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Physiologic and Psychodynamic Mechanisms inConstipation and DiarrheaTHOMAS S. SZASZ, M.D.

Signs and symptoms of somatic disorders are theend results of a complex chain of events which com-prise numerous factors. Essential to the understand-ing of any causal chain of events is a clarification ofthe physiologic mechanisms involved in the pro-duction of the changes responsible for the signs andsymptom s. This is particularly true in any considera-tion of the role of psychodynamic factors in theetiologyof constipation and diarrhea.

The classic studies of Abraham (1,2,3) revealedthe existence of a relationship between psychodyna-mic factors and constipation and diarrhea. The sub-sequent contributons by Alexander (5,6) and morerecently, by Melitta Sperling (14 ,15 ) left little doubtas to the existence of such a relationship. All thesestudies, however, consisted in the correlation ofpsychodynamic mechanisms with the end result ofthe physiologic distortion, i.e., with the signs andsymptoms of constipation and diarrhea, rather thanwith the specific physiologic processes involved inthe production of these symptoms.

Constipation and diarrhea are referable to dis-orders of the lower portion of the gastrointestinaltract which induce a change in 1) the frequency ofdefecation and 2) the consistency of the stools. Thus,diarrhea may refer a) to a state in which there is anincrease in the number of evacuations of stools offairly normal consistency, or b) to a state in whichthere is a normal number of evacuations of stoolswhich are abnormal in that they are fluid in con-sistency, or c) to a state in which there is anincreased number of evacuations of fluid stools.Similarly with constipation, which may refer toeither the decreased frequency of defecation, or tothe dehydrated character of the stools, or to thecombination of both. Consequently, the patient whomerely states that he is constipated or has diarrheaPresented at the Annual Meeting of the American Psy-chosomatic Society, Atlantic City, New Jersey, April 29,1950.Research Assistant, Chicago Institute for Psychoanalysis.The author is indebted to Dr. I. Arthur Mirsky of Cincin-nati , and Dr. Samuel D. Lipton and Dr. Alan M. Robertsonof Chicago for many helpful suggestions concerning thepreparation of this paper.Received for publication April 6, 1950.

provides no information as to what he means, whilethe physician who uses these terms without furtherelaboration provides no information as to the precisephysiologic dysfunction to which he is referring.Examination of the known facts concerning thefunctions of the lower intestinal tract yields moreaccurate information concerning the significance ofthe forms in which constipation and diarrhea mayappear in patients. The lower alimentary tract isdivisible into two distinct functional units: 1) thecolon and rectum which are regulated by the auto-nomic nervous system, and 2) the external analsphincter which is under voluntary control as aresult of previous toilet training. Consequently,disorders of the colon and rectum may express them-selves in one of two ways: 1. Increased secretionand motility of the large bowel, under the influenceof parasympathetic stimulation, results in a decreasedconsistency of feces so that the patient will haverelatively watery evacuations, with or without anincrease in their frequency. 2. Decreased activity ofthe large bowel, under the influence of sympatheticstimulation, results in an increased consistency ofthe stool, with or without a necessarily fewer num-ber of evacuations. Disorders of the anal sphincterare best analyzed in terms that are also applicableto the vesical sphincter, namely, retention, frequencyand incontinence. Thus, constipation may resultfrom increased retention, and diarrhea from in-creased frequency.

