Anxiety,Depression And Ego - Strength Assessment In Duodenal Ulcer And Somatizer Patients

By:h/l.S.Abdel Gawad, M.S. Hunter, E.H. Ghoz, Sanaa Ahmed, Sanaa Sayed, AdArafa, M.A. Askar

ABSTRACT Tim work is &A igncd to assess tire psychological condition

of peptic 111:. :r yutients;lOO r~~n le tiuodozal ulccr paticnts and 30 rnnle sornillixrs Icere sturiicii. 30 normal males as controls were t~lkcn and ~ I I L ' Y were all subjected to Beck Depression Inventory fdr asscssin;. depression. Haruilton Anxiety Scale and Barron Ego-Srrcngiii Sculcs.We found that pcrsonality characteristics of ciuodcnai 1d;~'r ajrd sornatizer groups were neariy the same, both grolps dflercd from the control. They scored higher on anxiety, sornatizutioa. dcprcssion, oOscssions but lower on ego strength scales compared to the control group, which can be explained by the posszblc role of chronic iatrogenic factor, in our culture, which could invite dependency, decornpcnsation leading to parmrtic rc i,mon.

INTRODUCTION

No rigorous dciinition, or even acceptable dcscription of psychosomatic illness has ever txcn proposed, lhe only common characteristic being the assumption that psycological Fdctors play an important role in their complex, obscure actiology(Lipowski 1984). Myrcn(1983) said that factors such as anxlcty, maskcd dcprcssion and emotional conflicts were repor~cd to bc relatcd 10 pcptic ulccr. iri a study by Piper ct a1(1077), they found that gastric ulcer male paticnts w r c significanlly morc ncurolic and less extraverted than co~~rrols and lhcq ~t crc charactcrizcd by a pcrsonality pattcrn of independence

MSAbdel Gawad et 01.

and self-sufficiency and were prone to anxiety and depression. Alp et al(1970) found gastric ulcer patients to be more independent, depressed and anxious than controls. Lyketsos et al(1982) in their study on duodenal ulcer patients, rcported that ulcer paticnts showed less dominant hostility and more dependent bchaviour com~ared to controls. Anxiety only and depression appeared to be

p-ominent in ulcer patients. Magni et a1 (1982) in their study, found anxiety and ne ~roticisni but no: depression to be prominent too.

'Th: aim of this work is to assess anxiety, depression and ego-strength in a group o' duodenal ulcer patients compared to a group of somatizers (patients complaming of symptoms simulating peptic ulcer disease, but endoscopic examination revealed normal finding), and a control healthy group not suffering from any gastrointestinal troubles.

MATERIAL AND METHODS

The three groups compared in this work were: 1;) Duodenal Ulcer Group : this group included 100 male patients diagnosed endoscopically as having duodenal ulcer disease. 2) Somatizers Group: this group included 30 male patients who were complaining of symptoms simulating peptic ulcer disease, but on endoscopic e:tamination, no abnormal findings were revealed. 3).Control group : included 30 normal males not suffering from any gastrointestinal troubles and were selected from the attendants coming with

patients as their parulers in work or relatives. The three groups were matched for age, educational level and social class,

on the assumption that such factors may affect the affective tone and personality of the individual.

The three group'were subjected to the following procedures: 1) Beck Depression Inventory : Arabic version by Souief and Darwish (1978). 2) Hamilton Anxiety Scale : Arabic version by Okasha (1979). 3) Banon Ego-strength Scale : Arabic version by Kafafy.

The results were compared and analysed statistically .

RESULTS All the rcsults obtained in this study are summarized in the following tables and fibxrcs. Table (1) : showing the difference between the three groups: Duodenal ulcer group, the somatizers group and the control group on Beck Depression scale.

+ * * P < .001 highly significant ** Pc02 r P < . 1

From table (1) it was observcd that only 13.3% of control and 62% of duodcnal ulcer and 83.38% of somalizcrs scorcd pathologically on the dcprcssion scale. The highcst scorc of Lhe duodcnal ulccr group was obtained on modcratd and scvcr dcprcssion scalc which differs significantly from the control group at P<0.001. While the duodcnal ulccr group did not dificr significantly fmm the sornatizcrs group. The highcst scorc of the somatizers group was obtaincd on normal and mild dcgrcc scale which differs significanUy from the duodcnal ulcer group P<0.02. Both duodcnal ulcer and somati-wr groups rccordcd pathological on the dcprcssion to the same extcnt. Fig.(l) shows the mean of different groups (Duodenal ulcer, somatizers and the control group on Beck Depression scale.)

