Intended for healthcare professionals

Rapid response to:

Clinical Review

Chronic constipation in adults

BMJ 2009; 338 doi: (Published 20 March 2009) Cite this as: BMJ 2009;338:b831

Rapid Response:

Chronic Constipation: The Importance of Psychological Factors

Constipation Review Reply

Firstly we wish to thank the authors for their comprehensive and
clear review
highlighting the practical aspects of managing constipation.

We would like however to raise some key issues. We are concerned
the lack of emphasis on the role of psychological factors which are
associated with constipation and which may influence health seeking
behaviour and therapeutic options for patients. For example work from our

group has previously described the prevalence of anorexia nervosa in
constipated patients.1 The study demonstrated that 60% of those presenting

to our tertiary centre who were eventually diagnosed with anorexia nervosa

had an initial presentation with symptoms of constipation. In addition
work by
Boyd and co workers in Australia found that nearly one in four patients
presenting to their eating disorders clinic with anorexia nervosa suffered

from functional constipation.2 This may have contributed to the female to
male gender bias in chronic constipation as mentioned by the authors in
epidemiology section.
The clinical history should also aim to identify additional factors that
predispose to functional disorders like constipation, particularly
abuse and somatiform disorder. Data from the United States showed that 27%

of people in one study had depression related constipation.3 Furthermore
Wald et al. identified two distinct groups with constipation, those with
colonic transit and those in whom transit was abnormally slow. The normal

transit population had higher scores for psychological distress than those

with delayed transit. In light of this they proposed a dual therapeutic
approach to severe idiopathic constipation based either on behavioural and

psychological support or on modifying disordered transit.4
We highlight these issues because, omission of psychological evaluation
places patients at risk of inappropriate surgical interventions Moreover,
acknowledging and addressing the psychological factors may play a role in
symptom improvement by helping patients adopt better coping strategies to
deal with symptoms.

1. Emmanuel AV, Stern J, Treasure J, Forbes A, Kamm MA. Anorexia
in gastrointestinal practice. European Journal of Gastroenterology &
Hepatology. 16(11): 1135-1142
2. Boyd C, Abraham S, Kellow J. Psychological features are important
predictors of functional gastrointestinal disorders in patients with
disorders. Scandinavian Journal of Gastroenterology. 40: 929-935
3. Garvey M, Noyes Jr R, Yates W. Frequency of constipation in major
depression: relationship to other clinical variables. Psychosomatics. 30:
4. Wald A, Hinds JP, Caruana BJ. Psychological and physiological
characteristics of patients with severe idiopathic constipation.
Gastroenterology. 97(4): 932-937

Competing interests:
None declared

Competing interests: No competing interests

31 December 2009
Neil J Ikin
Specialist Registrar
Naila Arebi, Julian Stern
St Mark's Hospital, HA1 3UJ