In view of the preceding, any description ofconstipation and diarrhea must be such as to permita distinction between those symptoms which are theresults of a disorder in the function of the colonand rectum on the one hand, and of the analsphincter on the other.Consideration of the psychodynamic factors thatmay influence the above-mentioned functional unitsmakes pertinent Alexander's differentiation betweenthe mechanisms of hysterical conversion and vegeta-tive neurosis: Th e hysterical conversion symptom isan attempt to relieve an emotional tension in asymbolic way; it is a symbolic expression of a definiteemotional content. This mechanism is restricted tothe voluntary neuromuscular or sensory perceptivesystems whose function is to express and relieve

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THO MAS S SZASZemotions. A vegetative neurosis consists of a psy-chogenic dysfunction of a vegetative organ which isnot under control of the voluntary neuromuscularsystem. The vegetative symptom is not a substituteexpression of the emotion, but its normal physiologicconcom itant (4 ). These concepts have become oneof the firmest cornerstones of modern psychosomaticresearch. This distinction between hysterical con-version and vegetative neurosis represents the firstdeparture from the older psychoanalytic approachto physiologic disturbances, according to which everysymptom, regardless of its precise pathogenesis, wasoften regarded in a more or less anthropomorphicway, and was thought to express either some un-conscious emotional striving or the prohibition ofsuch a striving, or both. Actually, up to recenttimes, all psychoanalytic interpretations of constipa-tion and diarrhea have been precisely of such anature. Thus, constipation is usually interpreted tomean retainin g, as a form of withho lding, anddiarrhea is usually interpreted to mean giving, asa form of restitution, or eliminating in a hostile anddestructive mann er (5, 6, 12, 15, 22) . Such formula-tions, however, follow the pattern of hysterical con-version mechanisms and can thus apply only to dis-orders of the external anal sphincter. When suchformulations are applied to clinical syndromes suchas mucous colitis and ulcerative colitis, or even totransient attacks of diarrhea or constipation, theirvalue is limited and conclusions based on suchconsiderations are likely to be erroneous. It is moreprobable that the usual psychoanalytic formulationsconcerning constipation and diarrhea are correctonly insofar as they apply to disorders of the externalanal sphincter.*

It is necessary therefore to examine the nature ofthe disorders of the colon and rectum in greaterdetail. The best approach to this problem appearsto be to consider first the nature of the normalexcremental act.

In the infant (or in undomesticated animals),defecation occurs in a definite pattern: the nursinginfant experiences hunger feeds then defecates andfalls asleep. This is the basic physiologic rhythm ofthe gastrointestinal tract. The filling of the stomach

*It should be emphasized, however, that the views put for-ward in this paper do not exclude the possibility thateliminative and retentive (i.e., anal-erotic) tendencies mayinfluence colonic activity; but, whereas the nature of suchpsychologic tendencies (i.e., anal-erotic drives) is well under-stood, the precise physiologic mechanisms whereby emotionalprocesses of this type could affect the regulation of the colonand rectum, remain to be elucidated.MARCH-APRIL. 1951

leads to peristaltic movements of the colon andrectum and to defecation (the gastrocolic reflex)(7 , 23). It would appear that this mechanism maybe of basic importance in constipation and diarrhea.In accord is Spock's description of the bowel habitsof the infant: A breast-fed baby usually has severalmovements a day in the early weeks. Some have amovement after every nursing (16) . Thu s bothinfants (prior to toilet training) and undomesticatedanimals have a definite pattern of bowel habitswhich must be regarded as basic. Deviations fromthis pattern may occur in infants and animals withthe development of a tendency to constipation or todiarrhea. It may well be that the preceding accountsfor the marked susceptibility of infants to thedevelopment of severe diarrhea. In such instancesthe diarrhea is due to colonic and rectal hyper-activity, since in the infant the external anal sphinc-ter does not function as yet as a separate unit butacts in unison with the parts above it.

The usual psychoanalytic formulations concern-ing the etiology of diarrhea are largely dependentupon the psychology of toilet training. Conceptswhich are based on the influence of toilet trainingmust assume that defecation is a completely delibe-rate voluntary act. Physiologic evidence reveals thatdefecation is not a deliberate, voluntary act. Just asone cannot consciously decide when to becomehungry, although one may be able to postpone orotherwise deliberately regulate the satisfaction ofthis need, similarly, one cannot control the activitiesof one's colon. Th is is a funda me ntal fact whichseems to have been overlooked in formulationswhich deal with defecation and its disorders as ifthey constituted voluntary acts such as are possibleonly by structures activated by skeletal muscles. Intoilet training, all that is accomplished is that theexternal anal sphincter, which consists of stripedmuscles and is supplied by fibers from the cerebro-spinal nervous system, is brought under voluntarycontrol. Essentially, toilet training is an inhibitoryfunction in that the child is taught when not todefecate rather than when to do so. In other words,one can learn to control the expression, the satis-faction, or more precisely, the timing of the phy-siologic act demanded by the particular urge ortension.