Table (2) : showing the difference between the three groups; Duodenal ulcer group, the Somatizer group and the Control group on Hamilton Anxiety scale {Total morbidity scale (Psychic Anxiety Scale + Somatic Anxiety Scale)).

P < 0.001 High significant . ** P < 0.1

The total scale of Hamilton Anxiety scale is the sum of both Psychic and Somatic Anxiety scales.

From table (2) it can be observed that the duodenal ulcer group scored higher in level (16 - 25). (26)+ than the control group to a highly statistically significant level at P< 0.001. On the other hand, the somatizers group did not differ statistically from the duodenal ulcer group at all levels.

4 6 MSAbdtd Cawad et al.

'I'ablc (3) : shohting the difference between the three groups (Duodenal ulcer group, the S o m a l i ~ e r s group and the Control group on Haniillon Anxiety scale (I'sychic Anxiety scale).

Duodenal ulcer

No %

-GI 4 41.00

Control

Egypt. J . Psychint. (1988). 11: 41-56

Table (4) : showing the differences between the three groups (Duodenal ulcer, Control, and the Sornatizers group) on (Ifamiltion Anxiety Scale). Sornntic Anxiety Scale.

** P < 0.001 Highly significant

From table (3) and (4) it was obscrved that, duodenal ulcer group scored highcr significantly than the control group at Pc0.001 at levcl from (9 - 14) , ( 1 5 ~ ) .

Although the somatizers group scorcd highcr than the ulccr group at level (9- 14), it was not to a statisticslly significant lcvcl.

MSAbdeI Gawad et al.

Fig.11 shows the mean of different groups : duodenal ulcer groups, somatizers group and normal control group on Hamilton Anxiety Scale (both Psychic and Somatic Anxiety Scales).

Egypt. J . Psychiat. (1988). 11: 41-56 49

Table (5) : Showing the difference between the three groups : duodenal ulcer group, the control group and the somatizers group (on Barron Ego - strength Scale).

* P < 0.001 Highly significant. * * P c0.1

S. D

32+ High score

Mean

S. D

Total

Mean S. D

From table (5) we can observe that 62% of duodenal ulcer patients were having low scores (score below 32). which is significantly higher than the control (P<0.001). On the other hand, 80% of the controls and 38% onIy of ulcer group were having high scores (32+) at (Pc0.001). While ulcer group scored more or less the same as that of somatizers group.

2 4.67

38 38.00

35.63

i 2.87

100

29.18 2 6.49

+ 5.09 -

24 80.00

38.83

k 3.38

30 100

35.97 56-90

* 24.97

8 k4.72

* 4.67 38 38.00

_ 35.63

- + 2.87

100 100

29.18 26-49

rt 5.99

11 36.67

34.00 ,

+ 2.68

30 100

27.97 - +6.83

* * + 0.13

* * f 0-85

MSAbdel Cawad et al.

DISCUSSION The interpretation of our findings should be taken within the limitations of

the applicd tools The first tool is Beck's Inventory which is not yet standardized on the

Egyptian population, that is why wc are going to rely, for some limited validation at his stagc, on the control sample bcing matched for age, education lcvcl and social class,

As a whole, duodcnal ulcer paticnts scored higher on this test than the control. Simply, this is cvidcnccd by the Pact that the normal score in the control group outnumbers significantly thc corrcsponding normal score in the duodcnal ulccr samplc (and vice versa). If we consider that this means that peptic ulccr paticnts arc more dcprcsscd, we find ourselves agreeing with Myren (1983) who found dcprcssion to bc morc prominent in duodenal ulcer paticnts than controls. Wc have to take this agrccmcnt cautiously with the least generalization. It is a wcll known psychodynamic assumption that psychosomatic disorder alleviates, at least partly, the intolerable affective discomfort. The prcscnt higher score could indicate the original dysthymia (underlying the psychosomatic discase) as wcll as the possible resulting disturbances secondary to the somatic pain and awareness of the disease. Moreover, we did not correlate the degree of exacerbation of ulcer symptom (including endoscopic findings) with the degree of deprcssion as Lyketsos (1982) did. He reported that the acute dcpression encountered in some patients was not seen during pcriods of cxaccrbation of ulcer symptoms. This reciprocal relation strcssed by Dumbar (1959) needs to be verified through a longitudinal study, individual analysis of certain cases as wcll as cliicodynamic assessment ralher than quantitative sclf report questionnaire.

