Psychosomatic Considerations in Peptic UlcerMANUEL D. ZANE, M.D.

MOST clinicians are impressed with the emo-tional elements in peptic ulcer. Many (9, 10,

12, 22, 34, 36) consider it to be a psychosomatic dis-order. This approach makes understandable obser-vations which previously were difficult to integrateinto the accepted concepts of peptic ulcer. The oft-repeated admonition that the whole individual mustbe considered in managing the disease, and not justthe stomach (6, p. 438; 11; 40, p. 177), thereby alsobecomes more readily realizable.

Over a two-year period 85 patients with X-rayand clinical evidence of gastric or duodenal ulcerwere observed, studied, and treated by the authorat the Bronx Veterans Hospital. The patients wereveterans of World Wars I and II; one was a woman.From these studies it became apparent that allaspects of the disease were intricately bound upwith the character structure of the patient. Psy-chosomatic considerations affected vitally everyphase of peptic ulcer. In all the cases studied acommon conflict was found; tension accompaniedefforts to resolve this conflict.

THE SOURCE OF TENSIONIN PEPTIC ULCER

Many (14, 19, 21, 23, 27, 36, 38) have noted re-currence of ulcer activity with the appearance oftension in the lives of ulcer patients. The characterstructure of the peptic-ulcer patient is such thatwhen the proper stimulus presents itself, he becomesembroiled in a conflict which produces tension.

Alexander (1), Mittelmann and Wolff (21) andothers have described the peptic ulcer conflict asdeveloping from an unconscious longing for a de-pendent relationship and a reactive striving forassertive independence. In the present study thepeptic-ulcer conflict was found to have begun inearly childhood. The child seeks security by strivingto meet rigid, exacting standards set up by theearly authoritative figure, while at the same time

From the Medical Division, Veterans' Hospital, Bronx,N. Y.

Published with the permission of the Chief Medical Di-rector, Department of Medicine and Surgery, Veterans Ad-ministration, who assumes no responsibility for the opinionsexpressed or conclusions drawn by the author.

anticipating failure because of a strong feeling ofinadequacy. To allay his fear of failing, of losinghis security, he struggles to perform precisely inthe manner he feels is expected of him.

As the individual grows he continues to utilizethe same pattern in seeking security but new cir-cumstances in his life engender further develop-ments. At adolescence strong investigative and crea-tive urges emerge which he feels have to be sup-pressed; unconsciously he still harbors the com-pelling fear that his security is threatened if he pur-sues any but the goals that have been set for him.This is the source of conflict; resentment inevitablyaccompanies the need to deny and reject his owninclinations and fancies. In addition, the demandsof society—representing security to him—appear tohave become more elusive and unattainable thanthey were in childhood. Tension develops in hispursuit of security under these or similar circum-stances.

Such a conflict, involving simultaneous feelingsof fear and resentment, can also be described as"having to and fear of not being able to" or "mustand can't." The striking feature of the ulcer pa-tient, when he is caught up in such a conflict, isthat he either physically tries to do what he fears isimpossible or mentally wrestles with countless pos-sibilities in an endeavor to discover the "proper"solution.

The ulcer patient never gives up trying to ac-complish his set task. Frequently he continues untilhis ulcer symptoms or circumstances remove himfrom the conflict situation. Draper (11) describeshis ulcer patients as forever striving to attain somegoal notwithstanding difficulties which most menconsider insurmountable.

Although the underlying conflict in the pepticulcer patients studied has always been the same,the outward appearance and attitudes have variedconsiderably. Such differences depend upon thepersonality adjustments and defenses utilized anddeveloped to solve interpersonal problems of whichthe ulcer conflict is an important part. Thus theulcer patient may appear to be talkative, taciturn,chegrj;ul, sullen, beHig£npnt> mee^cocky, bashful,Misanthropic, amiable, hyperkinetic, sluggish,bright, dull, aggressive, or unobtrusive.

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PSYCHOSOMATIC CONSIDERATIONSIN ETIOLOGY

The relationship between the emotions and physi-ologic function has been a gradually developingconcept since Cannon's first experiments in thisfield. In 1932 Cushing (9) reported that several ofhis patients who had undergone operations forcerebellar tumors died of hemorrhage and perfora-tion resulting from rapidly developing ulcers ofthe esophagus, stomach, and duodenum. He postu-lated that the operative procedure resulted in adisturbance in the balance of the components of theautonomic nervous system supplying the esophagus,stomach, and duodenum, and that emotions mighteffect a similar imbalance likewise resulting inulceration.

