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This is to certify that the
thesis entitled
An mnerimentcl Test of Two Alternative Hypotheses
Concerning Peptic Ulcer Etiology

presented by

 

Jae ob O. Sines

has been accepted towards fulfillment
of the requirements for

P213). Psychology

degree in

Major professor

Date M m fifl"

AN EXPERINENTAL TEST OF TWO ALTERKATIVE HYPOTHESES
CONCERNING PEPTIC ULCER ETIOLOGY

by

JACOB o; SINES

A THESIS
Submitted to the School of Graduate Studies of Michigan
State College of Agriculture and Applied Science

in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSCPHY

Department of Psychology
1955

ABSTRACT

On the basis of a review of the literature concern-
ing the role and the nature of the psychogenic factor in
the etiology of peptic ulcer, two alternative hypotheses
were selected to be put to an experimental test. The
hypotheses were: (1) the Alexander and French formula-
tion that an unresolved conflict concerning passive-
dependent needs was the anxiety producing conflict in
persons with peptic ulcer, and (2) the formulation pre-
sented by Mahl that the anxiety which leads to the gastric
hyperactivity necessary for peptic ulcer formation need
not result from a conflict concerning passive-dependency
needs alone. Rather, any stressful situation might serve
to activate the autonomic nervous system and thus start
the physiological chain of events which eventuates in
peptic ulcer.

In order to test these hypotheses, three so-called
"crucial" pictures and a fourth, a neutral picture, were
employed. The crucial pictures were called "Hostile",
"Passive", and "Sexual" depending upon the group from
which they evoked the greatest number of increased auto-
nomically mediated physiological responses. The neutral
stimulus provided the "basal" level of autonomic activity
from which changes were calculated. There were three
groups of patients in the validation study, all of whom
had been carefully interviewed and tested by an advanced

pre-doctoral clinical psychology student or a staff

clinical psychologist in a large Veterans Administration
hospital. One group of patients (N of 8) was considered
by the supervising staff clinical psycholOgist to be pri-
marily conflicted concerning the expression or control of
hostile-aggressive impulses, another group (N of 7) ex-
hibiting anxiety primarily as a result of conflicts over
the expression of passive-dependent needs, and a third
group (N of 5) who seemed to have as the basis of their
anxiety, conflicts over the expression or inhibition of
sexual impulses. It was found that when these three groups
of subjects were presented with the stimulus pictures at
least two of the three physiological systems measured by
the Keeler Polygraph were characterized by increased acti-
vity. The increases in autonomically mediated physio-
logical activity in each group tended to occur with
greater than chance frequency following presentation of
the stimulus picture which was selected for its relation-
ship to the conflict hypothesized for each group.

These pictures were then presented to the peptic
ulcer and control groups. There were 24 subjects in each
group. When the proportion of increased physiological re-
sponses made by the peptic ulcer group following the pre-
sentation of the "Passive" stimulus was compared to the
proportion of such responses made by an appropriate con-
trol group, there were no significant differences.

This was interpreted as supporting the position taken

by Mahl and refuting the Alexander and French hypothesis.
A re-statement of Mahl's "generality" theory con-
cerning the psychogenic factor in peptic ulcer etiology
was made on the basis of the results of the present
study as well as several others recently published. A
few general suggestions about continued research in the

area of psychosomatic disorders were offered.

ACKNOWLEDGEENT

The writer wishes to express his gratitude U)
the many people whose cooperation aided so much in the
completion of this research.

Special credit is due to Dr. G. M. Gilbert,
Chairman of my committee. He not only served to direct
and advise me at many specific points but by his atti-
tude and friendliness provided the generalized climate
which is necessary for productive work.

The other members of my committee have also
been helpful and considerate; they are, Dr. D. M. John-
son, Dr. Alfred Dietze, and Dr. Chester Lawson.

Dirk Gringhuis deserves special thanks for the
drawing which was used in this study as the "Hostile"
stimulus.

The Clinical Psychology Staff at the Dearborn
V. A. Hospital were most helpful in providing much of
the time and subjects for the research.

Finally, and very important, was the stabilizing
influence of my wife, Janice. Her modulating influence
accounts for much of what may be good in this disserta-

tion.

TABLE OF

Acknowledgment . .
List of Tables . .
Chapter I . . . . .

Introduction

Definition . .
Incidence . . .
Etiology . . .
Physiology of Ulce

Chapter II . . . .

r F

CONTENTS
Page
0 O O O O O O O 0 O O 11
O O O O O O O O O O C 1v
0 0 O O 0 O O 0 O O O 1
O O C O O O O I O O O O l
O O 0 O O O O O O O O O 1
O O O O O O O O O O O O 2
O O O O O O O O O O O O 3
ormation . . . . . . . 7

O O O O I O O O O O O 10

The Psychosomatic Approach . . . . . . . . 10
The Specificity Hypothesis . . . . . . . . 14
Anxiety or Generality Hypothesis . . . . . 20

Chapter III . . . .

The Present Study

General Considerations

The Main Study .
Subjects . . . .
Procedure . . . .
Statistical Analys
Chapter IV . . . .

Discussion . . .
Summary . . . .

Bibliography . . .
Appendix I . . . .
Appendix II . . . .

is

O O O O O O O O O O O 34

O O O O I 0 0 O O 0 O O 34
. . . . . . . . . . 55
. . . . . . . . . . . . 51
. . . . . . . . . . . . 51
O O O O O O O O O O O O 53
and Results . . . . . 5

TABLE OF CONTENTS

Page

ACKnOVI'led-gment . O O O O O O 0 O O O O O O O 11
List of Tables . . . . . . . . . . . . . . . iv
Chapter I O O O O O O O O O O O O O O O O O 1
Introduction . . . . . . . . . . . . . 1
Definition . . . . . . . . . . . . . 1
Ineldence O O O O O O O 0 O O O O O O O O 2
Et101ogy . O O O O O I O O O O O O 0 O O 3
Physiology of Ulcer Formation . . . . . . . 7

Chapter II C O O O O O 0 O O O O O 0 O O O 0 10
The Psychosomatic Approach . . . . . . . . 10
The Specificity Hypothesis . . . . . . . . l4
Anxiety or Generality Hypothesis . . . . . 20

Chapter III 0 O O O O O O O O O O O O O O O O 34

The Present Study . . . . . . . . . . . . . 54
General Considerations . . . . . . . . . . 55
The Main Study . . . . . . . . . . . . . . 51
Subjects . . . . . . . . . . . . . . . . . 51
Procedure . . . . . . . . . . . . . . . . . 55
Statistical Analysis and Results . . . . . 56

Chapter IV C O O O O O O 0 O O O O O O O O O 63

Discussion . . . . . . . . . . . . . . . . 65
summary 0 O O 0 O O O O 0 O O O O O O O O '71

Bibliography . . . . . . . . . . . . . . . . 75
Appendix I O O O O O O O O O O O O I O O O O 77
Appendix II . . . . . . . . . . . . . . . . . 85

Table

II

III

IV

VI

VII

VIII

LIST OF TABLES

Chi Square Analysis of Scoreable Responses in
Each System Following Presentation of the
"Hostile" Card to the "Hostile" and Non-
Hostile Groups.

Chi Square Analysis of the Scoreable Responses
in Each System Made by the "Passive" and Non-
Passive Groups following Presentation of the
Passive Stimulus.

Chi Square Analyses of the Scoreable Responses
in Each System Occurring in the "Sexual" and
Non-sexual Conflict Subjects Following Present—
ation of the "Sexual" Picture.

Frequency of "Predicted" and "Other" Scores at
First and Second Test Sessions.

Control Group; Diagnostic Categories and
Number of Subjects in Each.

Means and Standard Deviations of Age, Education
and Vocabulary Level for the Experimental and
Control Groups.

Frequencies of Scoreable Responses in Each
System Which Followed Presentation of the
“Passive" Stimulus to the Ulcer and Control
Groups.

Frequency of Scoreable Responses Which Followed
Presentation of the "Hostile" Card to the Ulcer
and Control Groups.

Chi Square Analysis, by Separate Physiological
System, of the Frequency with Which Scoreable
Responses in the Peptic Ulcer and Control Group
Followed Presentation of the "Sexual" Stimulus.

Page

44

46

48

52

53

58

60

s
61

CHAPTER I

INTRODUCTION

That there is widespread interest in peptic ulcer
is well demonstrated by the amount of literature Which
has appeared on this subject. The bibliography of a re-
cent review (24) included over 500 references. In spite
of this apparently intense study of peptic ulcer, the
body of verified fact and accepted theory is quite small.

DEFINITION

The difficulties one encounters begin immediately
with.the definition of "ulcer“. While there are several
good ones, of varying degrees of completeness, the defi-
nition which seems most adequate is that given by Ivy,
Grossman, and Bachrach (21). According to them, peptic
ulcer is defined as "a circumscribed defect of the
mucosa of the stomach, duodenum, or jejunum.only when
the defect extends through the muscularis mucosae.

Only then is the continuity of the mucosa lost completely
and on healing does a scar result." Ulcer is differ-
entiated from."erosion" which is the term applied to an
area of the stomach, duodenum, or jejunum from which

the mucus coat is removed, allowing the gastric juices

to come in contact with.the mucus membrane. This letter
is necessarily preliminary to the ulcer; but for the

sake of clarity, it is differentiated by many.

- 2 -

The term "peptic ulcer" was introduced for the
first time in 1882 as both a generic term and also with
definite implications concerning the causative agent.
As a generic term it grouped those ulcers which are
found in the regions exposed to gastric juices. Eti-
ologically, it implies that these ulcers are caused
by the peptic activity of the gastric juices.

The use of this term, "peptic ulcer," followed
upon several discoveries; one in 1692 that the gastric
contents were acid; another in 1822 that this demon-
strated acidity was due to hydrochloric acid (H01);
and the determination of an enzyme, pepsin, in 1856
which was shown to be necessary in order for the diges-
tive action of H01 to take place.

1852 was the earliest reported date (21), at which
any writer attributed the ulcer to the corrosive action
of the gastric juices and turned the attention to ex-

cessive secretion of H01.
INCIDENCE

There has been within the last 50 or 60 years, a
radical change in the relative frequency of peptic
ulcer in men as compared withuwomen. In the period
before 1890 or 1900, the ratio of men to women who had

peptic ulcer was 1 male to 5 to 5 females, depending

- 3 -

upon the investigator reporting (21). By 1940, the
rates of incidence had been completely reversed. There
were by that time about 5 or 6 men to 1 woman with
peptic ulcer. There are no completely adequate explana-
tions of this phenomenon.

Rowntree (56) found on inspection of 15 million
Selective Service registrants that nearly 8% either
had peptic ulcer at the time of their medical examina-
tion or presented a history of it. This compares favor-
ably with the reported incidence of 10% in the general
population. Nine and four-tenths per cent of the white
registrants were in this group, while only 2.5% of the
Negro registrants were. An explanation and discussion
of this racial difference will be presented in the next
section. The same investigators (21,56) agreed in
their findings that the age of onset of duodenal ulcer
was in the decade from 51 to 40 years, and gastric
ulcer occurred most frequently in the decade from.41
to 50 years. These were the ranges of highest incidence
as well as the "average age of onset" range and are not

meant to obscure the large variability in age of onset.
ETIOLOGY

Sandweiss (57) has edited a volume in Which var-
ious past and present theories on the etiology of peptic

ulcer are discussed. Most of them have been presented

- 4 -

as "the cause“ of ulcer formation at one time or another.

Dunbar (14) also deals with some of the following material

at length.

(1)

(2)

(3)

(4)

(5)

Traumatic factors--It was felt that physical
damage to the mucus lining of the stomach or
duodenum which exposed it to the digestive
action of the gastric juices would neces-
sarily result in ulcer formation. It has
since been shown that it is a commonplace
thing for there to be occasional erosions

of the gastric mucosa which heal immediately
(within hours).

Vascular factors--Spasmodic contraction of
the'blood vessels of the stomach lining were
held to be the cause of the breakdown of the
resistance to the gastric juices. These have
been shown to be fundamental to the physical
trauma mentioned above and therefore inade-
quate as "the cause."

 

Mucus failure--The mere failure of mucus to
cover the mucus membrane is not in itself
sufficient to result in ulcer but is now
considered to be an important process in the
course of ulcer development.