Howcvcr, coming to some detailcd quantification of our results, we find that mild depression is less represented in duodcnal ulccr patients than in som rtizers. The absencc of significant diiicrcnccs bctwecn peptic ulcer group and control group docs not mean that both groups are the same in the overall deprcssion. On the contrary, we can deduce that a peptic ulcer patient , once

depressed, he surpasses the threshold of presenting as a mild complainer to present by some moderate and scverc presentation. On the other hand, a

Egypt. J . I'sychiat. (1988). 11: 41-56

sornarizcr occupics thc spcctrunl of gradcs of dcprcssion (mild, moderate and sevcrc) more or less cvcnly disturbed. Pcrhaps this could refer to the poss~bility that the dcprcssion diffcrs in both groups, not only in severity but also in quality. To vcrily this lattcr hypothesis some other measure, including clinical rating and judpmcnt is nccdcd.

Futurc rcscarch should be designed to disentangle and differentiate qualitativcly bctwccn dcprcssivc presentation in bolh groups, as well as to discntanglc the causc and cffcct rcla~ionship in thc ulccr group.

As regards anxicty, i t was ratcd through Hamilton rating scale. The general rrcnd was analogous to thosc found in Bcck's depression self rcport scores. EIowcvcr mild anxicty was rcprcscntcd higher than in normal controls just as modcmtc. and scverc dcgrce. This common gcncral inclination may refer to the difficulty to discntan::lc anxicty from dcprcssion. What the patient reports as dcprcssion could rcfcs lo Lhc samc aspcct Ihe r a w rcports as anxicty. However 4 clinical ratcr is expcctcd to scorc mild anxicty more readily than an ulcer p;iticn: uho may not k able to declare such suffering as mild depression (see bcforc). Again, we can observe that the anxicty was present simultaneously in b o ~ h the uIccr patients and the somatizcr paticnts.As regard the presence of anxicty in thc ulcer .group, this agrccs with Henderson and Batchelor(l964), hIagni ct a1 (1982), Lykctsos et al (1982), Myrcn (1983). and McIntosh et a1 (1 983). At thc same iimc, the appcarancc of thc ulccr sccms not to substitute the anxicty as a successful psychoson~atic outlct. It appcars that it only partially did so leaving the original anxiety prcscnt in the realm of consciousncss of the patient. Morcomr, chronic anxicty is claimed to be an active factor in the pathogenesis of psychosomatic disorder (Fcnichcl 1949). Bcing that chronic, it is not expcctcd to be wholly rcplaced by the ulcer producing mcchanism.Lastly, anxicty could be secondary to the disturbance causcd by the ulcer provoking continuous worry about one's heallh, diet and outcome of the disease.

Thc somatizers group shows anxicly as much as the ulcer group does with no statistical differences between both groups. In the somatizers, there is no such psychosomatic mechanism to absorb or alleviate the anxicty. Moreover, somatized anxiety was as represented as thc psychic anxiety which again could

MSAbdel G a d et d.

indicate that one does not replace the olher in this nosological category. Perhaps they are complcmentary.

Whcn we come to Barron's cgo-strcngth scale, we find that low ego scores were more represented in the ulcer group and the somatizer group more than the normal control. There has bccn no significant dilference between thc two former groups. Nevcrthelcss, explanations should differ. In the ulcer group, the results are beyond our expcctations and against the Millleman and Wolf study (1942) who described the patient as assertively independent. This could be explained by the fact such findings may be expected in the etiology of ulcer patient, but once thc ulccr sets in and perhaps bccause of the possible chronic iatrogenic factors in our culture which invite dcpcndency, decompcnsation into parasitic relation could explain the low score as indicatcd. However, othcr rccords as De M'uzan and Bonfils (1961) reported that (50% of their studied group had weak ego pattem), 25% of them had the (pseudo-independent profile). 15% of these patients wcre overlly passive and parasitic.

As regards the somatizer group, low score is expected as part and parcel of the nagging dependent tendency with the least painstaking tolerant attitude of such group.

SUMMARY In a study of 100 duodenal ulcer, 30 somatizers patients and 30 normal

controls, we found that personality characteristics of duodcnal ulcer and somatizcrs group wcre ncarly thc same, both groups diifcrcd from the conml. they scorcd higher on anxiety and dcprcssion but lowcr on cgo strength scales, compared to the normal control group.

REFERENCES

1. Alp, M.H., Court, J.H. and Grant, A.K. (1970) :Personality pattern and emotional stress in the genesis of gastric ulcer. Gut 11,773-777.

2. Ammon, G.(1970):Psychosomntic illncss as a result of a deficit in ego structure undcr considerations of h c genetic, dynamic, struc~ural and group dynamic point of vicw. Psychmotor .Psychosom. 3 1: 179-1 89.

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De M'uzan, M. and BonGls, S. (1961): Personality and pcptic ulcer disease. Psychmotor. Psychosom. 12 ,108-1 12.

