Psychogenic constipation: causes, symptoms, diagnosis

Constipation is a decrease in the frequency of bowel movements (once every two days or less), associated with the slow passage of contents through the intestinal tract and the presence of fecal stagnation (coprostasis).

Complaints of patients include the absence of spontaneous stool for several days or 1-2 weeks. In addition, when stool appears, there is a feeling of incomplete bowel movement, there is no satisfaction from defecation. A careful collection of anamnesis usually reveals various asthenic manifestations: sleep disturbance, increased irritability, bad mood, decreased tone, interest and attention during intellectual work, increased fatigue. Various vegetative-visceral manifestations are also common: a feeling of a full stomach, abdominal pain, etc. Palpation in case of spastic constipation can reveal a bead-shaped sigmoid colon filled with hard fecal matter, sometimes fecal stones. Proctogenic constipation (dyschezia) in the elderly should be highlighted, caused by muscle weakness and attenuation of the defecation reflex, which may also be associated with insufficiency of spinal regulation.

The analysis of the mental sphere is of great importance, since it allows to establish in some patients a certain focus of attention and interests on the problem of stool. In this case, it is necessary to identify two possible situations. A number of patients, as a result of futile attempts to normalize stool, try to find new ways to achieve this goal, and their searches, acquiring a certain neurotic-hypochondriac coloring, are nevertheless quite adequate to the real situation. Another part of patients in a similar situation significantly modifies their eating behavior and behavior in general. To cause defecation, to have a stool - for them it becomes an overvalued idea, in which the whole meaning of their life is concentrated. At the same time, they use large quantities of laxatives and other drugs, give themselves numerous enemas. It is important to note that in some patients such constipation is imaginary, not real, they have delusions of denial of stool.

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

The absence of signs of organic damage to the gastrointestinal tract and other body systems during a thorough clinical and paraclinical examination in combination with positive diagnostic criteria for psychogenic diseases allows for a correct clinical assessment of the nature of constipation. It is important to note that patients with psychogenic constipation rarely experience significant weight loss, increased ESR, and changes in blood count.

Persistent constipation may 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, tumors of the brain and spinal cord). In these situations, constipation is rarely the only or leading phenomenon in the clinical picture.

The pathogenesis of psychogenic constipation is complex, ambiguous and associated with various manifestations of psychovegetative-intestinal dysfunction. It is believed that constipation is a mental illness, one might say, a social disease, a consequence of civilization. Constipation does not occur in animals or in peoples at a lower stage of development. It is well known that constipation is one of the natural manifestations in depressive disorders. Three groups of causes can be distinguished that play a certain role in the occurrence of constipation.

1. Psychogenic (or rather, psychovegetative-endocrine) disorders that cause intestinal dysfunction through the channels of cerebrovegetative or neuroendocrine connections.
2. Certain behavioral stereotypes, usually beginning in childhood, which lead through the mechanisms of pathological learning to a weakening of the defecation reflex.
3. The patient's lifestyle, especially hypokinesia, a number of features of the diet (poor food with toxins, highly digestible food, consumption of small amounts of liquid, etc.) can also play a role in the pathogenesis of constipation.

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

Psychogenic (nervous, neurotic, functional, cortico-visceral) diarrhea (diarrhea) - increased frequency of defecation with the release of loose stools associated with accelerated evacuation of intestinal contents. Multiple daily release of feces of normal consistency is not considered diarrhea.

In stressful situations, unstable stool and emotional diarrhea ("bear disease") is a well-known fact that occurs in people with psychovegetative lability. Of clinical interest are those cases when frequent and loose stools last for many months and years, and do not respond to treatment with the means prescribed by gastroenterologists.

If constipation in some cases is the only manifestation of psychovegetative dysfunction, then psychogenic diarrhea is usually combined with numerous gastrointestinal, psychovegetative and other manifestations.

During diarrhea, the stool is mushy or liquid, its frequency is usually no more than 3-5 times a day, in severe cases - 6-8 times or more. Imperative false urges to defecate often occur. Patients also complain of heaviness, rumbling, distension, spasms and cramping pain in the abdomen, a feeling of bloating, flatulence. On palpation, the abdomen is bloated, the abdominal wall is moderately painful, the sigmoid colon is sensitive and painful. Asthenia, bad mood, fear of eating, which often causes diarrhea, are noted. The range of behavioral activity can narrow sharply, phobic disorders appear, 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 may alternate with periods of spasmodic painful constipation.

The connection 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 endocrine system allow us to assess the existing disorders as disorders of a psychovegetative nature.

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

The pathogenesis of diarrhea is associated with increased intestinal motility, decreased ability to absorb fluid in the large intestine, and increased secretion of fluid in the intestine, which leads to liquefaction of the stool. The above mechanisms are associated with descending vegetative activation in psychovegetative disorders. It is also necessary to consider the possibility of peripheral vegetative insufficiency. Various factors (psychovegetative, endocrine-humoral-metabolic, etc.) lower the threshold and increase the excitability of the gastrointestinal and defecation reflexes with the formation of a stable pathological pattern of reactions, which, according to the feedback mechanism, is maintained or even intensified 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.

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