THE ROLE OF STRESSFUL LIFE EVENTS IN DUODENAL ULCER RECURRENCE: A PROSPECTIVE STUDY

GUIDO MAGNI

Wyeth Ayerst, European CR & D, Paris, France

GIUSEPPE BORGHERINI, ALESSANDRA ZENNARO, AGOSTINO MUSCARA AND FRANCESCO DI MARIO

University of Padova, Italy

This study prospectively assessed whether stressful life events (LE) were predictive of duodenal ulcer (DU) recurrence during remission of disease. We administered Paykel's Interview for Recent Life Events to 80 patients to assess events that occurred 12 months prior to the first interview and again 6 t o 12 months later for LE that occurred during the interval. Upper gastrointestinal endoscopy detected DU recurrence in 11 patients. Prospec- tive data analysis showed no significant difference in LE between relapsing and relapse-free groups, whereas retrospective analysis showed significantly more LE 0, > .03) among relapsing patients. LE seems to have played a marginal role in DU recurrence.

The literature describes many studies on the relationship between stressful life events (LE) and physical illness (Rabkin & Struening, 1976), but the results are frequently equivocal and not easy to interpret because of various methodological difficulties in- herent in such investigations (Bass, 1986). One of the major issues concerns the fact that the vast majority of the available data derives from retrospective studies that are confounded by the fact that patients tend to seek a reason for their illness, which biases their recall of events.

Most recently published papers on the relationship between stressful LE and duodenal ulcer (DU) that used standardized measures to assess LE are also retrospective in design. The results are sometimes equivocal, but generally do not seem to suggest a significant role for acute LE in DU onset or recurrence (Gilligan, Fung, Piper, & Tennant, 1987; Piper et al., 1981). This paper describes a prospective assessment of whether stressful LE were predictive of DU recurrence in a follow-up period of 6 to 12 months.

METHOD

Subjects The sample included 107 consecutive outpatients with endoscopically diagnosed DU

in the remission phase at the time of assessment. The sample comprised 84 males and 23 females with a mean age of 47 years.

Life Events Assessment Stressful LE were assessed using the validated Italian version of Paykel's Interview

for Recent Life Events (Paykel, Emms, Fletcher, & Rassalby, 1980). This scale comprises

This research was conducted under the auspices of the Roberto Farini Foundation for gastroenterological research. Drs. Borgherini and Zennaro are in the Department of Psychiatry. Dr. Di Mario is in the Depart- ment of Gastroenterology.

Correspondence should be addressed to Giuseppe Borgherini, Istituto di Clinica Psichiatrica, via Giustiniani 2, 35128 Padova, Italy.

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712 Journal of Clinical Psychology, September 1994, Vol. 50, No. 5

64 well-defined events and has been used widely in psychiatry as well as in psychosomatic research; it provides quantitative as well as qualitative evaluation of LE, i.e., the total number of events experienced by a person over a certain period of time, quantitatively classified into three categories: (1) entrances and exits, meaning, respectively, the en- trance of a new person (for example, marriage or birth of a child) or the departure (divorce, death) of a person from the social field; (2) desirable or undesirable events; and (3) controlled or uncontrolled events: Controlled events were the choice and under the control of the subject, and uncontrolled events were beyond the subject’s control or against hidher will.

Procedure All patients were enrolled in a quiescent phase of DU disease, established by

endoscopic examination that showed a scarring picture of the lesion. At the first interview, all 107 patients were assessed with Paykel’s scale to identify

LE that had occurred during the preceding 12 months. Patients were re-assessed 6 to 12 months later to consider LE that had occurred between the first and second inter- views. Clinical check-ups, including upper gastrointestinal endoscopy, were scheduled about every 3 months and/or whenever they showed signs of recurrence (pyrosis and/or epigastric pain that lasted more than 3 days). In a few instances the follow-up period was longer than 12 months. All DU recurrences were endoscopically proven. After the second assessment patients were divided into 2 groups, those who had suffered from a recurrence (R group) and those who had not (NR group). Data on stressful LE were analyzed prospectively to consider data obtained at the first interview or evaluated retrospectively to consider data gathered at the second interview. Statistical analysis was performed using Student’s t-test, the paired t-test, the x2 test, and the analysis of covariance, as appropriate. All the p values are two-tailed.

