PsychologicalReports, 1990, 66, 763-767. @ Psychological Reports 1990
PAIN AND PERSONALITY IN DUODENAL ULCER: A PRELIMINARY REPORT ' GUIDO MAGNI
GIUSEPPE BORGHERINI
Wyeth-Ayerst, European Clinical Research and Development, Paris, France
Universi~of Padua School of Medicine, Department of Psychiahy, Italy
FRANCESCO DI MARIO Universiiy of Padua School of Medicine, Department of Gastroenterology. Italy Summary.-Personality factors measured by the Cattell's 16 Personality Factor Questionnaire were assessed for 78 duodenal ulcer patients with moderate to severe pain and in 30 duodenal ulcer patients with mild or no pain. The two groups were comparable for relevant sociodemographic variables. Patients with moderate to severe pain were significantly more tender-minded, kindly, and tended to be more introspective and glum than those reporting mild or no pain. However, the reported differences are small; adjustment of the p values to avoid Type I errors makes these differences no longer statistically significant. These results must be considered preliminary; further studies are necessary to understand the topic better.
Abdominal pain or heartburn are frequent symptoms in duodenal ulcer; they usually appear with a periodic pattern which corresponds to the clinical evolution of the disease, with exacerbations and remissions. I n duodenal ulcer, pain is more frequently localized in a specific point in the epigastrium centrally or sometimes in the right upper quadrant. I t is manifest more frequently when the patient is fasting, often during the night; meals can alleviate the sy mptomatology . The mechanisms of duodenal ulcer pain are not well known (2). Two have received particular attention, a possible alteration of motility and especially the low intraluminar pH; however, the administration of hydrochloric acid on the ulcer crater provokes typical ulcer pain only in a relatively low percentage of subjects, even when larger amounts of acid than those naturally occurring under physiological conditions are used (6). There are as yet unknown factors at work in duodenal ulcer pain: in some cases ulcers are recognized only upon hemorrhage or perforation (4), while other patients report severe pain with limited lesions. Surprisingly, no information gathered with standardized tools is today available on the possible role of psychological factors in duodenal ulcer pain. The aim of the present study was to remedy the situation.
'Address correspondence to Guido Magni, M.D., Ph.D., Wyeth-Ayerst, European Clinical Research and Development, 6, rue Clisson, 75013 Paris, France.
G.MAGNI, E T A L .
One-hundred-eight unselected patients with duodenal ulcer, being followed at the Gastroenterology Unit of the University of Padua, participated in the study. For several years this unit, in collaboration with the Department of Psychiatry, has carried out a research project on the psychological aspects of peptic ulcer disease (7, 8, 9). Diagnostic confirmation of active duodenal ulcer had been made previously in all patients by means of upper gastrointestinal endoscopy. Patients answered the Italian version of the Cattell's 16 Personality Factor Questionnaire, Form C (7, 8) while in a remission phase of the disease during which they were taking antisecretory drugs. The 16 P F is a multiphase questionnaire which allows the description of 16 personality factors with bipolar designation; see Table 1 . Form C has 105 questions. From the responses a standardized score (from 1 to 10) is assigned for each of the personality factors. A score of 5 and 6 is average, with 1 to 4 and 7 to 10 indicating an increasing departure from the mean. Medical charts were reviewed, and the presence of epigastric pain or heartburn was assessed for acute episodes of the disease during an average period of 3.6 yr. (SD 2.3). I n the charts, pain is reported as absent, mild, or moderate to severe according to clinical criteria. Mild pain has its onset during the fasting state and disappears with eating or with the assumption of antiacids. Moderate to severe pain has an onset unrelated to meals, with appearance also during the night, and disappears only after starting antisecretory treatment. If patients suffered from various episodes of different severities, they were ascribed to the more severe group. Classification according to such criteria allowed the distinction of two groups; the first of 78 patients with moderate to severe pain and the second of 30 patients with d d (Italian, lime) or no pain symptoms (in nine subjects of this last group a bleeding-episode determined the detection of duodenal ulcer). . The sociodemographic characteristics of the samples are shown in Table 2; mean duration of the disease was 10 yr. (SD:9.4) in the moderate to severe group, and 10 yr. (SD: 9.5) in the rnild or no pain group. Statistical analysis of the data was performed using Student t tests, or X 2 test when appropriate. No statistically significant differences emerged between the two groups for the sociodemographic variables.
