Hftilti-Disciplinary JournalofResearch andDevelopment PerspectivesVol. 2 No 1, June 2013

STRESS AND FRUSTRATION TOLERANCE DIFFERENTIAL IN PEPTIC ULCERDISEASE (PUD) AND NON-PEPTIC ULCER DISEASE INDIVIDUALS IN JOS

HARUNAKARICKZubairu Kwambo Dagona

And

YOHANNA GYARAZAMADepartment ofGeneral and Applied Psychology, University ofJos, Jos

ABSTRACT

ofStress andfrustration tolerance on peptic ulcer disease(JrUD) usingapopulationsample of200. The sample was made up of113 male (56.6%) and87jemale (43.5%) randomly selectedfor the study. Itemployed a multi-factorial design. The

Scale (FTS) was used as a measure offrustration tolerance, whileDA88-42was used as ameasure ofpsychological stress level. Results indicatedasignificantrelationship between Frustration Tolerance, Stress and Peptic Ulcer Disease, rho =-.583, p-0.00(stress);rho=-.644, p =0.000 (frustration tolerance); there was asignificant differencein the level offrustration tolerance between PUD and non-PUD respondents, t =10.955, p-0.000; and there was a significant difference in the stress level ofPUD and non-PUDparticipants, t =9.626, p =0.000. It is therefore suggested that strategies aimed at improvingsocialsupportshouldbe encotiragedso as to impacton coping withpsychologicaldistress andultimately improve health outcomes inpatients with PUD.

Introduction

Peptic ulcer disease (PUD) occurs inapproximately 10 percent of the populationand the peak ages have been identified as 40-60 years (Murphy - Blake &Hawks, 2005).Thoughthe incidence ofduodenalulcershasdropped significantly during the past30years, the incidence of gastric ulcers hasshown a small increase, mainly caused bythe widespreaduseofNSAIDS.

Some studies have foundcorrelations between smoking and ulcerformation (Kurata, John &Nogawa, 1997);others are irregular diet; spice consumptionandblood type (National Digestive DiseasesInformation Clearinghouse (NDDIC)).Similarly, while studies have found thatalcohol consumption increases risk whenassociated with H. pylori infection, it doesnot seem to independently increase risk andevenwhen coupled withH. pylori infection,the increase is modest in comparison to theprimary risk factor (Sonnenberg, Muller-Lissner, Vogel, Schmid, Gonvers, et al,1981).

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Researchers have continued tolookat stressasa possible causeorat leastacomplication in the development of ulcers.There is ongoing debate as to whetherpsychological stress can influence thedevelopment of peptic ulcers. Despite anincrease in the incidence of peptic ulcerdisease and number ofdeaths occurring asaresult of thisdiseaseinoursociety inrecenttime, little had been done to examine therole oftolerance for frustration and stress inthe development of this disease. Studies inan urban hospital in Northern Nigeriaproduced incidence of uppergastrointestinal of32.7% (Andrew, Dixon,lya,&Park, 1995), 35.6% inZaria,(Malu,Wali, Karim, Macaulay & Fakunle, 1990),and 65.13% in Enugu (Picardo andNwokediuko, 2001). But the incidenceratewas lower among children in NorthernNigeria (Holcombe, Omotara, Eldbridge &Jones, 1993)

Nevertheless, apart from the role ofH.pylori in the developmentof the diseasethe effects of frustration tolerance andstress have hardly been analysed. It is

Multi-Discipiinarv Journal ofResearch and Development PerspectivesVol. 2 No I, June 2013

Stress seems to have variable

effects on gastric motility. Delay in gastricemptying could increase the risk ofgastriculcer, while accelerated emptying couldincrease the net acid load delivered to theduodenum at any given level of gastricsecretion, enhancing the risk of duodenalulcer(Dubois& Castell, 1981).

