Abstract
Background:
Early adverse life events (EALs) and post-traumatic stress disorder (PTSD) are associated with irritable bowel syndrome (IBS). Disordered defecation (DD) presents with symptoms of IBS or functional constipation (FC) and is associated with psychological distress. However, the role of trauma and stress in chronic constipation is poorly defined. We aimed to examine EALS, PTSD, and psychological symptoms in patients with constipation and suspected DD.
Methods:
We conducted a survey study among adults with constipation who completed anorectal manometry (ARM) and balloon expulsion testing (BET). Data were collected on socio-demographics, EALs, PTSD, bowel symptoms, quality of life, and anxiety and depression. We performed comparisons between individuals with normal vs. abnormal ARM or BET, subgroup analysis by detailed ARM and BET findings, and latent class analysis using individual EAL domains.
Key Results:
Among 712 eligible patients, 69 completed the study. EALs and provisional PTSD were present in 75.4% and 27.5%, respectively; rates did not differ between those with normal vs. abnormal ARM or BET. Normal testing was associated with higher rates of specific EAL domains (emotional abuse and mental illness), higher depression scores, and poorer mental component scores in both primary and subgroup comparisons (all p<0.05). Normal testing was associated with a lower likelihood of high-EAL latent class (p=0.01) membership. Presence of IBS or FC did not influence associations.
Conclusions & Inferences:
EALs and PTSD are prevalent in patients with constipation and suspected DD. Those with normal ARM and BET have higher rates of prior emotional abuse and poorer mental health.
Keywords: irritable bowel syndrome, mental health, abuse, psychological distress, biopsychosocial
Graphical Abstract
INTRODUCTION
Lower functional bowel disorders such as irritable bowel syndrome (IBS) and functional constipation (FC) are highly prevalent conditions that are associated with decreased health-related quality of life (QOL), increased healthcare costs, and increased psychological distress.(1) No one pathophysiological abnormality can explain symptoms across all patients; however, multiple biological and psychological mechanisms including disturbances in brain-gut interactions(2) have been implicated in the pathogenesis of these multifactorial conditions. A comprehensive understanding of the central nervous system and biopsychosocial basis of lower functional bowel disorders is necessary to effectively evaluate and manage these challenging disorders.(3)
Early life experiences and trauma are key environmental factors that may influence both the brain and the gut within the biopsychosocial model. Studies have identified adverse childhood experiences or early adverse life events (EALs)(4, 5) and post-traumatic stress disorder (PTSD)(6–8) as risk factors for IBS. Psychological distress and prior abuse history have also been reported in patients with severe constipation by some,(9) though not by others.(10, 11) Functional disorders of defecation such as dyssynergic defecation may coexist with IBS or FC,(12) and have been correlated with prior sexual or physical abuse and increased psychological distress.(13–16) These observations have provided evidence suggesting that adverse and stressful life experiences may be important events in activating the neurophysiologic pathways that exacerbate symptoms of constipation or in determining the clinical response to therapeutic interventions.(17) Despite these well recognized relationships, there remains limited information on the prevalence of PTSD or specific domains of EALs in patients with constipation-predominant functional bowel disorders and functional disorders of defecation. Quantifying rates of co-existing PTSD, EALs and individual domains of EALs may be critical steps in developing effective multidisciplinary strategies that address specific factors within the biopsychosocial model to improve patient-important outcomes and QOL. In this study, we aimed to assess EALs and provisional PTSD in patients undergoing evaluation for disordered defecation for symptoms of constipation.
MATERIALS AND METHODS
Study Design and Participants:
We performed a cross-sectional survey study from June, 2018 to July, 2020 among adults ≥ 18 years who underwent anorectal manometry (ARM) and balloon expulsion test (BET) within the last five years. The study was approved by the Indiana University Institutional Review Board. Patients referred for ARM with BET at the Indiana University Motility Laboratory for a history of constipation were identified through review of the electronic medical record (EMR) systems including the specialized gastroenterology EMR, Provation. Results of ARM and BET were reviewed for features of impaired evacuation.
All eligible individuals were sent an invitation to participate in an online survey study on general health, bowel symptoms, QOL, mental health, and traumatic life experiences. Reminder invitations were sent to primary non-responders within 4 weeks after the initial invitatation to minimize response bias. Individuals were invited to complete the survey through a secure web-based environment (Research Electronic Data Capture) by accessing the provided study link or by requesting paper survey materials. Participants were also invited to complete the survey at the time of presentation for ARM and BET at the motility laboratory. Individuals with a self-reported history of microscopic colitis, inflammatory bowel disease, celiac disease, visceral cancer, or uncontrolled thyroid disease were excluded.
