p<0.003).

   Categorisation of events Top
[Table - 4]a, b

The life events were categorized in seven areas of activity, in addition to desirable and undesirable events. The total number of DU and FD patients experiencing life events in each area of activity was always more than the number of controls, except in the "family and social' area, where controls were more than DU patients. No significant differences were noticed between DU and FD in relation to the categorized life events, except that more FD patients reported "family and social problems" (p<0.05) and more DU patients reported "work problems" (p<0.002). More FD patients reported "undesirable" events than DU patients and controls (p<0.000001). DU patients also reported more undesirable events than the controls (p<0.02). There were no group differences in the desirable and ambiguous (neutral) life events between the three groups.

   Discussion Top

The relationship of life events stress and gastrointestinal disorders (physical and functional) is controversial. While many researchers confirm the strong existence of such relationship, others were unable to prove it [17],[22],[23],[24],[25],[26] . Such controversy is most probably due to methodological problems such as the nonquantitative methods used in evaluating stress and that most of the research published in this area was retrospective and not controlled [17] .

Although no scaling of life events was carried out in the present study, a degree of quantification was achieved by categorizing life events into areas of activity, studying the frequency of the most common individual life events and the number of life events per person. In addition, desirability and undesirability of life events which correlate with the magnitude of stress, i.e. objective, positive and negative impacts were also included [21] . The six-month period for life events before the diagnosis of the dyspepsia was selected to reduce recall bias [27]. The prospective nature of the study and the selection of a control group are further attempts in the quantification process.

Contrary to findings by Haug et al, no significant differences were observed in the number of life events between DU, FD and control groups in relation to age, sex and marital status [27] . There were no significant differences between the patients in the two groups and the controls in relation to the distribution of life events per person, though more FD patients experienced life events than DU patients and controls [Table - 3]. Similar findings to the above mentioned ones however, were reported by Talley and Piper in FD patients and Mahgoub et al in DU patients [17],[19] .

Analyzis of the significant individual life events between DU, FD patients and controls revealed some significant differences which, unexpectedly, added to the controversy surrounding the role of life events stress in gastrointestinal disorders. Three individual events were reported by more DU patients, three by FD patients and three events by more controls [Table - 3]. However, the three individual events reported by the FD patients were undesirable ones while none of those reported by the DU patients were undesirable. The analyzis of the most common individual life events casts some doubts on the reports that FD patients experience more such events than DU patients (27). Similar findings were reported by Huag et al in a controlled study of 100 dyspeptic patients and others [17],[­19],[27] .

Categorisation of life events into seven areas of activity in the present study did not produce significant differences between DU, FD patients and controls though in general more DU and FD patients reported life events than the controls. However, more FD patients reported "family and social" problems and more DU patients reported "work" problems (p<0.05,0.002) respectively. Similar results were reported by Talley and Piper in FD patients, but Haug et al in a comparable study to ours reported significant differences with more FD than DU patients and controls in relation to areas of "health", "work" and "family" [17],[27] . Undesirable life events in the present study were reported more among FD patients than DU patients and controls, but again DU patients were significantly more than the control [Table - 4]b. Similar results were reported by Haug et al, but Talley and Piper did not report any significant differences between the dyspeptic patients and controls and Mahgoub et al in a peptic ulcer study on Saudi patients could not confirm these differences [17],[19],[27] .

Only few significant differences had been identified in the present study between the DU, FD patients and the controls on one hand and between the DU and FD patients on the other. The DU, FD patients and controls reported equal number of the most common individual events, three each. The undesirable life events however, were reported by significantly more FD, DU patients than controls, but this is definitely not enough to reach a final decision on such a complex matter as the relationship between life events stress and gastrointestinal disorders. The response of a patient to stress depends on many other variables than the ones studied here, such as personality and cognition. The impact of life events is a complex interaction of stressors, availability of social support, individual ability to cope with stress and personality [27] . Research in this area has been criticized on many methodological aspects such as nonquantitative methods, retrospectivity and non-controlability of the reported studies [1],[21] . The present study is definitely not immune to these critics, in spite of the attempts made for quantification. The scaling of life events in some studies, on the other hand, did not change the situation as more or less similar results were produced in these studies [17],[27] .

In conclusion, the significance of life events in FD and DU was not substantiated in the present study and the issue remains still controversial. Further studies that include the various aspects of the problem, as mentioned above are no doubt needed before a final conclusion is reached.