Studies have also shown that oncean ulcer has developed, therapy is lesseffective in distressed individuals(Levenstein, Prantera, Scribano, et al,1996). Research into the influence ofstresson wound healing elsewhere in the bodylends insight into possible mechanisms.Restraint-stressed mice heal more slowlythan control mice, with lower leukocyteinfiltration of theirwoundsites,apparentlybecause of increased glucocorticoidsecretion affecting proinflammatorycytokines. (Padgett, Marucha& Sheridan,1998).

Martinez-Augustin, Sanchez andSanchez (2000) summarized studiespublished over the last twenty years on theeffects of psychogenic stress ongastrointestinal function, using animalmodels. Their finding indicated that effectsof stress on gastric ulceration havereceived wide attention and the central andlocalmechanisms ofmucosal damage havebeen, for the most part, clearly delineated.In comparison, relatively few studies havefocusedonthe impactofstress on intestinal'and colonic physiology, even though itsinfluence on intestinal motility, mucosalpermeability and inflammation has beenestablished.

In another study, Mawdsley andRampton (2004) examined psychologicalstress on increase disease activity ininflammatory bowel disease (IBD), theirfindings suggest that stress inducedalterations in gastrointestinalinflammation may be mediated throughchanges in hypothalamic-pituitary-adrenal(HPA) axis function and alterations inbacterial-mucosal interactions, and viamucosal mast cells and mediators such ascorticotrophin releasingfactor(CRF).

Furthermore, Fernandez (2006) in

against this backdrop that the study seeks toinvestigate the influence of psychologicalstress level and Frustration Tolerance in thedevelopment of Peptic UlcerDisease(PUD)among the people ofJos, Plateau State.

Stress and Peptic ulcer DiseaseA large body of research has

examined the effect of stress on the uppergastrointestinal tract in animal models.Though most such models producesuperficialgastric lesions, enough is sharedwith chronic human peptic lesions to haveconsideration ofevidence from these modelsworthwhile. In rats, susceptibility to gastriclesions is increased by such social stressorsas premature separation of the rat pup fromits mother (Ackerman, Hofer & Weiner,1975). In the same vein, in rats taught toavoid ulcer-producing electric shocks byoperant responses, the occurrence oflesionscan be dr^tically reduced if the animalrelieves more information abouttheefficacyof its response, demonstrating thatperceptions and their integration intoretrievable information affect the course ofulcerformation (Weiss. 1971).

Among potential mediators, severalknown behavioural risk factors for ulcersuch as smoking, alcohol abuse and lack ofsleep have clear associations with real-lifestress and are known to impair woundhealing through their effects on immunefunction (Veldhuis &Iranmanesh, 1996)sleep loss can also increase cortisol levels.Individuals understress mayalsobelikely toincrease NSAJD use(Levenstein, Kaplan &Smith, 1997).

From the physiological view pointstress isknownto modifygastric blood flowwhich playsan importantrole in the gastricmucosal barrier and to affect possiblemediators such as thyrotrophin-releasinghormone, cytokines and corticotrophin-releasing hormone. Stimulation of gastricacid secretion has historically beenconsidered another mechanism by whichstress increases susceptibility to duodenalulceration and researchers have reportedincreases in acid secretion in associationwith psychosocial stressors (Peters &Richardson, 1983).

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a review indicated that clinical and animalstudies showed that stress can contribute totheonsetand/or theworsening of thecourseof inflammatory bowel diseases (IBD). In amodel (immobilisation stressfor6 hours) inrats it has been demonstrated that stressincreases colonic inflammatory damage, aswell as anti-inflammatory prostaglandinsand of the nuclear receptor PPARgamma.This inflammation is followed by anincrease in the permeability of the colonicmucosabarrierand a decrease in IgAlevels.All these parameters contribute to thebacterial translocationto otherorgans.