Study procedures:
All participants completed a series of self-administered questionnaires: a basic screening questionnaire to confirm study eligibility; a questionnaire on sociodemographic information and medical history; the standardized Rome IV questionnaire for IBS and FC;(18) the Short Form (SF)-12(19) for assessment of health-related QOL; the Hospital Anxiety and Depression Scale (HADS)(20); the PTSD Checklist for DSM-5 (PCL-5);(21) and the Adverse Childhood Events (ACE) questionnaire.(22) Validated questionnaires, constructed to present non-leading questions, were utilized to minimize recall bias. All participants were blinded to study hypotheses. If survey responses were collected on paper, forms were returned to the study team and manually entered into the electronic data capture platform.
Study endpoints and power calculation:
Primary endpoints were prevalence of EALs or provisional PTSD as determined by responses to the ACE and PCL-5 questionnaires, respectively. Secondary endpoints were overall ACE or PCL-5 scores and prevalence of EAL domains including physical, emotional, and sexual abuse, and general trauma. Other variables of interest included presence of absence of IBS or FC (Rome IV criteria), (2) existence and severity of anxiety and depression (HADS), and (3) health-related QOL (SF-12). Potential covariates included age, sex and race/ethnicity. The sample size of 69 survey respondents was sufficient to estimate the prevalence of EALs and PTSD with no more than 12% margin of error at the 95% confidence level assuming the prevalence rates of 75%.(23) and 50%(24) for EALs and PTSD, respectively, as has been previously reported in IBS.
Statistical analysis:
Data were summarized using means with standard deviations (±SD); medians with interquartile ranges (IQR); and frequencies with proportions. We compared study endpoints between patients with and without features of impaired evacuation using the two-sample t-test or Wilcoxon rank sum test for continuous variables and Pearson’s chi-square test or Fisher’s exact test for categorical variables. We further assessed associations across subgroups based on detailed ARM and BET results (normal; impaired evacuation by both ARM and BET; abnormal ARM or BET, but not both) using the ANOVA F-test or Kruskal-Wallis test for continuous variables and Pearson’s chi-square test or Fisher’s exact test for categorical variables. Follow-up pairwise comparisons were performed for significant p-values with adjustments using the Bonferroni method. To identify patient clusters based on the eight EAL domains, we further conducted latent class analysis (LCA) and compared classes by ARM and BET results. LCA with 1, 2, and 3 latent classes was performed and these models were compared using the Bayesian information criterion to determine the optimal number of classes. All analyses were performed in SAS 9.4 (SAS Institute, Cary NC).
RESULTS
Patient Characteristics:
A total of 712 patients (81.2% females, mean [±SD] age of 48.1 [±16.5] years) underwent ARM and BET at the Indiana University Motility Laboratory for constipation symptoms from July, 2014 to September, 2019. Among these patients, 363 (51%) demonstrated abnormal anorectal evacuation pattern types 1–4 by ARM (Table 1); 203 (28.6%) had evidence of abnormal BET; and 184 (26.0%) had evidence of impaired evacuation by both ARM and BET. All 712 patients were invited to participate and 125 responded. Complete survey responses were obtained from 69 patients (Figure 1). Responders were (p=0.01) younger (mean age, 43.4±14.6 years) than non-responders (mean age, 48.6±16.7 years). There were no significant differences in sex or the proportion of patients with features of impaired evacuation by ARM and BET between responders and non-responders (Table 1). Among 69 participants, 12 (17%) had normal ARM and BET and 57 (83%) had features of impaired evacuation (N=17 [24.6%] with abnormal ARM and BET; N=40 [58.%] with abnormal ARM or BET, but not both). Demographics, smoking status and alcohol consumption patterns did not differ between patients with and without features of impaired evacuation (Table 2).