CNS damage or disease--There have been re-
peated studies quoted in Sandweiss (57)
which attempt to find in specific CNS damage
the etiologic factor for ulcer. The fact
that the results of such investigations

have not been consistent and have 222 found
any particular loci in which.damage will re-
sult in ulcer formation has led present in-
vestigators to relegate it to a less than
essential position in their explanations.

Allergic reactions-hToxic factors and upper
respiratory diseases have all been shown at
some time to be related to incidence or re-
currence of peptic ulcer. Their influence
is so variable and the success in isolating
this influence has been so meagre that these
factors, too, are now considered not to be
central to the problem.

(6)

('7)

(8)

-5-

Hereditary factors--There have been striking

 

examples of;mu1tiple incidence of ulcer in
several generations of some families. It has
been suggested (56) that there is a greater
probability of finding etiologic factors in
the environmental and emotional stress
patterns characteristic of certain families
than there is in finding hereditarily trans-
mitted characteristics.

Seasonal incidence--Severa1 writers (21,57)

 

have reported a differential incidence of
peptic ulcer for various seasons of the year.
Ivy, et al., (21) compare figures for the
Northern and Southern hemispheres and find
there a clear rise in rate of ulcer detec-
tion as well as fatalities during the cold
months. In this latter study (21) the in-
cidence in the Northern hemisphere is, in
agreement with others, seen to fall sharply
during the months of May, June, July, and
August while in the Southern hemisphere the
incidence during those months is at its peak.
This has been variously interpreted as due
to some factor intrincis in the weather, or
due to physiolOgical change in the individual
related possibly to upper respiratory system
infections in the winter, but the most re-
alistic verifiable view is that during the
cold season there are more and greater
stresses put on the individual to achieve,
accomplish, and to survive. Conversely,
during the warmer months less effort is re-
quired to maintain oneself with a resultant
relative relaxation.

Constitutional factors-bEven though this

 

area is relatedito hereditary influences, its
consideration as an etiologic factor in and
of itself is necessary as a result of the
importance given it by some writers (11,45).
These investigators seem to agree that it is
the aesthetic, longitudinal type of person
who most likely succumbs to peptic ulcer.
Ivy, et al., (21) discuss the only study
which to their knowledge was designed ex-
pressly to test the constitutional hypothesis.
They conclude that body build is not related
to ulcer incidence.

(9)

(10)

(11)

_ 5 _

Racial factors-hThe highly significant differ-
ential incidence of peptic ulcer in Negroes
and whites mentioned earlier (56) has been
the subject of considerable theorizing and
some investigation. Ivy (21) described the
results of several studies, original sources
not available, which deal with this question.
For some time, it was generally held that
peptic ulcer was a characteristic disease of
western competitive society as it affected
the white man. It seems that the Negro
sample on which preliminary conclusions were
drawn was southern and rural, with the re-
sult that ulcers were infrequently observed.
Chinese were found to have a very low in-
cidence in several groups observed in China.
In the light of later reports, it has been
shown that when Negroes or Chinese are found
in situations which approximate the competi-
tive conditions under which whites so often
function, the incidence of ulcer is essenh
tially the same for all groups. It is even
stated that Westerners who have lived in
China and who are relatively well assimilated
into that culture show a significantly lower
incidence of ulcer, resembling more closely
the rate of Chinese in China than whites in
Western.countries.

Tobacco--A1though smoking is known to be
positively related to difficulty in medical ,
management of ulcers, there have been studies
(21) which found no difference between the
effects of smoking regular cigarettes and
de-nicotinized cigarettes. Two possible
explanations for this finding present theme
selves; one, there are other materials in

the tobacco besides nicotine which have in-
cremental effects upon gastric acid secre-
tion; or, it may be a verification of the
orality of ulcer patients which is postu-
lated by Alexander and French, to be dis-
cussed at length later.

Alcohol and coffee-~The effects of these two
tfixic substances on ulcer control are con-
sistently negative, but are not now considered
to be important enough to bring about ulcer
formation unless they are in combination with
other factors.

PHYSIOLOGY OF ULCER FORMATION

Sullivan and McKell (40) explain the formation of
peptic ulcer as occurring "by spasmodic contraction of
the musculature, possibly supplemented by accompanying
local spasms of the terminal blood vessels, small areas
of ischemia or hemorrhagic infarction are produced,
leaving the overlying stomach.mucosa exposed to the
digestive effects of its own hyperacid juices." The
usual mucosal coating of the stomach is resistant to
the digestive forces of the gastric juice. Since the
duodenal cap is less protected in this manner the
greater incidence of duodenal ulcer may thus be accounted
for.

Ivy, Grossman, and Bachrach (21) present a des-
cription which divides the ulcer development into three
stages.

(1) Engorgement of the gastric mucosa, hyper-

acidity of gastric juices, hypermotility of

the stomach and duodenum.

(2) Minute erosions and mucosal hemorrhages re-
sulting from even the most trifling trauma.

(5) Gastric juices digest the exposed mucus memp
brane, and this contact in turn stimulates
greater acid secretion.

As can be seen from.these essentially identical

explanations, the present trend is to incorporate as

minor steps, many of the erstwhile "causative" factors

-8'...

listed above. Conclusions based upon various experi-
ments with sham feeding in dogs, histamine injection,
or the direct introduction of pepsin acid into the stomp
ach have led to the belief that hyper-acidity alone
cannot destroy the vitality and digestion-resistance
of the mucosa. There had to be some factor to account
for the sloughing of the mucus coat. When it was found
that with the introduction of acid solutions, equal to
the maximum strength possible for natural gastric juices,
the resulting ulcers, when they occurred, were typical,
circumscribed areas rather than diffuse general weaken-
ing of the mucosal wall, it was postulated that the
"minute erosions" mentioned above were frequently the
result of the normal and intensified muscular spasms
of the walls and the blood vessels-Ethis was the addi-
tional "locus minaris resistentiae" needed (21).

While the above view of the formation of ulcer is
restricted to physiological terms, it does not share
the shortcomings of former "theories" in that it does
not claim there to be “a cause“ even on this physio-
logical level. It is a description of the steps in
peptic ulcer develOpment rather than an attempt to
attribute causative importance to any one factor. Even
though it does not specifically take each of the factors
listed earlier into account, it is not too difficult to

see how most of them fit into the scheme of things.

_ 9 -

Although the physiological mechanisms are now fairly
reliably estimated, the antecedent conditions are a
source of confusion. Some of the factors mentioned
earlier are of the nature of a "first cause" in a
restricted sense, but those Which presume to fulfill
this function have been pretty uniformly negated.

CHAPTER II
THE PSYCHOSOMATIC APPROACH

The psychosomatic approach to peptic ulcer, that
is, concerted interest in a psychogenic basis for the
physiological mechanisms leading to peptic ulcer devel-
opment, is very recent. The importance of “anxiety",
however, was mentioned comparatively early in the history
of the study of peptic ulcer. Brinton, in a treatise
written in 1857 (45) entitled "0n the Pathology, Symp-
toms, and Treatment of Ulcers of the Stomach," stated
that "Mental anxiety so frequently coincides with ulcer
that we are fully entitled to regard it as a more or
less immediate cause." There were no attempts to evalu—
ate this statement, nor was the emotional causative
aspect even mentioned again for a full 60 years. At
the end of this period, in 1918, Kaufman (45) “recog-
nized that psychic influences such as emotional display,
nervous shock, and unduly prolonged or intense mental
strain," play an important role in ulcer development.

Even as late as 1929, most authors relegated the
psychological aspects to an unimportant position in
the grouping of etiological factors. In that year,
Stewart wrote a 500—page treatise on the peptic ulcer
problem and devoted only three sentences in passing to
psychological factors. Since the 1950's, however, and

increasingly at the present time, writers on peptic

-11...

ulcer are turning their attention to the emotions in
search of a complete explanation.

Weiss and English (45) state very simply the
agreed-upon feeling of most workers in this field when
they say, "The gastro-intestinal tract, is above all
other systems, the pathway through which emotions are
often expressed in behavior." It is felt that, "constant
unconscious (emotional) stimulation results in the pro-
longed gastric stimulation“ described earlier as the
first stage in ulcer production.

Cantor (10), in his recent handbook, states that
“we may thus summarize laboratory and clinical findings
by stating that a gastro-duodenal ulcer is the result
of emotional disturbances acting through the autonomic
nervous system to produce altered motor and secretory
functions in the gastro-duodenal region." Other factors
are also important, however, as recognized by Cantor
when he states that, "not all ulcers are emotionally
conditioned.“ In this latter respect, one might state
safely, however, that in the majority of the verified
peptic ulcer cases, the presence of a pathological
physiological condition sufficiently severe to account
by itself for the development of the ulcer is rarely
found. It is, on the other hand, quite obvious in

most cases of peptic ulcer, that there are psycholOgical

-12;

and emotional factors which appear to be sufficiently
serious to initiate and sustain the autonomic responses
necessary for peptic ulcer development.

Ivy, Grossman, and Bachrach (21) have reviewed
most of the existing psychosomatic formulations of ulcer
formation and have stated Alexander's (1) three basic
assumptions as being characteristic of all such theoa
ries. These three basic premises are (1) There is a
characteristic personality pattern 23 conflict situa-
tion; (2) This emotional status is accompanied by
hypersecretion and hypermotility of the stomach or
some other change in the stomach or duodenum; and (5)
Hyperactivity or some other functional alteration of
the stomach leads to peptic ulcer.

In general, it is possible to subdivide the
present-day theories concerning the importance of
psychological factors in peptic ulcer etiology into
two groups. Both grant that anxiety is the necessary
condition for gastric hyperfunction, but differ in raw
gard to what they consider produces the anxiety. The
first has been referred to by Mahl (29) as the "Speci-
ficity Hypothesis." It states that there is a specific
conflict situation which eventuates in sufficient
anxiety to innervate the autonomic nervous system
enough to account for the necessary gastric hyperacti-

Vityo

_ 15 -

The second theoretical approach.to the psychoso-
matic factor in peptic ulcer has been called the "Gener-
ality or Anxiety Hypothesis“ (29). This point of View
denies that any circumscribed psychological conflict
situation is the fundamental agent in producing the
anxiety. In contrast, it holds that the anxiety may be
present, to be sure, but that it results from general
circumstances to which the individual is incapable of
adequately adjusting himself, and which are sufficiently
threatening to him to produce the anxiety necessary for
the above-mentioned autonomic innervation.

Although Mahl seems to have been the first writer
to present this point of view in relation to a specific
syndrome, Gilbert (18) has discussed this general
approach under the name of "The Psycho-Social approach"
to personality dynamics. It is in this genera1.frwne
of reference that he emphasizes the fact that there is
no necessary relationship between the nature of an
existing conflict within a personality and the type of
symptom, psychological or psychosomatic, which.may re-
sult. With these general introductory commants we will
now proceed to a more detailed consideration of the
problem at hand.

The following<discussion will be divided into

two parts; the first will.be a consideration of the

'..14..

specificity hypothesis and some of the studies published
which bear on it; and the second, a section which deals
with'the.generality'hypothesis and studies which have
been published and contribute to the evidence for this

latter position.
THE SPECIFICITY HYPOTHESIS

The outstanding proponents of the specificity
hypothesis are Alexander and French and their co-workers
(l,2,3,4). These authors have discussed several types
of persons, differentiated primarily on the basis of
the symptom.picture they present. One of the major
types thus arrived at is called by them "the gastric
type". These patients, in addition to presenting a
reasonably common symptom, that is, gastric distress
and/orpeptic ulcer, were found to have similar con-
flict situations significantly observable in their
personality structure. There was not, however, any
determinable environmental source for these conflicts.

The conflict situation was one in which there
were strong repressed wishes to be cared for and loved.
In a word, oral receptive. The repressive forces orig-
,1nated in the ego which found the parasitic strivings
incompatible with its own strivings for independence

and activity.

- 15 _

The discussion presented by Alexander and French
(3) will be loosely followed, and we will paraphrase
freely. Those authors feel that the prototypical symp
bol of being loved is being fed, that is, receiving love
is equivalent to receiving food. The repressed longings
for love or food mobilize the innervations of the stomp
ach, and these innervations serve as a chronic stimulus
for the stomach hyperafunction which lead to its dis-
function. They become the conditioned stimulus for
gastric secretion. As they state, "the stomach behaves
as if it were about to receive food whenever the strong
oral dependent drives are stimulated” by a frustrating
situation. "Food, then, becomes a symbol of help."

