13.7 SUMMARY The term enuresis refers to the habitual involuntary discharge ofurine, usually at night, after the age of expected continence (age 5). In DSM-5, functional enuresis is described as bed-wetting that isnot organically caused and classified under elimination disorders. Children who have primary functional enuresis have never beencontinent; children who have secondary functional enuresis havebeen continent for at least a year but have regressed. Enuresis may vary in frequency, from nightly occurrence tooccasional instances when a child is under considerable stress oris unduly tired. It has been estimated that some 4 to 5 millionchildren and adolescents in the United States suffer from theinconvenience and embarrassment of this disorder. Enuresis may result from a variety of organic conditions, suchas disturbed cerebral control of the bladder, neurologicaldysfunction, other medical factors such as medication sideeffects, or having a small functional bladdercapacity and a weak urethral sphincter. One groupof researchers reported that 11 percent of their patientswith enuresis had disorders of the urinary tract. However,most investigators have pointed to a number of other possiblecausal factors: faulty learning, resulting in the failure to acquireinhibition of reflexive bladder emptying; personal immaturity,associated with or stemming from emotional problems; disturbedfamily interactions, particularly those that lead to sustainedanxiety, hostility, or both; and stressful events. The term encopresis describes a symptom disorder of childrenwho have not learned appropriate toileting for bowel movementsafter age 4. Many of the children soiled their clothing whenthey were under stress. A common time was in the late afternoonafter school; few children actually had this problem at school. Most of the children reported that they did not know when theyneeded to have a bowel movement or were too shy to use thebathrooms at school. 13.8 KEY WORDS Aetiology: The study of the origins of disease: physical, mental or emotional. Encopresis: The repeated passing of faeces into inappropriate places (e.g. clothing or the floor), often associated with childhood constipation. 201 CU IDOL SELF LEARNING MATERIAL (SLM)
Enuresis: Involuntary release of urine, such as bed-wetting in children, usually from emotional disturbance rather than organic causes. Nocturnal enuresis: Enuresis occurring during the night. Psychological debriefing: A type of crisis intervention that requires individuals who have recently experienced a traumatic event to discuss or process their thoughts and feelings related to the Psychological model: Psychological model includes personality, learning, stress, self-efficacy, cognition and early life experiences and the way in which they affect mental illness Psychological tests: Psychological tests are used for assessment of different attributes personality, social skills, intelligence, cognitive abilities, emotional responses, behavioral responses and interests. They can be administered either individually or to groups using pen and paper or oral method. Psychopathology: The scientific study and research on psychological disorders Public stigma: When people in a society approve negative stereotypes towards a person with a mental disorder and discriminate against them. 13.9 LEARNING ACTIVITY 1. Explain with the help of the case study given in the unit, the DSM criteria for elimination disorder? ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain with the help of the case study given in the unit, the ICD 10 criteria for elimination disorder? ___________________________________________________________________________ ___________________________________________________________________________ 13.10 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What is elimination disorder 2. What is enuresis? 3. What is encopresis? 4. What is another word for enuresis? Long Questions 202 CU IDOL SELF LEARNING MATERIAL (SLM)
1. Explain the DSM criteria for enuresis. 2. Explain the DSM criteria for encopresis. 3. Explain the ICD 10 criteria for enuresis. 4. Explain the ICD 10 criteria for encopresis. 5. What are some of the causes of enuresis? 6. What are some of the causes of encopresis? B. Multiple Choice Questions 1. In childhood disorders there are different types of problems such as Symptom-Based Disorders. One such disorder is known as enuresis, which means: a. Sleepwalking b. Bedwetting c. Lack of bowel control d. Stammering 2. In childhood disorders there are different types of problems such as Symptom-Based Disorders. One such disorder is known as encopresis, which means: a. Lack of bowel control b. Bedwetting c. Stammering d. Sleepwalking 3. In childhood disorders there are different types of problems such as Symptom-Based Disorders. One such disorder is known as somnambulism, which means: a. Stammering b. Bedwetting c. Lack of bowel control d. Sleepwalking 4. Which of the following is an area of psychology that is concerned with mapping how early childhood experiences may act as risk factors for later diagnosable psychological disorders, and attempts to describe the pathways by which early experiences may generate adult psychological problems? a. Clinical psychopathology b. Developmental psychopathology c. Applied psychopathology d. Cognitive psychopathology 5. Which of the following are risk factors for childhood psychiatric disorders? a. Parental psychopathology, 203 CU IDOL SELF LEARNING MATERIAL (SLM)