The comparison of the two groups on the 16 PF variables is presented in Table 1. A statistically significant difference was found for Factor I and a significant trend for Factor F. Patients with moderate to severe pain were more tender-minded, kindly, and to a lesser extent more introspective and glum than those reporting rmld or no pain. The level of significance, how-
PAIN, PERSONALITY IN DUODENAL ULCER TABLE 1 DESCR~O OFN16 PF FACTORS: MFANSA N D STANDARD DEVIA~ONS FOR PATIENTSWITH MODERATE-SEVERE AND MILD-NO PAIN Low Score
Factor
Reserved, cool
A
Unintelligent Emotionally unstable, low ego strength Submissive, conforming Introspective, glum Fickle, low superego strength Shy, restrained Tough-minded, hard Trusting, tolerant Practical, conventional
B
Naive, forthright Self-assured, impenitent Conservative of temperament Dependent Uncontrolled Relaxed, tranquil
High Score
ModerateSevere, (n = 78) M SD
0
Outgoing, warm-hearted Intelligent Emotionally stable, high ego strength Assertive, rebellious Enthusiastic, cheerful Conscientious, high superego strength Socially bold, friendly Tender-minded, kindly Suspicious, tyrannical Imaginative, unconventional Shrewd, astute Apprehensive, guilt-prone
Q1 Q2 Q3 Q4
Liberal, analytic Self-sufficient Controlled Tense, anxious
C E F
G H I L M N
MildNo Pain, (n = 30) M SD
t
4.73 1.99 3.91 1.96
4.77 1.65 -0.09 3.70 1.68 0.52
3.96 2.63 4.69 2.10 4.97 2.43
4.17 2.59 -0.36 4.97 2.31 -0.59 5.93 2.20 -1.8Yt
6.46 4.50 6.71 5.17
6.13 4.83 5.60 4.80
2.07 2.08 1.85 1.99
2.24 0.72 2.12 -0.74 2.30 2.59t 2.48 0.80
4.82 2.14 5.81 2.42 7.05 3.57
4.90 1.79 -0.18 5.47 2.30 0.67 6.73 1.78 0.47
3.55 3.96 4.54 8.10
3.70 4.00 3.87 7.57
1.91 2.50 1.82 1.77
1.66 -0.37 2.18 -0.07 2.15 1.63 2.08 1.34
*p< .07. t p < .02.
ever, is relatively low, and, if we adjust the p value for the number of variables studied (Bonferroni procedure), the difference no longer reaches statistical significance. TABLE 2 ~OCIODEMOGRAPHIC CHARACTERIS~CS FOR PATIENTSWITH MODERATE T o SEVEREPAINA N D MILDO R NO PAIN Characteristics Sex
Male Female
Age Status
M i SD (yr.)
Education
Married Single Widow 5 5 yr. 6 to 8 yr. 9 to 13 yr. and> 13 yr.
Moderate to Swere, (n = 78)
Mild or None, (n = 30)
66 12 45.8 12.0 65 12 1 35 26 17
28 2 44* 11.0 26 4 0 10 7 13
*
G. MAGNI, ET AL.
A comment is needed about the type of patients we stuhed. I t is in fact evident that some of the subjects who suffer from duodenal ulcer are referred to a special unit for treatment, while many others are treated by their own physicians. I t is likely that clinical or other variables affect this selection process. This might explain why in our sample the great majority of the subjects present moderate to severe pain. Patients reporting more severe pain appear to prove more tender-minded and to a lesser extent are more introspective and glum. Alp, Court, and Kern-Grant, commenting on similar personality characteristics, affirm that they support the notion of internalization of aggression which had been reported in some ulcer patients (1). The existence of a relationship between aggressive feelings and pain has been reported in the literature ( l l ) , but in this perspective often pain has been linked to the guilt provoked by internal aggressive desires (5). I t is difficult to reconcile this hypothesis with the datum that patients with more severe pain d o not score higher in the 0 subscale of the 16 PF (guilt-prone). I n any case, it is clear that we must be very cautious in interpreting the differences in pain between the two groups with duodenal ulcer in terms of psychological differences. These in fact could be simply secondary to the presence of the pain symptoms or due to chance. An adjustment of the p values for a more conservative statistical approach to avoid Type I errors makes the differences no longer statistically significant. I t is also possible that the clinical criteria used to differentiate the two groups are not good enough to discriminate substantially different severities of pain. Another last consideration which deserves discussion concerns the fact that it is possible that a difference on the 16 PF questionnaire is not clearly evident between the two groups because the weight of the psychological factors linked to duodenal ulcer mask the effect of the pain experience. I t is clear that doubts are still present, and this study can be considered only as an initial approach to the problem which deserves further research. REFERENCES 1. ALP, M. H., COURT, J. H., & KERN-GRANT, A. (1970) Personality pattern and emotional stress in the genesis of gastric ulcer. G u t , 11, 773-777. 2. BLENDIS,L. M., HILL, 0. W., & MERSKEY, H. (1978) Abdominal pain and emotions. Pain, 5, 179-191. 3. CATTELL, R. B., EBER,H. W., & TATSUOKA, M. M. (1950) Handbook for the Sixteen Personalio Factor Questionnaire (16 PF). Champaign, IL: Institute for Personalicy &
Ability Testing. 4. DEW,M. J. (1987) Asymptomatic peptic ulcer disease. British Medical Journal, 2, 401. 5. ENGEL, G. L. (1959) Psychogenic pain and the pain prone patient. American Journal of Medicine, 26, 399-416. 6. KANG,J. Y., YAP, I., GUAN, R., & TAY,H. H. (1986) Acid perfusion of duodenal ulcer craters and ulcer pain. A controlled double blind study. Gut, 27, 942-945.