Wolf and Wolff (40), working with their subjectTom, who had a gastric fistula, found during statesof fear or depression a predominantly sympatheticstimulation resulting in gastric hyposecretion, hypo-motility, mucosal pallor, and decreased mucin pro-duction. Emotions of resentment, anger and anxietywere found to be associated with hypersecretion ofacid and pepsin, hypermotility, hyperemia, and in-creased mucin elaboration—predominantly para-sympathetic effects. Where conflict involving bothfear and resentment existed (39), a dissociation ofresponse was frequently observed, resulting inhypersecretion of acid and pepsin, increased motility,and decreased mucin—a substance which ordinarilyprotects the mucosa from the erosive action of nor-mal gastric juice. Such a conflict, then, results inphysiologic changes that appear to be highly con-ducive to the development of erosion. Sustainedemotional tension, productive of overactivity of thestomach, can eventually lead to ulceration (37).

Sandweiss and Ivy are investigating, each withhis coworkers, two anti-ulcer substances, antheloneand enterogastrone, respectively. Anthelone (28)appears to promote fibroblastic proliferation, newformation of blood vessels and epithelialization.Enterogastrone (17) depresses gastric secretion andmotility, and appears also to increase the resistanceof the mucosa to ulceration. Shedding of columnarepithelium in the stomach has been described (15)as another protective device available to the mucosa.The resistance of normal gastric epithelium to ero-sion and of peptic ulcer to perforation in the pres-ence of acid and pepsin are well discussed by Bach-rach, Grossman, and Ivy (19).

It is conceivable that the effectiveness of protec-tive substances and mechanisms may be reduced,just as is mucin, during a conflict involving bothfear and resentment. If this can be proved to be so,

NOVEMBER, 1947

the clinical fact that ulcer patients are found caughtup in such a conflict just prior to development ofsymptoms would have an adequate physiologicexplanation. Other evidence of autonomic nervoussystem imbalance, such as excessive palmar sweat-ing, tachycardia, bradycardia, urinary frequency,spastic colitis, and mucous colitis, is very frequentlypresent in cases of peptic ulcer and may persist evenafter disappearance of the epigastric distress.

It is not the autonomic nervous system distur-bance alone, but the particular imbalance whichoccurs with the ulcer conflict situation that appearsto favor development of ulceration. In normalpeople such a conflict situation may result in ap-pearance of transient heartburn or epigastric dis-tress which is relieved by milk and alkalies. Butin the ulcer patient, the character structure is suchthat this conflict becomes sufficiently lasting andintense for him to develop actual ulceration.

PATHOLOGIC CONSIDERATIONS

It has been said that the individual ulcer can becured but that the tendency to develop the diseasecannot (16). Rienhoff (26) found evidence ofmultiple ulceration of the duodenum in 75 per centof his 260 cases which were said to have come togastric resection only after conscientious medicalmanagement had failed. Palmer and Schindler (24)found recurrence of ulcer in the same, adjacent, andneighboring areas of the stomach. They also re-ported gastroscopic observation of small, multipleulcers which disappeared rapidly (one month).

From the psychosomatic point of view, the multi-plicity of lesions found by these observers is readilyexplained by the usually diffuse nature of the gas-tric and duodenal response to the emotions. Localfactors such as exist in the gastric pathway of thestomach (13) probably account for the develop-ment of an ulcer at a particular site. Prolongationof the peptic-ulcer conflict situation could effect thedevelopment of a mucosal erosion and its progres-sion to acute, and then chronic ulceration.

The ulcer diathesis, which is the bane of the sur-geon's existence (20), has, when considered psycho-somatically, its origins in a character structurewhich becomes readily involved in the ulcer typeof conflict over a relatively sustained period. Rien-hoff (26) states that gastric resection, regardless ofthe extent, short of almost total gastrectomy, willnot ensure against the development of jejunal com-plications, and he observes that the best results areobtained in cases with the lowest postoperativegastric acidity. Bockus ([6] , p. 181) refers to the

374 PEPTIC ULCER

ulcer patient with interdigestive hypersecretion andGrade 4 hyperchlorhydria as being most apt to haverecurrences despite adequate medical or surgicaltherapy. Recurrent ulceration following a subtotalgastrectomy may be explained by the conflict situa-tion persisting or reappearing in the presence ofsufficient remaining acid- and pepsin-bearing gland-ular tissue.