b. Repeated early separation from parents c. Harsh or inadequate parents d. All of these Answers 1-b, 2-a, 3-d, 4-a, 5-d 13.11 REFERENCES Textbooks Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. American PsychiatricAssociation (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc. Clifford Morgan, Richard King, John Weisz, John Schopler (2004) Introduction to Psychology, McGraw-Hil, New Delhi Domjan Michael (2010). The Principles of Learning and Behavior (6th Edt) Wadsworth, Cengage Learning. Hergenhahn B R (2008). An introduction to the history of psychology, Wadsworth, Cengage Learning. Robert S. Feldman (2011) Understanding Psychology, McGraw-Hil, New Delhi. Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. Emery, R.E., &Oltmans, T.F. (1998). Abnormal Psychology (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc. Kay J, Tasman A. (2006) Essentials of Psychiatry, Chichester, John R. Wiley and Sons. Sadock, Benjamin, J., & Virginia A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams &Wilkins. Levine MD (1975) Children with encopresis: A descriptive analysis. Pediatrics 56, 412–416. Loening-Baucke VA (1995) Biofeedback treatment for chronic constipation and encopresis in childhood: Long-term outcome. Pediatrics 96, 105–110. 204 CU IDOL SELF LEARNING MATERIAL (SLM)
March JS, Parker JDA, Sullivan K et al. (1997) The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability and validity. J Am Acad Child Adolesc Psychiatr 36, 554–565. Mikkelsen EJ and Rapoport JL (1980) Enuresis: Psychopathology sleep stage and drug response. Urol Clin N Am 7, 361–377. Nolan T, Debelle G, Oberklaid F et al. (1991) Randomized trial of laxatives in Treatment for childhood encopresis. Lancet 338, 523–527. Pretlow RA (1999) Treatment for nocturnal enuresis with an ultrasound bladder volume controlled alarm device. J Urol 162, 1224–1228. Rutter M, Tizard J and Whitmore K (eds) (1970) Education, Health and Behavior. Longman, London. Rutter ML, Yule W and Graham PJ (1973) Enuresis and behavioral deviance: Some epidemiological considerations in Bladder Control and Enuresis. Clinics in Developmental Medicine, Nos. 48/49. (eds Kolvin I, MacKeith R, and Meadow SR). Heinemann/Spastics International Medical Publications, London, pp. 137–147. Serel TA, Perk H, Koyuncuoglu HR et al. (2001) Acupuncture therapy in the management of persistent primary nocturnal enuresis – preliminary results. Scand J Urol Nephrol 35(1), 40–43. Shaffer D, Stephenson JD and Thomas DV (1979) Some effects of imipramine on micturition and their relevance to their antienuretic activity. Neuropharmacology 18, 33–37. Shaffer D, Gardner A and Hedge B (1984) Behavior and bladder disturbance in enuretic children: A rational classification of a common disorder. Dev Med Child Neurol 26, 781–792. Stein Z and Susser M (1967) Social factors in the development of sphincter control. Dev Med Child Neurol 9, 692–700. Steinhausen HC and Gobel D (1989) Enuresis in child psychiatric clinic patients. J Am Acad Child Adolesce Psychiatry 28, 279–281. Taylor E and Hersov L (1994) Fecal soiling, in Child and Adolescent Psychiatry: Modern Approaches, 3rd edn. (Eds Rutter M, Taylor E, Hersov L et al.) Blackwell Scientific, London. van Ginkel R, Benninga MA, Blommaart PJ et al. (2000) Lack of benefit of laxatives as adjunctive therapy for functional non retentive fecal soiling in children. J Pediatry 137(6), 808–813. Wilkins R (1985) A comparison of elective mutism and emotional disorders in children. Br J Psychiatry 146, 198–203. Woodmansey AC (1967) Emotion and the motions: An inquiry into the causes and prevention of functional disorders of defecation. Br J Med Psychol 40, 207–223. 205 CU IDOL SELF LEARNING MATERIAL (SLM)
Sarason I., G & Sarason B. R. (2005).Abnormal psychology: The problem of maladaptive behavior. (11th edn). PHI Learning Private limited. World Health Organization (1993). The ICD-10 Classification of Mental and Behavioral Disorders Websites www.simplypsychology.com http://www.human-memory.net www.simplypsychology.org https://psychcentral.com https://courses.lumenlearning.com https://www.sparknotes.com 206 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 14 – ELIMINATION DISORDER PART II STRUCTURE 14.0 Learning Objectives 14.1 Introduction 14.2 Incidence of Elimination Disorder 14.3 Prevalence of Elimination Disorder 14.4 Assessment of Elimination Disorder 14.5 Prognosis of Elimination Disorder 14.6 Treatment for Elimination Disorder 14.7 Summary 14.8 Key Words 14.9 Learning Activity 14.10 Unit End Questions 14.11 References 14.0 LEARNING OBJECTIVES After studying this unit, you will be able to, Explain the incidence of Elimination Disorder Explain the prevalence of Elimination Disorder Describe the process of assessment of Elimination Disorder Describe the prognosis of Elimination Disorder Explain the Treatment