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APP| Published By AEIRC| https://doi.org/10.29052/2412-3188.v7.i1.2020.25-30 

Ann. psychophysiol. 
ISSN 2412-3188 (Online) | 2410-1354 (Print) 

 
 
Original Article                                                                                  

Relationship of functional dyspepsia with 
mental and physical stress 
Prem Shankar, Nikeeta Mandhan, Syed Muhammad Hussain Zaidi,  
Muhammad Saad Choudhry & Akshay Kumar  
Dow Medical College, Dow University of Health Sciences (DUHS), Karachi-Pakistan.  
 

Abstract 
Background: Functional Dyspepsia is a globally prevalent illness, which although 
not life-threatening, displays a strong influence on the quality of life. Functional 
Dyspepsia is essentially chronic indigestion with no obvious physical cause. The 
objective of this study was to evaluate the frequency of functional dyspepsia and 
its association with mental and physical stress. It could have the same significant 
association as Irritable Bowel Syndrome has with stress. 
Methodology: The data were collected from 221 students from 3 medical colleges 
of Karachi, Pakistan. Subjects were asked to fill out questionnaires concerning 
demographics, lifestyle, and dietary habits. Rome III criteria was employed to 
identify functional dyspepsia and sub-sections of the Sadaf Stress Scale (SSS) was 
used to measure mental and physical stress.   
Results: Out of the 221 subjects majority were females (67.4%) with a mean age of 
21.47 years. 34.8% of subjects were diagnosed to have functional dyspepsia, out of 
which around three quarters were females (68.5%). A moderate positive 
correlation was observed between functional dyspepsia and mental and physical 
stress. 
Conclusion: It is concluded from the study results that there is a high frequency 
of functional dyspepsia among individuals with mental and physical stress or 
functional dyspepsia might cause the stress. 
 

Keywords 
Functional Dyspepsia, Physical Stress, Mental Stress, Sadaf Stress Scale (SSS), 

Rome III Criteria. 

 

 

 

Citation: Shankar P, Mandhan N, Zaidi 
SMH, Choudhry MH & Kumar A. APP. 
2020; 7(1):25-30 
 
Corresponding Author Email: 
mohdzaidi06@hotmail.com 
 
DOI: 10.29052/2412-3188.v7.i1.2020.25-30 
 
Received 16/02/2020 
 
Accepted 02/09/2020 
 
Published 01/10/2020 
 
Copyright © The Author(s). 2020 This  
 is an open access article distributed under 
the terms of the Creative Commons 
Attribution 4.0 International License, 
which permits unrestricted use, 
distribution, and reproduction in any 
medium, provided the original author and 
source are credited.  
 

 

Funding: The author(s) received no 
specific funding for this work. 

Conflicts of Interests: The authors have 
declared that no competing interests 
exist. 

 

http://creativecommons.org/licenses/by/4.0/)
http://creativecommons.org/licenses/by/4.0/)


 

   

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APP| Published By AEIRC| Volume 7 Issue 1  

 

ISSN 2412-3188 (Online) | 2410-1354 (Print) 

 

Introduction  
Functional Dyspepsia is a common 
gastrointestinal disorder characterized by 
chronic indigestion with no obvious physical 
cause1. It is usually referred to as a diagnosis 
of exclusion, which is made when all 
required investigations reveal no identifiable 
etiology1. The condition is multifactorial and 
therefore the etiological factors are diverse. 
Globally, the prevalence lies in between 
11.3% age ≥ 60 years compared  to 9.9% with 
patients aged below 60, whereas in Asian 
regions the reported frequency is in between 
8% to 23%2,3. The prevalence among medical 
students is unknown. Pathophysiological 
abnormalities accompanying the condition 
include accelerated gastric emptying, 
impaired gastric accommodation, gastric or 
duodenal hypersensitivity to distension, and 
nutrients4.  
 
