The very model of a modern etiology: A biopsychosocial view of peptic ulcer

Objective: Research on ulcer psychosomatics has plummeted since the early 1 970s, to the applause of many who argue that ulcer is simply an infectious disease. The purpose of this article is to discuss the relevance of ulcer p sychogenesis in the age of Helicobacter pylori. Methods: A critical literat ure review was conducted. Results: There is a substantial and methodologica lly sound body of prospective studies linking stress with the onset and cou rse of peptic ulcer. Psychosocial factors can be estimated to contribute to 30% to 65% of ulcers, whether related to nonsteroidal antiinflammatory dru gs, H. pylori, or neither. The observed association between stress and nice r is accounted for, in part, by recall bias, misreported diagnoses, and con founding by low socioeconomic status (a source of stress and of ulcer risk factors, such as H. pylori and on-the-job exertion) and by distressing medi cal conditions (which lead to use of nonsteroidal antiinflammatory drugs). Of the residual, true association. a substantial proportion is accounted fo r by mediation by health risk behaviors, such as smoking, sleeplessness, ir regular meals, heavy drinking, and, again, nonsteroidal antiinflammatory dr ugs. The remainder results from psychophysiologic mechanisms that probably include increased duodenal acid load, the effects of hypothalamic-pituitary -adrenal axis activation on healing, altered blood flow, and impairment of gastroduodenal mucosal defenses. Conclusions: Peptic ulcer is a valuable mo del for understanding the interactions among psychosocial, socioeconomic, b ehavioral, and infectious factors in causing disease. The discovery of H, p ylori may serve, paradoxically, as a stimulus to researchers for whom the c oncepts of psychology and infection are not necessarily a contradiction in terms.