Psychogenic constipation: causes, symptoms, diagnosis

Constipation (constipation) is a reduction in the act of defecation (once every two days and less often), associated with a slow passage of contents through the intestinal tract and the presence of stasis of stool (coprostasis).

Complaints of patients consist in the absence of a spontaneous stool for several days or 1-2 weeks. In addition, when a chair appears there is a feeling of incomplete emptying of the intestine, there is no satisfaction from defecation. When you carefully collect an anamnesis, you usually find various asthenic manifestations: sleep disturbances, increased irritability, bad mood, decreased tone, interest and attention in intellectual work, increased fatigue. Often there are also various vegetative-visceral manifestations: sensation of a crowded stomach, abdominal pain, etc. Palpation in the spastic character of constipation can reveal a distinct sigmoid colon filled with hard fecal masses, sometimes fecal stones. It should be noted proctogenic constipation (dyshexia) in the elderly, due to the weakness of the musculature and the attenuation of the defecation reflex, which may be associated with a lack of spinal regulation.

The analysis of the psychic sphere is of great importance, since it allows us to establish a certain center of attention and interests for a part of patients on the stool problem. It is necessary to identify two possible situations. A number of patients as a result of futile attempts to normalize the stool are trying to find new ways to achieve this goal, and their search, acquiring a certain neurotic hypochondriac coloring, is nevertheless quite adequate to the real situation. Another part of the patients in a similar situation essentially changes their eating behavior and behavior in general. To cause defecation, to have a chair - for them becomes an overvalued idea, in which the whole meaning of their life is concentrated. In doing so, they use large amounts of laxatives and other drugs, put themselves numerous enemas. It is important to note that in some patients such constipation is imaginary, but not real, they have a delusion of negating the stool.

Traditionally, psychogenic constipation is divided into spastic (with prevalence of vagal influences) and atonic (prevalence of sympathetic tendencies), although a combination of both types is most often encountered.

The absence of signs of organic damage to the gastrointestinal tract and other body systems with a careful clinical and paraclinical study in combination with positive criteria for the diagnosis of psychogenic diseases makes it possible to clinically evaluate the nature of constipation. It is important to note that in patients with psychogenic constipation, a marked loss of body weight, an increase in ESR and a change in the blood formula are seldom observed.

Persistent constipation can also be a manifestation of a number of endocrine diseases (hypothyroidism, hyperparathyroidism, Simons disease, etc.), organic diseases of the nervous and neuromuscular systems (parkinsonism, cerebral atherosclerosis, myasthenia gravis, brain and spinal cord tumors). In these situations constipation is rarely the only or leading phenomenon in the clinical picture.

The pathogenesis of psychogenic constipation is complex, ambiguous and is associated with various manifestations of psycho-vegetative-intestinal dysfunction. It is believed that constipation is a mental illness, one might say, a social illness, a consequence of civilization. Constipation does not occur either in animals or in peoples at a lower stage of development. It is well known that in cases of depressive disorders, constipation is one of the regular manifestations. There are three groups of causes that play a role in the onset of constipation.

1. Psychogenic (or rather, psychovegetative-endocrine) disorders, which through the channels of cerebrovascular or neuroendocrine connections cause intestinal dysfunction.
2. Certain stereotypes of behavior, beginning usually from childhood, which lead by the mechanisms of pathological learning to weaken the defecation reflex.
3. Lifestyle of the patient, especially hypokinesia, a number of features of the diet (food poverty slag, highly digested food, intake of small amounts of fluid, etc.) can also have a role in the pathogenesis of constipation.

A certain role in the pathogenesis of intestinal dysfunction is played by peripheral vegetative insufficiency, which is most often found in patients with diabetes, porphyria and other diseases.

Psychogenic (nervous, neurotic, functional, cortico-visceral) diarrhea (diarrhea) is an acceleration of the defecation act with the release of a loose stool associated with accelerated evacuation of intestinal contents. Multiple daily allocation of normal stool consistency is not considered diarrhea.

In stressful situations, unstable stools and emotional diarrhea ("bear illness") is a well-known fact that occurs in people with psycho-vegetative lability. Clinical interest is represented by those cases when a frequent and liquid stool lasts for many months and years, is not amenable to treatment by means appointed by gastroenterologists.

If constipation in some cases is the only manifestation of psycho-vegetative dysfunction, then psychogenic diarrhea is combined, as a rule, with numerous gastrointestinal, psycho-vegetative and other manifestations.

Stool with diarrhea is mushy or liquid, its frequency is usually no more than 3-5 times a day, in severe cases - 6-8 times or more. Often there are imperative false urges to defecate. Patients also complain about the severity, rumbling, raspiranie, spasms and cramping pain in the abdomen, a sensation of bloating, flatulence. When palpation the abdomen is swollen, the abdominal wall is moderately painful, the sigmoid colon is sensitive and painful. There are asthenia, bad mood, fear of eating, which often causes diarrhea. The range of behavioral activity can be sharply narrowed, phobic disorders appear, the fear of diarrhea in an inappropriate place, etc.

Vegetative manifestations can be sharply expressed - from permanent disorders to paroxysms of a vegetative nature.

It should be emphasized that periods of diarrhea can alternate with periods of spastic painful constipation.

The association of diarrhea with psychogenic causes, the absence of fat, blood, pus, and other signs of inflammation in the feces, the exclusion of organic diseases of the gastrointestinal tract and the endocrine system make it possible to assess the existing disorders as psycho-vegetative disorders.

An important differential diagnostic feature of organic intestinal diseases, such as dysentery, ulcerative colitis, Crohn's disease, colon cancer, is disturbed sleep in these diseases and normal sleep in patients with psychogenic diarrhea. In addition, with rare exceptions, the general condition with psychogenic constipation remains relatively satisfactory.

The pathogenesis of diarrhea is associated with increased intestinal motility, a decrease in the ability of fluid absorption in the large intestine and increased secretion of fluid in the intestine, which leads to dilution of the stool. These mechanisms are associated with descending vegetative activation in psycho-vegetative disorders. It is also necessary to take into account the possibility of peripheral autonomic failure. Various factors (psychovegetative, endocrine-humoral-metabolic, etc.) reduce the threshold and increase the excitability of gastrointestinal and defecation reflexes with the formation of a stable pathological pattern of reactions, which is supported or even enhanced by the pathological behavior of the patient. All this underlies the pathogenesis and symptom formation of not only diarrhea and constipation, but also other disorders of the gastrointestinal system.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]