Ivy et al. (8) state that there is no correlationbetween healing time, size of crater, recurrence,and duration of symptoms, and suspect that thereis usually little difference between the potential rateof healing of the acute traumatic ulcer of the non-ulcer patient, and of the chronic lesion of the peptic-ulcer patient under proper conditions of therapy(4). These findings could well be accounted for byassuming that physiologic changes favoring prompthealing (three and four weeks) also result whenthe conflict situation is removed, even in large-sized,apparently indolent, chronic peptic ulcers.

CONSIDERATIONS INCLINICAL PATHOLOGY

The gastroscope has disclosed many unexpectedfindings. Schindler ([32], p. 179) notes that 50 percent of all his patients gastroscoped had some evi-dence of chronic gastritis. Furthermore, mucosalhemorrhages and erosions {ibid., p. 148) wereoccasionally found in otherwise perfectly normalmucosa:; the mucosa surrounding ulcers was ofteninflamed and edematous, although frequently thesurrounding mucosa was normal {ibid., p. 162).The inflammation about the ulcer usually seemedto subside long before the ulcer healed {ibid., p.168). Hemorrhages in "superficial gastritis" con-sisted of small, dark red spots lying in an edematousmucosa {ibid., p. 184). Small erosions and acuteulcerations were frequently seen in cases of chronicgastritis, but they disappeared quickly.

There is a striking similarity between thesemucosal appearances and those seen in the stomachof Wolf and Wolffs subject Tom, when he wasexperiencing emotions of anxiety, hostility, and re-sentment of long standing, at which time he de-veloped edema, hyperemia, and petechial hemor-rhages ([40], p. 173). Wolf and Wolff state thatthe extent of gastric hyperactivity and secretion isroughly proportional to the intensity and durationof the emotions experienced {ibid., p. 129).

Gastroscopic examination of a patient with gas-tric ulcer shortly following the disappearance of theulcer type of conflict would reveal an ulcer withsurrounding mucosa of normal appearance. The

frequency of sustained emotions, embracing anxiety,hostility or resentment, probably accounts in largemeasure for the high incidence of "gastritis" ob-served, particularly when one appreciates, withouttoo great a stretch of the imagination, that havingthe gastroscope shoved down one's esophagus couldarouse anxiety or resentment. The response of thestomach to the emotion is instantaneous, just as ispallor during fright {ibid., p. 112).

Schindler cites two pieces of evidence to disputethe psychosomatic origin of most cases of ulcer.Firstly ([32], p. 168), he states that he has neverobserved a chronic ulcer develop in an area ofhypertrophic gastritis, although acute ulcers do.Secondly {ibid., p. 190), a number of patients suf-fering from severe psychogenic disturbances asso-ciated with varying acidity had perfectly normalgastric mucosa gastroscopically. However, beforethis evidence can be evaluated properly, the natureof the emotions experienced by these patients whilebeing gastroscoped would have to be known.Furthermore, as Wolf and Wolff point out, Schind-ler's observations lasted only a few minutes ([40],p. 55). Gastroscopic observations of varyingmucosal changes in the same and different patientsfrom time to time have been made (29) and theseaccord very well with the psychosomatic conceptthat the patient at the time of each examinationmay be experiencing different emotions based uponboth his reaction to the examination and to the con-stantly changing circumstances of his daily life.Schindler's concept ([31], p. 156) of progressiontaking place from hemorrhage to erosion to acuteulcer to chronic ulcer is certainly not at odds withthat of Wolf and Wolff (37) where sustained emo-tional tension results in hyperacidity, gastritis,minor mucosal erosions, and finally, peptic ulcer.

The presence of hydrochloric acid in sufficientconcentration to activate pepsinogen is a sine quanon for the development of peptic ulcer (31). Al-though higher levels of acid are found in mostcases of active peptic ulcer, ulceration does not de-velop in all cases of hyperacidity and may heal inthe presence of hyperacidity (25). Furthermore,normal or low levels of gastric acidity may also beassociated with the development of ulcer providingthe acid concentration is sufficiently high to activatepepsinogen. It is not at all unusual to find varyinglevels of acid at different times in the same indi-vidual. Sandweiss (29) has reported about equalconcentrations of acid in the nocturnal gastricjuice of normal and uncomplicated, mildly dis-tressed duodenal-ulcer patients. The variable acidlevels in the same and different ulcer patients could

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be related to the variation in intensity and characterof the emotional feelings experienced at the timeof each examination, just as are the varying gastro-scopic observations.