Table 1:
Baseline characteristics of survey responders and non-responders
| Total (N = 712) | Responders (N = 69) | Non-responders (N = 643) | |
|---|---|---|---|
| Age, mean (SD) * | 48.1 (16.5) | 43.4 (14.6) | 48.6 (16.7) |
| Females, N (%) | 578 (81.2%) | 60 (87.0%) | 518 (80.6%) |
| ARM result, N (%) | |||
| Normal | 160 (22.5%) | 14 (20.3%) | 146 (22.8%) |
| Type 1 | 37 (5.2%) | 3 (4.3%) | 34 (5.3%) |
| Type 2 | 76 (10.7%) | 5 (7.2%) | 71 (11.1%) |
| Type 3 | 58 (8.2%) | 5 (7.2%) | 53 (8.3%) |
| Type 4 | 192 (27.0%) | 15 (21.7%) | 177 (27.6%) |
| Other abnormal | 187 (26.3%) | 27 (39.1%) | 160 (25.0%) |
| Abnormal BET, N (%) | 203 (28.6%) | 19 (27.5%) | 184 (28.8%) |
Two group comparisons were performed using the two-sample t-test for continuous variables and Pearson’s chi-square test or Fisher’s exact test for categorical variables.
p-value = 0.013; all other p-values were non-significant.
Figure 1:
Patient Flow Diagram
Table 2:
Comparisons of baseline characteristic between participants with normal and abnormal anorectal manometry (ARM) and balloon expulsion test (BET)
| Normal ARM and BET (N = 12) | Features of impaired evacuation by ARM or BET (N= 57) | |
|---|---|---|
| Age, mean (SD) | 49.0 (14.0) | 44.1 (14.6) |
| Females, N (%) | 12 (100%) | 48 (84.2%) |
| Caucasians, N (%) | 12 (100%) | 52 (91.2%) |
| Married, N (%) | 9 (75.0%) | 30 (52.6%) |
| Education, N (%) | ||
| High school | 4 (33.3%) | 17 (30.9%) |
| College | 7 (58.3%) | 30 (54.5%) |
| Above college | 1 (8.3%) | 8 (14.5%) |
| Smoker, N (%) | 0 (0%) | 8 (14.0%) |
| Alcohol, N (%) | ||
| Never | 4 (33.3%) | 26 (45.6%) |
| Rarely or occasionally | 6 (50.0%) | 27 (47.4%) |
| Regularly or frequently | 2 (16.7%) | 4 (7.0%) |
| Body mass index (kg/m 2 ), mean (SD) | 26.9 (5.3) | 26.6 (6.7) |
Two group comparisons were performed using the two-sample t-test for continuous variables and Pearson’s chi-square test or Fisher’s exact test for categorical variables. All p-values were non-significant.
Early Adverse Life Events Among Survey Respondents:
EALs (Figure 2) were reported in 75.4% (N=52) of participants overall (83.3% of participants with normal ARM and BET; 73.7% participants with any features of impaired evacuation by ARM or BET [abnormal testing]). There was no significant difference in reported rates of EALs between those with normal testing and those with abnormal ARM or BET (p=0.72). Median (IQR) total ACE score for the overall group was 2.0 (1.0–4.0); higher overall scores among participants with normal testing compared to those with abnormal testing (Table 3) were of borderline significance (p=0.05). Assessment of individual EAL domains (Figure 2) revealed higher rates of emotional abuse (p<0.01) and mental illness in the household (p=0.01) among participants with normal testing compared to those with abnormal testing. There were no significant differences in rates of other EAL domains (all p=ns).
Figure 2:
Early Adverse Life-Events (EAL) and EAL Domains in Study Participants with Normal and Abnormal Anorectal Manometry or Balloon Expulsion Testing
Table 3:
Adverse Childhood Events (ACE), Post-traumatic Stress Disorder (PTSD), Psychological Symptoms, and Health-related Quality of life (SF-12) in Survey Participants With and Without Features of Impaired Evacuation by Anorectal Manometry (ARM) and Balloon Expulsion Test (BET)
| Data show median (IQR) except where specified | Total (N=69) | Normal ARM and BET (N=12) | Abnormal ARM or BET (N=57) |
|---|---|---|---|
| ACE total score * | 2.0 (1.0–4.0) | 4.0 (2.5–5.5) | 1.0 (0.0–4.0) |
| Presence of early adverse life events, N (%) | 52 (75.4%) | 10 (83.3%) | 42 (73.7%) |
| ACE domains, N (%) | |||
| Emotional abuse** | 33 (47.8%) | 10 (83.3%) | 23 (40.4%) |
| Physical abuse | 24 (34.8%) | 7 (58.3%) | 17 (29.8%) |
| Sexual abuse | 26 (37.7%) | 7 (58.3%) | 19 (33.3%) |
| Substance abuse | 22 (31.9%) | 4 (33.3%) | 18 (31.6%) |
