Psychological stress and early adverse life events have been associated with irritable bowel syndrome (IBS) and chronic constipation[1, 2]. The risk of IBS development is influenced by several psychological factors, with severity of trauma and greater number of early adverse life events conferring increased odds of IBS, while confiding in others may ameliorate this risk[1]. Likewise, early adverse life events and post-traumatic stress disorder (PTSD) are prevalent in patients with constipation and defecatory disorders, with rates of early adverse life events mirroring those described in IBS, and rates of PTSD exceeding previously reported rates in non-Veteran IBS populations[2]. Among the IBS subtypes, IBS-C has the highest prevalence of comorbid anxiety and depression[3]. Those with defecatory disorder and normal anorectal physiologic tests have also been shown to be at higher risk of prior emotional abuse and poorer mental health[2]. These prior findings highlight the importance of further studies to assess the impact of traumatic events and psychological symptoms in patients with defecatory disorders to help guide evaluation and management. We hypothesized that early adverse life events and psychological symptoms negatively impact symptoms of defecatory disorders. The aim of our study was to investigate whether exposure to early adverse life events and the severity of psychological symptoms including depression and anxiety correlated with severity of defecatory disorders. Since many patients with defecatory disorders have concurrent fecal incontinence (FI) we also assessed the association between severity of psychological symptoms and traumatic events with FI severity.

We performed a retrospective analysis of an IRB approved prospectively maintained registry of patients with primary complaint of incomplete and difficult evacuation symptoms who were referred for anorectal physiologic testing, at our tertiary referral academic center. Clinical characteristics, including symptoms severity scores, were assessed using the Cleveland Clinic Fecal Incontinence (CCFI), and the Obstructed Defecation Syndrome (ODS) questionnaires. Patients also were asked to complete The Hospital Anxiety and Depression Scale (HADS) and The Adverse Childhood Experiences (ACE) questionnaires to assess psychological stress and adverse childhood experiences. Linear regression analysis and analysis of variance (ANOVA) were used to determine the association between the psychological factors and early adverse life events with bowel symptom severity scores, respectively.

Overall, 125 patients, majority female (67%) and average age 55.8 years (SD 16) completed the surveys. Average ODS score was 10.4 (4) with 80 (64%) of patients having clinically severe symptoms evidenced by ODS >8. Over half (53%) of patients had concurrent severe FI symptoms with a CCFI >8 and the average CCFI score was 8.5 (6.7). In total, nearly one third (28%) of patients had concurrent severe symptoms of FI and difficult defecation. Adverse childhood experiences (ACE>1) were reported by 73 (58%) of patients. 

Patients with HADS Anxiety>7 or HADS Depression>7 were on average younger (51 vs 60 years p=0.001 and 50 vs 58 years p=0.011, respectively). There was a significant correlation between advancing age and worsening FI severity (p =0 .001) and less severe obstructive defecation symptoms (p =0 .007). Although the average age of patients with severe obstructed defecation symptoms was younger than those without severe symptoms this was not statistically significant (p>0.05). In contrast, patients with clinically severe FI evidenced by CCFI>8 tended to be older with average age 61 years compared to 49 years (p<0.0001). In total, 20 (16%) patients had mild depressive symptoms and 30 (24%) had mild anxiety symptoms with HADS specific score 8-10. 14 (11%) patients had moderate to severe depressive symptoms and 37 (30%) anxiety symptoms with HADS specific scores ≥11. Age of patients with and without adverse life events were comparable (p>0.05).
As shown in Table 1, severity of ODS symptoms positively correlated with psychological symptoms as assessed by HADS anxiety and depression scores (p=0.004 and p=0.002, respectively). The correlation remained significant when adjusted for age (p=0.037 and p=0.014). Conversely, psychological symptoms did not significantly impact the severity of FI symptoms and there was no correlation between CCFI and HADS anxiety and depression scores (p=0.427 and p=0.180). Interestingly after adjusting for age, the correlation between severity of FI symptoms and HADS anxiety and depression scores became significant (p=0.022 and p=0.006). 

Patients with history of trauma and early adverse life events had significantly higher ODS scores which was mainly driven by differences in their response to abdominal pain severity p=0.004. Otherwise, the rest of ODS symptoms such as significant straining, sensation of incomplete defecation, need for laxatives, and digital maneuvers to empty the rectum did not significantly differ between those with and without early adverse life events (p>0.05). Likewise, FI symptoms such as frequency of gas, liquid stool, or solid stool leakage, as well as pad usage, and effect on quality of life did not differ significantly between those with and without history of early adverse life events (p>0.05).

Early adverse life events and psychological symptoms including depression and anxiety symptoms are common in patients with defecatory disorders. More than half of patients had reported early adverse life events which was associated with more severe abdominal pain and therefore overall ODS scores. Nearly one third (27%) of patients had depressive symptoms while anxiety symptoms were reported in over 54% with 30% reporting moderate to severe anxiety symptoms. 

Although patients with and without severe obstructive defecation symptoms were of comparable age, those experiencing severe FI were notably older. Additionally, among the older patients, there was a higher likelihood of the absence of psychological symptoms. Severity of obstructed defecation symptoms was directly associated with higher anxiety and depression scores regardless of age. However, the higher psychological symptom scores did not appear to influence the severity of FI until adjustment was made for age. Upon correcting for age, a significant correlation emerged between the severity of FI and anxiety and depression scores.

Adverse early life events, anxiety and depression symptoms are common among patients with defecatory disorders and negatively impact the severity of defecatory symptoms. In patients with defecatory disorders who had concurrent FI, severity of FI was only influenced by psychological factors in younger patients. The higher severity of FI among older patients irrespective of the severity of psychological symptoms, suggests potential differences in the underlying pathophysiology of FI in older individuals with defecatory disorders. Future research is needed to delineate the impact of psychological factors on anorectal pressure profile and anatomical pathologies, potentially associated with the severity of obstructive defecation and FI symptoms.

Ju, T., et al., Risk and Protective Factors Related to Early Adverse Life Events in Irritable Bowel Syndrome. J Clin Gastroenterol, 2020. 54(1): p. 63-69.
Hendrix, J., et al., Early adverse life events and post-traumatic stress disorder in patients with constipation and suspected disordered defecation. Neurogastroenterol Motil, 2022. 34(3): p. e14195.
Hu, Z., et al., The level and prevalence of depression and anxiety among patients with different subtypes of irritable bowel syndrome: a network meta-analysis. BMC Gastroenterol, 2021. 21(1): p. 23.

Continence 12S (2024) 101678
DOI: 10.1016/j.cont.2024.101678