Literature confirms that stress affects the gut-
brain communication, and induces pain, 
bloating and other gastrointestinal 
problems4,5. Stress either be physical or 
mental greatly influences the gut bacteria 
which in turn alters the mood, emotion and 
behaviour. Therefore, there is a direct impact 
of brain and gut activity over one another5. A 
study indicated that personality patterns 
including depression, anxiety and stress 
altered the individual’s gastrointestinal tract 
activity6. Significant exposure to stress 
increases the risk of gastrointestinal tract 
diseases7. It is proposed that the mood 
alterations are associated with Irritable 
Bowel Syndrome (IBS) and functional 
dyspepsia6. Moreover, the young population 
is more likely to develop such gastric 
conditions as the current educational model 
imposes inadvertently opposing effects on 
the mental health of the learners and due to 
high frequency of depression and anxiety, 
they have increased susceptibility for 
disorders such as functional dyspepsia8. 
 
Although it is believed that a little stress 
makes a positive impact and always makes 
the immune system stronger. Individuals 
with moderate physical stress usually have 

improved cardiac health and their immune 
system performs better against infections. In 
addition, the progress after surgical 
procedures is also faster among individuals 
undergoing modest levels of stress9. It is said 
that physical stress is necessary for survival 
but within the optimal range. As chronic 
physical stress weakens the immune system 
and causes hypertension, anxiety, 
depression, fatigue, gastrointestinal, and 
cardiac difficulties9. Mental stress affects 
parts of the brain involved in memories, 
perception, thoughts and decision-making 
processes. Moderate stressful events enable 
the brain to perform better. But continuous 
academic stress and/or work stress involving 
increased cognitive functioning leads to 
psycho-somatic abnormalities which in turn 
affects the gastrointestinal system and 
function9.  
 
The Rome III criteria is frequently employed 
to establish the diagnosis of functional 
dyspepsia and other gastrointestinal 
disorders which includes postprandial 
fullness, early satiety, pain and burning 
sensation in epigastrium providing negative 
status on the required investigation 
including an upper GI endoscopy, with the 
onset of at least six months and the duration 
of at least three months10. A stress evaluation 
concept and specific stress evaluating tool for 
the local Pakistani population, Sadaf Stress 
Scale (SSS) has been developed and widely 
used for the evaluation of seven different 
types of stresses specifically among the 
Pakistani people11.  The scale is divided into 
seven subcategories comprising of 114 items 
entitled physical, mental, psychosocial, 
traumatic, nutritional, emotional, and 
chemical stress. Preliminary data collected 
showed high variability and predictability. 
Cronbach reality test obtained a value 
between 0.945 and 0.916. Revises SSS use 95 
items, employing Spearmen brown 
coefficient analysis with significant 
coefficient levels9. 
 
Although dyspepsia is not a life-threatening 
entity, it certainly has dreadful effects on the 
patient’s quality of life12. It is one of the 



 

   

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diseases having a significant medical, 
economic, social, and political impact on the 
society. In Pakistan, information about 
epidemiology and risk factors for functional 
dyspepsia and related disorders specifically 
among university or medical students is 
scarce. The objective of the present study was 
to determine the frequency of functional 
dyspepsia and its association with mental 
and physical stress among medical students 
of Pakistan. 
 

Methodology 
A survey based study was conducted at 3 

medical colleges (Karachi medical & dental 

college, Sindh Medical College, and Dow 

Medical College) of Karachi, Pakistan. We 

approached a total number of 240 medical 

students out of which 221 volunteered to 

participate in the study. Prior Informed 

consent was obtained from all subjects. Study 

participants were asked to fill a structured 

questionnaire comprising of demographics, 

lifestyle, and food intake information. Rome 

III criteria were used to identify functional 

dyspepsia10 and to measure the physical and 

mental stress, sub-section of Sadaf stress scale 

(SSS) was used11, this Likert scale consists of 

5-point scale ranging 1 to 5 i.e., Never, Rarely, 

Sometimes, very often, always and the 

response scores were calculated and 

categorized into the level of stress i.e., 

Normal, Mild, Moderate, and Severe.  

 

Data analysis was performed using the SPSS 

version 22.0. The frequency was calculated 

for functional dyspepsia. Correlation with 

stress variables and gender differences were 

determined using Spearman’s rho and Mann 

Whitney U test, respectively. We also 

calculated the Mean rank for functional 

dyspepsia and physical and mental stress 

with the Kruskal Wallis H test. The p-values 

≤ 0.05 was considered statistically significant. 
 