Similarly, Goodhand andRampton (2008) in a review indicated thatthere was increasing evidence thatpsychological stress and associated mooddisorders are linked with, andcanadverselyaffect the course of inflammatory boweldisease (IBD). Of 11 longitudinal studies ofthe effects of stress or depression on thecourse of IBD, most suggested that stressworsened IBD, the* rest giving eithernegative or inconclusive results. If stressdoes have an adverse effect on the naturalhistory ofIBD, then measures which reducestress shouldhelp symptomsand activityofIBD. Unfortunately, because ofmethodological difficulties inherent inundertaking appropriately targeted andblinded trials, good data about the effects onIBD of interventions aimed to amelioratestress and mood disorders are limited.Emerging trial evidence supports thesuggestion that psychologically orientatedtherapy may ameliorate IBD-associatedmood disorders, but there is no strong datayet to indicate that stress management has abeneficial effect on the activity or course ofIBD.

The study therefore examined thefollowing hypotheses:

1. An association will be found

between fhistration tolerance, stressand peptic ulcer disease.

2. Non-peptic disease participants willhave a significant higher level offrustration tolerance than pepticulcer diseased participants.

3. Participants with peptic ulcer

disease will have a higher level ofstress than non-peptic ulcerparticipants

METHOD

ParticipantsA total of 200 participants

participated in the study: 113 males(56.5%). and 87 females (43.5^^. Theminimum age was 17 years, maximumage70 years with a mean age of43.5. The ideanage for male was 43.5 while that of thefemale was 41. Majority ofthe participants(65) fell within the age range of 17-37years. Sixty-seven percent of thep irticipants had attained tertiary education,35% were students and 29% were civil

servants. Also, 29% of the participants hadmoderate stress, 7.5% had severe stress and1% had extremely severe stress. Fifty pointfive percent of the participants had pepticulcer and 40.5% were non-peptic ulcerparticipants. It covers The sample wasdrawn from Dogon Dutse, AngwanRukuba, YanTrailer and Nassarawa Gwongareas ofJos metropolis Churches were usedwithin these areas to get participants.

DesignThe study was a single factor study with

two levels namely: peptic ulcer disease(Peptic Ulcer disease participants and nonpeptic ulcer participants). There were twodependent variables Frustration Toleranceand Stress.

Materials

The research materials used were

questionnaires.Depression Anxiety Stress Scale (DASS

42.) using the 14 Stress items from thescde, and The DASS-42 consists of 14items of stress scale and each item had 4response options: Did not apply to me at all.Applied to me to some degree or some ofthe time, applied to me a considerabledegree or a good part of the time, andApplied to me very much or most of thetime. The scores or the 4 responses are: 0,1,2, and 3 respectively.

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Perceived Stress Scale (PSS 10),Theperceived stress scale (PSS 10) is a measureofFrustration Tolerance and consisted of 10itemsand each item had 5 responseoptions:Never, Almost never. Sometimes, Fairlyoften and Very often. The scores for theresponses were: 0,1,2,3, and 4 respectively.From both scales the higher the total score ofthe participant the higher the possibility ofpeptic ulcer occurring.

Procedure

Since churches were used to getparticipants, the researchers had audiencewith individual clergymen in charge of thefollowing churches COCIN Church YanTrailer, ECWA Church Angwan Rukuba,Gospel Church Dogon Dutse and GoodnewsChurch Nassarawa. After getting clearancefrom them, the process of administering thequestionnaires commenced as follows: atime table was created involving fourchurches as follows.

CCYT (First Sunday) 10:00am -12:00noon

ECAR (Second Sunday) 12:00noon-2:00pmGCDD (Third Sunday) 10:00am -12:00noon

GNCNG (Fourth Sunday)12:00noon—2:00pmThe researchers attended Sunday

services in the four churches after beinggranted approval by the Ministers. Two

Table 2: Correlation matrix

volimteers helped \vith the selection(which was by balloting) of participantsand distribution ofquestionnaires. In eachof the designated churches, fifty (50)participants were selected. There was nodrop out in the selected participants.Theirquestions were also addressed at the end ofthe exercise.

RESULTSThe data collected was subjected

to two statistical techniques. This enabledthe researchers to test their hypotheses.The two techniques were correlations andt-test unrelated

Frustration Tolerance,Stress andPepticUlcerDisease

An association will be found between

frustration tolerance ulcer disease andstress and peptic ulcer disease. Thehypotheses were tested with theSpearman's correlation matrix. Resultsindicated ^a significant relationshipbetween frustration tolerance, stress andpeptic ulcer disease, rho = -.583, p = 0.00(stress) rho = -.644, p = 0.000 (frustrationtolerance). Table 2 present the correlationmatrix.