CONSIDERATIONS INSYMPTOMS

The seasonal recurrence of ulcer symptoms andtheir frequent association with upper respiratoryand other infections is well recognized. Too muchemphasis, however, has been laid on the purelyphysical factors involved. When seasonal recurrenceis present, an inquiry into the patient's problemsrelated to that time of year usually discloses ade-quate basis for the onset of symptoms.

The return of ulcer pain with colds or other in-fections usually has its basis in the character struc-ture of the patient. For example, the patient maybe engaged in working out a difficult problem. Theintercurrent infection interferes with his efficiencyand conflict is created when he feels that he mustsolve his problem despite his new handicap, at thesame time being inwardly fearful that he will notsucceed. He refuses to permit himself to slow downor take a less exacting standard of performance forhimself and again tries to function in the presenceof a conflict of "I must but I can't," which is theulcer-producing situation.

On the other hand, many ulcer patients havingan intercurrent illness are able to accept this ex-ternal factor as being responsible for any deficiencyin their performance and do not attempt to solvethe insoluble. They remain free of conflict anddo not develop ulcer symptoms at this time.

Frequent recurrence of symptoms further charac-terizes peptic ulcer. In the Army, the strain of mili-tary life was found to induce recrudescence (13, 27).Among civilians one usually finds that each newattack is precipitated by events of such significanceto the patient that sustained emotional tension de-velops. The patient may himself be consciouslyquite unaware of the disturbing nature of the eventsrecited, but the effects on the stomach and duo-denum are none the less marked. Under such cir-cumstances administration of food, milk, or alkalieshas beneficial effect only during the period in whichthe free acid is reduced. The attack itself will lastas long as the patient experiences the ulcer type ofconflict situation.

Usually the problems of the ulcer patient aretemporary, and with their solution comes remis-sion. When the ulcer type of conflict either dis-NOVEMBER, 1947

appears or is worked through by the patient, thepresumption is that the balance of the autonomicnervous system, affecting the stomach and duo-denum, is restored with resurrection of the pro-tective devices and fall in gastric secretion. Whenthis happens, the attack comes to an end.

The cause of pain in peptic ulcer is still obscure([6] , p. 129). It has been established ([40], p. 156),however, that stimulation of a hyperemic mucosawill result in pain while no pain can be thus elicitedin the normal stomach; in the engorged state thereis increased sensitivity to pain induced by vigorouscontractions. Physiologic changes associated withemotional experiences have been found roughly pro-portional in extent to the intensity and duration ofthe emotion experienced (ibid., p. 129). Thus,emotions that give rise-to persistent hyperemia maylower the threshold to pain for a prolonged period.

Nocturnal pain, a typical symptom of pepticulcer, has been related to the nocturnal secretion ofgastric juice without the buffering action of food.Methods of treatment have been devised to main-tain some milk or amphogel in the stomachthroughout the night (35), thereby preventing theacid from activating the pepsinogen. The cause ofnocturnal hypersecretion in the active peptic ulcerpatient has not yet been satisfactorily elucidated,but it should be recalled that the patient may utilizehis dreams to seek a solution to his conflict, and inthis way the same physiologic response to the sameemotional conflict as occurred in the daytime mayappear and operate through the night. Alvarez (2)states that sleep does not bring quiet to all parts ofthe brain in tense persons and they may continuesecreting strong acid in the late evening.

Here again it is fitting to cite the findings ofSandweiss (29) that the nocturnal secretion of acidis about the same in normal subjects and uncompli-cated, mildly distressed duodenal-ulcer patients.Clinically one finds that the asymptomatic ulcer pa-tient, dissociated from situations which create thepeptic ulcer type of conflict, is for all practical pur-poses a normal individual—able to eat and drinkalmost anything without untoward symptoms pro-vided that his departure from the prescribedregimen does not in itself constitute a tension-producing stimulus.

