Psychological disorders in patients with evacuation disorders and constipation in a tertiary practice

THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 2000 by Am. Coll. of Gastroenterology Published by Elsevier Science Inc.

Vol. 95, No. 7, 2000 ISSN 0002-9270/00/$20.00 PII S0002-9270(00)00976-X

Psychological Disorders in Patients With Evacuation Disorders and Constipation in a Tertiary Practice Vandana Nehra, M.D., Barbara K. Bruce, Ph.D., Doris M. Rath-Harvey, R.N., John H. Pemberton, M.D., and Michael Camilleri, M.D. Division of Gastroenterology and Hepatology, Section of Behavioral Medicine, and Section of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

OBJECTIVE: We aimed to evaluate the prevalence of psychological impairment in patients with rectal evacuation disorders and the influence of psychological disorder on the early outcome of behavioral treatment. METHODS: We retrospectively reviewed the medical records of patients with rectal evacuation disorders referred for biofeedback retraining at a tertiary referral center. The psychological disorder was classified using the DSM IV criteria. Outcome of biofeedback treatment of evacuation at 2 wk was based on symptoms or on the ability to spontaneously expel a balloon placed in the rectum. Improvements in the groups without versus with a psychological disorder or an eating disorder were compared by Fisher’s exact test. RESULTS: In the 60 patients (55 women; 5 men; mean age, 38 yr), psychological disorders were identified in 39 (65%); also noted were eating disorder (n ⫽ 5), rumination syndrome (n ⫽ 3), pain disorder (n ⫽ 6), anxiety-depression (n ⫽ 10), a combination of depression and pain disorder (n ⫽ 3), and a combination of eating disorder with anxietydepression and pain disorder (n ⫽ 12). There was an association between psychological status and outcome at 2 wk of behavioral treatment for evacuation disorder (p ⫽ 0.03). The coexistence of eating disorder and psychological disorder resulted in an unfavorable outcome (p ⫽ 0.02), compared with those without psychological disorder. CONCLUSION: Psychological impairment was identified in 65% of the patients with evacuation disorder and constipation in a tertiary care practice, and has a significant negative impact on the outcome of behavioral treatment. These data reinforce the importance of a multidisciplinary approach in the management of these patients. (Am J Gastroenterol 2000;95:1755–1758. © 2000 by Am. Coll. of Gastroenterology)

INTRODUCTION Constipation that is unresponsive to conservative measures such as fiber supplementation or osmotic laxatives is a common reason for referral to gastroenterologists. In recent years, evacuation disorders have been recognized increasingly as a cause of chronic constipation in adults (1, 2).

Anorectal manometry with balloon expulsion test, as well as colonic transit studies, provide a useful means to evaluate these patients with chronic constipation. More specific tests of pelvic floor function have been developed and are becoming standardized, thereby permitting identification of evacuation disorders (3). Constipation has also been reported in up to 60% of patients with eating disorders (4, 5), and it has been shown that, despite reporting severe constipation, most patients with anorexia nervosa have normal colonic transit and anorectal function when consuming a well-balanced diet (6). Our aims were to assess the prevalence of psychological disorders in patients with constipation related to rectal evacuation disorders in a tertiary referral population and to evaluate the influence of the associated psychological impairment on the early outcome of biofeedback treatment and pelvic floor rehabilitation in these patients.

MATERIALS AND METHODS We retrospectively reviewed the medical records of patients with evacuation disorders referred for a combined behavioral treatment and biofeedback training during 1997–1998 at Mayo Clinic Rochester. All patients underwent a colonic transit test with radiopaque markers or scintigraphy and anorectal manometry with balloon expulsion test and assessment of rectoanal inhibitory reflex to determine the etiology of the constipation before referral for biofeedback. A subset of patients also underwent clinically indicated measurement of rectoanal angle or defecography. All patients were treated by the same two physical therapists and participated in a multidisciplinary program, which included dietetic and formal psychological consultations. The cause of the constipation was characterized using the following criteria (2): ●

●

Slow-transit constipation, defined scintigraphically as the geometric center at 24 h of ⬍1.7 or by radiopaque marker transit by a mean colonic transit time ⬎72 h. These patients also had a normal anorectal manometry and balloon expulsion test. Anismus was defined as a squeeze sphincter pressure

1756

●

●

●

●

Nehra et al.