| Parental separation or divorce | 22 (31.9%) | 4 (33.3%) | 18 (31.6%) |
| Mental illness*** | 28 (40.6%) | 9 (75.0%) | 19 (33.3%) |
| Prison | 5 (7.2%) | 0 (0%) | 5 (8.8%) |
| Parent treated violently | 16 (23.2%) | 4 (33.3%) | 12 (21.1%) |
| PCL-5 total score | 17.0 (4.0–37.0) | 28.5 (5.5–43.5) | 13.0 (3.0–28.0) |
| Provisional PTSD, N (%) | 19 (27.5%) | 5 (41.7%) | 14 (24.6%) |
| Irritable bowel syndrome, N (%) | 34 (49.3%) | 5 (41.7%) | 29 (50.9%) |
| Functional constipation, N (%) | 16 (23.2%) | 3 (25.0%) | 13 (22.8%) |
| HADS anxiety score | 8.0 (5.0–11.0) | 9.0 (6.5–11.0) | 7.0 (4.0–12.0) |
| HADS anxiety, N (%) | |||
| Normal (0–7) | 33 (47.8%) | 4 (33.3%) | 29 (50.9%) |
| Borderline abnormal (8–10) | 14 (20.3%) | 4 (33.3%) | 10 (17.5%) |
| Abnormal (11–21) | 22 (31.9%) | 4 (33.3%) | 18 (31.6%) |
| HAD depression score **** | 5.0 (2.0–11.0) | 11.5 (4.5–13.0) | 4.0 (2.0–9.0) |
| HADS depression, N (%) *** | |||
| Normal (0–7) | 40 (58.0%) | 4 (33.3%) | 36 (63.2%) |
| Borderline abnormal (8–10) | 11 (15.9%) | 1 (8.3%) | 10 (17.5%) |
| Abnormal (11–21) | 18 (26.1%) | 7 (58.3%) | 11 (19.3%) |
| SF-12 | |||
| Physical component score | 43.7 (32.8–51.7) | 45.0 (35.6–52.9) | 43.7 (32.5–51.7) |
| Mental component score** | 42.3 (31.0–51.9) | 32.5 (24.2–39.7) | 45.8 (33.5–53.3) |
PCL-5, PTSD Checklist; HADS, Hospital Anxiety and Depression Scale; SF-12, Short-Form 12. Two group comparisons were performed using the two-sample t-test or Wilcoxon rank sum test for continuous variables and Pearson’s chi-square test or Fisher’s exact test for categorical variables.
p-value=0.053
p-value < 0.01
p-value = 0.01
p-value = 0.03; all other p-values = non-significant
Subgroup analysis across groups as defined by detailed ARM and BET results (normal testing; impaired evacuation by both ARM and BET; abnormal ARM or BET, but not both) demonstrated significant differences in the EAL domains of emotional abuse (p=0.03) and mental illness (p<0.01); higher rates of emotional abuse and mental illness were reported among participants with normal ARM and BET (83.3%) compared to those with impaired evacuation by both ARM and BET (41.2%) or those with abnormal ARM or BET, but not both (40.0%). There were no significant differences (all p=ns) in rates of any EAL, median ACE scores, or rates of other EAL domains across subssgroups (all p=ns).
LCA using the eight EAL domains suggested the presence of two classes, a low and a high ACE class. Classes differed by likelihood of adverse experiences and represented 53% and 47% of participants, respectively (Figure 3). The difference between the high and low ACE classes were mainly in the domains: emotional abuse, physical abuse, sexual abuse, mental illness, and parent treated violently. Approximately 68% of the high ACE class members had abnormal ARM or BET, while 95.5% of the low ACE class members had abnormal ARM or BET; those with abnormal testing were significantly less likely to be in the high ACE class (OR=0.101, 95% CI=0.014 to 0.735).
Figure 3:
Latent Classes by Estimated Prevalence of Adverse Childhood Events (ACE)
Post-Traumatic Stress Disorder:
A provisional PTSD diagnosis was present in 27.5% of participants overall (41.7% of participants with normal ARM and BET; 24.6% participants with any features of impaired evacuation by ARM or BET). There was no significant difference in rates of provisional PTSD between those with normal testing compared to those with abnormal testing (p=0.29). Median (IQR) PCL-5 score for the overall group was 17.0 (4.0–37.0). There were no significant differences in median scores between those with normal testing vs. abnormal testing (Table 3). Subgroup analysis by detailed ARM and BET results revealed no significant differences (all p=ns) in rates of provisional PTSD (overall p=ns) or median PCL-5 scores across subgroups (overall p=ns).
