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Recent Separation and the Onset of Peptic UlcerDisease in Older Children and AdolescentsSIGURDH. ACKERMAN, MD, SCOTT MANAKER, BA, AND MICHAEL I.COHEN, MD

The onset of peptic ulcer disease in adolescents often appears to be preceded1 >ya separation orloss. We attempted to review data on, or to recontact, the 59 adolescent a id preadolescentpatients with peptic ulcer disease (gastric ulcer, duodenal ulcer, and hemater lesis of unknownetiology) admitted to Montefiore Hospital and Medical Center between 1968JUid1979. We wereable to obtain adequate retrospective data for 24 of these patients. Ten(42 %) ad encountered aseparation or loss within 12 months of the onset of their illness. In 6 patients the event occurredwithin 4 weeks of admission. In a matched group of 24 appendectomy patinnts, 1 separationoccurred in the 12 months prior to admission (X2=9.6; p


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of unk now n etiology H). The diagnosesof DU and GU were established radiologi-cally and/or endoscopically.

We evaluated the association betweenseparation or loss and the onset of pepticulcer disease by retrospectively compar-ing patients admitted for peptic ulcer dis-ease with patients admitted with symp-toms of acute appendicitis. Patients withappendicitis were selected as a controlgroup because they represented a popula-tion with an acute abdominal disorder butone not thought to be associated withrecent loss. The inherent limitations of aretrospective analysis, including poor pa-tient recall, should decrease the chancethat the index group would differ from thecontrol group. However, if the results ofthis conse rvative but relatively easy test ofthe original observation should support it,a more extensive prospective study wouldbe justified.

METHODSFifty-nine older children and adolescents withpeptic ulcer disease, 720yearsof age, were hos-pitalized between 1968 and 1979. These patientswere matched with a group of 103appendicitispatients for age at admission, years ofadmission,and sex.Information was not available retrospec-tively to match groups for ethnic and socioeconomicbackground, but patients came from similar localneighborhoods surrounding the hospital. Dataonpatients from both groups were gathered only after

approvalof the hospital CommitteeonResearchonHuman Subjects.For each patient we tried to ascertain the presenceor absenceofa separationorlossin the12 monthsprior to admission. Table1shows the data that were

'This clinical observation wasinitially madein1968byDr. Sheila Weinberg, who died beforeshewas able to pursue it. The present reportisbasedinparton her original observations. We were abletoreview tape-recorded interviews made by herat thetime of admission of 6 patients included in thisstudy.

TABLE 1 Questionnaire on Recent LossesWe are interested inyour recollectionofthe 12-monthperiod priorto admission date)1. Howmany family members were living w ith you?

Listbyrelationship).1. 7.2. 8.3 94. 10.5. 11.6. 12.

2 Didanyone moveout ofyour household becauseof:

a) anew jobb) schoolingc) marriaged) divorcee) retirementf) other

3. Were thereanyserious illnesses ifso,specify):a) within your familyb) among peoplew howere very closeto you

4. Were thereanydeaths ifso, specify):a) within your familyb) among people who were very closeto you

sought from both subjects with peptic ulcer diseaseand acute appendicitis.We expected that wewould beunable tolocatemany of these former patients for follow-up inter-views. Therefore, wetried to obtain data on sep-arations and losses from all available sourcesofinformation. The sources of information aboutpatients with peptic ulcer disease included hospitalrecords, tape-recorded admission interviews of 6patients seefootnote 1), and follow-up question-naires for those patients who could be located.Initially, all hospital records were carefully re-viewed. If there was specific referenceinthe recordsto a recent loss, e.g., a close friend died 1 week priorto admission, we accepted this information. Iftherewasno specific mention ofeither thepresenceorabsenceof loss we disregarded the record and triedto contact the patient or the patient's familybytelephone. When this proved unsuccessful, we at-tempted to reach the index group member or familyby mail.In addition, tape-recorded admission inter-viewsof 6patients were available foranalysis. Re-gardlessof the source, information was elicitedac-cording to the structured outline showninTable1.