⬎200 cm of H2O, associated with an abnormal balloon expulsion test. Pelvic floor dysfunction (puborectalis spasm) was defined as an abnormal balloon expulsion test, as well as failure of the anorectal angle to open by ⬎15 degrees between the resting and straining positions. Excessive perineal descent was defined by visible ballooning of the perineum on examination or descent measured ⬎4.5 cm during scintigraphic assessment. Rectocele was deemed as being clinically significant when there was demonstrable herniation of the rectal wall with either preferential filling during defecting proctogram or failure of the rectocele to empty during the process of defecation. Evacuation disorder not otherwise specified (NOS): Characterized by symptoms of failure of evacuation and failure of balloon expulsion suggestive of pelvic floor dysfunction, but without fulfilling other diagnostic criteria for excessive perineal descent, puborectalis spasm, anatomical defects or high resting anal sphincter tone.

In addition, we assessed the category of the psychological disorder which was defined using DSM IV criteria (7), as well as the outcome of treatment at 2 wk based on symptoms or ability to spontaneously expel a balloon placed in the rectum. No psychological intervention or pharmacotherapy was given during this 2-wk period other than simple psychological evaluation and recommendations. Statistical Analysis Fisher’s Exact Test was used to assess the association between psychological status and outcome.

RESULTS Characterization of Patients and Cause of Evacuation Disorder There were 55 female and 5 male patients. The age range was 15– 68 yr, with a mean age of 38 yr. Among the patients with symptoms of evacuation disorder, the demonstrable physiological abnormalities were varied, i.e., anismus (n ⫽ 11), puborectalis spasm (n ⫽ 23), descending perineum syndrome (n ⫽ 2), rectocele (n ⫽ 1), evacuation disorder NOS (n ⫽ 16), and combined disorder (n ⫽ 7). In this latter category, patients exhibited a combination of two etiologies that may have contributed to the evacuation disorder, i.e., anismus with descending perineum syndrome (n ⫽ 4), and anismus with puborectalis spasm (n ⫽ 3). The group of patients classified as evacuation disorder NOS were characterized by the symptoms of failure of evacuation and the inability to spontaneously expel a balloon placed in the rectum but without fulfilling all the diagnostic criteria listed earlier (Fig. 1). Psychological Disorder The patients were given a psychological diagnosis after review and interview by a single psychologist and the di-

AJG – Vol. 95, No. 7, 2000

Figure 1. Distribution of the causes of rectal evacuation disorder in 60 patients. NOS (not otherwise specified) patients were characterized by clinical history of evacuation problem and inability to expel a 50-ml balloon from the rectum despite addition of 200 g weight.

agnosis was based on DSM IV diagnostic criteria. Psychological disorders were identified in 65% of patients and included eating disorder (n ⫽ 5), rumination syndrome (n ⫽ 3), pain disorder (n ⫽ 6), anxiety-depression (n ⫽ 10), a combination of eating disorder with depression, anxiety, and pain disorder (n ⫽ 12), and depression with pain disorder (n ⫽ 3). No psychological disorder was identified in 21 patients (Fig. 2). Outcome of Biofeedback Retraining The outcome of the biofeedback training program was assessed at the end of 2 wk by the ability of the patient to have spontaneous bowel movements and the ability to spontaneously expel a 50-ml latex balloon placed in the rectum (Tables 1 and 2). Figure 3 shows the result of treatment, classified as improved or not improved, according to the underlying psychological or eating disorder. An association was noted between psychological status and outcome of

Figure 2. Distribution of identified psychological disorders in 39 of 60 patients (65%) with rectal evacuation disorders.