Functional Bowel Disorders, Anxiety, Depression, and Quality of Life:
A total of 50 participants (72.5%) fulfilled Rome IV criteria for IBS or FC. Comparisons of participants with and without features of impaired evacuation by ARM or BET demonstrated no significant differences in rates of IBS or FC (Figure 4). Median (IQR) anxiety score for the overall group was 8.0 (5.0–11.0). There were no significant differences in anxiety scores (9.0 [6.5–11.0] vs 7.0 (4.0–12.0]; p=0.42), or the proportion of abnormal anxiety scores (Figure 4) between participants with normal ARM and BET and those with abnormal testing. Median (IQR) depression score for the overall group was 5.0 (2.0–11.0); scores were higher (p=0.03) in participants with normal ARM and BET (11.5 [4.5–13.0]) than in those with abnormal testing (4.0 [2.0–9.0]). A significantly higher proportion of abnormal depression scores (Figure 4) was observed in participants with normal testing compared to those with abnormal testing (58.3% vs. 19.3%, p=0.03).
Figure 4:
Prevalence of Functional Bowel Disorders and Abnormal Anxiety or Depression Scores Among Study Participants with Normal and Abnormal Anorectal Manometry or Balloon Expulsion Testing
Assessment of health-related QOL based on SF-12 responses demonstrated no significant differences in median (IQR) physical component scores between participants with normal testing (45.0 [35.6–52.9]) and those with features of impaired evacuation by ARM or BET (43.7 [32.5–51.7]). However, median (IQR) mental component scores were significantly lower (p<0.01) in participants with normal testing (32.5 [24.2–39.7]) than in those with abnormal testing (45.8 [33.5–53.3). Post-hoc analyses examining the effect of the presence of IBS or FC on the associations of ARM and BET results with EALs, PTSD, anxiety, depression and QOL scores did not change overall results.
Subgroup analysis by detailed ARM and BET results demonstrated significant differences in median (IQR) depression (overall p=0.04) and mental component scores across groups (overall p=0.02); highest depression scores (11.5[4.5–13.0]) and lowest mental component scores (32.5 [24.2–39.7]) indicating poorer mental health were observed in participants with normal testing compared to those with abnormal ARM and BET (depression score, 3.0 [2.0–8.0]; mental component score, 47.0 [33.5–53.6]) or those with abnormal ARM or BET, but not both (depression score, 5.0 [2.5–10.0]; mental component score, 45.6 [33.9–52.3]). Rates of IBS or FC, median anxiety scores, rates of abnormal anxiety or depression scores, or median physical component scores did not differ across subgroups (all p=ns).
DISCUSSION
Prior history of traumatic or stressful life events including physical, emotional, or sexual abuse have been described as important risk factors for functional gastrointestinal disorders such as IBS. Studies have demonstrated that the pathway by which these events contribute to symptom development may be related to pathophysiological changes within the brain-gut axis such as decreased resilience(25) and abnormal hypothalamic-pituitary-adrenal (HPA) axis reactivity(26). These hypotheses are further supported by the observation that PTSD, a psychiatric condition characterized by hypervigilance and hyper-arousal, is frequently associated with IBS.(6) Although the role of traumatic life experiences in FC is less well described, a high prevalence of psychological disorders has been reported in patients with constipation and underlying evacuation disorders,(17) suggesting that these disorders should also be considered within the framework of the biopsychosocial model. In this comprehensive questionnaire-based study, we assessed for prior history of EALs, specific domains of EALs, and signs of PTSD in patients undergoing evaluation for disordered defecation to seek insight on the role that stress and trauma may play in the development of chronic constipation and impaired evacuation.