forElimination Disorder 14.1 INTRODUCTION Elimination disorders are commonly diagnosed in childhood and are characterized by the absence of bladder or bowel control that would be expected based on the child’s age or current stage of development. This chapter provides an overview of the two primary elimination disorders identified in The Diagnostic and Statistical Manual of Mental Disorders: enuresis and encopresis. Elimination disorders all involve the inappropriate elimination of urine or feces and are usually first diagnosed in childhood or adolescence. This group of disorders includes enuresis, the repeated voiding of urine into inappropriate places, and encopresis, the repeated passage of feces into inappropriate places. Subtypes are provided to differentiate nocturnal from diurnal (i.e., during waking hours) voiding for enuresis and the presence or absence of 207 CU IDOL SELF LEARNING MATERIAL (SLM)
constipation and overflow incontinence for encopresis. Although there are minimum age requirements for diagnosis of both disorders, these are based on developmental age and not solely on chronological age. Both disorders may be voluntary or involuntary. Although these disorders typically occur separately, co-occurrence may also be observed. 14.2 INCIDENCE OF ELIMINATION DISORDER Incidence of Enuresis Nocturnal enuresis is as common in boys as girls until the age of 5 years, but by age 11 years, boys outnumber girls 2: 1. Not until the age of 8 years do boys achieve the same levels of night-time continence that are seen in girls by the age of 5 years, probably due to slower physiological maturation in boys. In addition, the increased incidence of secondary enuresis (occurring after an initial 1-year period of acquired continence) in boys further affects the sex ratio seen in later childhood. Daytime enuresis occurs more commonly in girls and is associated with higher rates of psychiatric disturbance. 14.3 PREVALENCE OF ELIMINATION DISORDER 14.3.1 Prevalence of Enuresis UTI has been found to occur frequently in children, especiallygirls and a large proportion (85%) of them have beenshown to have nocturnal enuresis. Also, in 10% of bedwettinggirls, urinalysis results show evidence of bacterial infection. Theconsensus is that as treating the infection rarely stops the bedwetting,UTI is probably a result rather than a cause of enuresis. Approximately 70% of children with nocturnal enuresishave a first-degree relative who also has or has had nocturnalenuresis. Twin studies have shown greater monozygotic (68%)than dizygotic (36%) concordance. 14.3.2 Prevalence of Encopresis The overall prevalence of encopresis in 7- and 8-year-old children has been shown to be 1.5%, with boys (2.3%) affected more commonly than girls (0.7%). There was a steadily rising likelihood of continence with increasing age, until by age 16 years the reported prevalence was almost zero. Rutter and coworkers (1970) reported a rate of 1% in 10- to 12- year-old children, with a strong (5: 1) male/female ratio. Retrospective study of clinic-referred encopretic children has shown that 40% of cases are primary (true failure to gain control), with a mean age of 6.7 years, and 60% of cases are secondary, with a mean age of 8 years (Levine, 1975). Eighty percent of patients were constipated, with no difference in this feature seen between primary and secondary subtypes. 208 CU IDOL SELF LEARNING MATERIAL (SLM)
14.4 ASSESSMENT OF ELIMINATION DISORDER 14.4.1 Assessment for Enuresis History Information on the frequency, periodicity and duration of symptomsis needed to make the diagnosis and distinguish functionalenuresis from sporadic seizure-associated enuresis. If there isdiurnal enuresis, an additional treatment plan is required. A familyhistory of enuresis increases the likelihood of a diagnosis offunctional enuresis and may explain a later age at which childrenare presented for treatment. Projective identification by theaffected parent–whereby the parent does not separate feelingsabout himself having the diagnosis and the current experienceof the affected child– may further hinder treatment. For subjects with secondary enuresis, precipitating factors should be elicited,although such efforts often represent an attempt to assign meaningafter the event. Questions that are useful in obtaining information for treatmentplanning include “Why is this a problem?” and “Why doesthis need treatment now?” because these factors may influencethe choice of treatment (is a rapid effect needed?) or point to otherpressures or restrictions on therapy. It is important to inquireabout previous management strategies used at home, for example,fluid restriction, nightlifting (getting the child out of bed to taketo the toilet in an often semiasleep state), rewards and punishments. Parents often come with the assertion that they have triedeverything and that nothing has helped. Examining the reasonsfor failure of simple strategies is useful for ensuring that moresophisticated treatments do not befall the same fate. There is littleevidence that fluid restriction is useful, although nightlifting maybe beneficial for the large number of children who never reachprofessional