AJG – July, 2000

Psychological Disorders, Evacuation Problems

1757

Table 1. Effect of Evacuation and Psychological Disorders on Outcome Positive Response to Treatment

Psychological Disorder Disorder (n)

Absent

Present

PD Absent

PD Present

p*

Puborectalis spasm (23) Anismus (11) Pelvic floor dysfunction NOS (16) Descending perineum syndrome (2) Anismus with puborectalis spasm (3) Anismus with descending perineum syndrome (4)

8 (35%) 6 (55%) 7 (44%)

15 (65%) 5 (45%) 9 (56%)

6 (75%) 3 (50%) 3 (43%)

8 (53%) 2 (40%) 3 (33%)

NS NS NS

2 (100%)

1 (50%)

NS

3 (100%)

2 (66%)

NS

3 (75%)

1 (25%)

3 (100%)

0 (0%)

NS

* p value based on Fisher’s exact test. PD ⫽ psychological disorder; NOS ⫽ not otherwise specified.

behavioral treatment for evacuation disorders at 2 wk (p ⫽ 0.03). The coexistence of an underlying eating disorder with the psychological disorder was associated with unfavorable outcome, compared to patients without psychological disorder (p ⫽ 0.02). Moreover, among those with psychological disorder, the presence of eating disorder tended (p ⫽ 0.09) to negatively affect response to treatment. When the eating disorder was disregarded, the outcomes for the patients with or without psychological disorder were not significantly different (p ⫽ 0.13).

DISCUSSION Patients with rectal evacuation disorder and constipation are treated with behavioral approaches such as biofeedback. These have been generally successful in the management of chronic constipation caused by evacuation disorders (8). Biofeedback training involves the use of auditory or visual displays of a physiological process to aid the patient in learning to control this process voluntarily. It is based on the most common type of learning, i.e., trial and error, in which behaviors that are followed by desirable consequences tend to be repeated, whereas behaviors that are followed by

undesired consequences tend not to be repeated. The two types of biofeedback training used for pelvic floor dysfunction include pelvic floor relaxation techniques, in which sensors in the anal canal applied adjacent to the anus are used to monitor and provide feedback to the patient on striated pelvic floor muscle tension, and simulated defecation, in which the patient practices defecation of a simulated stool consisting of a water filled balloon (9). The two techniques are often combined. Studies show that both techniques are effective and the overall rate of success is approximately 67% (8). Constipation is a frequent complaint in patients with anorexia nervosa and has been reported by up to 60% of patients with eating disorders (4, 5). Anorectic and bulimic patients also report bloating and abdominal pain, which may be suggestive of abnormal gastrointestinal motility or distorted perception. Kamal et al. (10) demonstrated an overall delay in gastrointestinal transit in eight anorectic patients within 2 wk of hospitalization for exacerbation of their eating disorder. On the other hand, slow colonic transit and anorectal dysfunction are uncommon in anorexic patients who are eating a well-balanced diet (6), even though they have frequent complaints of constipation. Psychological dis-

Table 2. Effect of Age, Abuse History, Duration of Constipation, and Psychological Disorder on Outcome Psychological Disorder

Positive Response to Treatment

Parameter (n)

Absent

Present

PD Absent

PD Present

p*

History of abuse positive (14) History of abuse negative (46) Age ⱕ36 yr (31) Age ⬎36 yr (29) Duration of constipation ⱕ5 yr (20) Duration of constipation ⬎5 yr (40)

5 (36%)

9 (64%)

2 (40%)

3 (33%)

NS

24 (52%)

22 (48%)

17 (71%)

10 (46%)

NS

18 (58%) 12 (41%) 11 (55%)

13 (42%) 17 (59%) 9 (45%)

10 (56%) 9 (75%) 7 (64%)

8 (62%) 5 (29%) 4 (44%)

NS NS NS

18 (45%)

22 (55%)

12 (67%)

9 (41%)

NS

* p value based on Fisher’s exact test. PD ⫽ psychological disorder; NS ⫽ not significant.

1758

Nehra et al.