CONSIDERATIONS INDIAGNOSIS

Finding the character traits typical of the pepticulcer patient aids in making the diagnosis of pepticulcer. No differences have been found between the

376 PEPTIC ULCER

gastric- and duodenal-ulcer types (21). Such traits—outgrowths of the central conflict described—include being overconscientious, meticulous, care-ful, and hardworking. A frequent remark ofpeptic-ulcer patients is, "If I do anything, I like todo it right and get it done quickly." They anticipatedifficulties far in advance and rely heavily on plansto achieve their goals—all the while fearing andanticipating failure. They react badly to change,feeling inadequate to meeting the new require-ments as they construe them, no matter how manysuccesses were theirs in the past. They do not allowthemselves the right to make an error and theyfunction in many seemingly unimportant jobs asthough their very existence were at stake. Suchtension is made the greater and more obvious whenthey work under supervisors whom they considerstrict and stern.

CONSIDERATIONS INMANAGEMENT AND THERAPY

The usual treatment, embracing milk, cream,alkalies, antispasmodics, and rest, has therapeuticeffects beyond those already established in the labo-ratory. The emotional experiences of the patientaffect the response to treatment to an importantdegree. Wolf and Wolff ([40], p. 136) have shownthat fat may entirely fail to decrease motility andsecretion of the stomach, as it normally does, whenthe patient experiences emotions of anger and re-sentment. Similarly, if tension continues, milk andcream may fail to have their usually beneficialeffect.

Most ulcer patients respond promptly to routineoffice therapy, and dramatically to hospitalization,but the type of treatment prescribed plays a minorrole. Society sanctions, and the patient accepts hisright to be treated while under the doctor's ordersor when hospitalized. He need struggle no longerto achieve the impossible; his stomach and duo-denum once again come into physiologic balance.Frequently, however, upon discharge from the hos-pital the patient returns to the conflict-exciting situ-ation and despite careful dietary observance hissymptoms promptly reappear.

The physician is confronted with one of his mostconfounding problems when the patient is unableto relax and accept his right to treatment and care.This type of ulcer patient either refuses silently tosubmit himself to the care of others or persistsovertly in trying to direct management of his ownillness. Such a patient is recognizable by his capa-city to find fault with hospital personnel or treat-

ment rendered. In these circumstances, epigastricpain becomes worse despite the usual forms oftherapy. Danger of penetration and perforationalways threatens these patients. When the patientaccepts his right to treatment and care and delegatesthis responsibility to others, favorable response totherapy follows.

The patient's feeling towards the physician, how-ever unwarranted, is one of the most importantelements in the entire therapeutic situation; it oftendetermines the success or failure of a particularmode of treatment. In evaluating the effect of aspecific form of therapy, the attitudes of the patienttowards his environment as well as towards thephysician demand the utmost consideration.

The comfort derived from the hospital environ-ment, and not the particular diet or medication,appears to be the significant factor in the patient'simprovement. In an overseas Army hospital (14)patients improved promptly despite "relatively crudedietary measures available." Zetzel (42) observedthat when soldiers with peptic ulcer anticipatedautomatic discharge from the Army because of thediagnosis they improved promptly during hospitali-zation. But when separation from service was notautomatically a consequence of their ailment, theirimprovement was no longer uniform or prompt.In a civilian hospital (41) most ulcer patients im-prove promptly even though the diet includes, fromthe first day, beef, coffee, and whole vegetables,and no restriction is imposed on tobacco. Despitethe widespread adherence to a strict dietary regime,an adequate comparison between strict and laxmanagement has not been made (18).

The real attitudes of the patient toward his dietaffect considerably the course of his illness. The pa-tient may have no difficulty in adhering to a strictdiet because of a disinterest in food, a desire topunish himself, or because he may be using hisillness, and hence the ulcer diet, to explain hisshortcomings.

The diet may also be the source of resentmentand conflict to the patient. When, for example,he has to order mashed potatoes and chicken whilehis companions have "French fries" and spareribs,the emotions experienced may be more damagingto the mucosa of the stomach and duodenum thanthe forbidden foods would have been. On theother hand, if the patient throws caution to thewind, orders the "ribs and French fries" so as notto be too unlike his fellows, and if his conscienceassails him for his transgression while he is eatingor afterwards—and the ulcer patient has an over-dose of conscience—again he will be led into con-

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flict. Part of him will be self-recriminatory, whilethe other part will continue to support the actionhe took.