PAIN, PERSONALITY IN DUODENAL ULCER
767
7. MACNI,G., Dl MARIO, F., AGGIO,L., & B O R G H E ~G., (1986) Psychomatic factors and peptic ulcer disease. Hepatogastroenterology, 33, 131-137 8. MAGM,G., DI MARIO, F., RIZZARDO, R., RJLIN, S., & NACCARATO, R. (1786) Personalicy profiles of patients with duodenal ulcer. American lournal of Psychiatry, 143, 1297-1300. 9. MAGM,G., SMI, A,, PATEWUI,A,, & MERLO,A. (1982) Psychological distress in duodenal ulcer and acute gastroduodenitis. Digestive Diseases and Sciences, 27, 1081-1084. M., & PEDON,A. (1977) Contrzbuto allo studio della perronalztir: 11. 16 PF dz 10. NOVAGA, Cattell. Firenze: Organizzazioni Speciali. 11. TINLING, D. C., & KLEM, R. F. (1766) Psychogeruc pain and aggression: the syndrome of the solitary hunter. Psychosomatic Medicine, 28, 738-748.
Accepted March 29, 1990.
PAIN AND PERSONALITY IN DUODENAL ULCER: A PRELIMINARY REPORT ' GUIDO MAGNI
GIUSEPPE BORGHERINI
Wyeth-Ayerst, European Clinical Research and Development, Paris, France
Universi~of Padua School of Medicine, Department of Psychiahy, Italy
FRANCESCO DI MARIO Universiiy of Padua School of Medicine, Department of Gastroenterology. Italy Summary.-Personality factors measured by the Cattell's 16 Personality Factor Questionnaire were assessed for 78 duodenal ulcer patients with moderate to severe pain and in 30 duodenal ulcer patients with mild or no pain. The two groups were comparable for relevant sociodemographic variables. Patients with moderate to severe pain were significantly more tender-minded, kindly, and tended to be more introspective and glum than those reporting mild or no pain. However, the reported differences are small; adjustment of the p values to avoid Type I errors makes these differences no longer statistically significant. These results must be considered preliminary; further studies are necessary to understand the topic better.
Abdominal pain or heartburn are frequent symptoms in duodenal ulcer; they usually appear with a periodic pattern which corresponds to the clinical evolution of the disease, with exacerbations and remissions. I n duodenal ulcer, pain is more frequently localized in a specific point in the epigastrium centrally or sometimes in the right upper quadrant. I t is manifest more frequently when the patient is fasting, often during the night; meals can alleviate the sy mptomatology . The mechanisms of duodenal ulcer pain are not well known (2). Two have received particular attention, a possible alteration of motility and especially the low intraluminar pH; however, the administration of hydrochloric acid on the ulcer crater provokes typical ulcer pain only in a relatively low percentage of subjects, even when larger amounts of acid than those naturally occurring under physiological conditions are used (6). There are as yet unknown factors at work in duodenal ulcer pain: in some cases ulcers are recognized only upon hemorrhage or perforation (4), while other patients report severe pain with limited lesions. Surprisingly, no information gathered with standardized tools is today available on the possible role of psychological factors in duodenal ulcer pain. The aim of the present study was to remedy the situation.
'Address correspondence to Guido Magni, M.D., Ph.D., Wyeth-Ayerst, European Clinical Research and Development, 6, rue Clisson, 75013 Paris, France.