What then are the psychologic factors which caninfluence the activity of the colon and rectum andthus lead to diarrhea and constipation? A detailedexamination of this problem is not within the scopeof this presentation which is designed only toattempt an elucidation of some basic methodologicalprinciples in the psychosomatic approach to lower

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CONSTIPATION AND DIARRHEAgastrointestinal dysfunctions.* From the foregoing,however, it is evident that disorders of the colonand rectum must be evaluated with due regard tothe fundam ental pattern of activity of the gastro-intestinal tract, viz., that filling of the stomach leadsto activation of the colon and rectum and sub-sequent defecation.f This phenomenon was firstobserved by Macewen (13) and was later designatedby He rtz and Newton (1 1) as the gastrocolicreflex. Since then, a num ber of importa nt phy-siologic studies have appeared which elucidate themechanisms concerned with the effects of feedingupon intestinal motility (8, 9, 23). Welch and Platt(20) have observed that the introduction of foodinto the stomach is not the only stimulus for in-creased colonic activity and have suggested that psychic stimula tion may be responsible for thephenomenon.:]: An association between feeding and

*The writer's views on this subject are based on bothclinical and psychoanalytic observations, some of which havealready been published and others of which will appearshortly (17, 18, 19).tT he basic physiologic pattern : hunger>feedingdefeca-tion, is characteristic of the breast-fed infant and undergoescertain changes in the course of maturation. Accordingly, onlybabies tend to have a bowel movement after each meal; inadults this phenomenon occurs only once per day, most com-monly after breakfast. This increased sensitivity of the gastro-colic reflex early in the morning is probably due to a deepregression of essentially all psychologic and physiologic func-tions during sleep. Similarly, the increased sensitivity orresponsiveness of the colon and rectum to varying oral ten-sions in orally regressed individuals with gastrointestinal dys-functions (e.g., patients with duode nal ulcer, ulcerative colitis,etc.) may be interpreted as a manifestation of a physiologicregression in the self-regulating activity of the digestive ap-paratus.

JWelch and Platt (20) stated: We frequently observedthat the activity of the colon was apparently stimulated ifthe attendant who fed the dogs entered the room during anexperiment. This occurred so frequently that it suggestedthe probability of a psychic stim ulation. Wh en thebowel was normally full, feeding by mouth always increasedits muscular activity. When the bowel was empty, feedingby mouth produced no obvious change, unless the recordingballon w as of large size . The evidence indicates thatthis is a feeding reflex, dependent upon appetite and thecondition of the bowel as to conte nt. These writers evensuggested that the meal must be taken by mouth to elicitthe reflex, but Galapeaux and Templeton (9) reported thatincreased colonic motility was produced when the stomachwas filled through a gastrostomy. Hertz and Newton (11)noted the case of a woman faint with hunger in whomcolonic movements occurred as soon as food was broughtinto the room. These observations indicate that the expecta-tion of the individual (or of the animal) is the crucialpsychologic factor in this phenomenon; in other words, theexpectation of impending satisfaction of a need may be theequivalent, in some ways, of actual satisfaction. Thus, assoon as satisfaction of the hunger-needs appears certain, theremay occur the physiologic concomitants of satisfaction, i.e.,