An inner, brooding resentment may developagainst his having to be so different from otherpeople. Not uncommonly revolt springs violendyto the surface; the patient then completely violateshis diet and prescribed regimen. For a while he isastonished to note how little distress results. Beforelong, however, the conflict situation returns andagain he is seized with pain and distress.

Such unhappy developments, common to manyulcer patients at one time or other, may be avoidedby explaining to the patient what the diet seeksto accomplish, that the diet is not the most impor-tant thing in his life, and by assuring him thatoccasional indulgence in food or drink medicallycontraindicated will have no dire effects. If the pa-tient is encouraged to take an adult interest in hisdiet, and not to feel that it is something imposedfrom without, he will voluntarily follow the diet,feeling free to depart occasionally from the pre-scribed regimen.

When one recognizes that a particular patientwould object to such instructions or be confusedby them, the doctor had best then outline a specificdiet and mode of conduct unless or until basicchanges in the patient's attitude toward his dietcan be effected. The approach to the diet is alsothus determined by the character structure of theparticular patient.

Occasionally a full psychosomatic history intro-duces features of personality which make possiblea departure from the usual criteria for surgery. Tocite one of several examples in the author'sexperience:

A patient, aged 52, had three episodes of tarry stoolsin the previous four years, with a history of recurrentulcer type of pain since 1920. In 1935 an X-ray firstrevealed a duodenal ulcer. The most recent episodeof bleeding was of a massive nature. The hemoglobindropped to 6.0 grams. The immediate treatment con-sisted of bedrest, amigen feedings, morphine sedation,and reassurance that his fear of cancer was withoutfoundation. His response was prompt. His hemoglobinreturned to normal within two weeks, and he wasplaced on a convalescent Sippy diet within a week'stime. The case had been considered one for intervalsurgery because of the age of the patient and repeatedhemorrhages. A personality study, including a Ror-schach, Wechsler-Bellevue, modified Goodenough, andpersonal interview, indicated that the patient's anxietieslay in the realm of his occupational endeavors. Athome with his family he had no real disturbances, forhe accepted the dependent role with his wife as hehad with his mother during his early childhood. Onhis jobs he worked under great tension, as though his

NOVEMBER, 1947

very life were at stake. No matter how unfair or in-ordinate were the demands made upon him by hisemployers and supervisors, he sought to meet theirrequirements, and often struggled unnecessarily to ad-just to imagined standards and requirements.

In the course of several interviews, the patient cameto realize and appreciate how his attitudes toward hiswork were derived from earlier attitudes, the basis forwhich no longer existed. In this way the patient wasable to take a more rational approach to his work.Fortunately, he was receiving a pension which, becauseit provided a basic security, allowed him in reality togive up his compulsive attitudes toward his work. Hewas brought to see and accept his basic right to keepchanging his job, if necessary, until he secured one inwhich he felt relaxed and happy. It was felt that withthe even limited insight obtained, the patient, becauseof his favorable life situation, could avoid getting in-volved in the tension-producing endeavors associatedwith his ulcer symptoms, or at least not so frequentlyor to such intensity as formerly. The patient was askedto return for a brief interview periodically.

This case is cited as an indication that adequatemanagement of an ulcer patient must necessarilyinvolve the psychosomatic considerations, or as hasbeen said many times, consideration must be givento the whole individual. An interesting and highlyinstructive discussion of the psychiatric treatmentof peptic-ulcer patients is given by Saul (30).

In considering exercise for the ulcer patient, thephysician must take into account the personalityof the patient. Cannon ([7], p. 135) states thatdigestive processes may be profoundly affected byinert and idle excitement almost as much as if theutmost physical exertion were anticipated, andrecommends (ibid., p. 141) hard physical labor towork off the bodily changes which have occurredin preparation for vigorous physical effort. An ulcerpatient unwittingly supported the basic wisdom ofthis advice when he described epigastric pain whilebowling but freedom from symptoms while en-gaged in a strenuous game of football. While bowl-ing, this patient was under tension, feeling that hehad to do well before the spectators and fearing thathe could not. Still he tried to meet what he believedwere their expectations. The exercise involved inbowling was limited, the effect of the emotions onthe stomach uninhibited. While playing football,the patient was in action constantly; his visceralfunction was subordinate to muscular activity. Tobalance movement, the autonomic nervous systemmust bring continual adjustments in visceral organactivity as well as in dynamics of the circulatorysystem, metabolism, and respiration (36). Further-more, while the individual is in motion, conflict andtension are rare.

