Emotional antecedents of bleeding from peptic ulcer.

Since the publication more than thirty years ago by Alexander and his co-workers [ 11 of their psychosomatic studies of patients with peptic ulcers, numerous reports have appeared on various aspects of the subject. Hemorrhage, a common complication of peptic ulcer, has evoked surprisingly little attention, however, and it has never been singled out for special consideration. The attention of one of the authors (M.H.H.) was directed to the part possibly played by an emotional crisis in precipitating bleeding from a peptic ulcer in two patients, seen for teaching purposes, whose histories will be presented later. On the basis of these two instances and case notes in the literature, the following hypothesis is suggested: A disturbing experience, arousing intense feelings and creating a situation which seemed insoluble, might be a precipitating stress in producing hemorrhage from a peptic ulcer. “Disturbing experience” refers to a conscious conflict. It does not depend on unconscious reverberations, although, to be sure, these also may be involved. The lapse of time between the disturbing experience and the bleeding usually is no more than 48 to 72 hours, and often is considerably less. In interviewing thirteen patients with acute bleeding episodes, we found five additional instances in which bleeding followed an emotional crisis and a sixth in which the connection was equivocal. Although no claim can be made that an emotional crisis regularly precedes bleeding, the relationship between the two is so striking in the cases we will describe that it seems unlikely that it is purely coincidental. On the basis of our experience, we believe that in each instance of bleeding a possible connection should be sought and explored by the clinician. All patients for this study were drawn from the ward or private services of medical center teaching hospitals and were interviewed two or three times. Participation was voluntary; three patients refused to take part. All interviews were tape recorded. A review of the pertinent literature will precede the presentation of case histories and comments on our findings.