defecation is said to exist not only in mammals, butalso in birds (8).The physiologic interrelations between feedingand lower gastrointestinal activity may be sum-marized as follows. During periods of hunger, (i.e.,during increased vagal activity), the large bowel isinhibited; and upon satisfaction of hunger (i.e.,decreased vagal activity), activation of the colonand rectum ensues. Chronic (psychologic) stimuliof either type, i.e., stimuli which result in eitherchronic vagal activity or inhibition, may producewhat may be regarded as exacerbations of the essen-tially normal pattern: chronic inhibition of the largeintestine, in the first instance, and chronic stimula-tion, in the second. Vagotomy, for example, simu-lates a condition of the upper gastrointestinal tractwhich is like that occurring after feeding; and thisis thought to be the mechanism responsible for thefrequent change in bowel habits in such patients,in the direction of looser and more frequent bowelmovements (18).Psychoanalytic studies (19) of a variety of patientsrevealed that the colonic and rectal hypo- and hyper-activity could be correlated most accurately withchanges in the patients' unconscious oral-intaking

tensions (drives). Thus, mobilization of strong(unconscious) oral-incorporative strivings (whichare expressed physiologically by vagal hypertonus)were accompained by constipation; and a suddendecrease in such strivings, usually because of guiltfeelings, regularly resulted in diarrhea.** Thus,changes in the function of the large intestines seemto constitute the remote physiologic sequelae ofcertain changes in the upper parts of the digestivetract.The foregoing hypothesis is in harmony withthe clinical characteristics of the majority of theaffections of the large intestine. Syndromes such asmucous colitis and ulcerative colitis have a typicala diminution of vagal tonus. Psychoanalytic observationsshow clearly that the unconscious expectation of the patientis a crucial factor in the regulation of the intensity andexpression of oral-incorporative tendencies (19). I t must be emphasized that the activation as well as the-inhibition of the oral-incorporative tendencies may represent-entirely unconscious processes. One cannot predict reliablyfrom the manifest symptoms or the overt behavior of thepatient the precise nature of the libidinal tendencies seekingsatisfaction. For example, in a patient with an anorexic-bulimic type of eating disturbance, intense unconscious oral-incorporative drives may at one time lead to anorexia, atanother time to bulimia; during periods of anorexia, eatingis inhibited, but the unconscious libidinal strivings mayexpress themselves in a bulimic type of intellectual activity,in an overwhelming need to incorporate knowledge, to readand to learn.

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THOMAS S. SZASZpattern according to which periods of constipationand diarrhea often occur alternately in the samepatient (21). This clinical fact cannot be accountedfor either by the concept that certain personalitytypes develop constipation and others diarrhea, orby Alexander's concept of opposing types of con-flicts. Th e hypothesis suggested herein circumventsthese difficulties by linking various degrees of activa-tion or inhibition of the lower digestive tract tovarious degrees of activation and inhibition of theupper gastrointestinal tract.*

In accord with the foregoing considerations, whenconstipation or diarrhea are the results of colonicand rectal dysfunction, they do not express orrepresent any specific psychologic meaning,f i.e.,the symptom, per se, is withoutprimary psychologiccontent. In colonic dysfunction, only the first linkin a chain of events has psychologic meaning, in thesense of certain psychologic factors motivating (o rbeing translated into) certain physiologic processes.For example, the first link in the causal chainresponsible for the development of diarrhea maybe the emergence of intense guilt over oral-destruc-tive impulses, and a concomitant inhibition of thevagi; the subsequent physiologic disturbances whichmay ensue, may in turn give rise to a number of