Combat troops were found to have a lower in-

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cidence of peptic ulcer than base troops (14). Theirsymptoms appeared when hostilities ceased or whenthey were returned to a rear area (5). It may bepresumed that both the integration of the organismand the physical activity involved in meeting actualdanger protects against ulcer while the tension ofwaiting in the rear area and reacting to a feelingof "must and can't" predisposes toward the de-velopment of ulcer.

When a patient fears exercise will be harmful, thebest course is to forego it until the patient's atti-tude changes. Otherwise, in attempting to followthe doctor's counsel, while not really wanting toand therefore feeling unable to, he may be throwninto the ulcer type of conflict anew. The type ofexercise recommended during remissions must bethe kind that the patient enjoys and which doesnot create tension in him. It is not the amount ofenergy expended but the needs of the individualwhich determine the exercise prescribed.

CONSIDERATIONS INPROGNOSIS

The longer the interval between attacks, the bet-ter the chances for response to treatment. Adequateadjustment during this period may be inferred fromthe prolonged freedom from symptoms. Shouldsymptoms recur frequently, they themselves maybecome a source of new tension because the patientfinds or fears that they are an added handicap.Then a vicious cycle, symptoms giving rise to ten-sion and tension to symptoms, is established. Hos-pitalization or other drastic measures may be neces-sary to break the cycle.

When one encounters an ulcer patient who hasno apparent areas of real satisfaction and whosecharacter structure is fixed and rigid, the chancesfor response to medical treatment, which includesinvestigation of personality, are very slight.

When a patient can be guided, either by manipu-lation of the environment or by the developmentof insight into an area where he functions freelyand with relaxation, recurrences are fewer and occa-sionally eliminated. The more difficult patientmust be brought to recognize the relationship be-tween his ulcer and his emotional tension. He maythen be encouraged to accept his right to rest andtreatment when symptoms recur. In this way thesymptoms are prevented from causing additionaltension and conflict.

Bockus ([6] , p. 431) refers to the pseudo-ulcersyndrome, which he calls pyloroduodenal irrita-bility. Gastrointestinal X-rays are negative but this

condition is still characterized by the same symp-toms, personality, and constitutional configurationcommon to peptic ulcer patients. The treatmentis the same and the etiologic features present induodenal ulcer are provocative of this syndrome{ibid., p. 432). Pyloroduodenal irritability is im-portant because it is in accord with many clinicalobservations in which patients have an ulcerlikesyndrome for many years and later develop roent-genographically demonstrable ulceration. Such pa-tients exhibit the same type of underlying conflictduring an attack of pain as does the true ulcerpatient, and they react to their conflict in a similarmanner. Unless adequate measures are taken toweaken the propensity of the individual to developsuch conflict, the ultimate occurrence of chronicpeptic ulcer may be anticipated.

COMMENTS

Although the psychosomatic approach lendsunderstanding to many of the unusual findings inpeptic ulcer, it does not, at this stage of our knowl-edge, provide the answers to all peptic-ulcer prob-lems. As far as has been determined to date, gastricand duodenal ulcers are identical from the psy-chosomatic approach (21). Striking clinical dif-ferences between them have been observed; post-operative anacidity is more frequent in cases ofgastric ulcer than in duodenal ulcer, and the for-mation of marginal ulcer is rare as compared withcases of duodenal ulcer (3). No matter what thepsychosomatic factors may be, the possibility ofcarcinoma in gastric ulcer cases must always beconsidered. Many patients, furthermore, who havethe specific type of conflict described do not developpeptic ulcer. This may be a difference of intensityand duration.

The appearance of peptic ulcer is regarded asa pathologic development incident to the specifictype of autonomic nervous system imbalance ob-taining in the emotions associated with the peptic-ulcer conflict situation and not as an answer tothe needs of the patient, either conscious or uncon-scious. When the conflict is dissipated or the pa-tient learns to handle his problem with greaterequanimity, peptic ulcer may not develop, aldioughevidences of other autonomic imbalance may stillbe apparent.