attention. Rewards are usually material and are givenonly for unreasonably high-performance levels, with the delay betweenaction and reward being too long. Physical punishment andverbal chastisements, ineffective at best, may well maintain theenuresis. Punishment is often too harsh and tends to be appliedinconsistently depending on parental mood. If specific treatmentshave been prescribed, either behavioral or pharmacological, it isimportant to discover the reasons they may have failed. Mental Status Examination The child’s views and any misconceptions that he or she may haveabout the enuresis, its causes and its treatment should be fullyexplored. Asking the child for three wishes may help determinewhether the enuresis is a concern to the child. This may unmaskmarked embarrassment or guilt from behind a facade of denialabout the problem and can be educational for parents who believetheir children could stop wetting “if only they wanted to or triedharder”. Pictures drawn by the child that describe how the childviews himself or herself when enuresis is a problem and when itis not appropriate for younger children and can graphically illustratethe misery experienced by children with enuresis. Physical Examination 209 CU IDOL SELF LEARNING MATERIAL (SLM)
All children should have a routine physical examination, with particularemphasis placed on detection of congenital malformationsindicative of urogenital abnormalities. A midstream specimen ofurine should be examined for the presence of infection. Radiologicalor further medical investigation is indicated only in thepresence of infected urine, enuresis with symptoms suggestive ofrecurrent UTI (frequency, urgency and dysuria), or polyuria. 14.4.2 Assessment for Encopresis The main efforts during the diagnostic process are to establishthe presence or absence of constipation and, to a lesser extent,distinguish continuous (primary) from discontinuous (secondary)soilin. Taylor and Hersov (1994) listed threetypes of identifiable encopresis in children: 1) it is known that thechild can control defecation, but she or he chooses to defecate ininappropriate places; 2) there is true failure to gain bowel control,and the child is unaware of or unable to control soiling; and 3) soiling is due to excessively fluid feces, whether from constipationand overflow, physical disease, or anxiety. In practice, thereis frequently overlap among types or progression from one to another. Unlike enuresis, fecal soiling rarely occurs at night or duringsleep, and if present, is indicative of a poor prognosis. Soilingdue to anal masturbation has been reported, although this causesstaining of the sheets rather than full stools in the bedclothes. Phenomenology In the first group, in which bowel control has been established,the stool may be soft or normal (but different from fluid-typefeces seen in overflow). Soiling due to acute stress events (e.g.,the birth of a sibling, a change of school, or parental separation)is usually brief once the stress has abated, given a stable homeenvironment and sensible management. In more severe pathologicalfamily situations, including punitive management orfrank physical or sexual abuse (Boon, 1991), the feces may bedeposited in places deliberately to cause anger or irritation,or there may be associated smearing of feces on furniture andwalls. Other covert aggressive antisocial acts may be evident,with considerable denial by the child of the magnitude or seriousnessof the problem. In the second group, in which there is failure to learnbowel control, a nonfluid stool is deposited fairly randomly inclothes, at home and at school. There may be conditions such asmental retardation or specific developmental delay, spina bifida,or cerebral palsy that impair the ability to recognize the need todefecate and the appropriate skills needed to defer this functionuntil a socially appropriate time and location. In the absence oflow IQ or pathological physical condition, patients have been reportedas having associated enuresis, academic skills problemsand antisocial behavior. They present to pediatricians primarilyand are usually younger (age 4–6 years) than other encopreticindividuals. It is thought that this type of soiling is considerablymore common in 210 CU IDOL SELF LEARNING MATERIAL (SLM)
socially disadvantaged, disorganized familiesbecause of stressful, faulty or inconsistent training. In the third group, excessively fluid feces are passed, whichmay result from conditions that cause true diarrhea (e.g., ulcerativecolitis) or, much more frequently, from constipation withoverflow causing spurious diarrhea. A history of retention, eitherwillful or in response to pain, is prominent in the early days ofthis form of encopresis, although later it may be less apparent becauseof fecal overflow. Behavior such as squatting on the heelsto prevent defecation or marked anxiety about the prospect ofusing the toilet (although rarely amounting to true phobic avoidance)may be described. Issues and Further Assessment The comprehensive assessment process should include a medicalevaluation, psychiatric and family interviews, and a systematicbehavioral recording. The