G.MAGNI, E T A L .
One-hundred-eight unselected patients with duodenal ulcer, being followed at the Gastroenterology Unit of the University of Padua, participated in the study. For several years this unit, in collaboration with the Department of Psychiatry, has carried out a research project on the psychological aspects of peptic ulcer disease (7, 8, 9). Diagnostic confirmation of active duodenal ulcer had been made previously in all patients by means of upper gastrointestinal endoscopy. Patients answered the Italian version of the Cattell's 16 Personality Factor Questionnaire, Form C (7, 8) while in a remission phase of the disease during which they were taking antisecretory drugs. The 16 P F is a multiphase questionnaire which allows the description of 16 personality factors with bipolar designation; see Table 1 . Form C has 105 questions. From the responses a standardized score (from 1 to 10) is assigned for each of the personality factors. A score of 5 and 6 is average, with 1 to 4 and 7 to 10 indicating an increasing departure from the mean. Medical charts were reviewed, and the presence of epigastric pain or heartburn was assessed for acute episodes of the disease during an average period of 3.6 yr. (SD 2.3). I n the charts, pain is reported as absent, mild, or moderate to severe according to clinical criteria. Mild pain has its onset during the fasting state and disappears with eating or with the assumption of antiacids. Moderate to severe pain has an onset unrelated to meals, with appearance also during the night, and disappears only after starting antisecretory treatment. If patients suffered from various episodes of different severities, they were ascribed to the more severe group. Classification according to such criteria allowed the distinction of two groups; the first of 78 patients with moderate to severe pain and the second of 30 patients with d d (Italian, lime) or no pain symptoms (in nine subjects of this last group a bleeding-episode determined the detection of duodenal ulcer). . The sociodemographic characteristics of the samples are shown in Table 2; mean duration of the disease was 10 yr. (SD:9.4) in the moderate to severe group, and 10 yr. (SD: 9.5) in the rnild or no pain group. Statistical analysis of the data was performed using Student t tests, or X 2 test when appropriate. No statistically significant differences emerged between the two groups for the sociodemographic variables.
The comparison of the two groups on the 16 PF variables is presented in Table 1. A statistically significant difference was found for Factor I and a significant trend for Factor F. Patients with moderate to severe pain were more tender-minded, kindly, and to a lesser extent more introspective and glum than those reporting rmld or no pain. The level of significance, how-
PAIN, PERSONALITY IN DUODENAL ULCER TABLE 1 DESCR~O OFN16 PF FACTORS: MFANSA N D STANDARD DEVIA~ONS FOR PATIENTSWITH MODERATE-SEVERE AND MILD-NO PAIN Low Score
Factor
Reserved, cool
A
Unintelligent Emotionally unstable, low ego strength Submissive, conforming Introspective, glum Fickle, low superego strength Shy, restrained Tough-minded, hard Trusting, tolerant Practical, conventional
B
Naive, forthright Self-assured, impenitent Conservative of temperament Dependent Uncontrolled Relaxed, tranquil
High Score
ModerateSevere, (n = 78) M SD
0
Outgoing, warm-hearted Intelligent Emotionally stable, high ego strength Assertive, rebellious Enthusiastic, cheerful Conscientious, high superego strength Socially bold, friendly Tender-minded, kindly Suspicious, tyrannical Imaginative, unconventional Shrewd, astute Apprehensive, guilt-prone
Q1 Q2 Q3 Q4
Liberal, analytic Self-sufficient Controlled Tense, anxious
C E F
G H I L M N
MildNo Pain, (n = 30) M SD
t
4.73 1.99 3.91 1.96
4.77 1.65 -0.09 3.70 1.68 0.52
3.96 2.63 4.69 2.10 4.97 2.43
4.17 2.59 -0.36 4.97 2.31 -0.59 5.93 2.20 -1.8Yt
6.46 4.50 6.71 5.17
6.13 4.83 5.60 4.80
2.07 2.08 1.85 1.99
2.24 0.72 2.12 -0.74 2.30 2.59t 2.48 0.80
4.82 2.14 5.81 2.42 7.05 3.57
4.90 1.79 -0.18 5.47 2.30 0.67 6.73 1.78 0.47
3.55 3.96 4.54 8.10
3.70 4.00 3.87 7.57
1.91 2.50 1.82 1.77
1.66 -0.37 2.18 -0.07 2.15 1.63 2.08 1.34
*p< .07. t p < .02.
ever, is relatively low, and, if we adjust the p value for the number of variables studied (Bonferroni procedure), the difference no longer reaches statistical significance. TABLE 2 ~OCIODEMOGRAPHIC CHARACTERIS~CS FOR PATIENTSWITH MODERATE T o SEVEREPAINA N D MILDO R NO PAIN Characteristics Sex
Male Female
Age Status
M i SD (yr.)