Result 
The data from 221 medical students was 
analyzed, of them, the majority were females 
(67.4%). The mean age of the sample 
population was 21.47 years. A total of 34.8% 
of subjects were diagnosed to have functional 
dyspepsia, out of which around three 

quarters were females (68.5%). A strong 
positive correlation was observed among 
functional dyspepsia and both mental 
(r=0.411; p=0.001) and physical stress 
(r=0.475; p=0.001) (Table 3). The difference 

in symptoms of dyspepsia was statistically 
insignificant between both genders (p-
value=0.69). 

 
Table 1: Demonstrates the gender-based differences in the relative frequency of  

functional dyspepsia in the study population 

Variable  Gender n(%) p-value 

Male (n=72) Female (n=149) 

Frequency of dyspepsia 25(32.4) 52(68.5) 0.69 

*p-value<0.05 is considered significant  
 

As per the results obtained from Rome III Criteria, functional dyspepsia was more frequent among 
the 3rd year (32.4%) and 5th year (22%) medical students. Concerning physical and mental stress, 
the results were comparable in all years but it was observed that the 1st year students had relatively 
maximum physical and mental stress.       

 
 
 
 

Table 2: Demonstrates the yearly distribution of the sample population with reference to the 
frequency of dyspepsia and stress (mental & physical) 



 

   

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Years  

 
Total 
n(%) 

Rome III Criteria (n)  
Dyspepsia 

n(%) 

SSS 
(Mean Ranks) Heartburn Epigastric 

Pain 
Abdominal 

Fullness 
Early 

Satiety Mental 
Stress 

Physical 
Stress 

1st   31(14) 12 13 13 13 13(16.9) 136 140 

2nd   26(11.8) 11 11 11 11 11(14.3) 111.5 130.8 

3rd   75(33.9) 25 24 25 25 25(32.4) 106.6 98.8 

4th   31(14) 11 11 12 11 11(14.3) 118.5 125.1 

5th   58(26.2) 17 17 17 17 17(22) 97.6 93.3 

 

Table 3 shows the correlation of physical and mental stress with functional dyspepsia, it was found 
to be significantly correlating with mental and physical stress among the studied population (p-
value=0.001). 
 

Table 3: Correlation of functional dyspepsia with mental and physical stress. 

Variables Co-relation coefficient p-value 

Dyspepsia Mental Stress 0.411 0.001* 

Physical Stress 0.475 0.001* 
*p-value < 0.05 is considered significant  

Discussion 
Stress was determined as a positive risk 

factor for the development of functional 

dyspepsia among the local medical students, 

which is also supported by several previous 

studies13-16. The regular diagnostic rate of 

functional dyspepsia among the Pakistani 

population ranges between 11 to 15%, as 

reported by local physicians17. In our study 

population, the frequency of functional 

dyspepsia was found to be 34.8%. In 

comparison, an Indian study reported a 

lesser frequency than our estimated figure 

despite having similar demographics and 

lifestyle factors2. This inflated rate might be 

due to higher (moderate and severe) physical 

and mental stress in our study population.  

 

In support several studies confirmed the bi-

directionality of the brain-gut pathway i.e. 

stress has detrimental effects on the quality of 

life of an individual, influencing mood, 

emotions and gut activity and hence leads to 

functional gastrointestinal disorders18,19. A 

higher frequency of functional dyspepsia is 

observed among individuals enduring high 

occupational stress, intense physical activity 

and those involved in cognitive activities, 

specifically students20,21.  

 

Other than stress, several other lifestyle 

factors including tobacco smoking, alcohol 

consumption and junk food consumption, 

etc. increase the likelihood of development of 

functional dyspepsia2,22,23.  Although alcohol 

consumption is yet not common locally but 

smoking and junk food consumption remain 

at the forefront of doing the damage to the 

normal gut activity in addition to stress. 

Increased consumption of junk and fried food 

was found among the enrolled study 

participants with a high frequency of 

functional dyspepsia.  