The question of how the acute ulcer which goeson to perforation differs in the psychic backgroundfrom the nonperforating ulcer remains to be an-swered. Although the psychosomatic approachposes for the physician certain real problems of

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time and training, these must be mastered if thepatient is to receive the most effective treatmentpossible.

SUMMARY

1. The concept of peptic ulcer as a psychosomaticdisorder affects considerations in etiology, path-ology, clinical pathology, symptomatology, diagno-sis, management, therapy, and prognosis.

2. In the usual case of chronic peptic ulcer, anunderlying conflict exists in which the individualfeels compelled to function in a certain mannerdespite anticipation of failure. The origins and sig-nificance of this conflict are presented and discussed.

3. The peptic-ulcer conflict situation involves bothfear and resentment, each of which has opposingeffects on the stomach and duodenum. When fearand resentment are experienced simultaneously,the reactions in the stomach are dissociated, oftenresulting in increased acid, motility, and vascularity,with decreased mucin (H. G. Wolff). It is postu-lated that during such dissociation other protec-tive substances and mechanisms are likewise de-ficient in the presence of increased acid and pepsin.Such physiologic concomitants to this conflict situa-tion are highly conducive to the development ofulceration.

4. The adjustments of the patient to his under-lying conflict may be infinitely varied so thatthe outward appearance of these patients differsmarkedly.

5. The ulcer diathesis resides in the basic charac-ter structure which readily thrusts the patient intothe peptic-ulcer type of conflict situation. If thesituation is of short duration, the symptoms willalso be brief; if sustained, they will be prolonged.

6. Chronic, indolent peptic ulcers heal as rapidlyas acute ulcers when the conflict situation isremoved.

7. The variations in gastroscopic findings, whichare described, are best integrated by the psychoso-matic concept, which assumes both that the emotionsaffect the color and appearances of the stomach,and that changing emotions are accompanied byprompt changes in the appearance of the stomach.

8. Varying gastric juice and acid levels duringthe day and night are explained by the changingemotions experienced.

9. Seasonal recurrence, frequent association ofsymptoms with infections, and frequency of recur-rence are all related to the character structure ofthe patient.

10. The diagnosis of peptic ulcer is supported by

NOVEMBER, 1947

finding a character structure which readily thruststhe patient into the peptic-ulcer conflict situation.Some of the character traits commonly found inulcer patients are described.

11. The psychosomatic effect of treatment, in-cluding diet, rest, hospitalization, and exercise, isdiscussed. The emotional reaction of the patient isheld to be of greater significance than the particulardiet or drugs utilized in treatment. This does notpreclude the possibility of developing measures tocorrect the autonomic imbalance in the stomachand duodenum associated with the ulcer type ofconflict.

12. The evaluation of the character structure, thepsychosomatic history, and the changes possible inthe environment afford the best means of deter-mining the prognosis in a particular case. Thelikelihood that the patient will become involved inthe peptic-ulcer conflict situation is the basis forsuch prognosis.

13. The best prognosis exists for patients withthe longest intervals between attacks, implying asit does, adequate adjustment during the intervals.

14. Patients with pseudo-ulcer syndrome (pyloro-duodenal irritability) may develop demonstrableulceration in later years if the conflict situationbecomes sufficiently intense and sustained.

15. The patient's concern with his diet and painmay in turn result in tension which gives rise tomore pain.

CONCLUSION

Peptic ulcer is a psychosomatic disease. Sucha concept affords a better understanding of themany confusing manifestations of the ailment andmakes available a more flexible and effective ap-proach to them.

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NEUROPSYCHIATRIC RESIDENCIES OPEN UNDERVETERANS ADMINISTRATION

Openings are available in Neuropsychiatric Residency at the Veterans Administration Hos-pital, Lyons, New Jersey.

The program consists of one, two or three years' training with intensive post-graduate teach-ing in Clinical Neurology and Psychiatry, Psychopathology, Clinical Psychology and relatedSciences, in Neuroanatomy, Neurophysiology, Neuropathology and Neuro-roentgenology, alsoexperience in Female and Child Outpatient Psychiatry and Inhospital Training for FemalePatients and Feebleminded Children and Juvenile Delinquents.

The type of instruction, supervision and training is carried out in accordance with the require-ments of the American Board of Psychiatry and Neurology.

The Residency has been approved by the Council on Medical Education and Hospitals, Ameri-can Medical Association and by the American Board of Psychiatry and Neurology.

VOL. IX, NO. 6