30 6 Psychosomatic Medicine Vol.43,No.4 August1981


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LOSS AND PEPTIC ULCER

tion were obtainedbytelephone interviewat the time of the study.Nevertheless, we believe that these datawarrant the tentative interpretation that arecent loss or separation may, in fact, be asetting in which peptic ulcer disease islikely to occur in adolescents.Loss or separation is not likely to havespecific relevance to peptic ulcer disease,exceptasa setting in which these diseasesmay manifest themselves in persons atrisk. Indeed, loss has been reported toaffect the timing of the onset of carcinomaof the breast (5), hematoproliferative dis-orders (6), infectious diseases (7), hyper-thyroidism (8), and ulcerative colitis (9).In a systematic comparison of childrenwith insulin-dependent diabetes andnondiabetic matched control children,Leaverton et al. (11) report a significantlyincreased incidence of parental lossamong the diabetic children. In this study,the authors included loss or continuedabsence of one or both parents, throughseparation, divorce, or death, up to 10years prior to the clinical manifestation ofthe disease.Because of such diverse reports, someauthors have suggested that there may bea general relationship between loss anddisease onset (11,12]. Other studies indi-cate that any emotionally important life

changes can alter general susceptibility todisease and can affect the onset of diseaseduring the period of adaptation to them,for both children (8) and adults (9).This increase in general susceptibilitymay help to explain why, in the presentstudy, clinically, anatomically, and mor-phologically different peptic disorders(DU, GU,andH)have in common an onsetassociated with recent loss or separation.It may be that while the timing of theirclinical occurrence is affected by loss, thespecific gastrointestinal lesion which de-velops depends upon other predisposingfactors such as familial, genetic, or dietaryinfluences.However, even among persons at risk(13),one cannot tell which of the predis-posed persons will actually become ill, orwhen. The data from this report suggestthat recent loss may be a statisticallyreliable marked for the timing of theoccurrence of some forms of peptic ulcerdisease in predisposed older children andadolescents.

This work was supported in part by agrant from the Robert Wood JohnsonFoundation and by Research ScientistDevelopment Award K1-MH00077 toS.H.A.).

R F R N S1. Rotter JI, Rimoin DL: Peptic ulcer disease : a heterogeneous group of disorders? G astioenterology76:604-607, 19772. Weiner H: Psychobiology and Hum an Disease. New York, Elsevier, 1977, pp 4 1- 623. Weiner H, Thaler M, Reiser M, Mirsky IA: Etiology of duoden al ulcer. I. Relation of specificpsychological characteristics to rate of gastric secretion (serum pepsinogen). Psychosom Med 19:1-12 ,19594. Christodoulou GN, Gargoulas A, Paploukas A, Marinopoulou A, Sideris E: Primary pept ic ulcer inchildhood. Psychosocial, psychological and psychiatric aspects. Acta Psychiatr Scand 56:215-222,19775. Muslin HL, Gyarfas K, Pieper WJ: Separation expe rience and cancer of the breast. Ann NY Acad Sci25:802-806 , 1966

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Greene WA: The psychosocial setting of the development of leukemia and lymphoma. Ann NY AcadSci 25:79 4-801, 1966Meyer RJ, Haggerty RJ: Streptococcal infections in families: factors altering individua l susceptibility.Pediatrics 29:539-549, 1962Morillo E, Gardner LI: Bereavement as an antecedent factor in thyrotoxicosis of childhood: four casestudies with survey of possible m etabolic pathw ays. Psychosom Med 41:545555, 1979Engel GL: Studies of ulcerative colitis. V. Psychological aspects and their implications for treatment.Am J Dig Dis 3:315-337, 1958HeiselJS,Ream S, RaitzR,Rappaport M, CoddingtonRD:The significance of life events as contributingfactors in the diseases of children. HI. A study of pediatric patients. Behav Pediatr 83:119-123, 1973Leaverton DR, White CA, McCormick CR, Smith P, Sheikholislam B: Parental loss antecedent tochildhood diabetes mellitus. Am Acad Child Psych 19:678-689, 1980Rahe RH, Arthur RJ: Life change and illness studies: past, present and future directions.JHum Stress4:3-15,1978RotterJI,PetersenG,Samloff IM,McConnellRB,Ellis A, Spence MA, RimoinDL:Genetic heterogeneityof hyperpepsinogenemic I and normopepsinogenemic I duodenal ulcer disease. Ann Intern Med91:372-377, 1979

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