Durnbcr, F.(1959):Psychiatry in thc medical spccialitics. McGraw-Hill Book Co., Ncw York and London.

Fcnichcl, 0. (1945):Thc psychosomatic thcory of ncurosis. Norton, New York.

Henderson, D. and Batchclor, R.C.(1964):Textbook of Psychiatry. Oxford University Press.

Kafafy, A.:Ba~on Ego Smngth Scdc(Arabic version).

Lipowski , C.J.(1984):What docs the word psychosomatic really mean? an historical and scmantic inquiry. Psychosom .Mcd .46,153-171.

Lyketsos, G. (1982):Psychological characteristics of hypcncnsion and ulccr paticnts. J.Psychosom. Res.26225-262.

Magni, G.,Salmi, A. , Patcr1ini.A. and Mcrlo, A.(1982):Psycholog ical distrcss in duodcnal ulcer and acutc gaslrocnteritis. A convollcd study. Dig. Dis. Scicn. 27:108-1084.

MaN, G.F.(1950): Anxicty, hydrochloric acid sccrction, peptic ulcer ctio1ogy.Psychosom.Mcd .12:158.

Mclntosh, J.H.,Frydman, M. and Nasiry, R.W.(1983): The personality pattern of paticnts with chronic ulccr. A casc control study. Scand. J. Gastrocntcrol. 18: 945-950.

Mi ttlcman, B. and Wold, H.G.(1942): Emotions and gastroduodenal function. Psychosomat. Mcd.45.

Myrcn, J.(1983):The natural history of pcptic ulcer. Vicws in the 1980's. Scand.J.Gastrocntcro1. 18:993-997.

15. Okasha. A.(1979):Hamilton Anxicty Scale.(Arabic version).

MSAbdcl Gawad el a!.

Pkanz, M.(l'f7 1): Epidcniiological and sociocultru J factors in the actiology of duodcnal ulccr . In Advances in Psychosomatic Mcdicine. Vol.6. Duodcnd Ulccr .H.Wcincr (cd). S. Kargcr. Switzcrland.

Pipcr, D.W., Greig, M., Thomas, J.and Shinncrs, J. (1977):Personality pattcm of paticnts w i h chronic gastric ulccr.GastrocntcroEogy 73:444- 446.

Soucif, M. and Danvish, Z.A. (1978);Bcck Dcprcssion 1n.vcntory. (Arabic vcrsionj. Pcrsonal con~mn~unication.

Spcrling, M. (ic)bl):Psycl~osornaiic disorders in adolcsccrit psychoanalysis approach to problcms and thcmpy. Lora S , and Shnccr A. L. (eds). Harper & Brothcrs.Ncw Y0rk.P 202.

Wolf ,S. (1982):Pcptic ulccr .Psychosomatic illncss rcvic.w.No.3 in a serics. Psychosoma~ics 23: 1 10 1 - 1 105.

AUTIlORS h1.S. Abdel Gawad, Profcssor sf Psychiatry, Cairo University. M.S. Hunter, Profcssor of Tropical Medicine, Cairo Univcrsity

E.H.Ghoz, Assistant Profcssor of Psychiatry, Cairo University Sanaa Ahmed, Assistant Profcssor of Psychiatry, Cairo Univcrsity Sanaa Sayed , Assistant Profcssor of Psychiatry , Cairo University. M.Araafa, Assistant Profcssor of Psychiatry,Cairo Univcrsity M.A.Askar, Assistant Lcclurcr of Psychiatry, Cairo Univcrsity

Egypt. J. Psychiat. (1 988). 11: 41 -56

ABSTRAIT Nous savons quc lcs factcurs psychologiqucs joucnt un rolc important dans

l'dtiologic dcs maladics psychosomatiqucs. Nous avons 6valu6 lcs conditions psycholgiques dcs paticnts atteints

d'ulcCrc duoddnal ainsi quc 30 maladcs, mile, somatiscurs ont 616 dLudiCs. Nous wons administr6 Ics tests psychomdtriques suivants aux dcux

groupcs ainsi qu'8 30 malcs, contr8lcs , nornmux. Dans l'invcntairc dc la depression dc Bcck, 1'CchClle d'angoissc d'Hamilton,

ct l'Cch6llc dc la "force du moi" dc Barron, nous avons trouvC que les charact6ristiqucs dc la pdrsonalite dcs paticnts atlcints dlulcCrc duodCnale 6taicnt scmblablcs A ccux dcs somatiscurs, lcs dcux groupcs Ctaicnt differents du groupc contrble.

hI.SAbdc1 Gawad el al.

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