Advertisement

Frequency of Eating Disorder Pathology Among Patients With Chronic Constipation and Contribution of Gastrointestinal-Specific Anxiety

  • Helen Burton Murray
    Correspondence
    Reprint requests Address requests for reprints to: Helen B. Murray, MS, Department of Psychiatry, Massachusetts General Hospital, 2 Longfellow Place, Suite 200, Boston, Massachusetts 02114. fax: (617) 726-1595.
    Affiliations
    Department of Psychology, Drexel University, Philadelphia, Pennsylvania

    Eating Disorders Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts
    Search for articles by this author
  • Ryan Flanagan
    Affiliations
    Center for Neurointestinal Health, Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
    Search for articles by this author
  • Bryana Banashefski
    Affiliations
    Center for Neurointestinal Health, Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
    Search for articles by this author
  • Casey J. Silvernale
    Affiliations
    Center for Neurointestinal Health, Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
    Search for articles by this author
  • Braden Kuo
    Affiliations
    Harvard Medical School, Boston, Massachusetts

    Center for Neurointestinal Health, Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
    Search for articles by this author
  • Kyle Staller
    Affiliations
    Harvard Medical School, Boston, Massachusetts

    Center for Neurointestinal Health, Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
    Search for articles by this author
Published:January 07, 2020DOI:https://doi.org/10.1016/j.cgh.2019.12.030

      Background & Aims

      Individuals with eating disorders (EDs) frequently have constipation-related symptoms, although the mechanisms of this relationship are not clear. We examined the frequency of and relation between EDs and constipation in patients with chronic constipation referred for anorectal manometry.

      Methods

      We analyzed data from 279 patients with chronic constipation (79.2% female) evaluated at a tertiary center from June 2017 through September 2018. Participants completed a standardized psychometric assessment (patient assessment of constipation symptoms questionnaire and hospital anxiety and depression scale and visceral sensitivity index analyses) and anorectal manometry. A subset of patients completed colonic transit testing. Participants with clinically significant ED pathology were identified based on scores of 20 or higher on the Eating Attitudes Test-26. We performed a logistic regression analysis to examine factors associated with the likelihood of having ED pathology. Odds ratios were calculated based on continuous variables. We examined the contribution of anxiety to the relationship between severity of ED pathology and symptoms of constipation (such as abdominal pain) using a regression-based bootstrapping approach.

      Results

      Of the study participants, 53 (19.0%) had clinically significant ED pathology. The presence of ED pathology was associated with greater general anxiety scores, based on the hospital anxiety and depression scale (odds ratio, 1.20; 95% CI, 1.05–1.38), and greater gastrointestinal-specific anxiety scores, based on the visceral sensitivity index (odds ratio, 1.06; 95% CI, 1.03–1.09). Gastrointestinal-specific anxiety fully mediated the relationship between the severity of ED pathology and constipation (standardized β, 0.11–0.16; P = .026–.024). We found no differences in anorectal manometry or colonic transit between patients with vs without ED pathology.

      Conclusions

      In an analysis of patients with chronic constipation, we found that 19% had clinically significant ED pathology. Our preliminary finding indicated that ED pathology might contribute to constipation via gastrointestinal-specific anxiety. Clinicians should consider screening patients with chronic constipation for EDs—especially patients who report symptoms such as bloating and abdominal pain.

      Keywords

      Abbreviations used in this paper:

