Psychological & Behavioural Factors Associated with Encopresis James Banham Ipswich Hospital Overview • What is the Biopsychosocial Model • Bob and a Biopsychosocial Model of Encopresis – Predisposing Factors of Encopresis – Triggering Events Associated with Encopresis – Maintaining Factors of Encopresis • Take Home Message • Questions Biopsychosocial Model • The patient is viewed as being embedded within a series of systems that reciprocally interact with one another that impacts the patient’s ability to cope and recover – Biological factors: anatomical, structural & molecular substances of a medical condition and its effects on biological functioning – Psychological factors: effects of psychological wellbeing, motivation and personality on the experience or reaction to a medical condition – Social Factors: cultural, environmental and familial influence of the expression and experience of a medical condition Bob & a Biopsychosocial Model of Encopresis My Ideal Referral Question: Please kindly review Bob who is a 10 y.o. Caucasian male with significant history of unresolved problems with constipation & soiling. Never been toilet trained. He continues to wear nappies and refuses medication. Please assist with management. Bowel function at intake: Passed a large hard bowel motion once every 1-2 weeks and significant overflow 6-7 times a day Biopsychosocial Predisposing Factors: Individual Context Individual Biological Factors • Poor sensation to rectal filling • Congenital mega-rectum • Anorectal abnormalities Individual Psychological Factors • Temperament and Early attachment • Intelligence & Developmental • Attention difficulties • Impaired social skills • ASD • Toilet Readiness Biopsychosocial Predisposing Factors: Family & Social Context • Parental personality characteristics • Coercive/ punitive behaviour management strategies & inadvertent rewards • Parental skill set re. avoidance/anxiety • Chaotic family environments • Previous experiences with health professionals & health beliefs • Abuse • Early life exposure to family problems • Low Socio-economic status • Limited social supports • Previous negative experiences with health professionals Triggering Event/s • Individual Factors • • • • • Anal Fissures Gastrointestinal illness Chronic constipation Low fibre diet Low water intake • Family & Social Factors • Coercive/ punitive/ intrusive toilet training • Acute life stressors • Lack of privacy when toileting Biopsychosocial Maintaining Factors of Encopresis: Individual Biological Level Initial Predisposing Factors Withholding Fear of painful bowel motion Bowel starts to stretch Brain starts to ignore defecation urge Stomach pain/ Nausea Painful bowel motion Biopsychosocial Maintaining Factors of Encopresis : Individual Biological Level Escalation Predisposing Factors Fear of painful bowel motion reinforced Painful bowel motion Withholding Stomach pain/ Nausea Overflow of faecal material into underwear Bowel stretches Brain ignores defecation urge Stool becomes harder & painful to pass Rectum continues to fill Overstretched bowel & reduced sensitivity to defecate Biopsychosocial Maintaining Factors of Encopresis : Individual Psychological & Behavioural Level Predisposing Factors Fear of painful bowel motion reinforced Painful bowel motion Withholding Overflow of faecal material into underwear Potential secondary gains to soiling Stomach pain/ Nausea Stool is harder & painful to pass Increased resistance to engage in pro-bowel/ appropriate toileting activities Brain ignores defecation urge Bowel stretches Child embarrassment/ guilt about passing bowel motion hides prior to BM Rectum continues or soiled to fill underwear Overstretched bowel & reduced sensitivity to defecate Significant emotional disturbance may start to develop Learnt helplessness denies/ unaware of soiled underwear & odour Psychological Differences Between Children with and without Chronic Encopresis (Cox, Morris, Browitz & Sutphen, 2002) • Comparisons between sibling & non-sibling groups did not significantly differ on an measure • Encopretic children experienced: – Greater number of anxiety and depression symptoms – Family environments with significantly lower levels of expressiveness and organisation – Difficulties with attention – More social problems – Demonstrated more disruptive behaviours – Lower levels of academic performance – No differences in self-esteem Biopsychosocial Maintaining Factors of Encopresis : Family Level Predisposing Factors Painful bowel motion Potential secondary gains to soiling Increased family stress Overflow of faecal material into underwear Fear of painful bowel motion reinforced Stomach pain/ Nausea Stool is harder & painful to pass Increased resistance to engage in pro-bowel/ appropriate toileting activities Increased likelihood of family social isolation Withholding Bowel stretches Brain ignores defecation urge Rectum continues to fill Overstretched bowel & reduced sensitivity to defecate Learnt helplessness Emotional disturbance Family develops –ve view of child Child embarrassment/ guilt reinforced Parental attempts to resolve soiling and may neglect own health needs Parental embarrassment/ anger Biopsychosocial Maintaining Factors of Encopresis : Social & School Level Predisposing Factors Fear of painful bowel Painful bowel motion motion reinforced Potential secondary gains to soiling Increased financial strain Poor academic performance Overflow of faecal material into underwear Increased resistance to engage in pro-bowel/ appropriate toileting activities Stomac h pain/ Nausea Stool is harder & painful to pass Brain ignores defecation urge Bullied/ teased for soiling at school Bowel stretche s Rectum continues to fill Overstretched bowel & reduced sensitivity to defecate Learnt helplessness Emotional disturbance Parental embarrassment/ anger re: child’s soiling Family social isolation Increased school absenteeism/ refusal Withholding Family develops –ve view of child School requests parents to change child or sends child home for soiling Social withdrawal Parental attempts to resolve soiling Child attempts to supress urge to defecate more Child guilt/ embarrassment reinforced Biopsychosocial Maintaining Factors of Encopresis : Community Level Predisposing Factors Painful bowel motion Overflow of faecal material Potential into underwear secondary gains to soiling Increased financial strain Poor academic performance Economic Impact/ Health Care Provision Increased resistance to engage in pro-bowel/ appropriate toileting activities Increased likelihood of family social isolation Increased school absenteeism/ refusal Stomach pain/ Nausea Fear of painful bowel motion reinforced Withholding Bowel stretches Child embarrassment/ Brain guilt reinforced Rectum ignores continues defecation to fill Overstretched bowel & urge Parental attempts Stool is reduced sensitivity to to resolve soiling harder & defecate Learnt painful to helplessnes pass Bullied/ s Emotional teased for disturbance soiling at Parental school embarrassment/ Child attempts to anger re: child’s soiling supress urge to Family defecate more develops –ve view of child Community stereotypes School requests parents to change child or sends child home for soiling Low family help seeking behaviour Low Socioeconomic status Questions for you • What appropriate treatment goals might you to pursue to assist Bob and his family recover from encopresis? • From what has been covered today, what treatment interventions might be appropriate in Bob’s treatment? Take Home Message Need to consider the systems in which medical conditions like encopresis exists how they may impact on a patient’s adherence to management and treatment Questions