As a further support for the foregoing hypothesis con-cerning colonic activity, we may note the well known clinicalobservation that patients with peptic ulcer are commonlyconstipated; according to the writer's hypothesis, the constipa-tion would constitute a physiologic sequela of the chronicallyincreased vagal tonus. Interestingly, Held and Goldbloom(10) , in their textbook on peptic ulcer, after noting thatconstipation occurs very commonly in ulcer patients, statetha t: Occasionally a patient has a tendency towards loosebowel movements, espec ially after a meal. This symptom ismore noticeable in duodenal than in gastric ulcer. There isno plausible explanation for it, although it may be due tothe fact that the hypermotility that accompanies duodenalulcer may extend to die descending colon and sigmoid.(Italics mine.)tT he term psychologic me anin g is here used only todenote primary psychologic content or, in other words, psy-chologic factors which have a causal relationship to th ephysiologic processes in question. It is recognized, of course,that every type of physiologic disturbance, once it has arisen,may be utilized by the person for the expression of emotionalstrivings; such secondary elaborations of p hysiologic d ys-functions must, however, be differentiated from emotionalfactors playing an etiologic role. Such a differentiation isoften extremely difficult and what might be considered byone w orker an etiologic factor may be tho ught o by anotheras merely a secondary elaboration. I believe that a securedistinction between these two types of psychologic factors,present in every vegetative neurosis, can be made only onthe basis of sound knowledge concerning the physiologicmechanisms involved in the particular disorder, togetherwith precise psychologic data obtained by the psychoanalyticmethod.MARCH-APRIL, 1951

5symptoms. None of such symptoms have any pri-mary psychologic meaning, but simply constitutethe physiologic sequelae of earlier links in the chainof pathogenetic events. From this point of view,the diarrhea is analogous to a duodenal ulcer, inthat such a lesion has no direct psychologic mean-ing, but is the end result of long-standing hypersecre-tion and hypermotility of the stomach (5). In thisinstance, it is only the gastric hyperactivity whichhas psychologic meaning, i.e., which is psychologi-cally motivated.

The comparison between peptic ulcer and colonicdysfunction illustrates that in the psychosomaticinvestigation of physiologic disturbances it is neces-sary to understand the precise pathogenetic mecha-nisms of the condition under consideration. Themore complicated and numerous the physiologicsteps involved in the chain of events which finallylead to a symptom, the more difficult it is to makemeaningful psychosomatic correlations. Moreover,direct correlations of psychologic factors and certainsyndromes of complex etiology (such as coronaryartery disease or neurodermatitis) are in themselvesof little significance. In the study of such syndromes,it is essential first to understand the precise patho-genesis in terms of a physiologic chain of events.Only when such knowledge is available will it bepossible to isolate the factors which initiate th epathogenetic sequence. Then, the initiating phy-siologic factors may be correlated with preciselydefined (unconscious) psychologic processes.

SummaryConstipation and diarrhea are symptoms relatedto disorders of the lower portions of the gastro-intestinal tract. In the past, little consideration hasbeen given to the precise portions of the tract in-

volved in these symptoms.The lower alimentary tract is divisible into twodistinct functional units: that of the colon andrectum which are regulated by the autonomicnervous system, and that of the external analsphincter which is under voluntary control inconsequence of previous toilet training. Disordersof the colon and rectum express themselves either inan increased secretion and motility resulting indiarrhea, or a decreased activity with resultingconstipation. Disorders of the anal sphincter arebest analyzed in terms that are also applicable tothe vesical sphincter, viz., retention, frequency, andincontinence. Thus, constipation may be the resultof increased retention, and diarrhea the result of anincreased frequency. Whereas the disorders of

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n 6 CONSTIPATION AND DIARRHEAcolonic function are related to the dynamicsof thevegetative neuroses, the dysfunctions of the analsphincter are related to the dynamics of hystericalconversion symptoms.

The usual psychoanalytic formulations concerningconstipation an d diarrhea are inadequate becausethey can account only for dysfunctions of the analsphincter.A newhypothesisof thephysiologic basisand of thepsychodynamics of colonic dysfunctionsis presented. It is suggested that colonic activationand inhibition, leadingtodiarrheaan dconstipation,represent the physiologic sequelae of certain altera-tionin the upper gastrointestinal tract. Constipationis regarded as the remote physiologic consequenceof astateofincreased vagal excitation;anddiarrheais interpreted as the result of a sudden decreasein vagal tonus. Psychologic factors of etiologicsignificance in colonic dysfunctions are related tomobilization an d inhibition of oral-incorporativetendencies. The symptoms themselves which resultfrom colonic dysfunctions have no primary psy-chologic meaning.