Education
Married Single Widow 5 5 yr. 6 to 8 yr. 9 to 13 yr. and> 13 yr.
Moderate to Swere, (n = 78)
Mild or None, (n = 30)
66 12 45.8 12.0 65 12 1 35 26 17
28 2 44* 11.0 26 4 0 10 7 13
*
G. MAGNI, ET AL.
A comment is needed about the type of patients we stuhed. I t is in fact evident that some of the subjects who suffer from duodenal ulcer are referred to a special unit for treatment, while many others are treated by their own physicians. I t is likely that clinical or other variables affect this selection process. This might explain why in our sample the great majority of the subjects present moderate to severe pain. Patients reporting more severe pain appear to prove more tender-minded and to a lesser extent are more introspective and glum. Alp, Court, and Kern-Grant, commenting on similar personality characteristics, affirm that they support the notion of internalization of aggression which had been reported in some ulcer patients (1). The existence of a relationship between aggressive feelings and pain has been reported in the literature ( l l ) , but in this perspective often pain has been linked to the guilt provoked by internal aggressive desires (5). I t is difficult to reconcile this hypothesis with the datum that patients with more severe pain d o not score higher in the 0 subscale of the 16 PF (guilt-prone). I n any case, it is clear that we must be very cautious in interpreting the differences in pain between the two groups with duodenal ulcer in terms of psychological differences. These in fact could be simply secondary to the presence of the pain symptoms or due to chance. An adjustment of the p values for a more conservative statistical approach to avoid Type I errors makes the differences no longer statistically significant. I t is also possible that the clinical criteria used to differentiate the two groups are not good enough to discriminate substantially different severities of pain. Another last consideration which deserves discussion concerns the fact that it is possible that a difference on the 16 PF questionnaire is not clearly evident between the two groups because the weight of the psychological factors linked to duodenal ulcer mask the effect of the pain experience. I t is clear that doubts are still present, and this study can be considered only as an initial approach to the problem which deserves further research. REFERENCES 1. ALP, M. H., COURT, J. H., & KERN-GRANT, A. (1970) Personality pattern and emotional stress in the genesis of gastric ulcer. G u t , 11, 773-777. 2. BLENDIS,L. M., HILL, 0. W., & MERSKEY, H. (1978) Abdominal pain and emotions. Pain, 5, 179-191. 3. CATTELL, R. B., EBER,H. W., & TATSUOKA, M. M. (1950) Handbook for the Sixteen Personalio Factor Questionnaire (16 PF). Champaign, IL: Institute for Personalicy &
Ability Testing. 4. DEW,M. J. (1987) Asymptomatic peptic ulcer disease. British Medical Journal, 2, 401. 5. ENGEL, G. L. (1959) Psychogenic pain and the pain prone patient. American Journal of Medicine, 26, 399-416. 6. KANG,J. Y., YAP, I., GUAN, R., & TAY,H. H. (1986) Acid perfusion of duodenal ulcer craters and ulcer pain. A controlled double blind study. Gut, 27, 942-945.
PAIN, PERSONALITY IN DUODENAL ULCER
767
7. MACNI,G., Dl MARIO, F., AGGIO,L., & B O R G H E ~G., (1986) Psychomatic factors and peptic ulcer disease. Hepatogastroenterology, 33, 131-137 8. MAGM,G., DI MARIO, F., RIZZARDO, R., RJLIN, S., & NACCARATO, R. (1786) Personalicy profiles of patients with duodenal ulcer. American lournal of Psychiatry, 143, 1297-1300. 9. MAGM,G., SMI, A,, PATEWUI,A,, & MERLO,A. (1982) Psychological distress in duodenal ulcer and acute gastroduodenitis. Digestive Diseases and Sciences, 27, 1081-1084. M., & PEDON,A. (1977) Contrzbuto allo studio della perronalztir: 11. 16 PF dz 10. NOVAGA, Cattell. Firenze: Organizzazioni Speciali. 11. TINLING, D. C., & KLEM, R. F. (1766) Psychogeruc pain and aggression: the syndrome of the solitary hunter. Psychosomatic Medicine, 28, 738-748.
Accepted March 29, 1990.