medical evaluation comprises a history, review ofsystems, physical examination, and appropriate hematologicaland radiological tests. Although the vast majority of patientswith encopresis are medically normal, a small proportion havepathological features of etiological significance. Physical causesof encopresis without retention include inflammatory bowel disease(e.g., ulcerative colitis, Crohn’s disease), central nervoussystem disorders, sensory disorders of the anorectal region orpelvic floor muscles (e.g., spina bifida, cerebral palsy). Organiccauses of encopresis with retention include Hirschsprung’s disease(aganglionosis in intermuscular and submucous plexuses ofthe large bowel extending proximally from the anus), neurogenic megacolon, hypothyroidism, hypercalcemia, chronic codeine orlaxative usage, anorectal stenosis and fissure. It should also beremembered that these conditions rarely have their first presentationwith encopresis alone. The physical assessment should include an abdominal andrectal examination, although a plain abdominal radiograph is themost reliable way to determine the presence of fecal impaction.Anorectal manometry should be considered in the investigationof children with severe constipation and chronic soiling, especiallythose in whom Hirschsprung’s disease is suspected. Psychiatric and family interviews should include a developmentalhistory and a behavioral history of encopresis (antecedents,behavior and consequences). Specific areas of stress,acute or chronic, affecting the child or family, or both, should bediscovered. Associated psychopathological conditions are morecommonly found in the older child, in secondary encopresis, andwhen soiling occurs not only in clothes. Anxiety surroundingtoileting may indicate pot phobia, coercive toileting, or a historyof painful defecation. A history should be obtained of theparents’ previous attempts at treatment together with previouslyprescribed therapy so that reasons for previous failure can beidentified and anticipated in future treatment planning. 211 CU IDOL SELF LEARNING MATERIAL (SLM)
14.5 PROGNOSIS OF ELIMINATION DISORDER 14.5.1 Prognosis of Enuresis The acquisition of urinary continence at night is the end stage ofa fairly consistent developmental sequence. Bowel control duringsleep marks the beginning of this process and is followed bybowel control during waking hours, bladder control during theday, and finally night-time bladder control. Most children achievethis final stage by the age of 36 months. With increasing age,the likelihood of spontaneous recovery from enuresis decreases.The chronic nature of the condition is further shown in the studyby Rutter and colleagues (1973), in which only 1.5% of 5-year-oldbed-wetters became dry during the next 2 years. 14.5.2 Prognosis of Encopresis Less than one-third of children in the USA have completed toilet training by the age of 2 years with a mean age of 27.7 months. Bowel control is usually achieved before bladder control. The age cutoff for “normality” is set at 4 years, the age at which 95% of children have acquired fecal continence (Stein and Susser, 1967). As with urinary continence, girls achieve bowel control earlier than boys. 14.6 TREATMENT FOR ELIMINATION DISORDER 14.6.1 Treatment for Enuresis The overall goals of treatment can depend on the reason forreferral. Commonly, the child is brought to the physician beforesome planned activity, for example, a family vacation or a trip tocamp, and the need is for a rapid (e.g., pharmacological) shorttermtherapy. A gradual behavioral approach would not likelymeet with much approval even though it may offer a chance for apermanent cessation of wetting. Standard Treatment About 10% of children have a reduction in the number of wetnights after a single visit to a clinician in which the only interventionwas the recording of baseline wetting frequency and simplereassurance. Such reassurance should make clear that enuresis isa biological condition that is made worse by stress and that maybe associated in a noncausal way with other psychiatric disorders. Younger children can be told that their problem is shared bymany others of the same age. The excellent prognosis for patientswho comply with therapy should be stressed. Recording the frequencyof enuresis can be achieved by using a simple star chart. This is most effective if performed by the child, who records eachdry night with a star. The completed chart is then shown to theparents on a daily basis, and they can provide appropriate praiseand reinforcement. Waking and Fluid Restriction 212 CU IDOL SELF LEARNING MATERIAL (SLM)