The behavior of the stomach in preparing itself for the
entrance of food is characterized by hypermotility and
hypersecretion of gastric Juices. Thus, in an often
frustrated person, the stomach is exposed continually
to physiological stimuli, with which it must usually
00pe only periodically. At this point, we have reached
the first stage described earlier in the discussion of
the physiology of ulcer development.

The authors of this formulation make no attempt
to address themselves to the question of constitutional
or acquired weakness of the stomach.as a responsible or
important condition for peptic ulcer deve10pment. They
also restrict the application of their principles quite

-16...

conservatively to a group whom they have studied who
had duodenal ulcers. This theoretical formulation is
documented by the authors with several case histories
and a discussion of the psychoanalytic therapeutic
attempts at manipulation of the relevant personality
variables.

An article by Kapp, Rosenbaum, and Romano (25)
seems to agree in general with the Alexander formulation.
This study was concerned with 20 men with peptic ulcers,
who were admitted to a general hospital. On the basis
of the examinations and studies of these 20 men, it
was possible to divide them into three groups. Group 1
was made up of 6 patients, who appeared to fit the
usually accepted ulcer personality type, in that they
were outwardly independent, hard-driving, and success-
ful. However, in each instance, it became obvious, so
report these authors, that such overt behavior was an
over-compensation for deeply repressed, intense, re-
ceptive desires.

Group 2 was made up of 5 patients. Each of these
had been fairly successful, but were outwardly meek,
shy, and often quite effeminate. In this group the
dependent longings seem to be at least partially cons-
cious. Suchciesires were satisfied in these men by

overtly depending upon a mother or mother substitute.

Ilirl‘lllfl'i’l’llll
llll’lll
ll‘l'li’ll

-17...

Group 3 was made up of 9 patients. Each patient
in this group represented a severe character disorder.
Eight of them were chronic alcoholics. Many traits of
the psychopathic personality were present in this group,
such as repetitive, sterotyped, self-destructive be—
havior in the form of drinking, gambling, delinquency,
and inability to make a living. They expressed their
strong oral cravings and demands by intense acting out,
as well as by their pathOphysiological symptoms. In
general, the authors conclude that this study confirms
Alexander's hypothesis that the fundamental psychologi-
cal factor in this disease is a conflict over intense
dependent desires. Such.a conflict, they feel, may
arise from opposition within the personality or from
opposition between the psychological needs of the in-
dividual and the environment. Although the conflict
situation is similar in all men with peptic ulcer, the
resulting personality facade may vary from exaggerated
independence to parasitic dependence.

Osborne and Sanders (54) report a study in which
the Rorschach was administered to 50 white male veterans
of World War II, who were diagnosed as having duodenal
ulcer, functional G.I. condition, or gastric neurosis.
The age range was 22 to 41, with a mean age of 29.4

years. These authors summarized their findings by

-18"...

stating that this group of patients, on the whole, pre-
sented a neurotic pattern, with hysteroid features,
showing considerable sterotypy and little creative
ability or originality. They feel that these patients
are emotionally immature and affectively impulsive,
making it necessary for them to have their demands
satisfied immediately. These authors feel that peptic
ulcer patients behave on the emotional level of a child,
but show intellectual self-assertiveness and ambitions
which are beyond their capacities.

A second Rorschach study of peptic ulcer patients,
the results of which seem to support the specificity
point of view, is one reported both by Brown, et al.,
(8) and Poser (55). In this study, the Rorschach was
administered to two groups of 25 male veterans of World
War II, between the ages of 21 and 60. There was one
group consisting of patients receiving treatment for
duodenal ulcer. Another group, the controls, was made
up of subjects hospitalized for various complaints,
none of which were referrable to the gastro-intestinal
tract. There were no appreciable differences found
between the two groups in terms of social economic
status, intellectual level, and marital status. In
general, the results suggest the following: (1) A

greater similarity exists between ulcer patients than

-19.—

between the cases used in this control group; (2) It
is generally reflected in the Rorschach scores that the
assumption that ulcer patients express exaggerated shame
and guilt, in view of intense dependent desires, is cor-
rect; (5) On the basis of this study, it is felt that
many ulcer patients basically correspond to Rorschach's
M-type, but have secondarily acquired an extraversive
orientation, by which they seem to compensate for what
they consider to be unacceptable tendencies; (4) The
ulcer group appears to be made up of individuals who
are essentially at the mercy of their instinctive
promptings, without the capacity for adequate, rational
control. The author states that as far as this study
goes, it offers some confirmation for Alexander's
formulation regarding psychogenesis of peptic ulcer.
Ivy, Grossman, and Bachrach (21) devote some
space and discussion to Draper, Dupertuis, and Caughey,
whose work was not available in the original. The con-
clusions drawn by these latter writers were that chronic
fear is at the root of the ulcer problem, and that this
fear was primarily motivated by a fancied or actual imh
pending loss of mother or mother surrogate approval. In
addition to this characteristic, the following factors
were found to be operative in the order of their fro;

quency; intense feelings of inferiority, jealousy,

- 20 -

aggression and compensatory strivings. These reported
characteristics of ulcer patients are highly similar
to those found by Alexander and co-workers and can be
conceived of as identical, if the dissimilar frames of
reference of the investigators are considered.

Another report which tends to support the speci-
fic conflict hypothesis is one by Wilson (44) in which
he states on the basis of his experience with peptic
ulcer patients that the precipitating stress is "always"
related to life situations involving insecurity, in-
dependence and responsibility.

These above-mentioned studies and articles are
the most important and most often quoted which appear
to support the specificity hypothesis. It will be
noted that none of the above mentioned reports makes
use of measures or observations on the patient which
allow for objective evaluation and interpretation.
Quite to the contrary, all of the data which are in-
terpreted as supporting the specificity point of view,
are highly susceptible to preconceived Opinion and
attitude.

ANXIETY OR GENERALITY’HYPOTHESIS

We now come to consideration of the opposing point

of view, which as was stated above, holds that there is

-21'.

no specific conflict situation within the individual

or between the individual and his environment. This point
of view states that there may be a conflict situation in
each ulcer patient, but this conflict situation need have
no similarity from patient to patient. One of the chief
proponents of this hypothesis has been Mahl (28,29,30).
The point of view is best demonstrated by one of his
recent studies (50). The study is based on but two
cases, but it is clearly an experimental approach and
allows for more objective interpretation of objective
data. This is an experimental approach toward resolving
the conflict between an oral dependency and.an anxiety
hypothesis of peptic ulcer etiology. It is designed to
determine the nature of hydrochloric acid secretion
during anxiety reactions related to dependency, as well
as to other emotional responses such.as hostility and
sexual wishes.

The author assumes that if one has an index of
hydrochloric acid secretion during psychoanalytic hours
in which anxiety, oral dependent needs, and other emo-
tions vary in intensity and in their interrelationships
and that reliable indices of such variables are avail-
able, it would be possible to test the following pre-

dictions: (a) Hydrochloric acid secretion increases

-22...

with the increase in the intensity of oral dependency
needs; (b) Hydrochloric acid secretion increases with
the increase in intensity of anxiety; (c) This anxiety
hydrochloric acid relationship is independent of the
source of the anxiety. The oral dependency hypothesis
would predict confirmation of (a) and also (b), if the
anxiety is elicited by oral.dependency needs, or their
nonhgratification. It would not predict (c). The
anxiety hypothesis is noncommital about (a), but pre-
dicts confirmation of'both (b) and (c). The problem
was to test these predictions.

As stated earlier, this was a study involving the
analysis of the patient's gastric secretion during and“
following psychoanalytic treatment. In this case, the
patient's treatment included four hours of psychoanalytic
therapy each week, with.gastric sampling occurring in
the middle two sessions of each.week. The regularly
appointed time was late in the afternoon, and the pa-
tient was requested to eat what he regarded as a light
lunch, but not to take food or liquid after 12 noon.
Just before the therapeutic hour, the patient was in-
tubated nasally, and the stomach was washed with 1,000 cc
of isotonic solution of sodium chloride at body tempera-
ture to remove residual contents and standardize the

stomach.at the outset of all hours. The tube was then

_ 23 _

withdrawn, and the psychoanalytic sessions ensued.
Immediately afterwards, the fasting gastric sample was
obtained. Its free hydrochloric acid and total acidity
were taken as an index of the hydrochloric acid secretion
during the preceding 50 minutes. The therapist had been
in the practice of taking notes during each session; and
on the days of gastric sampling, he took as extensive
notes as possible. After determining the acidity of
the gastric samples, he immediately dictated a record
of the hour from the detailed verbatim notes. Since
the therapist knew the results of the gastric analysis
at the time he dictated the records which were later
used for judgments, there was the possibility that an
unconscious bias influenced the nature of the dictated
records. While this is an undesirable source of possible
contamination, it was not felt by the authors to be ser-
ious.

The results of this study are in agreement with
predictions based upon an anxiety hypothesis. There
is disagreement with predictions based upon an oral
dependency hypothesis. All of the high acid hours are
high anxiety hours, and 3 of these high acid hours are
low dependency hours. All of the low acid hours are
low anxiety hours, yet in 3 of these low acid hours,

there were expressions of intense, dependency cravings

-24...

and marked hostility over their frustration. Since
only extreme hours were used, the uniformity of the
anxiety-hydrochloric acid relationships may be spur-
iously high.

The authors conclude that the small amount of
data obtained demonstrates that hydrochloric acid secre-
tion increases with anxiety, be it evoked by sexual,
hostile, or passive dependent wishes, ideation, or
motives. Hydrochloric acid secretion does not increase
with these needs themselves. The evidence of anxiety
mediation of increased hydrochloric acid secretion
under these clinical conditions of observation is in
agreement with the laboratory studies of humans and
other species. To the extent that hydrochloric acid
secretion plays an essential role in peptic ulcer, these
findings do not support an oral dependency or specificity
hypothesis of peptic ulcer. They support, on the other
hand, an anxiety hypothesis of peptic ulcer or a gener-
ality hypothesis.

One of the better known and most frequently
quoted studies is that by Mittelman, Wolfe, and Scharf
(32). These authors studied a group of ulcer patients
and a group of control patients in an effort to deterh
mine the motility, amount, and quality of gastric

secretion under various emotions. This was accomplished

- 25 _

by inserting two nasal catheters into the patient's
stomach; one of which was attached to a kymograph re-
cording the frequency and intensity of peristaltic move-
ments and the other was an open tube through which peri-
odic samples of the gastric contents could be withdrawn.

They found that when emotionally charged topics
were discussed, both acid secretion and peristalsis in-
creased. These investigators inferred what emotional
responses their patients were making, as well as obtain-
ing the patient's description of the emotion, such as
guilt, anxiety, resentment, and hostility.

They found that anxiety, insecurity, guilt, and
frustration were characteristic reaction patterns in
their ulcer group, but unfortunately they did not pre-
sent a description of the characteristic reaction
patterns of their control group. Thoroughgoing compari-
sons of the ulcer group with its controls are required
before it is possible to discuss a reaction pattern
characteristic of ulcer patients as a group.

Mittelman and his co-workers emphasized the fact
that superficial personality differences within the
ulcer group did exist, but they pointed out that
“behind the facade of independence and self-sufficiency,
there was a background of long-standing and severe

anxiety, feelings of helplessness, feelings of being

-267.

caught, frustration, and desperation." Resentment and
manifestations of aggression stood out.

These authors addressed themselves to the problem
of explaining the dramatic reversal in ulcer incidence
from a predominately female disorder previous to 1900
to the present overwhelmingly greater incidence among
men. They state that since 1900, women have been able
to feel equal with man. They can compete, and in doing
so, experience an open catharsis of their feelings. At
the same time, they are not bound by the strict social
demands as are men in expressing their emotions directly
and freely. Men can no longer arbitrarily rule the home
as formerly, and they have no great frontiers against
which to pitch themselves. Conflicts are now lessened
for the women and greatly increased for men. These
conflicts result in the reaction pattern of guilt,
anxiety, hostility, and resentment, which in turn,
activates physiolOgical mechanisms eventuating in peptic
ulcer.