AJG – Vol. 95, No. 7, 2000

Figure 3. Influence of psychological and eating disorders on response to biofeedback for rectal evacuation disorder.

turbances may contribute to these symptoms, and it is unclear whether they affect the response to therapy. In our study, psychological disorders were identified in 65% of patients with evacuation disorder and constipation seen in a tertiary practice; this association has significant negative impact on the outcome of behavioral treatment of the evacuation disorder. The presence of an underlying eating disorder tended to affect the outcome of biofeedback treatment (p ⫽ 0.09). The combination of psychological and eating disorder significantly impacted the negative outcome, compared to those without psychological disorder (p ⫽ 0.02). Biofeedback is a process of training individuals to be more aware of and responsive to biological information. In one series, it was evident that age, gender, duration of symptoms, and presence of rectal pain did not influence outcome; however, the willingness to comply with the treatment protocol was the most important predictor of success (11). In patients with psychological disorders, a lack of motivation, associated depression, and the lack of interest may interfere with the learning process. Distractions caused by other extraneous influences may further interfere with the retraining process. It appears that the combination of psychological and eating disorder is most predictive in our patients of a lack of response to biofeedback. The high prevalence (65%) of an underlying psychological disorder seen in this group of patients emphasizes the advantages of a team approach provided by a gastroenterologist, colorectal surgeon, psychologist, physical therapist, and dietitian for the optimal management of these patients. Such an approach has been effective in our practice in patients with rectal evacuation disorder and serves to avoid unnecessary surgery or costly medications.

ACKNOWLEDGMENTS We thank Mses. Patricia Olson, Karen Nehring, and Jeanette Wiebrand for excellent patient care, and Ms. Cindy Stanislav for typing and preparing the manuscript. This

study was supported in part by grants #R01 DK54681 and K24 DK02638 from National Institutes of Health. Reprint requests and correspondence: Michael Camilleri, M.D., Mayo Clinic, GI Unit - Alfred 2-435, 200 First St. S.W., Rochester, MN 55905. Received June 29, 1999; accepted Feb. 25, 2000.

REFERENCES 1. Kuijpers HC. Application of the colorectal laboratory in diagnosis and treatment of functional constipation. Dis Colon Rectum 1990;33:35–9. 2. Surrenti E, Rath DM, Pemberton JH, et al. Audit of constipation in a tertiary referral gastroenterology practice. Am J Gastroenterol 1995;90:1471–5. 3. Diamant NE, Kamm MA, Wald A, et al. AGA technical review of anorectal testing techniques. Gastroenterology 1999; 116:735– 60. 4. Wardholtz BD, Anderson AE. Gastrointestinal symptoms in anorexia nervosa. Gastroenterology 1990;98:1415–9. 5. Chami TN, Anderson AE, Crowell MD, et al. Gastrointestinal symptoms in bulimia nervosa: Effects of treatment. Gastroenterology 1991;11:A427. 6. Chen AB, Sokol MS, Kaye WH, et al. Colonic and anorectal function in constipated patients with anorexia nervosa. Am J Gastroenterol 1997;92:1879 – 83. 7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Washington, DC: American Psychiatric Association, 1994. 8. Enck P. Biofeedback training in disordered defecation. A critical review. Dig Dis Sci 1993;38:1953– 60. 9. Farrugia G, Camilleri M, Whitehead WE. Therapeutic strategies for motility disorders: Medications, nutrition, biofeedback and hypnotherapy. In: Camilleri M, ed. Gastroenterology Clinics of North America: Gastrointestinal motility in clinical practice, Vol. 25. Philadelphia: WB Saunders, 1996:225– 46. 10. Kamal N, Chami T, Anderson A, et al. Delayed gastrointestinal transit times in anorexia nervosa and bulimia nervosa. Gastroenterology 1991;101:1320 – 4. 11. Gilliland R, Heymen S, Altomare DF, et al. Outcomes and predictors of success of biofeedback for constipation. Br J Surg 1997;84:1123– 6.