Psychological Stress and Peptic Ulcer

November 25, 2014

Psychological Stress and Peptic Ulcer

  1. David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)

Population-based data show a positive association and warrant further evaluation.

  1. David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)

For decades, psychological stress has been thought to play a role in the development of peptic ulcers, but supporting data are scarce.

In a prospective, population-based study in Denmark, investigators collected blood samples and psychological (stress scale of 0–10), medical, and socioeconomic data from 3379 Danish residents without prior peptic ulcers at baseline (1982–1983). During 12 years of follow-up, based on participant interviews and hospital discharge data, 76 patients developed peptic ulcers.

Patients in the highest tertile of stress scores were more likely to develop ulcers than those in the lowest tertile (3.5% vs. 1.6%, adjusted odds ratio, 2.2; 95% confidence interval, 1.2–3.9). A one-point increase in the stress score increased the ulcer risk by 19% (OR, 1.19; 95% CI, 1.09–1.31). This was unaffected by Helicobacter pylori status. Adjusting for socioeconomic status decreased the OR to 1.17, and adjusting for smoking, use of nonsteroidal anti-inflammatory drugs (NSAIDs) and lack of exercise further decreased it to 1.11. In a multivariate model, the stress score, socioeconomic status, smoking, H. pylori infection, and NSAID use were independent predictors of ulcer risk.


This intriguing study has several limitations. First, asymptomatic ulcers and those diagnosed outside of a hospital were missed, resulting in a lower incidence than suggested in other studies. Nearly 1000 participants had been lost by the final interviews in 1993 and 1994. Also, the study took place during a time of rapidly evolving treatment for peptic ulcers, including H. pylori, histamine-2 receptor antagonists, and proton-pump inhibitors, which may have been given empirically to patients with symptoms. Despite these possible confounders, the finding of stress as an independent risk for peptic ulcers warrants further evaluation for validation and explanation.

Editor Disclosures at Time of Publication

  • Disclosures for David J. Bjorkman, MD, MSPH (HSA), SM (Epid.) at time of publication Leadership positions in professional societies World Gastroenterology Organization (Treasurer)


Reader Comments (3)

Susan Levenstein, MD Physician, Internal Medicine, Rome, Italy

My coauthors and I appreciate the interest from Journal Watch and its readers. Dr. Bjorkman is right to emphasize the potential of empirical treatment for confounding the association between stress and ulcer, but this is actually a strength of our study period: even by the time of follow-up, H2-blockers and proton pump inhibitors were being used in our cohort almost exclusively (99.5%) for documented ulcers, not empirically for dyspepsia. Also, to clarify, by far most ulcers diagnosed outside a hospital were in fact detected – we missed a symptomatic ulcer only if the patient specifically denied the diagnosis on subsequent interview. To answer Dr. Kolev, our data did not include personality measures, though the "mental vulnerability" construct has some trait characteristics; alcohol consumption was examined but was not associated with ulcer. The distinguished Peter Down knows of what he speaks, but unfortunately without access to his book we’re in the dark about the Asher reference.

Kolyu Kolev Resident, Family Medicine/General Practice, UK

The notion that stress affects the stomach appears confirmed by this study. However, it would be good to add other factors that mitigate the effects of stress (type of personality, hobbies, family environment) to the assessment of the overall stress before drawing conclusions. Beside this, stress is a dynamic process which can be worse at times and not present at all at others. Finally, it is not clear whether any other co-morbidities and alcohol were part of the evaluation process.

Peter Down Physician, Gastroenterology, Dorchester UK

A long standing controversy, reminding me of the late Dr Richard Asher's story (see pp 91-93, A history of Luminal Gastroenterology in Britain..The Inside Guide)

Your Comment

(will not be published)

Filtered HTML

  • Allowed HTML tags: <a> <em> <strong> <cite> <blockquote> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Do you have any conflict of interest to disclose?
This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

* Required

Reader comments are intended to encourage lively discussion of clinical topics with your peers in the medical community. We ask that you keep your remarks to a reasonable length, and we reserve the right to withhold publication of remarks that do not meet this standard.

PRIVACY: We will not use your email address, submitted for a comment, for any other purpose nor sell, rent, or share your e-mail address with any third parties. Please see our Privacy Policy.