In general, this study is in agreement with the
generality formulation (30). It was found that frequent
emotions were feelings of inadequacy, guilt, hostility,
resentment, and shame. It must be remembered, however,
that the results of this study were reported anecdotally,

rather than statistically, and there was no comparison

-27'.

with a control group reaction.

An interesting monograph which fits very well
into the frame of reference held by those who espouse
the generality hypothesis of peptic ulcer etiology is
one by Sullivan and McKell (40). Although this is not
one of the most widely known or accepted formulations,
it deserves consideration as a rather sophisticated
approach. These authors state that peptic ulcer is
produced not by one etiological factor, but rather by
a combination of many factors, varying in their importance
in each case. They have found that peptic ulcer occurs
in three fundamental types of persons. These are: (l) gaIV
Those with a typical ulcer personality; (2) Neurotic
persons; (3) Those who have experienced an intense pre-
cipitating situation, which may be either emotional or
physical trauma.

Before going on to describe the situations which
are typical in the three types of people with ulcers,
the typical peptic ulcer personality found by Sullivan
and McKell should be defined. They state that Alex-
ander's description of ulcer patients fits only 11% of
their cases, while 72%, the "typical ulcer personality,“
could be described as follows: (1) High drive i these
patients have a strong need to be active, to be coping

with the situation at hand, and they are continually

-28-

striving to excell in whatever they undertake; (2)
Highly versatile - they had many and diverse outlets

in their activity; 1.6., they are characterized as
joiners and organizers; (5) Emotionally responsive -
they were open, likable, and cooperative; (4) Self-
reliant - they had characteristically become independent
of family rule quite early; (5) Responsible - they were
quick to assume responsibility in varied situations and
to discharge it conscientiously; (6) Well-adjusted sexu-
ally h this group made a good heterosexual adjustment,
having the highest marriage rate of any group of gastro-
intestinal patients studied, and the lowest divorce
rate; (7) Determined - persistent defiance of their
illness characterized this group, and they presented

the antithesis of a group of hypochondriacs.

The precipitating situation was of considerable
interest to these authors. They found that for this
typical group of ulcer patients minor catastrophes re-
lated to their present or future material security was
sufficient to precipitate an ulcer, or at least to
precipitate gastric distress. For the neurotic patient,
peptic ulcer was brought out by "a complex pattern of
difficulties involving their own personal neurotic
conflict.“ No common characteristic, other than this,
can really be expected in such a homogeneous group.

In the normals, ulcer was produced following

-29...

physical injury to the stomach, or duodenum itself, or

to certain vaguely defined central nervous system,areas,v
or as a result of an objectively intense emotional situa-
tion.

Sullivan and McKell make no specific statements reh
garding treatment or prognosis, but it seems reasonable
to assume that medical treatment should be most effective
for this last group. In regard to the first group, the
typical ulcer personality, they feel "that the intense
drive and the tension it creates, as well as the in-born
cravings for superiority, together with the worries
generated by small failures, particularly anxiety re—
sulting from anticipated failure or future insecurity,
are the emotional patterns, which.are fundamental in
the production of ulcer.” They feel that "the ulcer
patient craves a true matter—ofhfact superiority which
they are determined to achieve." They point out that
since the psychiatrist sees a biased sample, he is prone
to produce a theory which reflects, to a high degree,
his patients' neurotic conflicts and failures. As was
mentioned earlier, they found Alexander's formulation
to fit only 11% of their patients, and 11% of their
patients were also diagnosed as neurotic. Whether the
two groups were identical was not stated.

Mahl (28) has shown that there is an increase in

- 50 _

the secretion of free H01 under fear stimulation in

dogs, without any resultant tissue damage observable

"on gross or histologic examination of the stomach and
duodenum." The demonstration that hyperacidity does
result from emotional stimulation; primarily what he calls
chronic anxiety as opposed to acute fear or acute anxiety
seems to have been his major purpose. This was demon-
strated, and this fact, combined with.his basic assump—
tion that HCl is essential to ulcer formation, allows
him.to state that the anxiety theory of ulcer etiology
seems to be the most substantiated of those so far
presented.

In another study, Mahl (29) found that with college
undergraduates interviewed preceding an important ex-
amination, increased H01 secretion occurs in response to
external stress situations.

A study by Bennett and Venables (6) conducted in
1920, using two or three veterans of World War I, found
that subjects under hypnotic suggestion of various emo-
tional responses, reacted with increased hydrochloric
acid secretion. They felt that the rise in gastric
acidity was related to anxiety, rather than to any
particular type of conflict.

Hoelzel (19) has published the results of a long

period of observation of his own fasting HCl level.

_ 51 -

0n the average, it had been from 0 to 13% of the gas-
tric contents. In one situation, however, during which
he himself was under severe, realistic, externally
caused fear conditions, and during which time he con-
tinued to sample his own gastric contents, he found
that acidity level rose to 26% and stayed above 17%

for as long as the situation remained unchanged. Im-
mediately following a change which resulted in a de-
crease in the fear response on his part, the gastric
acidity level again was lowered to the previously normal
range, namely, 0 to 15%. One might safely say that the
chronic emotion was anxiety, rather than fear.

Cathcart (11) has published an.article in which
he discussed the possible emotional bases for the
anxiety which is recognized as essential in the hyper-
secretion of gastric hydrochloric acid. He felt that
one of the most important emotional responses in this
respect is resentment. This opinion he based upon his
own clinical experiences and furnished no statistical
data to substantiate this statement.‘

One of the most famous studies concerning gastric
function and its emotional correlates is one by Wolf
and Wolff (45) concerning "Tom", a 56 year old male
with a gastric fistula. The investigators were able

to observe directly the appearance of the gastric

- 32 -

mucosa and the nature of the gastric juice simultaneously
with their observation of "Tom's" emotional state. The
general results of their prolonged study of these pheno-
mena are in agreement with the generality or anxiety
hypothesis here under discussion. Acceleration of
gastric function was found to occur when "Tem" was
anxious (irrespective of the situation which aroused

the anxiety) and when he evidenced hostility or resent~
ment.

In summary, the generality hypothesis may be
stated as follows, as taken from an article by Mahl
which was quoted earlier (30). The generality hypothe-
sis states: (1) The gastric hyperfunction essential for
peptic ulcer etiology is positively associated with
anxiety; (2) If these two associated processes; namely,
gastric hyperfunction and anxiety persist, peptic ulcer
will develop; (3) It is not important what the source of
the anxiety is; whether it is produced and maintained
by environmental stimuli or by internal ideational or
affective stimuli, whether these internal stimuli are
conscious or unconscious, nor whether the anxiety is
conscious or unconscious; (4) While the preceding factors
might vary, it is essential that the anxiety be unre-
lieved by the development of adequate defense mechanisms

or by changes in the stimulus conditions.

-33‘.

The "generality” hypothesis as stated by Mahl with
reference to the etiology of peptic ulcer is a special
case of the more general concept which has been intro-
duced by Gilbert (18) as the Psycho-Social determination
of pathology. Briefly, Gilbert's position is that the
etiology of any psychiatric disorder may involve stress
factors ranging from the classical Oedipal complex to
the loss of one's job. He would hold that there is no

necessary relationship between the symptoms observed

 

and the precipitating or even central conflict.

CHAPTER III

THE PRESENT STUDY

The fact that there is this controversy concern-
ing the etiology of such an important disease—-10% in-
cidence in the general population (21)--is sufficient
reason to attempt by objective experimental means to
evaluate the alternative hypotheses. It was the purpose
of this study to furnish additional information which
would be valid evidence in support of one or the other
of the two seemingly contradictory theoretical formula;
tions regarding the nature of the psycholOgical factors
in the etiology of peptic ulcer.

Much more information is necessary before the role
of psychological factors in this disease can be speci-
fied accurately. ‘When such information is available,
however, we will have a much firmer basis on which to plan
not only the psychotherapeutic programs for such patients
but more effective medical and surgical management as well.

The present study is designed to determine whether
or not peptic ulcer patients respond with greater auto-
nomic nervous system activity to situations or stimuli
which are related to passive-dependent needs, or whether
they show equally intense autonomic activity in response
to other types of stimuli as well. One of the hypotheses

discussed above, the specificity formulation, predicts

- 55 -

that the former is the case while the generality hypo-
thesis leads to the prediction that stimuli which are
related to passivehdependent needs are not necessarily
the most important or disturbing for persons with peptic

ulcer.

GENERAL CONSIDERATIONS

 

Before the primary study could be carried out,
there was one major preliminary obstacle to be overcome.
This involved the selection of laboratory stimuli or
situations which actually were disturbing to persons
who were known to have emotional conflicts of particu-
lar types. The problem was dealt with in two studies
(41), (59), which demonstrated the validity of four
pictures in discriminating between persons with conflicts
concerning the expression or control of hostility,
passiveidependent needs and heterosexual impulses.

Only the second of these studies (59) will be
discussed in detail because the first was primarily
exploratory and there were numerous changes in both the
design and the stimuli employed in the second. The
decision to employ pictures was based partially on conh
vention, that is, stimuli of this kind are assumed to
have considerable validity when used in projective

techniques; and partly on the fact that stimuli of this

- 55 -

type can be manipulated quite easily. Four pictures
were finally chosen, and are called for the purposes

of this study, “Neutral“, "Hostile", "Passive“, and
"Sexual" stimuli. The neutral picture is a glossy
print photograph of card l2BG from the TAT series (33).
In order to control as much as possible the interpreta—
tion the subjects made of the picture, the presentation
of it was accompanied by the statement, "Imagine your-
self in a situation like this--it's a nice summer day
when you can relax and really take it easy."

The hostile stimulus was a glossy print of a
photograph of a pencil sketch drawn especially for this
study. There are two figures, one quite indistinct
seated in the lower left corner, the other is a muscu-
lar man with manacles on his wrists and his arms raised
over his head. He is about to bring them down on the
seated figure. The aggressing figure has an enraged
expression on his face and his arm.and chest muscles
are taut with tension. The statement which accompanied
the presentation of this card was, "Put yourself in this
fellow's position-hyour feelings are breaking loose and
you're going to do something that you've wanted to do for
a long time!"

The passive stimulus was a similar photOgraph of

card 6BM from the TAT series (33). This too is a picture

-57...

of two figures, one male, one female. The statement
which was made with the presentation of this card was,
“Think of yourself as this kind of a fellow—-always
depending on your mother for help."

The fourth stimulus, the sexual card, was like-
wise a glossy photographic print of a picture taken from
Esquire Magazine (16). It is a picture of a young woman
lying on a bed. Her body is covered from the waist up
by a dressing gown which is open from the waist down.
She is wearing a pair of white briefs but her bare legs
are clearly visible and the hips are clearly outlined.
She is reaching up to embrace a man who leans over her.
As this picture was presented to each.subject he was_
instructed to, "Put yourself in this man's position-b
you have yourself all set up and whatever you do now is
entirely up to you."

Copies of the pictures used are to be found in
the Appendix.

Before, during and after the presentation of
these four pictures each subject's autonomic nervous
system activity as reflected by breathing, pulse rate
and galvanic skin response were continuously recorded
by means of a Keeler Polygraph (5). The measures which
were employed were respiration frequency, pulse rate

per minute and a function of the intensity and duration

_ 38 -

of the galvanic skin response for the first minute im-

mediately following the presentation of each card. The
measurements made during the periods following the pre-
sentation of the “Hostile", "Passive" and "Sexual“ cards
were then compared with the measurements made during the
minute following the presentation of the "Neutral" card.
These comparisons were made only for the measurements

obtained from each individual subject, that is, all come

parisons were intra-individual comparisons.

 

The records obtained were then inspected and each
of the three measures was scored either "H", "P", "S“
or "NS". A score of “H“ for respiration rate or pulse
rate meant that the activity in the system in question
was significantly greater following the presentation of
the "Hostile" card than it was following the "Neutral"
card. Likewise it was greater than that particular
systemic increase following both the "Passive" and
"Sexual” cards. A score of ”P” or "S“ for either res-
piration frequency or pulse rate was interpreted similarly.
The minimum increase on which a "score” was based had a
maximum probability of 1 in 100 of occurring by chance
alone. These parameters were determined on the basis of
the data from 20 cases. If there was no change of ac-
ceptable magnitude in a particular system that system

was given a score of "NS” or “not significant". The

-59...

means and standard deviations of these data were essen-
tially identical with those found by Jost, et a1, (22),
based on data obtained from 47 normal subjects.