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p. 318, London, The Hogarth Press, 1948.3. ABRAHAM, K.:Contributions to thetheory of theanalcharacter. In Selected Papers p. 370,London,Th eHogarth Press, 1948.4. ALEXANDER, F. :Fundam ental conc eptsofpsychosomaticresearch: Psychogenesis conversion specificity. Psycho-som. Med. 5:205, 1943.5. ALEXANDER, F.:The Influence of psychologic factorsupon gastrointestinal disturbances: A symposium. IGeneral principles objectives and preliminary results.Psycholoanalyt. Quart.3 :501 , 1934.6. ALEXANDER, F., and MEKNINGER, W. C: The relationof persecutory delusionsto thefunctioning of the gastro-

intestinal tract. J. Nerv. Mem. Dis.8 4 :5 4 1 ,1936.7. BEST, C. H., and TAYLOR,N. B.: The Physiological Basisof Medical Practice pp . 810-820. Baltimore, The Wil-liams & Wilkins Co., 1939.8. GARRY, R. C : Themovements of the large intestine.Physiol. Rev. 14:iO3, 1934.9. GALAPEAUX,E. A., and TEMPLBTON,R. D.: The influenceof filling the stomachon colon m otility in thedog. Am.J. Physiol. 119:312 , 1937.

10. H E L D , I. W., and GOLDBLOOM, A. A.: Peptic Ulcer: ItsDiagnosis and Treatment p.58 . Springfie ld, 111., Char lesC Thomas,1946.11. HERTZ,A. F., and N EWTO N , A. : The normal movementsof the colon in man J. Physiol. 47:57, 1913.12. LEVINE, M.: Pregenital trends in a case of chronicdiarrhoea and vomiting. Psychoanalyt. Quart. 3:584,

1934-13. MACEWEN, W.: The function of the caecumandappendix. Brit. M.J.,2:873, 1904.14. SPERLING, M.:A psychoanalytic study of ulcerativecolitis in children. Psychoanalyt. Quart. 15:302,1946.15. SPERLING, M.:Diarrhea: A specific somatic equivalentof an unconscious emotional conflict. Psychosom.Med.10:331,1948.16. SPOCK, B.:The Pocket Book of Baby andChild Care

p. 114. New Y ork, Pocket Books Inc., 1947.17. SZASZ, T. S.: Psychiatric aspects of vagotomy: II Apsychiatric study of vagotomized ulcer patients withcomments on prognosis.Psychosom. Med. 1 1:187 , 1949.18. SZASZ,T. S.:Psychiatric aspectso fvagotomy: III The

problem of diarrhea after vagotomy. J. Nerv. Ment.Dis., tobe published.19. SZASZ,T.S.: Oral mechanisms in constipation and diar-rhea. Paper presented at the Annual Meeting of theAmerican Psychoanalytic Association in Detroit, April

28, 1950.20. W E L C H , P. B., and PLATT, O. M.: A graphic study ofthe muscular activityof thecolon with special referenceto itsresponsetofeeding. Am.J.M. Sc,172:2 6i, 1926.2 1 . W H I T E , B. V., COBB, S., and JONES, C. M.: MUCOUSColitis: A Psychological andMedical Study of Sixtycases.Psychosom. Med. Monograph No .1,Washington,D.C., National Research Council, 1939.22. WILSON, G.W.:Typical personality trends and con flictsin caseso f spastic colitis. Psychoanalyt. Quart. 3:559,

'934-23. YOUMANS,W. B.:Nervous and Neurohu moral Regulationof Intestinal Motility Chapter XVI. NewYork, Inter-science Publishers, Inc., 1949.

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