Stress, Ulcers and Evidence-Based Medicine

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Up until the 1980’s doctors believed that ulcers were caused by stress and eating spicy foods. Now, thanks to a couple of Australian scientists who won a Nobel Prize for their work, stomach ulcers are no longer considered to be a mind-body issue, but strictly the result of an infection that can be easily cured with antibiotics. And yet, according to the Center for Disease Control (CDC) 16,000,000 adults reported having ulcers in the year 2014 alone.

In a recent article in the NY Times, writer Catherine Saint Louis describes her own battles with an ulcer and the advice and treatment she received. She talks about having pain so intense she was driven to chugging cartons of milk and doubling over in agony on a subway platform. This drove her to see a gastroenterologist who, after diagnosing her, stated unequivocally: “there’s absolutely no evidence that psychological stress or anxiety causes an ulcer.”

This paragraph from an article US NEWS and world report sums up the mainstream medicine position on ulcers:

The key cause of most ulcers is now believed to be infection with a common bacterium called Helicobacter pylori or H. pylori. Although the mechanism by which H. pylori leads to ulcers is not fully understood, scientists believe the bacterium causes chronic inflammation of the stomach…allowing acid to cause a sore, or ulcer, in the lining. Once an individual has been infected with H. pylori, the infection continues indefinitely until it is eradicated with antibiotics. In the United States, an estimated 30 percent of the population is colonized with H. pylori; 1 in 6 will develop ulcers.

Despite the fact that H. pylori is considered to be the cause of most ulcers, a significant number of people still get ulcers when there is no h. pylori present in their digestive system. That’s exactly what happened to Catherine Saint Louis who wrote the New York Times article. Her doctors said her ulcer was “idiopathic” which means they have no idea why she got it.

Dr. David Katz, head of the Yale Prevention Center, once told me that when you go to your doctor and he or she (after running a battery of tests) doesn’t know WHY you are feeling sick, that’s when it’s time to start considering whether stress is the cause. I’m not sure he’d agree with me specifically about this case, but in principle you can see how he might ask the patient about her stress levels in this example. Also, whenever I hear the word idiopathic, for the same reasons, I think the issue might be stress-related. Idiopathic alopecia ariota, for example, is when your hair falls out in clumps, often times the result of stress.

Secondly, there are millions of people with H. pylori bacterium in their guts and yet only a very small percentage of those people develop ulcers. So how does H. pylori cause ulcers in some cases and not in others? And as I said before, how can you NOT have H. pylori in your system and still develop ulcers? These questions, which remain unanswered, lead us again to the suggestion that PERHAPS stress might still be involved with the onset or exacerbation of ulcers. After all, stress has been shown to cause inflammation, which according to the article in US NEWS and WORLD REPORT is a key cause of ulcers.

I have a feeling that a lot of doctors don’t want to touch the subject of stress with a ten foot pole because they know so very little about it. Thus, they make definitive statements like: stress has nothing to do with your condition, so as to not confuse you or have you underestimate the seriousness of your condition. I suppose the thinking here is the outdated notion that “stress is all in your head.”

The words psychosomatic illness got dropped from common parlance for precisely this reason. Psychosomatic was perceived by most people (including doctors) as meaning it’s all in your head. That’s just not true. Psycho means mind and somatic means body. Stress-related illness (caused by psychological stress) may begin in the mind but it manifests inside your body, no different or less real than any other physical illness.

The first thing that doctors swear to do is uphold the Hippocratic Oath which deplores quackery in all forms by making doctors promise to “first do no harm.” So it would be unethical for any doctor to recommend a treatment that wasn’t “evidenced-based.” This may explain why doctors fret about suggesting relaxation techniques, meditation and yoga as a prescription for problems they suspect might be stress-related. These methods are hard to study (particularly in double-blind studies) and we just don’t have enough rock-solid evidence to support their use as a substitute for a pharmaceutical approach, which we have TONS of evidence to support.

Yet when it comes to stress-related, psychosomatic illness, these mind/body methods may in certain cases be the only treatments that actually address the SOURCE of the problem and certainly the only ones that can make the promise to “first do no harm.” Most pharmaceutical (evidenced-based) treatments include side effects. (Even antibiotics have side effects: think yeast infections.) And yet, there was a time, not so long ago, when taking an antibiotic to cure ulcers was NOT considered to be “evidenced-based.” It took an Australian scientist to drink a foul concoction containing a ton of H.pylori bacteria, (and then recover from the resulting ulcer by taking antibiotics) to convince the rest of the world that this form of treatment worked.

So what is and what is not considered “evidenced based medicine” is shifting all the time.*

But, if you think you have an ulcer, by all means see your doctor. And you should absolutely follow his or her “evidenced based” advice, because an ulcer, if left untreated, could become life-threatening. So take the antibiotics or whatever treatment is suggested to remove the immediate threat of something much worse happening to you if you don’t. Still, take into account whether you think stress might be a factor in your condition. If you do, consider integrating some of the interventions I described above, like meditation, yoga, and relaxation techniques as an adjunct to whatever your doctor advises you to do as well.

*For example the CDC is NO LONGER recommending that men get PSA tests to test for prostate cancer who have no symptoms of prostate cancer. In this case, evidence based medical advice is shifting.

So it’s quite possible, that at some point in the future, there might be a shift in regards to stress in ulcers. Already gastroenterologists are practicing what is being called “psycho-gastroenterology” where they recognize the mind/body component in their patient’s illnesses and are now prescribing anti-depressants to some people with irritable bowel syndrome.

This is one of those classic off-label applications of a pharmaceutical drug that doctors are allowed to do, if they believe that the prescription will help their patients in any way. When you have enough success with these off-label uses, the pharmaceutical company who makes it is highly motivated to run a double blind study to prove it. Now you have the same medicine (usually with a new name) used to treat something entirely different than what it was originally designed to treat. This happened when one pharmaceutical company started repackaging a particular anti-depressant as a treatment for social anxiety. This is how evidence-based medicine shifts.

Keep in mind, it’s the open-minded doctor who makes these connections and DOESN’T practice evidence-based medicine (by prescribing something off-label) that sometimes leads to a breakthrough that becomes evidenced-based. That’s exactly what happened with antibiotics and ulcers.

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