Increasing sensitivity of somatic (bodily) sensations
Altering psychological perceptions of pain
Enhancing stress and cortisol levels that influence the ENS
Disrupting immune function(13)
Although the mechanisms for these effects still being identified, they may arise through complex interactions described by the biopsychosocial model. The model suggests a connection between human biology, social interaction, and physiology. It explains how environmental factors such as stress and anxiety may cause physical effects on the gastrointestinal system.(14)
Sub types of IBS
There are three main sub types of IBS, classified based on stool consistency:
IBS with constipation (IBS-C) is the most common and accounts for approximately 60% of patients. IBS-D is the least common and comprises 5% of patients.(15)
Treatment of IBS-C
If you suffer constipation and have been diagnosed with IBS, you may suffer from IBS-C. Fortunately, there are several treatment options for patients with this condition. Many of these target not only the GI symptoms but symptoms of anxiety too. Treatments include:
Gut-directed hypnotherapy. This involves targeting IBS symptoms to promote normal digestive function. It is effective for all subtypes.
The low FODMAP diet. This diet eliminates common ‘trigger foods’ of IBS such as fruits and vegetables containing fructose, and dairy and is effective for all subtypes.
Cognitive behavioral therapy (CBT). This involves challenging negative thoughts and adopting a more positive, realistic outlook. Both symptoms of IBS and anxiety may benefit.
Antidepressants. These medications include serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) and are prescribed in low doses. SSRIs are particularly useful for constipation-predominant IBS.(16)
Medications for IBS-C, including: Lubiprostone (Amitiza). This drug was approved in 2008 by the FDA and increases fluid secreted by the small intestine. Linaclotide (Linzess). It was approved in 2012 and spurs more frequent bowel movements. Plecanatide (Trulance). This drug was approved in 2017 and increases fluid secretion in the digestive system.(17)
Constipation in mental health
Constipation is strongly linked with other psychiatric disorders, beyond anxiety disorder. Across-sectional study in the Netherlands studied patients with various psychiatric illnesses and found the following proportion suffered constipation:
Schizophrenia (50%)
Personality disorders (47%)
Depressive disorders (41%)
Bipolar disorder (40%)
Dementia (35%)
Anxiety disorders (33%)
Alcohol-related disorders (19%)
The study showed a substantial increase in constipation in patients with psychological illness, compared to the rate of of 15% in the general population.(18)
Constipation has been shown to worsen psychological scores of anxiety and depression. A UK study showed constipation leads to higher levels of distress in women. The women with constipation showed higher levels of depression and anxiety and social dysfunction than healthy controls.They also experience less satisfaction in intimate relationships and an altered sense of their ‘feminine’ role. It is therefore plausible that constipation may affect one’s self-image, and that this is the source of anxiety in a vicious cycle.(18)
Is anxiety disorder causing my constipation?
If you suffer chronic constipation, consulting a doctor will help to rule out diseases that cause constipation such as:
Diabetes Mellitus
Stroke
Parkinson’s disease
Multiple sclerosis
Scleroderma
Once these are ruled out, it is more likely that stress or anxiety is causing your constipation. Then, attention can be directed towards treating this form of constipation, known as functional constipation.
Functional constipation
Functional constipation (FC), also known as chronic idiopathic constipation (CIC), is constipation that does not have a physical cause. This distinguishes it from constipation caused by diseases, such as multiple sclerosis. FC is likely to be caused by psychological or neurological factors. A personal with functional constipation may be completely healthy, yet still suffer difficulty passing bowel movements.(19)
Treatment of functional constipation
The National Institute for Health and CareExcellence (NICE) guidelines and results of other studies indicate the following treatments are useful for functional constipation:
Lifestyle modification. Dietary change to increase fiber in diet through fruits and vegetables, and fluid intake.
Laxatives, including osmotic laxatives such as lactulose or stimulant laxatives such as senna and bisacodyl.
Probiotics. Those of the Bifidobacterium and Lactobacillus genera have been shown to increase stool frequency in adults and children and are a safe option.(19)
The Wrap Up
Constipation may severely impact your quality of life. There is a strong interaction between constipation and psychiatric disorders such as anxiety. At a medical center, gastrointestinal disorders such as ulcerative colitis may be ruled out through testing and diagnosis of functional constipation confirmed. Treatment for this condition will typically involve modifying lifestyle factors such as diet, and the prescription of laxatives or probiotics, or referral for cognitive behavioral therapy or hypnotherapy. These treatments are highly effective at treating constipation, and some also treat anxiety.
References
Drossman, D.A., 2006. Rome III: the new criteria. Chinese journal of digestive diseases, 7(4), pp.181-185. Link
Roque, M.V. and Bouras, E.P., 2015. Epidemiology and management of chronic constipation in elderly patients. Clinical interventions in aging, 10, p.919. Link
Hsieh, C., 2005. Treatment of constipation in older adults. Am Fam Physician, 72(11), pp.2277-84. Link
Hosseinzadeh, S.T., Poorsaadati, S., Radkani, B. and Forootan, M., 2011. Psychological disorders in patients with chronic constipation. Gastroenterology and hepatology from bed to bench, 4(3), p.159. Link
Kroenke, K., Spitzer, R.L., Williams, J.B., Monahan, P.O. and Löwe, B., 2007. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of internal medicine, 146(5), pp.317-325. Link
Jessurun, J.G., van Harten, P.N., Egberts, T.C., Pijl, Y.J., Wilting, I. and Tenback, D.E., 2016. The relation between psychiatric diagnoses and constipation in hospitalized patients: A Cross-sectional study. Psychiatry journal, 2016. Link
Furness, J.B., 2012. The enteric nervous system and neurogastroenterology.
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