Although systematic studies have failed to show any effect ofthese interventions with enuretic inpatients, it may be that thesestrategies work for the majority of enuretic children who are not referred for treatment. Surgery Based on the premise that enuresis is causally associated withoutflow tract obstruction, various surgical procedures havebeen advocated, for example, urethral dilatation, meatotomy,cystoplasty and bladder neck repair. This cannot be supportedbecause, in addition to the dubious concept of outflow tract obstructionper se, the surgery does not alter the urodynamics ofthe bladder. Reported positive treatment effects are slight (nocontrolled studies exist), and there remains a significant potentialfor adverse effects (urinary incontinence, epididymitis andaspermia). Pharmacotherapy Although it has been repeatedly demonstrated that temporarysuppression rather than cure of enuresis is the usual outcome ofdrug therapy, it remains the most widely prescribed treatment inthe USA. Four classes of drugs have principally been employed:synthetic antidiuretic hormones, tricyclic antidepressants, stimulantsand anticholinergic agents. Synthetic Antidiuretic Hormone A number of randomizeddouble-blind placebo-controlled trials (RCT) have shown thatthe synthetic Vaso peptide DDAVP (desmopressin) is effective inenuresis. The drug is usually administered intranasally, althoughoral preparations of equal efficacy have been developed (equivalentoral dose is 10 times the intranasal dose). Almost 50% ofchildren are able to stop wetting completely with a single nightlydose of 20 to 40 μg of DDAVP given intranasally. A further 40%are afforded a significant reduction in the frequency of enuresiswith this treatment. As with tricyclic antidepressants, however,when treatment is stopped, the vast majority of individuals relapse. Side effects of this medication include nasal pain and congestion,headache, nausea and abdominal pain. Serious problemsof water intoxication, hyponatremia and seizures are rare. It isimportant to be aware that intranasal absorption is reduced whenthe patient has a cold or allergic rhinitis. The mode of action ofdesmopressin is unknown. It may reduce the production of nighttimeurine to an amount less than the (low) functional volumeof the enuretic bladder, thereby eliminating the urge to micturate. With regard to identifying those most likely to respond toDDAVP treatment, it has been found that those most likely tobe permanently dry are infrequent wetting older children whorespond to lower dose (20 μg) desmopressin. Tricyclic Antidepressants The short-term effectiveness ofimipramine and other related antidepressants has also beendemonstrated via many RCTs. Imipramine reduces the frequencyof enuresis in about 85% of bed-wetters and eliminatesenuresis in about 30% of these individuals. Night-time dosesof 1 to 2.5 mg/kg are usually effective and a therapeutic effectis usually evident in the first week of treatment. Relapseafter withdrawal of medication is almost inevitable, so that 3months after the cessation of tricyclic antidepressants, nearlyall patients 213 CU IDOL SELF LEARNING MATERIAL (SLM)
will again have enuresis at pretreatment levels. Sideeffects are common and include dry mouth, dizziness, posturalhypotension, headache and constipation. Toxicity after accidentalingestion or overdose is a serious consideration, causingcardiac effects, including arrhythmias and conduction defects,convulsions, hallucinations and ataxia. Concern has beenexpressed about the possibility of sudden death (presumablycaused by arrhythmia) in children taking tricyclic drugs. Themode of action for tricyclic antidepressants is unclear, althoughone observation is that tricyclic agents seem to increase functionalbladder volumes possibly resulting from noradrenergicreuptake inhibition. Stimulant Medication Sympathomimetic stimulants such asdexamphetamine have been used to reduce the depth of sleep inchildren with enuresis; but because there is no evidence that enuresisis related to abnormally deep sleep, their lack of effectivenessin stopping bed-wetting is no surprise. Used in combinationwith behavioral therapy, there is some evidence that stimulantscan accentuate the learning of nocturnal continence. Anticholinergic Drugs wetter’s such as propantheline, oxybutyninand terodiline can reduce the frequency of voiding in individualswith neurogenic bladders, reduce urgency and increasefunctional bladder capacity. There is no evidence, however, thatthese anticholinergic drugs are effective in bed-wetting, althoughthey may have a role in diurnal enuresis. Side effects are frequentand include dry mouth, blurred vision, headache, nauseaand constipation. Psychosocial Treatments The night alarm was first used in children with enuresis in the1930s. This system used two electrodes separated by a device(e.g., bedding) connected to an alarm. When the child wetthe bed, the urine completed the electrical circuit, soundedthe alarm and the child awoke. All current night alarm systemsare merely refinements on this original design. A vibrating padbeneath the pillow can be used instead of a bell or buzzer, or theelectrodes can be incorporated into a single unit or can be miniaturizedso that they can be attached to night (or day) clothing. With treatment, full cessation of enuresis can be expected in80% of cases. Reported cure rates (defined as a minimum of 14 consecutive dry nights) have ranged from 50 to 100%. Themain problem with this form of enuretic treatment, however,is that cure is usually achieved only within the second monthof treatment. This factor may influence clinicians to prescribepharmacological treatments that, although more immediatelygratifying, do not offer any real prospect of cure. It has beensuggested that adjuvant therapy with methamphetamine ordesmopressin will reduce the amount of time before continenceis achieved. Using a louder auditory stimulus or using the body wornalarm may also improve the speed of treatment response. Factors associated with delayed acquisition of continence includefailure of the child to wake with the alarm, maternal anxietyand a disturbed home environment, although no influencehas been seen regarding the age of the child or the initial wettingfrequency. A further consequence of the delayed response to a nightalarm is premature termination occurring in as many as 48% ofcases and is more common in families that have made little 214 CU IDOL SELF LEARNING MATERIAL (SLM)