 

People suffering from functional dyspepsia 

exhibit a greater rate of absence from work, 

reduction in productivity, and higher 

dependence on healthcare resources 

compared to general population24. For 

students, the symptoms associated with 

functional dyspepsia may cause a significant 

impact on the study habits, concentration 

span, class attendance, and test performance.  



 

   

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To the best of our knowledge, none of the 

Pakistani universities currently have a 

students’ health counselling program 

particularly related to the students’ mental 

and psychological health. Campus-wide 

health seminars/workshops discussing and 

highlighting symptoms as well as 

management of stress-induced psychological 

and physical impairment, e.g. functional 

gastrointestinal disorders, can lead to a 

reduction in the overall prevalence of these 

disorders. Besides, one of the major 

limitations of the study was the 

unavailability of the Stool Antigen test for 

Helicobacter Pylori infection and upper GI 

Endoscopy, which should have been done as 

a screening protocol. 

Conclusion 
In conclusion, our findings indicated an 

alarming frequency of functional dyspepsia 

among medical students and its strong 

correlation with mental and physical stress. 

In order to devise better management of 

functional dyspepsia and to minimize the 

chronic depletion of resources, further large-

scale extensive studies investigating the gut-

brain communication among the subjects 

with functional dyspepsia must be carried 

out involving the local population. 

Acknowledgment  
The authors would like to acknowledge 

Momina Qureshi and Masharib Bashar for 

their support during the study conduction. 

References  
1. Oustamanolakis P, Tack J. Dyspepsia: 

organic versus functional. J Clin 

Gastroenterol. 2012; 46(3): 175-190. 

2. Basandra S, Bajaj D. Epidemiology of 

Dyspepsia and Irritable Bowel Syndrome 

(IBS) in Medical Students of Northern 

India. J Clin Diagn Res. 2014;8(12): JC13-

JC16.18. 

3. Egloff N, Beer C, Gschossmann JM, 

Sendensky AH, von Känel R. 

Pathogenesis of functional 

gastrointestinal disorders – an 

interdisciplinary Perspective. Praxis (Bern 

1994) 2010; 99: 419-427. 

4. Camilleri M, Functional Dyspepsia and 

Gastroparesis. Dig Dis 2016; 34:491-499. 

5. American Psychological Association. 

Stress Effects on the Body. Available at: 

https://www.apa.org/helpcenter/stress

/effects-gastrointestinal 

6. Huerta-Franco M-R, Vargas-Luna M, 

Tienda P, Delgadillo-Holtfort I, Balleza-

Ordaz M, Flores-Hernandez C. Effects of 

occupational stress on the gastrointestinal 

tract. World J Gastrointest Pathophysiol. 

2013; 4:108–118.  

7. Konturek PC, Brzozowski T, Konturek SJ. 

Stress and the gut: pathophysiology, 

clinical consequences, diagnostic 

approach and treatment options. J Physiol 

Pharmacol. 2011; 62:591–599.  

8. Altaf M, F.Altaf K, Zahid S, Sharf R, Inayat 

A, Owais M, Usmani H. Medical students 

bearing mental stress due to their 

academic schedule. IJEHSR. 2013;1(2):93-

97.  

9. Ahmed S & Noushad S. 

Psychophysiology of Stress. Pakistan: 

Advance Educational Institute & Research 

Centre. 2014: 1-147.  

10. Drossman DA, Corazziari E, Delvaux M, 

Spiller RC, Talley NJ, Thompson WG, 

Whitehead WE. Rome III: The Functional 

Gastrointestinal Disorders, Degnon 

Associates. Inc., McLean, VA. 2006:1-29. 

11. Noushad S, Ahmed S. Novel stress 

evaluating tool; Sadaf Stress Scale (sss), 

tested so far on Pakistani population. 

IJEHSR. 2013;1(2):57-61. 

12. Lee SW, Lee TY, Lien HC, Yeh HZ, Chang 

CS, Ko CW. The risk factors and quality of 

life in patients with overlapping 

functional dyspepsia or peptic ulcer 

disease with gastroesophageal reflux 

disease. Gut and liver. 2014; 8(2):160-164. 