Our findings reveal that EALs are highly common among this patient population, occurring in more than 75% of patients and at rates similar to those that have been reported(23) in patients with IBS. Assessment of individual domains of EALs demonstrated that a history of emotional abuse and mental illness were the most commonly reported forms of early life stress, which is also consistent with prior studies of IBS patients.(23) In our comparisons of individuals with normal vs. abnormal ARM and BET, we observed higher rates of prior emotional abuse and mental illness among participants with normal testing. We also observed higher depression scores, higher rates of abnormal depression scores, and lower mental health scores among participants with normal testing. In addition, there were two latent classes of EALs: a high ACE and a low ACE class. Individuals with abnormal testing were significantly less likely to be in the high ACE latent class. Our observations may seem unexpected at first given that psychological disorders and rectal evacuation disorders are common comorbid conditions,(16, 17) Similar findings, however, have been described(27) in a prospective study of emotional disturbances in patients undergoing defecography for bowel disturbances. In their report, Kashyap et al. observed higher rates of reported sexual abuse and PTSD as well as higher anxiety and depression scores in individuals with normal testing compared to those with abnormal testing. Defecography is commonly used to identify structural abnormalities, but is also supported by Rome IV criteria as a sufficient alternative to ARM and BET to evaluate functional parameters of defecation and identify disordered defecation.(28) Thus, our findings suggest that while EALs and psychological distress are common overall in patients undergoing diagnostic evaluation for refractory constipation, individuals who experience symptoms of impaired evacuation but exhibit normal physiologic testing, may be more likely to have experienced emotional or mental stress during childhood and be at higher risk of depression and poorer mental health. While patients with evidence of dyssynergic defecation are commonly referred for dedicated biofeedback therapy, a proven and safe treatment,(29) the optimal management strategies for patients with normal physiologic testing who have failed conventional treatments are less clear. Results of the current study suggest deeper investigations of the impact of psycho-developmental factors and other centrally-mediated mechanisms (e.g. changes in the functional and anatomical brain network that occur in response to EALs,(30) stress hyper-responsiveness,(31) altered resilience, HPA-axis reactivity,(26) direct effects on normal test results on psychological symptoms or somatization) should be pursued.
In our patient cohort, more than 27% of individuals met criteria for a provisional diagnosis of PTSD based on the PCL-5 questionnaire. Most studies describing the association between PTSD and functional gastrointestinal disorders have focused on PTSD and IBS within Veteran populations. Surprisingly, the rates described in our cohort are similar to PTSD rates that have been described among Veterans(8) and much higher than the 7–8% prevalence rates that have been reported in non-Veteran IBS patients.(7, 32) Presence or absence of a provisional PTSD diagnosis was not associated with results of ARM and BET in either the primary group comparisons nor in the subgroup analysis, which suggests that while PTSD is common overall, disordered defecation is not associated with an increased risk of PTSD in patients with severe chronic constipation referred for ARM and BET. Although the ability to detect significant associations may have been limited by the study sample size, our results suggest that patients with severe constipation who are suspected to have impaired evacuation may be at an especially high risk of comorbid PTSD. Further studies will be necessary to identify the reasons for this association; describe how the presence of comorbid PTSD and chronic constipation may produce a synergistic escalation of symptoms; and develop effective integrative management strategies.
Major study strengths include the use of validated questionnaires, verification of clinical and demographic data through detailed review of the EMR, blinding of study participants to the research hypotheses, and a wide distribution of survey invitations to all patients (>700 individuals) who underwent ARM and BET at a single institution. Study limitations, however, are recognized and include the survey-based design of the study and the potential for responder bias which may have contributed to a slightly younger study population. However, comparisons of other demographic and clinical characteristics between survey responders and non-responders showed no significant differences in gender or results of ARM and BET. The study was conducted at a tertiary referral site, which may limit generalizability to larger community-based populations. Comparisons across and between groups should be interpreted with caution given the relatively small sample size A future study aiming to detect a similar 20% difference in the presence of EALs between individuals with normal testing and those with impaired evacuation, would require larger participant numbers.
In summary, findings from our study demonstrate that EALs and PTSD are common among patients with constipation and suspected defecation disorders. Those with normal physiologic testing may have experienced higher rates of prior emotional abuse and be at greater risk of poorer mental health. Clinicians should be aware that EALs and PTSD may be important contributors to the pathophysiology of constipation-predominant bowel disorders and should consider asking patients about prior abuse or trauma to identify opportunities for intervention and support. Future studies should (1) assess the relative impact of EALs and PTSD in constipated patients compared to other disorders of brain-gut interaction, (2) examine specific aspects of the brain-gut pathway that may be directly impacted by a history of EALs and comorbid PTSD in constipated patients with normal defecation patterns, and (3) investigate the efficacy of early intervention and treatments that are designed to target the neurobiological and psychological aspects of the disease experience.
Funding:
AS is supported, in part, by the Board of Directors of the Indiana University Health Values Fund for Research Award and the Indiana Clinical and Translational Sciences Institute (Grant Number UL1TR002529 from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award) and NIDDK K23DK122015. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Disclosures: None
Data availability:
The data that support the findings of this study are available on request from the corresponding author, AS. The data are not publicly available due to their containing information that could compromise the privacy of research participants.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author, AS. The data are not publicly available due to their containing information that could compromise the privacy of research participants.