RESULTS

Eighty patients attended both interviews (67 males, 13 females; M age = 48.2 years f SD = 12.3, duration of DU 94 months f = 102), while 27 patients (17 males, 10 females, M age 44.1 years f = SD 13.6, duration of DU 113 months f SD = 105) dropped out of the study. No significant differences were found between these two groups for sex, age, working condition, and duration of DU disease.

Among the 80 patients who completed the trial, 1 1 had a recurrence of DU (R group). The NR group involved 58 males and 11 females with a mean age of 48 years (range 20 to 75 years). The R group comprised 9 males and 2 females with a mean age of 50 years (range 36 to 62 years). No significant differences emerged between these two groups in terms of age, sex, working condition, and duration of DU disease. The ma- jority of patients in both groups were receiving H2 antagonists treatment. However, at the time of the second interview, 15 (22%) patients in the NR group and 2 (18%) in the R group were without any specific H2 antagonists therapy. There was a trend difference between the two groups for the interval between interviews to be longer in the R group (10 months f: SD = 3.9 vs. 8 months f 2.8, t = 1.94 p = .053).

Table 1 summarizes data for stressful LE as gathered at the first interview (pro- spective analysis). No statistically significant difference emerged between the two groups for any of the quantitative analyses presented in Table 1 or for the qualitative distribu- tion of the events (entrances-exits, desirable-undesirable, controlled-uncontrolled; these data are not presented).

Table 2 summarizes the data on stressful LE gathered at the second interview (retrospective analysis): a slight, but significant, difference emerged between the two groups for total number of events, with a higher frequency of patients who suffered a recurrence. When the various qualitative categories of events were considered, the

Duodenal Ulcer Recurrence 713

Table 1 Occurrence 0.f Stressful Life Events among Patients with Duodenal Uker at the First Interview (Prospective Analysis)

Group NR Group R P (n = 69) (n = 11)

Events per person 2.6 f 1.5 2.6 f 1.4 ns

Events per person with a negative impact 1.6 f 1 1.6 f 1.1 ns

Number of patients who reported:

(M f SO)

(M f S O

More than 1 event 51 9 ns More than 2 events 32 5 ns More than 3 events 17 2 ns

only significant difference was found in the desirable events; here again, the R group reported a mean higher frequency than the NR group (.3 & .4 vs. .07 f .2 p = .04).

Because relapsing subjects were found to have a longer follow-up period, we con- sidered the possibility that this might have exposed them to higher risk of experiencing stressful events, and data on the total number of events were re-analyzed, with the dura- tion of follow-up as a covariate: The difference between the two groups was not statis- tically significant (p = .073).

Table 2 Occurrence o f Stressful Life Events among Patients with Duodenal Ulcer at the Second Interview (Retrospective Analysis)

Group NR Group R P (n = 69) (n = 11)

~

Events per person 2.1 f 1.4 3.0 f 1.1 < .036

Events per person with a negative impact 1 .3 f 1 . 1 1.6 f 1 . 1 ns

Number of patients who reported:

(M k SD)

(M f so)

More than 1 event 43 10 ns More than 2 events 28 8 < .05 More than 3 events 9 3 ns

DISCUSSION

Our results do not suggest that stressful LE, as measured by Paykel’s Scale, play an important role in the recurrence of DU, but a possible limitation of the research method adopted in this study, which may be quite relevant, was that only LE were con- sidered without assessing other factors known to influence the impact of LE on an in- dividual, e.g., personality structure and responsiveness, the existence and effectiveness of social support, the different coping styles, etc. (Andrews, Tennant, & Hewson, 1971; Magni, Rizzardo, & Andreoli, 1986). However, it is well known that researchers sometimes have to oversimplify matters, in the sense that only a portion of the observ- able phenomena can be studied and described. Moreover, other authors have reported that DU carriers do not perceive their reaction to LE as different from that of normal subjects (McIntosh et al., 1985).

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We have focused our attention only on stressful LE, using a straightforward pro- spective method in order to assess the relationship of LE to DU recurrence without the bias typical of a retrospective design. Given that no significant difference in stressful LE emerged between the recurrence and no recurrence groups in either the prospective or the retrospective analysis (that considers events taking place closer to the time of recurrences), it is reasonable to conclude that stressful LE generally play a marginal role in DU recurrence. This does not prevent LE possibly playing a more important role in an individual patient or in a small subgroup of patients (Levenstein et al., 1992).

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