A craterlike wound in the inner wall of the stomach or duodenum resulting from the corrosive effects of acid-containing digestive juices. Although certain types of food and drink stimulate the secretion of these juices, it is an established fact that emotional stress and strain are a major causal factor in many cases. For this reason peptic ulcer is classified in psychiatry as a psychophysiologic (psychosomatic) disorder of the gastrointestinal system.Family quarrels, business reversals, and other problems produce temporary stomach upsets in most people, and if these stresses are sufficiently severe and persistent, they may result in actual lesions. Brady (1958) has shown that stress situations can have the same effect on monkeys (PLATE 17)Many authorities, however, believe that this reaction occurs only in individuals who have a predisposition to oversecretion. They are sometimes referred to as “high pepsinogen secreters.”Modern society with its pressures and uncertainties is particularly conducive to the formation of ulcers, and it has been estimated that one out of ten people are afflicted at some time in life. The disorder is especially prevalent in large urban centers where the strain and tempo are greatest. (One indicative study showed that the incidence was fairly low among Negroes living in the South, but the rate among Negroes who had lived in Chicago for more than five years was the same as for whites. Steigmann, 1936.) Three times as many males as females suffer from ulcers, but the incidence among females is increasing. Recent studies have shown that ulcers are more prevalent in children than had previously been recognized.Although social and cultural factors help to account for the over-all prevalence of ulcers, specific types of situations and behavior patterns are believed to be responsible in many individual patients. A few cases seem to fall into the category of acute stress reactions—for example, the combat soldier who is subjected to situations of extreme tension, frustration, and threat to life may develop gastrointestional upsets that lead to ulcers. But most of the psychosomatic cases seem to be associated with a particular personality pattern. Alexander (1952) and others have found that these patients tend to be tense, hard-driving, and aggressive on the surface, but this facade hides an underlying wish to be passive, dependent, and cared for by others. As children they learned to associate food with affection, and as adults they continue to express their desire for loving care by overactivity of the digestive system when they find themselves in competitive or threatening situations. Evidence for this theory was found in the fact that when these individuals were under stress, their craving to be loved and “babied” was expressed in fantasies and dreams. Moreover, when they were confined to bed and cared for by a nurse, their ulcers frequently cleared up without medication.Other investigators (Mittelmann and Wolff, 1942) maintain that ulcer patients are not always hard-driving, but agree that they tend to demand the care and attention of others. When these demands are denied or frustrated, they become angry and their digestion becomes upset.Although psychoanalysis has been successful in treating ulcer patients, this long-term procedure is seldom undertaken. Bland diets, frequent feeding, drugs, and rest have proven effective in most cases, particularly when medical measures are coupled with direct counseling in which the patient is encouraged to lead a more relaxed way of life. If the ulcer condition is persistent and recurrent, and there is evidence that it is a response to emotional conflicts, short-term psychotherapy is usually indicated. A major aim of this approach is to help the patient accept his “dependency longings,” that is, his need for regular opportunities to let down and be cared for by others.Illustrative Case: PEPTIC ULCER The patient was the fourth of five boys. His father was an unsuccessful farmer whom the patient had disliked from an early age on and never respected. His mother, to whom he felt much closer, was nervous, frail, and had numerous bodily complaints which the family physician regarded as 90 per cent emotional. Nevertheless, she criticized and dominated her husband and nagged her sons into striving for the success that their father had never achieved.Poverty and a small physical stature contributed to making the patient feel inferior to other children, but he compensated by striving for academic achievement. He w^s very intelligent and although he worked in a store during noon hours, after school, and on Saturdays he was at the top of his classes. He completed college and two years of law school in evening classes. In World War II he rose from private to captain. At the age of twenty-four he married and subsequently became the father of three children.He was as ambitious and hard-driving in his career as he had been in school and in the Army. He began to work for a large company at the age of twenty-one and over the ensuing twenty-five years rose to a senior executive position. He felt personally responsible for much of the company’s growth and expansion. He was away from home traveling on company business a great deal, worked evenings and weekends, ate irregularly, and for fifteen years never took a vacation with his family. But after reaching a high position he began to feel that his talents—which were considerable but which he undoubtedly overvalued—and his dedication were neither appreciated nor adequately rewarded. His future seemed bleak, with little opportunity for future advancement financially or in prestige. Every morning he felt sick over the prospect of another day’s exhausting demands and inadequate rewards. However, he did not express his feelings of frustration and resentment while at work but became increasingly irritable at home. He also began to drink and smoke very heavily. At this point he developed stomach ulcers. Sedative medication reduced his pain but he continued to drink and became increasingly depressed. An added blow occurred when his eldest daughter married after graduation from high school instead of going on to college; his heart had been set on seeing all his children obtain college degrees. He became extremely unreliable on the job, often failing to keep business appointments, and finally was dropped by the company for alcoholism and unreliability.Shortly thereafter he was referred for psychiatric treatment. He was angry, tense, tremulous, and depressed. As a consequence of losing his position, he was confronted with the necessity of re-evaluating his goals and patterns of behavior. He was treated in psychotherapy and by minor tranquilizers and his tension and depression diminished. Being an intelligent man, he was able to acquire insight rapidly; his compulsive ambition decreased, he cut down on smoking and drinking, and his ulcer symptoms receded. He took a less demanding position with another company and during a two-year follow-up period there was no recurrence of the ulcers and alcoholism. (Rosen and Gregory, 1965)