-

Stress Frustration

tolerance2 PUD level Correlation -.583 -.644

coefficient .000 .000

a Sig. (1tailed) 200 200N

Frustration Toleranceand Peptic UlcerDiseaseNon-peptic disease participants will have a significant

level offrustration tolerance thanpeptic ulcer diseased participants.

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higher

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Table 3: Shows the mean values of frustration tolerance

N Mean Standard

deviation

Non-peptic ulcer diseasedparticipantsPeptic ulcer disease participants

99

101

21.08

15.03

3.778

4.029

Table 4: Showing t-test

T Df Sig.Frustration tolerance 10.955 196 0.000

The independent t-test resultsindicated that there was a significantdifference in the level of frustrationtolerance between PUD and non PUD, t =10.955, p = 0.000. This means thatparticipants with PUD had a lowerfrustration tolerance level thanparticipantsthatdidnothavepeptic ulcer disease.

Stress and Peptic UlcerDiseaseParticipants with peptic ulcer

disease will have a higher levelof stress than non-peptic ulcerparticipants

Table 5: Shows the mean values of frustration tolerance

N Mean Standard

deviation

Non-peptic ulcer diseasedparticipantsPeptic ulcer disease participants

99

101

12.4

20.25

5.313

6.087

Table 6: iShowing t-test

T Df Sig.stress 9.626 198 0.000

The result indicates that there wasa significant difference in the stress levelofPUD and non-PUD participants, t =9.626, p = 0.000. This implies that pepticulcer participants have a high level ofstress than non-peptic ulcer participants.DISCUSSION

Findings from the analysis of thehypotheses indicated that there was asignificant relationship between frustrationtolerance, stress and peptic ulcer disease,there was a significant difference in the leveloffiiistration tolerance between peptic ulcerdisease (PUD) and non PUD, and there wasa significant difference in the stress level of

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PUD and non-PUD participants. Thesefindings in hypothesis one is consistentwith the findings of Mawdsley andRampton (2004) which indicated thatpsychological stress was related todisease activity in inflammatory boweldisease (IBD), and also predict increasesin psychological wellbeing and health(Affleck &Tennen, 1996). Also, thestudy of Vidal; Gomez-Gil; Sans,Portella, Salamero, Pique and Panes(2005) that found associations betweenstressful life events or the emotional

impact of life events with peptic ulcerdisease relapses.

Multi'Disciplinary Journal ofResearch and Development PerspectivesyoL 2 No I, June 2013

drop out in the selected participants.Their questions were also addressed at theend ofdie exercise.

RESULTS

The data collected was subjected totwo statistical techniques. This enabled theresearchers to test their hypotheses. The twotechniques were correlations and t-testunrelated

Frustration Tolerance, Stress and PepticUlcerDisease

An association will be found between

frustration tolerance ulcer disease and stress

Table 2: Correlation matrix

and peptic ulcer disease. The hypotheseswere tested with the Spearman'scorrelation matrix. Results indicated asignificant relationship betweenfrustration tolerance, stress and pepticulcer disease, rho = -.583, p = 0.00 (stress)rho = -.644, p = 0.000 (frustrationtolerance). Table 2 present the correlationmatrix.

Stress Frustration

tolerance

PUD level Correlation -.583 -.644

coefficient .000 .000

Sig. (1 tailed) 200 200

N

Frustration Toleranceand Peptic UlcerDiseaseNon-peptic disease participants will have a significant higher

level offhistration tolerance than peptic ulcer diseased participants.

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Multi'Disciplinarv Journal ofResearch and Development PerspectivesVol.2 No I, June 2013

Table 3: Shows the mean values of frustration tolerance

N Mean Standard

deviation

Non-peptic ulcer diseasedparticipantsPeptic ulcer disease participants

99

101

21.08

15.03

3.778

4.029

Table 4: Showing t-test

T Df Sig.