   References Top

1.Creed F. Life Events and Physical Illness. J Psychosom Res 1985;29:113-23.  Back to cited text no. 1    
2.Holmes TH, Masuda M. Life Change and Illness Susceptibility In: Dohrenwendt DS, Dohrenwendt BP, editors. Stressful life events: their nature and effects. New York: Wiley 1974.  Back to cited text no. 2    
3.Rahe RH. Life change measurement as a predictor of illness. Proc Roy Sec Med 1968;61:1124-30.  Back to cited text no. 3    
4.Rabkin J, Struening E. Life Events, Stress and Illness. Science 1976;194:1013-20.  Back to cited text no. 4    
5.Wolf S. Wolf HG. Human Gastric Function. New York Oxford Press 1947.  Back to cited text no. 5    
6.Wolf S. The Psyche and the Stomach: an historical vignette. Gastroenterol 1981;80:605-14.  Back to cited text no. 6    
7.Tytgat GN, Graham DY, Lee A, Marshall BI, Dixon MF, Axon ATR. Helicobacter pylori; causal agent in peptic ulcer disease. J Gastroenterol Hepatol 1991;6:103-4.  Back to cited text no. 7    
8.Withelmsen I, Haug TT, Stipponen P, Berstad A. Helicobacter pylon in functional dyspepsia and normal controls. Scand J Gastroenterol 1994:29:522-7.  Back to cited text no. 8    
9.Malagelada JR, Stanghellini V. Manometric evaluation of functional upper gut symptoms. Gastroenterol 1985;88:1223-31.  Back to cited text no. 9    
10.Hill O, Blendis L. Physical and psychological evaluation of "non-organic"abdominal pain. Gut 1967;8:221-9.  Back to cited text no. 10    
11.Langeluddecke P, Goulston K, Tennant C. Psychological factors in dyspepsia of unknown cause: a comparison with peptic ulcer disease. J Psychosom Res 1990;34:215-22.  Back to cited text no. 11    
12.Davies DT, Wilson ATM. Observations in the life history of chronic peptic ulcer. Lancet 1937;2:1353-60.  Back to cited text no. 12    
13.Peters M N, Richardson C T. Stressful life events, acid hypersecretion and ulcer disease. Gastroenterol 1983:84:114-9.  Back to cited text no. 13    
14.Hislop IG. Nervous dyspepsia and all that. Mod Med 1977:20:80-4.  Back to cited text no. 14    
15.Hui WM, Ling PS, Lam SK. The perception of life events and daily stress in non-ulcer dyspepsia. Am J Gastroenterol 199 1;3:292-6.  Back to cited text no. 15    
16.Talley NJ, Piper DW. Major life event stress and dyspepsia of unknown cause: a case-control study. Gut 1986;27:127-­34.  Back to cited text no. 16    
17.Talley NJ, Piper DW. A prospective study of social factors and major life event stress in patients with dyspepsia of unknown cause. Scand J Gastroenterol 1987;22:268-72.  Back to cited text no. 17    
18.Piper DW. Mcintosh JH, Ariotti DE, et al. Life events and chronic duodenal ulcer: a case control study. Gut 1981;22;1011-7.  Back to cited text no. 18    
19.Mahgoub OM. Hafeiz HB, Al-Quorain A. et al. Life events stress in Saudi peptic ulcer patients of the Eastern Province. Annals of Saudi Med 1991;1 1:669-74.  Back to cited text no. 19    
20.Tennant C, Andrews G. A scale to measure the stress of life events. Aust & New Zealand J Psychiat 1978;10:27-32.  Back to cited text no. 20    
21.Paykel ES. Methodological aspects of life events research. J Psychosom Res 1983;27:341-52.  Back to cited text no. 21    
22.Dunbar H. Emotions and bodily changes: a survey of literature on psychosomatic relationship 1910-1935. New York: Columbia University Press 1935.  Back to cited text no. 22    
23.Selye H. Forty years of stress research: principal remaining problems and its conception. Can Med Assoc J 1976;115:53­6.  Back to cited text no. 23    
24.Rennet E, Beaurepaire J, Kello .I, Tennant C. Life stress and non-ulcer dyspepsia: a case control study. J Psychsom Res 1991;35:579-90.  Back to cited text no. 24    
25.Sjodin I. Psychotherapy in peptic ulcer disease. A controlled outcome study. Acta Psychiat Scand Suppl 1983;307:9-90.  Back to cited text no. 25    
26.Mcintosh JH. Nasiry RW, McNeil D, Coates C, Mitchell 11, Piper DW. Perception of life event stress in patients with chronic duodenal ulcer. Scand J Gastroenterol 1985;20:563­8.  Back to cited text no. 26    
27.Haug TT, Withelmsen I, Berstad A. Ursin II. Life events and stress with functional dyspepsia compared with patients with duodenal ulcer and healthy controls. Scand J Gastroenterol 1 995;30:524-30.  Back to cited text no. 27    

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

PMID: 19864799

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