      ARM (anorectal manometry), CC (chronic constipation), EAT-26 (Eating Attitudes Test), ED (eating disorder), IBS (irritable bowel syndrome), PAC-SYM (Patient Assessment of Constipation-Symptoms), VSI (Visceral Sensitivity Index)
      To read this article in full you will need to make a payment
      AGA Member Login
      Login with your AGA username and password.
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mitchell J.E.
        Medical comorbidity and medical complications associated with binge-eating disorder.
        Int J Eat Disord. 2015; 49: 319-323
        • Norris M.L.
        • Harrison M.E.
        • Isserlin L.
        • et al.
        Gastrointestinal complications associated with anorexia nervosa: a systematic review.
        Int J Eat Disord. 2016; 49: 216-237
        • Boyd C.
        • Abraham S.
        • Kellow J.
        Psychological features are important predictors of functional gastrointestinal disorders in patients with eating disorders.
        Scand J Gastroenterol. 2005; 40: 929-935
        • Chami T.N.
        • Andersen A.E.
        • Crowell M.D.
        • et al.
        Gastrointestinal symptoms in bulimia nervosa: effects of treatment.
        Am J Gastroenterol. 1995; 90: 88-92
        • Peat C.M.
        • Huang L.
        • Thornton L.M.
        • et al.
        Binge eating, body mass index, and gastrointestinal symptoms.
        J Psychosom Res. 2013; 75: 456-461
        • Chun A.B.
        • Sokol M.S.
        • Kaye W.H.
        • et al.
        Colonic and anorectal function in constipated patients with anorexia nervosa.
        Am J Gastroenterol. 1997; 92: 1879-1883
        • Chiarioni G.
        • Bassotti G.
        • Monsignori A.
        • et al.
        Anorectal dysfunction in constipated women with anorexia nervosa.
        Mayo Clin Proc. 2000; 75: 1015-1019
        • Satherley R.
        • Howard R.
        • Higgs S.
        Disordered eating practices in gastrointestinal disorders.
        Appetite. 2015; 84: 240-250
        • Zia J.K.
        • Riddle M.
        • DeCou C.R.
        • et al.
        Prevalence of eating disorders, especially DSM-5's avoidant restrictive food intake disorder, in patients with functional gastrointestinal disorders: a cross-sectional online survey.
        Gastroenterology. 2017; 152: S715-S716
        • Mari A.
        • Hosadurg D.
        • Martin L.
        • et al.
        Adherence with a low-FODMAP diet in irritable bowel syndrome: are eating disorders the missing link?.
        Eur J Gastroenterol Hepatol. 2019; 31: 178-182
        • Chey W.D.
        Elimination diets for irritable bowel syndrome: approaching the end of the beginning.
        Am J Gastroenterol. 2019; 114: 201-203
        • Wolitzky-Taylor K.
        • Craske M.G.
        • Labus J.S.
        • et al.
        Visceral sensitivity as a mediator of outcome in the treatment of irritable bowel syndrome.
        Behav Res Ther. 2012; 50: 647-650
        • Ljótsson B.
        • Hesser H.
        • Andersson E.
        • et al.
        Mechanisms of change in an exposure-based treatment for irritable bowel syndrome.
        J Consult Clin Psychol. 2013; 81: 1113
        • Garner D.M.
        • Olmsted M.P.
        • Bohr Y.
        • et al.
        The eating attitudes test: psychometric features and clinical correlates.
        Psychol Med. 1982; 12: 871-878
        • Frank L.
        • Kleinman L.
        • Farup C.
        • et al.
        Psychometric validation of a constipation symptom assessment questionnaire.
        Scand J Gastroenterol. 1999; 34: 870-877
        • Zigmond A.S.
        • Snaith R.P.
        The hospital anxiety and depression scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Labus J.
        • Bolus R.
        • Chang L.
        • et al.
        The Visceral Sensitivity Index: development and validation of a gastrointestinal symptom-specific anxiety scale.
        Aliment Pharmacol Ther. 2004; 20: 89-97
      1. Drossman D. Chang L. Chey W.D. ROME IV: functional gastrointestinal disorders – disorders of gut-brain interaction. 4th ed. Rome Foundation, Raleigh, NC2016: 2
        • Staller K.
        Role of anorectal manometry in clinical practice.
        Curr Treat Options Gastroenterol. 2015; 13: 418-431
        • Rao S.
        • Azpiroz F.
        • Diamant N.
        • et al.
        Minimum standards of anorectal manometry.
        Neurogastroenterol Motil. 2002; 14: 553-559
        • Hinton J.
        • Lennard-Jones J.
        • Young A.
        A new method for studying gut transit times using radioopaque markers.
        Gut. 1969; 10: 842-847
        • Hayes A.F.
        Introduction to mediation, moderation, and conditional process analysis: a regression-based approach.
        Guilford Press, New York, NY2013
        • MacKinnon D.P.
        • Fairchild A.J.
        • Fritz M.S.
        Mediation analysis.
        Annu Rev Psychol. 2007; 58: 593-614
        • Preacher K.J.
        • Hayes A.F.
        Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models.
        Behav Res Methods. 2008; 40: 879-891
        • Fritz M.S.
        • Mackinnon D.P.
        Required sample size to detect the mediated effect.
        Psychol Sci. 2007; 18: 233-239
        • Fairburn C.G.
        Cognitive behavior therapy and eating disorders.
        Guilford Press, New York2008
        • Academy for Eating Disorders
        Eating disorders: a guide to medical care. Academy for Eating Disorders Report.
        3rd ed. 2016 (Available at:)
        • Keefer L.
        • Palsson O.S.
        • Pandolfino J.E.
        Best practice update: incorporating psychogastroenterology into management of digestive disorders.
        Gastroenterology. 2018; 154: 1249-1257
        • APA
        Diagnostic and statistical manual of mental disorders (DSM-5).
        5th ed. American Psychiatric Publishing, Arlington, VA2013
        • Staller K.
        Refractory constipation: what is the clinician to do?.
        J Clin Gastroenterol. 2018; 52: 490-501