Frustration tolerance 10.955 196 0.000

The independent t-test resultsindicated that there was a significantdifference in the level of frustration

tolerance between PUD and non PUD, t =10.955, p = 0.000. This means thatparticipants with PUD had a lowerfhistration tolerance level than participantsthat did not have peptic ulcer disease.

Stress and Peptic Ulcer DiseaseParticipants with peptic ulcerdisease will have a higher levelof stress than non-peptic ulcerparticipants

Table 5: Shows the mean values of frustration tolerance

N Mean Standard

deviation

Non^peptic ulcer diseasedparticipantsPeptic ulcer disease participants

99

101

12.4

20.25

5.313

6.087

Table 6: Showing t-test

T Df Sig.

stress 9.626 198 0.000

The result indicates that there was

a significant difference in the stress levelofPUD and non-PUD participants, t =9.626, p = 0.000. This implies that pepticulcer participants have a high level ofstress than non-peptic ulcer participants.DISCUSSION

Findings firom the analysis of thehypotheses indicated that there was asignificant relationship between frustrationtolerance, stress and peptic ulcer disease,therewasa significant differencein the leveloffrustration tolerance between peptic ulcerdisease (PUD) and non PUD, and tiiere wasa significantdifference in the stress level of

PUD and non-PUD participants.These fmdings in hypothesis one isconsistent with the findings ofMawdsley and Rampton (2004) whichindicated that psychological stress wasrelated to disease activity ininflammatory bowel disease (IBD), andalso predict increases in psychologicalwellbeing and health (Affleck &Tennen,1996);Also,- thestudyofVidai,- Gomez-Gil, Sans, Portella, Salamero, Pique andPanes (2005) that found associationsbetween stressful life events or theemotional impact of life events withpeptic ulcer disease relapses.

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The outcome of this predictioncould be based on the fact that severalresearch methodologies indicated thatresilient individuals have optimistic,zestful, and energetic approaches to life,are curious and open to new experiences,and are characterized by high positiveemotionality or affect (Block &Kremen,1996), also, further evidencesuggests thathigh-resilient people proactively cultivatetheirpositive emotionality bystrategicallyelicitingpositiveemotions through the useof humour (Wemer & Smith, 1992),'Positive affect then, emerges as animportant element of psychologicalresilience and coping with daily stresswhichin tum reducespepticulcerdisease.

The outcome of the secondprediction indicates that there was asignificant difference between peptic ulcerdisease (PUD) patients and non-PUDpatients in their fhistration tolerance level.This conforms with Fredrickson's, (2001)broaden-and-build theory of positive andnegative affectwhichposits that negativeemotions narrow one's momentarythought-action repertoire bypreparing oneto behave in a specific way for example,attackwhenangry,escapewhenafraid;andJonas, Franks and Ingram (1997) foimdthathighlevels ofanxiety (negative affect)were associated with two to three timesgreater risk of hypertension andgastrointestinal infections in Whites andBlacks, relative to their less anxiouscounterparts. It also, conforms to findingswhich shed light on the many ways inwhich positive and negative emotions areinterconnected in times of stress (Zautra,2003; Zautra, Affleck, Tennen, Reich, &Davis, 2005)

The outcome of the secondpredictioncouldbearguedon thefact that itis possible that certain individuals have agreater tendency to draw on negativeemotions than their positive emotions intimes of stress, andnotunderstanding andusing positive emotions to their advantageratherthandwellintheirnegative emotionsasaresults ofstressful factors suchasbeingdiagnosedwithpepticulcerdisease.