previouseffort to treat the problem, in families that are negative orintolerant of bed-wetting, and in children who have other behavioralproblems. Factors reducing compliance also include failurein understanding or following the instructions, failure to awaken the child, and frequent false alarms. The only reported side effectof treatment with the night alarm is “buzzer ulcers” caused bythe child lying in a pool of ionized urine. This problem has beeneliminated with modern transistorized alarms that do not employa continuous, relatively high voltage across the electrodes to detectenuresis. Relapse after successful treatment, if it occurs, willusually take place within the first 6 months after cessation oftreatment. It is reported that approximately one-third of childrenrelapse; however, no clear predictors of relapse have beenidentified. Ultrasonic Bladder Volume Alarm The traditional enuresis alarm may have good potential for apermanent cure, the child is mostly wet during treatment. Moreover,the moisture alarm requires that the child to make therather remote association between the alarm event and a fullbladder after the bladder has emptied. In an exploratory research study, a new approach for the treatment of nocturnal enuresiswas investigated using a miniature bladder volume measurementinstrument during sleep. In this, an alarm would ring when bladdervolume reached 80% of the typical enuretic volume. Two groupswere studied. Group 1 used the night-time device alone; group 2,in addition, had supplementary daytime bladder retention training(aiming to increase functional capacity). In groups 1 and 2the mean dryness rate before study initiation versus during thestudy was 32.9 and 9.3% versus 88.7 and 82.1%, respectively.Night-time bladder capacity increased 69% in group 1 and 78%in group 2, while the cure rate was 55% and 60% respectively. Acupuncture The efficacy of traditional Chinese acupuncture has been studied(Serel et al., 2001) in a small (n 50) clinical sample. It wasreported that within 6 months, 86% of patients were completelydry and a further 10% of patients were dry on at least 80% ofnights. Relapse rates appeared better than with psychopharmacologicagents. Assessment and ManagementforDiurnal Enuresis Diurnal enuresis or daytime enuresis may or may not occur along with night-timeenuresis. However, itfollows a different pattern of associations and respondsdifferently to treatment. Diurnal Enuresis is more likely to beassociated with urinary tract abnormalities than withany other psychiatric disorders. Therefore, a detailed andfocused medical and psychiatric evaluation is necessary. Urineshould be tested for infection repeatedly, and the threshold forordering ultrasonographical visualization of the urological systemshould be low. The history will make it apparent that diurnal enuresis or daytime wetting is specific to a situation. This can help in treatment and therapy. For instance, school-basedenuresis in a child who is too timid to ask to use the bathroomcan be reduced by the teacher’s tactfully reminding the childto go to the bathroom at regular intervals. 215 CU IDOL SELF LEARNING MATERIAL (SLM)
Observation of children with diurnal enuresis has establishedthat they do experience an urge to pass urine before micturitionbut that either this urge is ignored or the warning comes toolate to be of any use because of an “irritable bladder”. Therefore,treatment programmes are based on establishing a pattern of toiletingbefore the times that diurnal enuresis is likely to occur which is usuallybetween 12 noon and 5 pm. It also uses positive reinforcementto promote regular use of the bathroom. Portable systems can be worn on the body. The parents can also use asensor in the underwear along with an alarm to be worn onthe wrist. Studies have shown no significant differences between the use of a wetness alarm to a simple timedalarm. The easiest therapeutic alternative, therefore, is to buy thechild a digital watch with a countdown alarm timer. Unlike nocturnal enuresis, pharmacological treatment using tricyclicantidepressants such as imipramine is found to be ineffective to treat diurnal enuresis. On the other hand, the uses of anticholinergic agents such as oxybutynin and terodiline haveshowna significantimprovement on reducing the frequency of daytime enuresis. 