Recent Separation and the Onset of Peptic Ulcer Disease in Older Children and Adolescents

SIGURD H. ACKERMAN, MD, SCOTT MANAKER, BA, AND MICHAEL I. COHEN, MD The onset of peptic ulcer disease in adolescents often appears to be preceded 1 > y a separation or loss. We attempted to review data on, or to recontact, the 59 adolescent aid preadolescent patients with peptic ulcer disease (gastric ulcer, duodenal ulcer, and hemater lesis of unknown etiology) admitted to Montefiore Hospital and Medical Center between 1968 JU id 1979. We were able to obtain adequate retrospective data for 24 of these patients. Ten (42 %) h ad encountered a separation or loss within 12 months of the onset of their illness. In 6 patients the event occurred within 4 weeks of admission. In a matched group of 24 appendectomy patinnts, 1 separation occurred in the 12 months prior to admission (X2=9.6; p <0.01). We cor elude that in an adolescent population, a recent separation or loss may be associated with tl e onset of peptic ulcer disease in predisposed persons.

Peptic ulcer disease is a heterogeneous group of disorders of uncertain pathogenesis (1). Studies of peptic ulcer disease in adults have indicated that emotional factors or life circumstances may affect the occurrence of some forms of these disorders (2). For example, Weiner et al. (3) found that, among men at risk for duodenal ulcer disease, induction into the army and the rigors of basic training appeared to be a setting for the occurrence of the disease in a significant number of them. However, the role of emotional factors

Presented in part before the Annual Research Meeting of the Society for Adolescent Medicine, Detroit, Michigan, October 1980. From the Department of Psychiatry and Division of Adolescent Medicine, Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Hospital and Medical Center, Bronx, New York 10467. Address requests for reprints to: Sigurd H. Ackerman, M.D., Albert Einstein College of Medicine, at Montefiore Hospital and Medical Center, 111 East 210th Street, Bronx, NY 10467. Received for publication May 14, 1980; final revision received April 6, 1981.

in the occurrence of peptic ulcer disease in children and adolescents has not been systematically examined. In the only other study we are aware of, Christodoulou et al. (4) evalmted 25 Greek children between the ages c f 6 and 16; all with radiologically confirmed duodenal ulcer. Patients were compared with well school children matched for age, sex, and socioeconomic status. The data are presented ambiguously, bv t at least 5 patients and probably as many as 8 of the 25 patients (32%) experienced either a death or a physical separation from a family member just prior to th s diagnosis of their disease. A loss occurred to only 1 of 25 control children during a 32-month observation period. A recent separation or loss within the family also appeared to be a frequent feature of the histories of older children and adolescents admitted to our Division of Adolescent Medicine with acute upper gastrointestinal bleeding.1 Patients on whom th is observation was made included those with duodenal ulcer (DU), gastric ulcer (GU , and hematemesis
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Copyright 1981 by Ihe American Psychosomatic Society, Inc. Published by Elsevier North Holland, Inc. 52 Vanderbilt Ave., New York, NY 10017

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S.H. ACKERMAN et al. of unknown etiology (H). The diagnoses of DU and GU were established radiologically and/or endoscopically. We evaluated the association between separation or loss and the onset of peptic ulcer disease by retrospectively comparing patients admitted for peptic ulcer disease with patients admitted with symptoms of acute appendicitis. Patients with appendicitis were selected as a control group because they represented a population with an acute abdominal disorder but one not thought to be associated with recent loss. The inherent limitations of a retrospective analysis, including poor patient recall, should decrease the chance that the index group would differ from the control group. However, if the results of this conservative but relatively easy test of the original observation should support it, a more extensive prospective study would be justified.
TABLE 1. Questionnaire on Recent Losses We are interested in your recollection of the 12-month period prior to (admission date) 1. How many family members were living with you? (List by relationship). 1. 7. 2. 8. 3. 9. 4. 10. 5. 11. 6. 12. 2 Did anyone move out of your household because of: a) a new job b) schooling c) marriage d) divorce e) retirement f) other Were there any serious illnesses (if so, specify): a) within your family b) among people who were very close to you

3.

4. Were there any deaths (if so, specify): a) within your family b) among people who were very close to you

METHODS Fifty-nine older children and adolescents with peptic ulcer disease, 720 years of age, were hospitalized between 1968 and 1979. These patients were matched with a group of 103 appendicitis patients for age at admission, years of admission, and sex. Information was not available retrospectively to match groups for ethnic and socioeconomic background, but patients came from similar local neighborhoods surrounding the hospital. Data on patients from both groups were gathered only after approval of the hospital Committee on Research on Human Subjects. For each patient we tried to ascertain the presence or absence of a separation or loss in the 12 months prior to admission. Table 1 shows the data that were sought from both subjects with peptic ulcer disease and acute appendicitis. We expected that we would be unable to locate many of these former patients for follow-up interviews. Therefore, we tried to obtain data on separations and losses from all available sources of information. The sources of information about patients with peptic ulcer disease included hospital records, tape-recorded admission interviews of 6 patients (see footnote 1), and follow-up questionnaires for those patients who could be located. Initially, all hospital records were carefully reviewed. If there was specific reference in the records to a recent loss, e.g., a close friend died 1 week prior to admission, we accepted this information. If there was no specific mention of either the presence or absence of loss we disregarded the record and tried to contact the patient or the patient's family by telephone. When this proved unsuccessful, we attempted to reach the index group member or family by mail. In addition, tape-recorded admission interviews of 6 patients were available for analysis. Regardless of the source, information was elicited according to the structured outline shown in Table 1.