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The findings on the thirdpredictionindicated thatPUDpatientshada significant higher stress level than non-PUD participants. This supports thefindings of Beasley, Thompson andDavidson(2001)which supported a directeffects model of the relationship betweenlife stress and physiological health.Cognitive hardiness, aspects of copingstyle and negative life events directlyimpacted on measures of physiologicaland somatic distress. It also conforms withFurthermore, Femandez (2006) whichindicated that clinical and animsd studiesshowed that stress can contribute to theonset and/or the worseningofthecourseofinflammatory bowel diseases (IBD).Similarly, Rampton (2008) in a reviewindicated that there was increasingevidence that psychological stress andassociatedmooddisorders are linkedwith,and can adversely affect the course ofPUD. Sumanen, Koskenvuo, Sillanmakiand Mattila (2009) showed that the mostcommonadversities among PUD patientswere long-lasting financial difficulties inthe family, serious conflicts in the family,and a family member seriously orchronically ill.Alltheadversities reported,except parental divorce, were morecommon among peptic ulcer patients thanamong controls. Age- and sex-adjustedodds ratios of childhood adversities forself-reported peptic ulcer varied betweenPUDand non-PUDpatients.

Although clinical psychology haslately tended to be overshadowed bymicrobiology in explaining the genesis ofpeptic ulcer, the suspicion that life stressmight trigger peptic has not been entirelyblotted out. The findings nourish thatsuspicion:psychologicalstressandseveralconcrete life difficulties do predispose toulcer development in general population.Inthe case ofpeptic ulcer, the "nfid-body"connection. makes. sense., Stress .could.,favour ulcers either through psycho-neuroendocrine mechanisms byincreasing gastric acid secretion (Peters, &Richardson, 1983) or via behaviourchanges: increased smoking increased

Multi-Disciolinarv Journal ofResearch and Development PerspectivesVoL 2 No 1, June 2013

drinking (Levenstein, Prantera, Varvo,Spinella, Arca&Bassi, 1992) and perhapsirregular meals. The findings lend somesupport to all the hypotheses becauseadjustment for health risk behaviourreducesthe predictivevalue oflife stress inpart.

Conclusion

The present findings providesinitial evidence that an individual'sPsychological stress may contribute to thedevelopment of peptic ulcers, possibly byincreasing the secretion of gastric acidandpepsin. It is notknown, however, whetherthis mechanism is applicable to everyone oronly to certain susceptible people(Shiotani& Graham, 2002).It is alsopossible that this association is accountedfor, at least in part, by the increasedlikelihood of Helicobacter pylori infectionin people with lower socioeconomicbackgrounds (Sonnenberg, 1997), which isin turn related to the number of childrenliving in the family - children seem topromote the spread of the infection withinthe household. In conclusion, the objective,observable life difficulties, such aspsychological stress and frustrationtolerance, contribute to the aetiology of atleast some ulcers and that their contributioncannot be explained away by thedifferential distribution of known riskfactors. Thesefindingslend credenceto theconcept of a relationship betweenpsychological stress andpeptic ulcer.

LimitationsLimitations ofthe study include the

method used to collect data, the accuracy ofthe data provided by respondents to thesurvey questionnaires. Another limitationof thestudy wastheuseof a Likertscale onthesurvey questionnaires. The Likert scaleused in the study creates pre-definedresponse boundaries, with - respondentsunable to provide other data possiblyrelevant to thestudy. Also,thesmallsamplesize and the use of correlation andregression statistics in testing of aprediction inthe study inhibit the ability to

draw meaningful conclusions that gobeyond speculation about the proposedrelationships. Theuseof questionnaires toscreen the participants was anotherdrawback. As all the cohort members didnotundergo endoscopy, these ulcers couldbe missed.

RecommendationsBased on the findings and

limitations in the present study, futurestudies are needed to determine thepractical predictive significance ofpsychological stress and other healthchallenges among college students andvarious other populations. These studiesshould evaluate the presence of actualcausative factors that shows the effect ofstress and positive and negative effectonthe coping strategies of individuals inhandling their respective stress levels. Theuse endoscopy to screen futureparticipants is highly recommended.More research into resilience factors incoping with stress should focus more onthe health implications in interpersonalrelationships as this forms an importantbase on societalgrowthand development.Also, behaviours that are motivated bynegative emotion can also have immediateand/or long-term effects on physiologyand health. The use of psychologicaltherapies in the management of pepticulcer disease should be used alongsidephysiological drugs ormedications.\

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