13. Mak AD, Wu JC, Chan Y, Chan FK, Sung 

JJ, Lee S. Dyspepsia is strongly associated 



 

   

30 
 

APP| Published By AEIRC| Volume 7 Issue 1  

 

ISSN 2412-3188 (Online) | 2410-1354 (Print) 

 

with major depression and generalised 

anxiety disorder‐a community study. 

Aliment Pharmacol Ther. 2012; 36(8):800-

810. 

14. Devanarayana NM, Mettananda S, 

Liyanarachchi C, Nanayakkara N, Mendis 

N, Perera N, Rajindrajith S. Abdominal 

pain–predominant functional 

gastrointestinal diseases in children and 

adolescents: prevalence, 

symptomatology, and association with 

emotional stress. J Pediatr Gastroenterol 

Nutr. 2011; 53(6): 659-665. 

15. Vanuytsel T, van Wanrooy S, Vanheel H, 

Vanormelingen C, Verschueren S, 

Houben E, Rasoel SS, Tόth J, Holvoet L, 

Farré R, Van Oudenhove L. Psychological 

stress and corticotropin-releasing 

hormone increase intestinal permeability 

in humans by a mast cell-dependent 

mechanism. Gut. 2014; 63(8):1293-1299. 

16. De la Roca-Chiapas JM, Solís-Ortiz S, 

Fajardo-Araujo M, Sosa M, Córdova-

Fraga T, Rosa-Zarate A. Stress profile, 

coping style, anxiety, depression, and 

gastric emptying as predictors of 

functional dyspepsia: a case-control 

study. J Psychosom Res. 2010; 68(1): 73-81. 

17. Azam Z. Functional GI disorders include 

Functional Dyspepsia and Irritable Bowel 

Syndrome [Internet]. Karachi (Pakistan): 

Pulse International; [Updated 2015 May]. 

Available at: 

http://www.pulsepakistan.com/index.php/

main-news-july-1-15/1237-functional-gi-

disorders-include-functional-dyspepsia-and-

irritable-bowel-syndrome-dr-zahid-azam 

18. Drossman DA, Li Z, Andruzzi E, Temple 

RD, Talley NJ, Thompson WG, Whitehead 

WE, Janssens J, Funch-Jensen P, 

Corazziari E, Richter JE. US householder 

survey of functional gastrointestinal 

disorders. Dig Dis Sci. 1993; 38(9): 1569–

1580. 

19. El‐Serag HB, Olden K, Bjorkman D. 

Health‐related quality of life among 

persons with irritable bowel syndrome: a 

systematic review.Aliment Pharmacol 

Ther. 2002; 16(6): 1171–1185. 

20. Huerta-Franco MR, Vargas-Luna M, 

Tienda P, Delgadillo-Holtfort I, Balleza-

Ordaz M, Flores-Hernandez C. Effects of 

occupational stress on the gastrointestinal 

tract. World J Gastrointest Pathophysiol. 

2013; 4(4):108-118. 

21. Ganasegeran K, Al-Dubai SA, Qureshi 

AM, Al-abed AA, Am R, Aljunid SM. 

Social and psychological factors affecting 

eating habits among university students 

in a Malaysian medical school: A cross-

sectional study. Nutr J. 2012; 11: Article 48. 

22. Shaib Y, El-Serag HB. The prevalence and 

risk factors of functional dyspepsia in a 

multiethnic population in the United 

States. Am. J. Gastroenterol. 2004; 99: 

2210-2216. 

23. Tougas G, Chen Y, Hwang P, Liu MM, 

Eggleston A. Prevalence and impact of 

upper gastrointestinal symptoms in the 

Canadian population: findings from the 

DIGEST study. Domestic/International 

Gastroenterology Surveillance Study. 

Am. J. Gastroenterol. 1999; 94: 2845-2854. 

24. Moayyedi P, Mason J. Clinical and 

economic consequences of dyspepsia in 

the community. Gut. 2002; 50 (suppl 4): 

iv10-2. 

 

  