'This clinical observation was initially made in 1968 by Dr. Sheila Weinberg, who died before she was able to pursue it. The present report is based in part on her original observations. We were able to review tape-recorded interviews made by her at the time of admission of 6 patients included in this study. 306

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LOSS AND PEPTIC ULCER

RESULTS We were able to obtain information adequate for analysis on 24 of 59 patients with peptic ulcer disease (Table 2). They ranged in age from 7 to 20 (median, 15). Thirteen patients had DU, 3 patients had GU, and 8 patients had H. Of these 24 study patients, 10 (42%) experienced a separation or loss in the 12 months prior to admission. Four of these patients experienced a death; the other 6 patients were separated from a close family member. In one case, an older brother left the home to join the army. One patient became ill after being sent away from her mother. One patient became ill when her grandfather, who lived in the household, was hospitalized for a nephrectomy. And one patient became ill while her father was hospitalized for a second myocardial infarction. Especially noteworthy is that, in 6 of the 10 patients, the loss or separation occurred within 1 month prior to the patient's admission. By diagnostic category, losses occurred prior to admission in 6 of 13 patients with DU, in 2 of 3 patients with GU, and in 2 of 8 patients with H. Loss preceding admission was significantly more common in females (8/12) than in males (2/12) (X2 = 5.66; df = 1; p <0.05). The reason for this apparent sex difference is not known. The history of one patient revealed no recent loss (patient 16, Table 2) but is nonetheless noteworthy. This 18-year-old adolescent had recently become the father of an illegitimate son. He was being pressured into marriage by both the child's mother and his own mother. He resented having to take on the responsibilities of marriage and parenthood but was afraid to refuse. As he was leaning toward a decision not to marry and to run away to South America, he was hospitalized be-

cause of hematemesis. A duodenal ulcer was confirmed radiogically. He believed that his hospitalization "saved me from getting married." Review of the hospital records of the 103 patients undergoing appendectomy revealed no mention of losses or separations. We therefore made telephone calls to members of this group, in random order, until we obtained questionnaire data on 24. Of these 24 patients, only 1 (4%) had encountered a loss or separation in the 12 months prior to admission. The difference between the incidence of these events in the peptic ulcer disease group and in_the appendicitis group was significant (X2=9.6; p <.01). The two groups did not differ statistically in age at the time of admission, calendar year of admission, or sex ratio.

DISCUSSION The results of this retrospective study suggest that a recent personal loss or separation may be a setting in which peptic ulcer disease is likely to occur. However, one should be cautious in interpreting these results. The sources and quality of information were not the same for the peptic ulcer disease and appendectomy groups. A social history obtained at the time of admission and noted in the medical record is likely to be much more extensive for patients with peptic ulcer disease than for patients with appendicitis. In addition, the tape-recorded interviews available for 6 of the peptic ulcer disease patient were, in part, directed toward a history of recent loss or separation (although only 2 of the 6 tapes were scored as positive for these events). By contrast, for the 24 patients with appendicitis, all data relating to losses or separa307

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TABLE 2. Information on Individual Peptic Ulcer Disease Patients

Patient

Age at Admission SeparationfLoss Parents separated 10-11 months PTA ~randfathkr (in household) hospitalized for nephrectomy just PTA None Father died 2-3 months PTA Close friend died 1 week PTA Uncle died 1 week PTA Parents separated 6 months PTA Brother left home for army several months PTA Mother hospitalized for month PTA; infant sibling died 1 week PTA None None None None None None None Father hospitalized for second myocardial infarction 3 weeks PTA Sent away from mother for 10 months PTA; two brothers disappeared 3 weeks PTA None None None None None None

Sex F

12

Source of Diagnosis Information GU Hospital chart ~ele~hone Telephone Telephone Hospital chart Hospital chart Hospital chart Telephone Tape Telephone Telephone Telephone Letter Letter Telephone Tape Hospital chart Tape Telephone Telephone Tape Tape Tape Telephone
=

hematemesis;

CU = gastric ulcer; DU =duodenal ulcer; H

&

PTA

prior to admission.

LOSS AND PEPTIC ULCER

tion were obtained by telephone interview at the time of the study. Nevertheless, we believe that these data warrant the tentative interpretation that a recent loss or separation may, in fact, be a setting in which peptic ulcer disease is likely to occur in adolescents. Loss or separation is not likely to have specific relevance to peptic ulcer disease, except as a setting in which these diseases may manifest themselves in persons at risk. Indeed, loss has been reported to affect the timing of the onset of carcinoma of the breast (5), hematoproliferative disorders (6), infectious diseases (7), hyperthyroidism (8), and ulcerative colitis (9). In a systematic comparison of children with insulin-dependent diabetes and nondiabetic matched control children, Leaverton et al. (11) report a significantly increased incidence of parental loss among the diabetic children. In this study, the authors included loss or continued absence of one or both parents, through separation, divorce, or death, up to 10 years prior to the clinical manifestation of the disease. Because of such diverse reports, some authors have suggested that there may be a general relationship between loss and disease onset (11, 12]. Other studies indicate that any emotionally important life REFERENCES

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