Scoring the GSR was done on a different basis.
Various writers including Darrow (12), Lacey (26),
Lauer (27), Hunt and Hunt (20), and Freeman (17) have
presented several different scoring systems for this
phenomenon. The scoring methods advocated by these
writers and others vary from the simple number of ohms
decrease in resistance (20) to very involved formulae
which take into consideration the background resistance,
number of ohms decrease in resistance, rapidity of the
return of resistance to the pre-stimulation level and
other factors (12). In general, the most frequently
mentioned factors which were considered to be indicative
of the intensity of the galvanic skin response were,
actual number of ohms decrease in resistance, the rapidity
of recovery of the resistance level, and the original
pre-stimulation level of resistance. Hunt and Hunt (20)
have clearly shown that the latter variable, basal re-
sistance, can be ignored if the successive measurements
of the GSR are made from the same level. This condition
was fully met by the present design in that the GSR
measures which were compared with one another were made

upon the same individual (that is, all comparisons were

-40;

intra-individual comparisons) and between readings the

 

palmar resistance was allowed to return to its original
pre-stimulation level.

Rather than employ both of the other two measures
in the present research (decrease in ohms resistance and
speed of return to basal resistance), one measure which
varied directly with both of them was used. This meas-
ure is the area under the GSR curve for the minute im-
mediately following the presentation of a stimulus
picture. 'When in use, the galvanometer can be set so
that one inch of upward deflection in the GSR tracing
is equal to a reduction in resistance of 750 ohms. As
Darrow (12) has demonstrated, the period immediately
following the peak of any galvanic response is charac-
terized by the most rapid increase in resistance. Thus
it is that the area under the GSR curve for the first
minute following the presentation of a stimulus is cone
sidered to be an adequate measure of the general magni-
tude of the GSR.

For the purposes of this study each person's
GSR's following the three affective stimuli were compared
with that same person's GSR following the Neutral card.
A scoreable GSR was defined as one which not only was
greatest in absolute magnitude but was, in addition, one

which showed at least twice the increase over the Neutral

- 41 -

card GSR that was shown by the average of the GSR's
following the other affective stimuli. This is an
empirically determined criterion which was found to dis-
criminate between the groups in the validation study
about to be discussed.

The subjects tested in this validation study were
selected from the patients who were referred to the Clini-
cal Psychology Service at the Veterans Administration
Hospital in Dearborn, Michigan. The basis on which the
patients were selected was the specific statement made
by a staff clinical psychologist that the primary source
of a man's anxiety was conflict concerning the expression
or control of either his hostile-aggressive impulses,
his passive dependent needs or his heterosexual impulses.
A verbal statement to this effect was not accepted.
Rather, the integration of such an impression into the
written report which became a permanent part of that
patient's file was the criterion. The basis for making
such a statement was most often the routine battery of
psychological tests which was administered to the referred
patient's but not infrequently it was rather extended
psycho-therapeutic contact with a patient. Abstracts of
the written reports are provided in the Appendix.

Because of the rarity of cases about which the

clinician will take such a definite stand or in which

-42'...

the case is quite so clear cut, the sample of cases on
which the pictures were validated is made up of only 20
patients. Of these 8 are "Hostile“, 7 are “Passive”,
and 5 are "Sexual", if classified according to the type
of conflict they were considered to present. None of
them were considered to be examples of "pure" cases of
one conflict or another but they were employed as the
best and most available group of such persons to be
found in six months of routine work in an 1100 bed GM&S
hospital.

The prediction was that if the stimuli presented
to these subjects were valid, those subjects whose major
conflict was stated to involve hostility would show the
greatest proportion of"scoreable' responses in the func-
tions measured following the presentation of the "Hostile"
stimulus. Likewise, the patients whose conflict involved
primarily passive-dependency or sexuality would show
their greatest increases following the presentation of
the "Passive" and the "Sexual" cards respectively.

The statistical evaluation of the validity of
the stimulus pictures was made in the following manner.
The frequency with which scoreable responses in each
system followed the presentation of a picture to a par-
ticular group was compared with the frequency of scoreable

responses following that same picture to the other two

-45..

"conflicted“ groups. Table I presents the Chi Square
data concerning the frequencies of scoreable responses
in the three systems following presentation of the

"Hostile“ card and both of the other two crucial cards

to the "Hostile" and the other two non-hostile groups.

-44..

TABLE I

Chi Square Analysis of Scoreable Responses in Each
System Following Presentation of The "Hostile" Card
to The "Hostile and Non-Hostile Groups.

A: Respiration Rate
Group

Non-
Hostile Hostile N

 

2

 

 

 

 

 

 

 

Hostile 3 l 4 X = .17
Scoreable Non-
Responses Hostile 4 5 9 P : .34
N 7 6 13
B:- Heart Rate
Group
. Non-
Hostile Hostile N
Scoreable Hostile 4 2 e x2 = 3.97
Responses Non- r
Hostile O 7 7 P = .02
N 4 9 15
C: Galvanic Skin Response (Area)
Group
Non-
Hostile Hostile N
Scoreable Hostile e 2 8 x2 : 4.03
Responses Non- .
Hostile 2 9 11 P = .02

 

N 8 ll 19

-45'.

On the basis of the data summarized in Table I,
it can be seen that although respiration rate did not
discriminate between the "Hostile“ and non-hostile
groups with respect to their response to the "Hostile"
card, there are significant differences in the fre-
quencies with which scoreable increases in the other
two systems were evoked by the "Hostile" picture.

Table II is similarly made up of the Chi Square
tables comparing the frequencies of scoreable responses
in each system which followed the presentation of the
"Passive" picture to the "Passive" and non-passive

groups of subjects.

- 46 -

TABLE II
Chi Square Analysis of the Scoreable Responses in Each

System Made by the "Passive" and Non-Passive Groups
following Presentation of the Passive Stimulus.

A: Respiration Rate

 

 

 

 

 

 

 

 

Group
Non-
Hostile Hostile N
Scoreable Hostile 2 2 4 X2 = .68
Responses Non-
Hostile 1 8 9 P = .21
N 3 10 13
B: Heart Rate
Group
Passive Non-Passive N
Scoreable Passive 4 0 4 X2 3 5.97
Responses Non-
Passive 2 7 9 P = .02
N 6 7 13
C: Galvanic Skin Response (Area)
Group
Passive Non-Passive N
Scoreable Passive 5 2 7 X2 = 5.59
Responses Non- _
Passive 2 10 12 P - .05

 

N 7 12 19

-47..

In respect to the Passive group, results similar
to those obtained with the Hostile group were found.
Again Respiration rate failed to show significant dis-
crimination between the "Passive" and non-passive sub-
jects following presentation of the Passive picture
while in the remaining two systems there were significant
differences in frequency of response which tend to
support the assumption of validity of the “Passive"
stimulus.

Table III is likewise an analysis of response
in each system comparing the "Sexual" and non-sexual
conflict subjects' responses following the "Sexual"

card 0

- 48 .
TABLE III

Chi Square Analyses of the Scoreable Responses in Each
System Occurring in the "Sexual" and non-sexual Conflict
Subjects Following Presentation of the "Sexual" Picture.

A: Respiration Rate.
Group
Sexual Non-Sexual N

 

 

 

 

 

 

 

Scoreable Sexual 2 3 5 X = .22
Responses Non- ;
Sexual 1 7 a P ' ~55
N 3 10 13
B: Heart Rate
Group
Sexual Non-Sexual N
Scoreable Sexual 5 o 3 x2 = 7.87
Responses Non- _
Sexual o 10 10 P ' ~01
N 3 10 13
C: Galvanic Skin Response (Area) A
Group
Sexual Non-Sexual N
Scoreable Sexual 4 l 5 X2 3 9.78
Responses Non- ‘
Sexual 0 14 14 P - .01

 

N 4 15 19

- 49 _

Again, support for the validity of the stimulus
picture in question is found only in the responses
occurring in the latter two systems, heart rate and area
of galvanic skin response.

In general the results support the assumption that
the stimuli employed are valid in that the pictures are
followed by increases in autonomically mediated activity
and further, each picture is most effective in arousing
such physiological activity in persons who are considered
to be emotionally conflicted in the area depicted by the
picture.

The reliability of the obtained scores was deter-
mined by retesting five of the subjects at a later time.
The reason that so few subjects were retested was that
before this procedure was decided upon, all but five had
been discharged from the hospital.

Among these five subjects there were 15 scores
which can be either Hostile, Passive, Sexual or Not
Scoreable. The reliability was calculated by determin—
ing the statistical significance of the difference beb
tween the obtained and expected number of scores which
changed (15;p.58).

The probability that a score would not change
from test #1 to test #2 is .25. Thus the number of

scores which were expected to remain the same was 15/4

or 3.75. The standard error of this expectancy is 0.14.
Actually, 6 scores remained unchanged. The obtained N
of 6 is thus 16.43 standard errors greater than the
number expected on the basis of chance alone. The
probability of a difference this large is far less than
one in a thousand.

Another way in which reliability was checked was
to calculate the Chi square obtained from a comparison
of the frequencies of "Predicted“ and "Other" scores
for the five subjects on both the first and second test
sessions. Table VIII presents these data. The fact
that the x2 is not significant further attests to the

reliability of the scores obtained.

TABLE IV

Frequency of "Predicted" and "Other“
Scores at First and Second Test Sessions.

Test Session

 

 

 

#1 #2 N
Scoreable Predicted 9 9 18 x2 : 0
Responses
Other 6 6 12 P = 1.00
N 15 15 30

It is on the basis of these findings that the
pictures are considered to be valid and reliable as
stimuli for the arousal of autonomically mediated physi-

ological activity in persons with emotional conflicts of

- 51 _

these three types: hostility, passive dependency, or

sexuality.

THE MAIN STUDY

 

With the validity and reliability of a set of
laboratory stimuli demonstrated, the main question con-
cerning the nature of the psych010gical factor in the
etiology of peptic ulcer can now be considered.

Subjects

The subjects in this study were obtained at the
Veterans Administration Hospital in Dearborn, Michigan.
A group of 24 patients whose medically verified diagnoses
were peptic ulcer served as the experimental group. The
diagnoses had been established by either X-ray or gastro-
scOpy. The control group was made up of 24 patients
from the general medical and surgical wards. Only those
patients were selected whose conditions were not neuro-
psychiatric, who had never been referred to Psychiatry
or Clinical Psychology and whose illnesses were not
among those generally referred to as “psychosomatic."

The actual diagnostic catagories and the number of sub-

jects in each are given in Table.

 

-52..

TABLE V

Control Group; Diagnostic Categories and Number
of Subjects in Each.

 

 

 

Diagnosis Number Diagnosis Number
Hernia 9 Pilonidal Cyst l

Gall Bladder Dis- Sacroiliac strain 1

order 2 Abscess: Neck 1

Lymphosarcoma 2 Abdomen 1

Anal Fistula 2 Lumbar strain 1

Appendicitis 1 Bronchiectosis l

Lipoma l

Kidney stone 1 Total 24

 

All of the subjects were male veterans of World
War II and both groups were equated for age, education
and vocabulary level, the latter by administering the
Wechsler-Bellevue Form I vocabulary subtest. Table X
contains the means and standard deviation obtained for
the variables which were controlled. It can be seen
that there were no significant differences between the

two groups in these respects.

- 55 -

TABLE VI

Means and Standard Deviations of Age,
Education and Vocabulary Level for the
Experimental and Control Groups.

 

 

 

 

 

Variable Peptic Ulcer Control .

Mean SD Mean SD Diff. "t" P
Age 33.71 5.85 33.04 6.68 .67 .36 .70
Education

(in years) 9.58 2.87 9.46 2.06 .12 .16 .80
Vocabulary 21.56 5.87 22.21 5.05 .55 .52 .70

 

Procedure

 

Each subject was seen individually and, after the
necessary background information was obtained, the pro-
cedures involved in the test were explained in a rela-
tively superficial fashion and any questions the subject
might raise were answered. The vocabulary subtest was
administered at the end of the session because it was
noted that being asked to define a series of words was
often a rather stressful experience for hospital patients
in general. If this were the case it might have artifi-
cially raised the background level of autonomic activity
before the experimental procedures and thereby mast some
of the reaction to the visual stimuli which were employed.

The subject was seated in a straight chair facing

a blank wall and the necessary attachments were made.

-54...

He was instructed to find a comfortable position in the
chair and to relax as much as possible in that position
without moving. He was explicitly instructed not to
speak from that time until the machine was turned off.
With the pneumograph, sphygmograph and galvwnometer
all in operation, the kymograph.motor was turned on and
the tracings were obtained for a variable length of
time, the shortest time being five minutes. ‘When the
recordings indicated that the subject's measured physio-
logical activity had stabilized, as suggested by Seward
(38), the first card, the neutral stimulus, was placed
before him about 28 inches from.his face and just below
the level of his chin. The so-called structuring state-
ment was made at that time. The picture was allowed to
remain in front of the subject for forty seconds after
which it was removed. Approximately 115 seconds after
the presentation of the picture, the air in the blood
pressure cuff was released. Although it would have been
desirable to observe all three recordings at all times
this was impractical due to the fact that the blood
pressure cuff tends to cut off circulation in the arm
around which it is wrapped causing considerable dis-
comfort after a minute or so.

The tracings were then closely observed and when

the GSR curve and the respiration rate had returned to

-55..

their pre-stimulation level the blood pressure cuff was
again inflated. The period which elapsed between the
time the blood pressure cuff was deflated and the trac-
ings returned to their basal level generally varied from
5 or 6 to 10 or 11 minutes and was never more than thir-
teen minutes. When the blood pressure cuff was inflated
again there was usually some slight irregularity in the
GSR and/or respiration curves but these changes were
always temporary and the tracings invariably stabilized
within a minute or so.

When the tracings were stable another card was
presented to the subject in the same nmnner as the
first. Each card was accompanied with the apprOpriate
statement as described earlier.

The order in which the crucial cards were presented
following the neutral card was systematically varied.
With three stimuli which can vary in order, there are
six possible arrangements. In'both the peptic ulcer
group and the control group, four subjects were pre-
sented with the cards in each of the six possible orders.

Following the presentation of each picture the
tracings were obtained for about 1% minutes. The blood
pressure cuff was then deflated and the GSR tracing was
allowed to return to its pre-stimulation level. Another

card was never presented before five minutes had elapsed

and the longest time required to bring about the reducé
tion in the GSR curve was about 12 or 13 minutes.

Hypotheses which follow from the two already
discussed opposed theoretical positions will now be pre-
sented phrased in terms of the present study. The first
hypothesis is based upon the so-called "Specificity
"Theory" of Alexander (3). The second hypothesis is
derived from the "Anxiety" or "Generality" position of
Mahl (30).

(l) Specificity: There will be a significantly greater
proportion of scoreable responses in a group of
peptic ulcer patients following the "Passive"
stimulus than there will be in an appropriate con-,
trol group.‘

(2) Generality: There will be no significant difference
between the proportions of scoreable responses in
the peptic ulcer and control groups which follow
presentation of the "Passive" stimulus.

(3) Generality: There will be no significant differ-
ence between the proportions of scoreable responses
following the presentation of the "Hostile" card to
the peptic ulcer and control groups.

(4) Generality: There will be no significant difference
between the proportions of scoreable responses
following the presentation of the "Sexual" card to
the peptic ulcer and control groups.

Statistical Analysis and Results

 

Each subject's responses following the presenta-
tion of each card were determined in the manner already
discussed. The responses in each system made by each sub-
ject following each of the three affectively toned cards

were compared with that subject's responses following

-57..

the neutral card. If there was a response in a system
which.was statistically significantly greater than the
subject's response to any other card, that system re-
ceived a "score” for that stimulus.

It had already been determined that a l per min-
ute increase in respiration rate was statistically
greater than chance well beyond the .01 level of confi-
dence. Thus, if subject's respiration rate following a
crucial card was 1 or more per minute greater than his
rate following the neutral card, that subject was given
a score for the appropriate card for respiration rate.

A change of 2 pulse beats per mdnute was found
to be statistically greater than chance also beyond the
.01 level of confidence. Thus, a subject obtained an
appropriate score for pulse rate if a particular card
was followed by a pulse rate which was 2 or more beats
faster than his pulse rate following the neutral card.

The basis for determining a scoreable response
for GSR has already been presented.

The statistical analysis of these data was made
by means of Chi Square. The proportion of scoreable
responses in each of the three physiological systems
among the peptic ulcer and control groups were compared.
Table VII is made up of the Chi Square tables which com-
pare the frequency of scoreable responses in each physio-

logical system which follow presentation of "Passive"

- 58 .

stimulus to the peptic ulcer and control groups.

TABLE VII

Frequencies of Scoreable Responses in Each
System.Which Followed Presentation of the
"Passive" Stimulus to the Ulcer and Control
Groups.

A: Respiration Rate

 

 

 

 

 

 

 

 

 

Group
_:: Control Ulcer N 2
Scoreable Passive 5 4 9 X : 0
Responses Non- P = 50
Passive 6 7 13 '
N 11 ll 22
B: Heart Rate
Group
Control Ulcer N
Scoreable Passive 7 2 9 X2 = 2.20
Responses Non- _
Passive a 12 20 P - -O8
N 15 14 29
C: Galvanic Skin Response (Area)
Group
Ulcer Control N
Scoreable Passive 5 2 5 x2 i .11
R S 3 Non- P = 058
espon 8 Passive 13 12 25
N l6 14 30

One can see from these data that there are no
significant differences in any of the three systems be-
tween the pr0portion of scoreable responses in the peptic
ulcer and control groups. This is non-confirming for

hypothesis #1 which was based upon Alexander's, "Passive-

-59-

Dependency" formulation and in agreement with hypothesis
#2 derived from the "Generality" theory as formulated
by Mahl.

The next table combines the Chi Square tables
comparing the frequency of the two groups Scoreable
responses in each system which followed the presentation

of the "Hostile" stimulus.

. .Il}

aw}.-ju1 .. .2.
- .

- 60 -

TABLE VIII

Frequency of Scoreable Responses Which Followed
Presentation of the “Hostile" Card to The Ulcer
and Control Groups.

A: Respiration Rate

 

 

 

 

 

 

 

 

 

Group
Ulcer Control N
Scoreable Hostile 4 2 e x2 : .25
Response Non- P - 30
Hostile 7 2 16 ' '
N 11 ll 22
B: Heart Rate
Group
Ulcer Control N
Scoreable Hostile 8 7 15 X2 Z .02
Response TNOn- _
Hostile e a 14 P - -45
N 14 15 29
C: Galvanic Skin Response (Area)
Group
Ulcer Control N
Scoreable Hostile 5 2 5 x2 s .05
Response Non-
Hostile 15 12 25 P ' ~45
N 16 14 30

These findings lend support to hypothesis #3
which was derived from the "Generality“ point of view.

Hypothesis #4, also derived from the "Generality“
theory is supported by the findings which are summar-
ized in Table IX.

-61-

TABLE IX

Chi Square analysis, by separate physiological
system, of the frequency with which scoreable responses
in the peptic ulcer and control groups followed pre-
sentation of the “Sexuar'Stimulus.

A: Respiration Rate

Group
Control Ulcer N

 

 

 

Scoreable Sexual 4 3 7 X2 2 .04
Response Non- _
Sexual 7 a 15 P - ~14
N 11 11 22

B: Heart Rate
Group

Ulcer Control N

 

 

 

 

 

Scoreable Sexual 4 l 5 x2 = 1.14
Response Non-
Sexual 10 14 14 P = .14
N 14 15 19
C: Galvanic Skin Response (Area)
Group
Control Ulcer N
Scoreable Sexual 10 10 20 2 = .02
Response Non- _
Sexual 4 6 10 P ' '45
N 14 16 50

On the basis of the above findings the present
study may thus be interpreted as supporting the position

taken by Mahl (30), and lending no support to Alexander's

position (3).

MMNERIV

DISCUSSION

 

The prediction based upon the Alexander and
French (3) hypothesis that a group of patients with pepe
tic ulcers would show a larger number of increased auto-
nomically mediated physiological responses to a stimulus
which is related to passive—dependent needs than would
an apprOpriate control group has not been supported by
the data obtained in this study. On the contrary, the
results conform to the predictions derived from the
generality theory as presented by Mahl (30).

In view of the fact that the stimuli used have
been found to differentiate between male veterans whose
major emotional conflict constellation involves one of
the three problems, hostility, passive-dependency or
sexuality, we may say that passive dependency is not
the central conflict among this group of ulcer patients.

In the light of these data it is not readily
apparent how the Alexander and French position can be
maintained.

On the other hand, the findings fit quite well
into another frame of reference, that frame of reference
of which Mahl's so-called generality formulation is a
special case. This has been mentioned earlier as being
essentially the position taken by Gilbert (18) when he

discusses the Psycho-Social aspect of psychopathology.

-63"-

The results of this study are in essential agreement
with the findings of the study by Mahl (30) which.was
quoted earlier. The major conclusion of both mahl's
study and the present one is that a stimulus which is
adequate to arouse autonomically mediated physiological
activity in persons with conflicts concerning passive-
dependency needs does not result in this type of response
in ulcer patients with greater than chance expectancy.

The writer will now present the results of several
other studies which, although they do not bear directly
on the problem.of the present research, do combine with
the present findings to provide the basis for an experi-
mentally derived formulation concerning the etiology of
peptic ulcers.

The first of these studies is one of a series
conducted under the direction of Lacey (25) at the Fells
Research Institute. Using 85 male college students who
were subjected to four essentially different stress
situations, there were found characteristic autonomic
response patterns which were consistent within each in-
dividual. The characteristic autonomic response patterns
were observed irrespective of the type of stress situa-
tion the subject experienced.

As stated by that author, the findings are inter-

preted as follows: "Some individuals are so constituted

-64-

that they will respond with.a given hierarchy of auto-
nomic activation, whatever the stress. Others will
show greater fluctuation from stress to stress, although
they will exhibit one pattern more frequently than others.
Still other individuals randomly exhibit now one pattern,
now another."

The next is an article by Browning and Houseworth
(9) which is the report of a follow-up study of two
groups of duodenal ulcer patients who had been selected
at random from the regular admissions to a large general
hospital. There were 30 patients in each group, one
group which had been treated by gastrectomy and the other
group which had been treated with the general medical
regime consisting of bed rest, antacids, antispasmodics,
and the Sippy dietary regime. The follow-up study con-
sisted of (1) An interview by a psychiatric social
worker*who obtained a complete social history, (2) A
detailed interview by one of the authors, and (3) medical,
laboratory, and X-ray follow-up examinations. None of
the patients in either group received psychotherapy.
Approximately 40% of the gastrectomy group had undergone
a vagotomy either before or at the time of the gastrectomy.
In the five patients who had undergone vagotomy prior to
the gastrectomy, the vagotomy had failed to relieve com-

pletely the ulcer symptoms.

-65..

Symptoms before and after treatment were classi- .
fied according to the following types: (1) Ulcer
symptoms, (2) Symptoms of presumably psychosomatic dis-
orders, other than peptic ulcer; i.e., hypertension,
arthritis, asthma, migraine and psychocutaneous dis-
orders, (3) psychoneurotic symptoms which included
hysterical, phobic, obsessive, compulsive, hypochondria-
cal, depressive and anxiety symptoms, except those in-
volved with the gastro-intestinal tract, and (4) charac-
terological symptoms, which included acting out in various
forms, such as poor relationship with wife and other
people, alcoholism, drug addition, antisocial behavior,
poor work adjustment, and in some cases flight into
work. For statistical purposes the severity of each
symptom category was calculated in the following manner:
mild symptoms were given a value of 1, moderate symptoms
a value of 2, severe symptoms a value of 3.

The results of this investigation indicated that
the incidence and severity of 21; symptoms, that is, a
combination of ulcer, psychosomatic other than ulcer,
psychoneurotic and characterological symptoms in both
the gastrectomy and medically treated groups did not
change significantly following treatment for duodenal
ulcer. The gastrectomy group showed a significant de-

crease in ulcer symptoms following the gastrectomy but

-66-

this was compensated for by a significant parallel in-
crease in other psychosomatic and psychoneurotic symptoms.

"Surgical removal of ulcer symptoms appears,
therefore, to be followed by their replacement by new
symptoms in a significant number of instances. These
new symptoms which presumably replace the ulcer symptoms
were consistently autoplastic reactions. The medically
treated group in which the ulcer symptoms were not sig-
nificantly reduced in incidence or severity, showed no
such redistribution of symptoms following treatment.
These findings indicate that successful removal of the
ulcer symptoms by surgical means alone, without the
resolution of the associated psychological conflict
offers little assurance that other pathological symptoms
will not soon deve10p."

The most probable interpretation which can be
made of these findings is based in large part on the
work of Lacey which was discussed above. In the groups
studied by Browning and Houseworth we may assume that
those patients who had ulcers were those who responded
to life stresses with an autonomic pattern which involved
overactivity of the gastric functions primarily. This
would be the case, of course, with the patients in both
of the groups studied. The surgically treated group

had undergone the removal of the organ.which was most

- 67 _

susceptible to autonomic innervation for them. Those
people then, gguli’ggt develop ulcers again, not because
the environmental stress was reduced and not because the
autonomic activity was less, but rather because their
former primary channel for the physiological expression
of the autonomic activity was gone.

It was among that group that the deve10pment of
other psychosomatic disorders was noted most frequently.
We may further assume that those persons, among the sur-
gically treated patients, who developed other psychoso-
matic disorders had originally been so constituted that
the second most susceptible organ system was the one in
which the new disorder was found.

This general position is supported by a recent
study by Malmo and Shagass (31). These authors obtained
electromyographic recordings from several patients during
a psychiatric interview which was considered to deal with
stressful material obtained from.the history of each in-
dividual. The results indicated that particular physio-
logical reactions which result in somatic complaints
were specifically susceptible to activation by stressful
experiences of any sort. The results which were most
clearly seen concerned the activation of the neck mus-
cles in patients whose major complaints were headaches.
The activation and resultant disturbances were inter;

preted by these authors as a lowered threshold for

- 68 -

stimulation in particular areas. These areas refer to
particular physiological responses which are dependent
upon autonomic innervation. Activation of these areas
is not dependent upon the type or content of the con-
flict or stress to which the person is exposed.

On the basis of these researches it would seem
that those persons who develop a "psychosomatic" dis-
order are those whose autonomic patterns of reaction
are consistent from time to time. Lacey has not been
willing to make this assumption but he is engaged in
longitudinal research which will provide an answer on
this point. At any rate, if this is the case, those
who develop a peptic ulcer will be those whose gastric
activity is increased consistently under stress.

Secondly, there is no necessary relationship be-
tween the type of conflict situation and the physiologi-
cal system which is activated. Agy stress situation
results in autonomic overactivity. ‘Whether or not a
peptic ulcer is present is not related to the autonomi-
cally controlled physiological activity which is aroused
by a particular type of stress stimulus, as this study
has shown, but the increase in gastric acidity necessary
for ulcer formation is related to the intensity of the
stress, as Mahl (30) has shown.

At this point it seems pr0per to discuss additional

- 69 -

methods of further testing the hypothesized role of
psychological factors in the psychosomatic illnesses in
general as well as peptic ulcer in particular. It might
well be valuable if one were able to employ apparatus
which could record changes in various physiological sys-
tems in addition to the three involved in this study.
Direct assessment of the gastric responses to the stimuli
employed here is another desirable possibility. Both of
these suggestions would necessitate rather complex equip-
ment but if the technical problems could be overcome and
subjects could be obtained who were as cooperative and
patient as those in the present study, quite valuable
information should be forthcoming in regard to the general
field of psychosomatic medicine.

In this respect the apparatus used here, the Keeler
Polygraph, seems to be admirably suited for the study of
the psycho-physiological reaction patterns in the psycho-
somatic disorders which are related to the three systems
for which recordings are made. Bronchial asthma, essen-
tial hypertension, and psychogenic dermatitis are all
serious and relatively frequently encountered conditions
which are generally agreed to be subsumed under the
general heading of "psychosomatic". In such disorders
there is also considerable controversy concerning the
nature of the psychogenic factor. Research is important

in regard to these as well as other psychosomatic disorders.

SUMMARY

On the basis of a review of the literature con-
cerning the role and the nature of the psychogenic
factor in the etiology of peptic ulcer, two alternative
hypotheses were selected to be put to an experimental
test. The hypotheses were: (1) the Alexander and
French formulation that an unresolved conflict concern-
ing passivesdependent needs was the anxiety producing
conflict in persons with peptic ulcer, and (2) the
formulation presented by Mahl that the anxiety which
leads to the gastric hyperactivity necessary for peptic
ulcer formation need not result from a conflict concern-
ing passive-dependency needs alone. Rather, any stress-
ful situation might serve to activate the autonomic
nervous system and thus start the physiological chain of
events which eventuates in peptic ulcer.

In order to test these hypotheses, three so-called
"crucial" pictures and a fourth, a neutral picture, were
employed. The crucial pictures were called "Hostile",
"Passive", and "Sexual" depending upon the group from
which they evoked the greatest number of increased
autonomically mediated physiological responses. The
neutral stimulus provided the "basal" level of autonomic
activity from which changes were calculated. There were
three groups of patients in the validation study, all of
whom had been carefully interviewed and tested by an

-71-

advanced pre-doctoral clinical psychology student or a
staff clinical psychologist in a large Veterans Adminis-
tration hospital. One group of patients (N of 8) was
considered by the supervising staff clinical psychologist
to be primarily conflicted concerning the expression or
control of hostile-aggressive impulses, another group

(N of 7) exhibiting anxiety primarily as a result of con-
flicts over the expression of passive-dependent needs, and
a third group (N of 5) who seemed to have as the basis of
their anxiety, conflicts over the expression or inhibithan
of sexual impulses. It was found that when these three
groups of subjects were presented with the stimulus pic—
tures at least two of the three physiological systems
measured by the Keeler Polygraph were characterized by in-
creased activity. The increases in autonomically mediated
physiological activity in each group tended to occur with
greater than chance frequency following presentation of
the stimulus picture which was selected for its relation-
ship to the conflict hypothesized for each group.

These pictures were then presented to the peptic
ulcer and control groups. There were twenty four sub-
jects in each group. When the proportion of increased
physiological responses made by the peptic ulcer group
following the presentation of the "Passive" stimulus was
compared to the proportion of such responses made by

an apprOpriate control grOUp, there were no

'-'72-

significant differences.

This was interpreted as supporting the position
taken by Mahl and refuting the Alexander and French
hypothesis.

A re-statement of Mahl's "generality" theory con-
cerning the psychogenic factor in peptic ulcer etiology
was made on the basis of the results of the present
study as well as several others recently published. A
few general suggestions about continued research in the

area of psychosomatic disorders were offered.

(l)

(2)

(5)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(ll)

BIBLIOGRAPHY

Alexander, F., Psychological factors in gastroin-
testinal disturbances. Psychoanal.
Quart., 3:501-588, 1934.

Alexander, F., Comments on "Hydrochloric Acid Se-
cretion During Psychoanalytic Hours."
Psychosom. Med., 15:327, 1953.

Alexander, F. and French, T. M., Studies in Psycho-
somatic Medicine, Ronald, New York, 1948.

 

 

Alexander, F., and Szasz, T. S., The Psychosomatic
Approach in Medicine, in Alexander, F. and
Ross, Dynamic Psychiatry, Univ. of Chicago
Press, 1952.

 

Associated Research, Inc., Handbook of Operation
and Service: Keeler Polygraph, Chicago,
IlIinois.

 

 

Bennett, T. I. and Venables, J. F., The effects of
emotions on gastric secretion and motility
in the human being. Brit. Med. J., 2:662,
1920.

Best, C. H. and Taylor, N. B. The Physiological
Basis of Medical Practice. Williams and
Wilkins, Baltimore, 1945.

 

 

Brown, M., Bresnahan, T. J., Chalke, F. C. F.,
Peters, 8., Poser, E. G., and Tougas, R. V.,
Personality factors in Duodenal ulcer: A
Rorschach study. Psychosom, Med., 12:1-5,
1950.

Browning, J. S. and Houseworth, J. H., Development
of new symptoms following medical and
surgical treatment for duodenal ulcer.
Psychosom. Med., 15:329-336, 1953.

Cantor, A. J., A Handbook of Psychosomatic Medicine:
With Particular Reference to Intestinal
DiSorders, Messner, New York, 195I}

 

 

 

Cathcart, J. P. S., The role 0f emotions in the
production of gastro-intestinal disturb-
ances. Canad. M. A. J., 55:465, 1946.

(12)

(15)
(l4)

(l5)

(l6)

(17)

(18)

(19)

(20)

(21)

(22)

(25)

(24)

- 74 _
Darrow, C. W., The equation of the GSR Curve I.
J. Gen. Psychol., 16:285, 1937.
Dietden Compmiy, Catalog, Chicago, Illinois, 1949.

Dunbar, F., Psychosomatic Diagnosis and Treatment,
C. V. MoSby, St. LouIs, 1948.

 

Edwards, A. L., Experimental Design in Psychologi—

cal Research, Rinehart, New York, 1950.

 

 

Esquire, The Magazine for Men, Vol. XLI, No. 4,

April, 1954, Page 48.
Freeman, G. L. and Katzoff, E. T., Methodological
evaluation of the galvanic skin response
with Special reference to the formula
for R. Q. (recovery quotient). J. Exper.
Psychol., 31:239-248, 1942.
Gilbert, G. M., Unpublished seminar notes, Michigan
State College, 1953.

Hoelzel, F., Fear’and gastric acidity. Am. J. Dig.
Dis., 9:188, 194:2.

Hunt, V. A. and Hunt, E. B., A comparison of five
methods of scoring the GSR. Exper.
Psychol., 18:383-387, 1935.

Ivy, A. 0., Grossman, M. I. and Bachrach, W. H.

Peptic Ulcer, Blakiston, Philadelphia,
1950.

 

Jost, H., Ruilmann, C. J., Hill, T. 8., and Gulo,
M. J., Studies in hypertension, I:
Technics and control data. J. Nerv.
Ment. Dis., 115:35-48, 1952.

Kapp, S. T., Rosenbaum, M. and Romano, J., Psycho-
logical factors in men with peptic
ulcers. Am. J. Psychiat., 103:700-704,
1946-47.
Kirsner, J. B. and Palmer, W. L., The prdblem of
peptic ulcer. Am. J. Med., 13:615-639,
1952.

(36)

(27)

(28)

(29)

(5O)

(31)

(32)

(35)

(54)

_ 75 _

Lacey, J. 1., Bateman, D. E., and Van Lehn, Ruth,
Autonomic response specificity.
Psychosom. Med., 15: , 1953.

Lacey, O. L., An analysis of the appropriate unit
for use in the measurement of level
of galvanic skin resistance. J. Exp.
Psychol., 37: 449-457, 1947.

Lauer, A. R., Reliability of the galvanic reflex,
Amer. J. Psychol., 41:263-270, 1929.

Mahl, G. F., Effects of chronic fear’on the gastric
secretion of HCl in dogs. Psychosom.
Med., 11:30-44, 1949.

Mahl, G. F., Anxiety, HCl secretion and peptic
ulcer etiology. Psychosom. Med.,
12:158-169, 1950.

Mahl, G. F. and Karpe, R., Emotions and hydro-
chloric acid secretion during psycho-
analytic hours. Psychosom. Med.,
15:312-327, 1953.

Malmo, R. B., Shagass, C. and Davis, F. H., Symptom
specificity'and bodily reactions during
psychiatric interview. Psychosom. Med.,
11:25, 1949.

Mittelman, B., Wolf, H. G. and Scharf, M. P.,
Emotions and gastroduodenal functions.
Psychosom. Med., 4:5-61, 1942.

iurray, H. A., Thematic Apperception Test, Manual,
1945}

 

Osborne, R. T. and Sanders, W. B., Rorschach
characteristics of duodenal ulcer
patients. J. Clin. Psychol., 6:258-
262, 1950.

Poser, E. G., Personality factors in patients with
duodenal ulcers: A Rorschach study.
J. PI'Oj. TGCh., 15:151-145, 1951.

(36)

(57)

(58)

(59)

(40)

(41)

(42)

(45)

(44)

(45)

- 7e -

Rowntree, L. G., Psychosomatic disorders as re-
vealed by 13 million examination of
Selective Service registrants. Psychosom.
Med., 7:27-30, 1945.

Sandweiss, D. J. Peptic Ulcer, Section II,
Saunders, Philadelphia, 1951.

 

Seward, J. P., and Seward, G. H., The relation
of galvanic skin reactions to preceding
resistance. J. Exper. Psychol.,
18:64579, 1935.

Sines, J. 0., Experimental demonstration of the
validity of certain specific psychologi-
cal stress stimuli. Unpublished study
under the direction of Dr. G. M. Gilbert,
Michigan State College, 1954.

Sullivan, A. J. and McKell, T. B., Personality in
Peptic Ulcer, Thomas, Springfield, 1950.

 

Tilton, J., and Sines, J. 0., An attempt to vali-
date certain stress stimuli. Unpublished
study, Michigan State College, 1954.

Wechsler, D., The Measurement of Adult Intelligence,
3rd Edition, Williams and Wilkins, Balti-
more, 1944.

 

Weiss, E. and English, 0. S., Psychosomatic Medi-
cine, Saunders, Philadelphia, 1949.

 

Wilson, A. T. M., Psychological observations on
haemetemesis. Brit. J. Med. Psy.,
18:112, 1939.

Wolf, S. and Wolff, H. G., Evidence on the genesis
of peptic ulcer in man. J. A. M. A.,
120:670-675, 1942.

- 77 _

APPENDIX I

ABSTRACTS OF PSYCHOLOGICAL REPORTS ON SUBJECTS USED IN

N0.

N0.

N0.

N0.

1.

2.

5.

4.

VALIDATION STUDY

Dx: Anxiety Reaction tests, W-B, DAP, BG,
Rorschach; Age, 57; Educ., ll; I.Q., 133. In
the effective Sphere (the pt is making) --
strong efforts to control emotions which are
clamoring for expression. These impulses are
hostile in nature (and) are too threatening for
the patient to recognize. The effect of this
repression is such tension that the patient is
unable to relax and often awakens in a rigid
posture. 'When control is complete, there is an
excessive restriction of his behavior leading
to feelings of listlesmless, apathy and ina-
bility to work.

Dx: Diabetes; Age, 27; Educ., 12; I.Q. 100;
tests, W. B., Rorschach, Blacky. He appears to
have considerable difficulty with regard to
sexuality, the exact extent of which was not
determined. His main defense is denial. Sexu-
ality, which appears to be the primary source
of conflict is denied in situations in which it
is an obvious component.

Dx: Anemia; Age, 36; Educ., 10; I.Q., 97; tests,
W. B., Blacky, DAP, Mich. Inv. Sent. Apparently
the patient's major difficulty is in never having
been able to form a relationship with.anyone with
whom he could feel secure and trusting. He feels
strongly that he has never received the proper
amount of attention and care from others. The
main way the patient handles this conflict is to
withdraw. Opposed to this strong need to be
cared for is his detached rather independent
attitude.

Dx: Anxiety reaction; Age, 27; Educ., 10; I.Q.
112; One could say that this is a well organized
person with.a conflict which leads him to respond
with behavior which has strong passive—receptive
qualities when he is under stress. He is an ex-
tremely dependent individual who is not consciously
aware of these needs. This need for nurturance

N0.

NO.

N0.

N0.

5.

6.

7.

8.

-78‘-

seems, on the contrary, to be quite unacceptable
to him, but nonetheless, present.

Dx: Dermatitis; Age, 31; Educ., 12; I.Q. 124.
This men's unconscious fears of his own masculine
inadequacy seem to be derived from an over-pro-
tective mother. He tends to withdraw from
sexually problematic situations and tends to
select the most expedient solution with little
consideration of its future consequences. This
has contributed to his marital turmoil and his
divided loyalties to both his mother and wife.

Dx: Anxiety Reaction; Age, 29; Educ. l2; I.Q.
Hi Av. tests, Rorschach. The relationships this
patient has maintained with both his mother and
wife as well as the test results point toward a
strong ambivalence concerning the satisfaction
of his sexual needs. The anxiety this patient
shows seems to be related to specific environ-
mental situations which have affected his re-
lationships with his mother and wife. At the
present time he appears to have adequately re-
pressed his own sexual impulses which were
initially so anxiety arousing.

Dx: Diabetes; Age, 39; Educ. 12; tests, Rors-
chach, Blacky. The patient has a strong expec-
tancy of being taken care of by others and of
getting things from them. For some reasons he
has come to believe that showing these personal
feelings represents a weakness and he avoids
both displaying and allowing himself to become
aware of these feelings. Denial, therefore, is
an important defense he uses. Occasional recog-
nition of his uncertain position in life and of
his wanting to be taken care of, produce consid-
erable tension in him, and he is not able to
withstand such tension very long.

Dx: Atopic Exzema; Age, 37; Educ. 12; I.Q. 124;
tests, W-B and Rorschach. The most blatant
symptom evident in his performance suggests a
severe sexual conflict. This conflict is probably
on the unconscious level judging from the other
information obtained in his background. One
almost feels that this man belongs to the classi-
cal position of paranoia because of his concern

No.

N0.

N0.

N0.

9.

10.

11.

12.

-79"-

and ambivalance over his sexual impulses and
his turmoil of attempting to adjust to them.

Dx: Alcoholic Gastritis; Age, 33; Educ. 1 year
college; I.Q. 114; tests, Rorschach, W-B. Due
to the frustration of his early dependency

needs he now has an insatiable need to be taken
care of and thus others seem to reject him since
they cannot possibly satisfy that need. The
patient appears to be a passive-dependent‘in-
dividual who reacts regressively when frus-
trated.

Dx: Chrone's Disease; Age, 24; Educ. l2; I.Q.
High Aver., tests, Rorschach, Blacky. Apparent-
ly the patient is taking the line of least re-
sistance in handling his hostility, the hostility
stemming from his frustration by'both his mother,
father, and older brother. He withdraws from

and evades situations involving his hostility

and thus fails to find means of reducing the
associated tension.

Dx: Anxiety Reaction; Age 28; Educ. 10; I.Q.
Average; tests, Rorschach, Blacky. His own
very highly emotionally-toned and aggressive
impulses tend to remain at the fantasy level.
The Blacky and the Rorschach indicate strong
hostile-aggressive impulses which are beginning
to be expressed in near delusional terms. (In
Therapy) His phobias were considered to reflect
his fear of retribution for having such hostile
feelings as well as the distortions of this
hostility and were dealt with on this basis.

Dx: Epidemophytoris; Age, 40; Educ. 16; I.Q.
125; tests, W.B., B.G., D.A.P., Rorschach.

The picture here is that of a highly intelligent
individual who tends to deal with his problems
intellectually. He is troubled by feelings of
aimless drifting but is too repressed to direct
himself into a more active channel of endeavor.
He harbors strong feelings of hostility, is
somewhat detached from his fellow beings and
uses intellectualization to explain his isolah
tion. His hostility appears to have developed
out of his early family environment in which

he resented the dominance of his parents.

No.

No.

No.

15.

14.

15.

-80-

Dx: Hypoglycemia; Age, 35; Educ. 1 year college;
1.0. superior; tests, M.M.P.I. and Rorschach.
Both tests indicate the existence of severe
anxiety which has become intense enough to inter-
fere with his general efficiency. The most
probable source of the present anxiety seems to
involve the ambivalence this man has developed

as well as the environmental frustration of

his generalized passive-dependent orientation
toward life. He has never actively sought to
completely care for himself but at present

seems to be seriously grappling with the need

and possibility of doing so.

Dx: Anxiety Reaction; Age 35; Educ. 3rd; Occup.,
Factory; Married. Emotionally there is an ex-
treme sensitivity to affective stimulation.

The patient's reactivity to such stimulation is
poorly controlled and can be characterized as
immature and egocentric. Hostile impulses,
thus far controlled, seem to be gaining ex-
pression more directly. Explosive outbursts
may be expected. The patient seems aware of
this tendency but apparently lacks any control
other than withdrawal to COpe with it. It
appears from the tests and clinical behavior
that this is a chronic condition in which
periodic episodes of disorganized behavior

will occur. The patient is extremely pre-
occupied with his condition and is desperately
seeking for some reasonable answer.

Dx: Nervousness; Age, 32; Educ. 8th; Occup.
Truck driver; married; white. The disturbance
of the cognitive processes is paralleled by a
disruption in the patient's emotional controls.
At present he is virtually at the mercy of
violent aggressive impulses. He attempts to
maintain control by withdrawal from inter-
personal associations and by attempts at com-
pulsive ordering of his environment. Direct
repression is attempted but seems very inade-
quate. The patient is so driven by his impulses
and his controls are so ineffective that he must
feel perpetually as if he had the proverbial
lion by the tail.

No.

No.

No.

16.

17.

18.

-81..

Dx: Anxiety Reaction, Acute; Age, 30; Educ.
11th; Occup. Factory Semi-skilled; Single;
Tests, Blacky, Rorschach. This patient's re-
sponses to psychometric tests point to a definite
disturbance in the sexual sphere. There are
indications also of inadequate identification
with a male.figure. This information in con-
junction with the nature of the situation
immediately preceding onset of the present
episode provide the basis for considering his
present state to be essentially a homosexual
panic.

Dx: Psychoneurosis, Anxiety; Age 28; Educ. 10th;
Occup, Cab driver; married; I.Q., 102; Tests,
W-B, Rorschach, MMPI; The present hospitaliza-
tion is the patient's third. The precipitating
situation seems to have been an attempt on the
part of the patient to assume the major responsi-
bility for supporting his family and himself.
Each occasion was preceeded by either his wife's
pregnancy or his being given greater responsi-
bility in his previous jobs (construction labor
and a small factory). It would appear, from
both the testing and the history, that the
patient is unable to function adequately unless
some other person (his wife or his employer)
assumes the dominant role in directing his life.
The patient appears to have no insight into his
reactions and psychotherapy is deemed to be of
questionable value.

Dx: Situational Maladjustment in a passive
dependent personality. Age, 38; Educ. 6th,
Occup, Heavy Machine Operator; Tests, W-B,
Rorschach, MMPI; I.Q., 96; The most outstanding
characteristic to be noted is the free-floating
anxiety which is closely related temporally to
the patient's seasonal layoff and most recently
to his wife's surgery. He gives a history of
adequate adjustment when employed under close
supervision but has repeatedly failed to adjust
when self-employed. The man may be described
essentially as a follower who is unable to
assume anything other than a subordinate role.
At present he is entirely willing to continue
in this status.

No.

No.

19.

20.

- 82 L

Dx: Schiz0phrenic Reaction, Simple Type; Age
39; Educ. 8th; Occup. handyman; Single; Tests,
W-B, Rorschach, MMPI; I.Q., 111; The history of
panhandling, occasional alcoholism, extremely
unstable employment and mildly seclusive be-
havior in combination with.the Rorschach results,
notably such responses as explosions, atomic
bombs, flying bullets and radar waves seem to
indicate a SchiZOphrenic reaction. The veteran
carries the diagnosis of Psychoneurosis, con-
version hysteria which appears inappropriate

at this time. Reason for this hospitalization
is the fact that this man was arrested for
assault following an unprovoked attack on a by-
stander in a local bar.

Dx: Alcoholism; Age, 40; Educ. 9th; Occup.
painter; Married; Tests, W-B, MMPI; I.Q. 108;
Under the influence of alcohol this patient

has repeatedly become argumentative and assaultive,
both with his family and others. Following such
episodes he is remorseful and his wife has agreed
to accept him back only if he seeks hospital
treatment first. The history indicates a long
standing tendency on his part to get into diffi-
culty with authority figures, especially when
drinking, but on other occasions as well. It

is only while drinking, however, that the patient
openly expresses the hostility which is usually
at least partially controlled.

- 83 -

APPENDIX II

Neutral Stimulus

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s a, we.

 

-34 -

Hostile Stimulus

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1
u
m
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Passive

 

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