14.6.2 Treatment for Encopresis Standard Treatment The principal approach to treatment is predicated on the results ofthe evaluation and the clinical category assigned. This differentiatesbetween the need to establish a regular toileting procedurein patients in whom there has been a failure to learn this socialbehavior and the need to address a psychiatric disorder, parent–child relationship difficulties, or other stresses in the childwho exhibits loss of this previously acquired skill in associationwith these factors. In both cases, analysis of the soiling behaviormay identify reinforcing factors important in maintaining dysfunction.Detection of significant constipation will, in addition,provide an indication for adjuvant laxative therapy. Behavioral Treatments Behavioral therapy is the mainstay of treatment for encopresis.In the younger child who has been toilet trained, this focuses onpractical elimination skills, for example, visiting the toilet aftereach meal, staying there for a maximum of 15 minutes, usingmuscles to increase intra- abdominal pressure and cleaning oneselfadequately afterward. Parents or caretakers, or both, needto be educated in making the toilet a pleasant place to visit andshould stay with the younger child, giving encouragement andpraise for appropriate effort. Small children whose legs may dangle above the floor should be provided with a step againstwhich to brace when straining. Initially, a warm bath before usingthe toilet may relax the anxious child and make it easier topass stool. Systematic recording of positive toileting behavior,not necessarily being clean (depending on the level of baselinebehavior), should be performed with a personal star chart. Forthe child with severe anxiety about sitting on the toilet, a gradedexposure scheme may be indicated. Role of the Family in Treatment 216 CU IDOL SELF LEARNING MATERIAL (SLM)
Removing the child’s and family’s attention from the encopresisalone and focusing onto noticing, recording and rewardingpositive behavior often defuses tension and hostility and providesthe opportunity for therapeutic improvement. Identifying andeliminating sources of secondary gain, whereby soiling isreinforced by parental (or other individuals’) actions and attention,even if negative or punitive, make positive efforts more fruitful. Some investigators advocate mild punishment techniques, suchas requiring the child to clean his or her own clothes after soiling,although care must be taken to prevent this from becoming toopunitive. In certain settings, particularly school, attempts aremade to prevent soiling by extremely frequent toileting that,although keeping the child clean, does not promote and mayeven hinder the acquisition of a regular bowel habit. Formaltherapy, either individual or family based, is indicated in onlya minority of patients with an associated psychiatric disorder,marked behavioral disturbance, or clear remediable family orsocial stresses. Physical Treatments In patients with retention leading to constipation and overflow,medical management is nearly always required, although it isusually with oral laxatives or micro enemas alone. The use ofmore intrusive and invasive colonic and rectal washout or surgicaldisimpassion procedures is nearly always the result of theclinician’s impatience rather than true clinical need. Uncontrolled studies of combined treatment with behavioraltherapy and laxatives reported marked improvement insymptoms (not cure) in approximately 70 to 80% of patients. Amore recent controlled randomized trial (Nolan et al., 1991) comparingbehavioral therapy in retentive primary encopresis withand without laxatives showed that at 12-month follow-up, 51% ofthe combined treatment (laxative plus behavioral therapy) grouphad achieved remission (at least one 4-week period with no soilingepisodes), compared with 36% of the behavioral therapy onlygroup (P 0.08). Partial remission (soiling no more than once aweek) was achieved in 63% of patients with combined therapyversus 43% with behavioral therapy alone (P 0.02). Patientsreceiving laxatives achieved remission significantly sooner, andthe difference in the Kaplan–Meier remission curves was moststriking in the first 30 weeks of follow-up (P 0.012). Whenpatients who were not compliant with the toileting program wereremoved from the analysis, however, the advantage of combinedtherapy was not significant. These results must also be viewed in light of a 50% spontaneous remission rate at 2 years reported in some studies. Biofeedback Therapy The finding that some children with treatment-resistant retentiveencopresis involuntarily contract the muscles of the pelvic floorand the external anal sphincter, effectively impeding passage ofstool, has led to efforts to use biofeedback in this instance. Ithas similarly been reported that as few as six sessions of biofeedbacktherapy can lead to a significant reduction in symptomfrequency for as many as 86% of previously treatment-resistantpatients (Loening- 217 CU IDOL SELF LEARNING MATERIAL (SLM)
Baucke, 1995). It is possible, however, that biofeedbackis principally of benefit to no retentive chronic spoilers(van Ginkel et al., 2000). 14.7 SUMMARY Estimates ofthe prevalence of enuresis reported in DSM IV are 5 to 10 percentamong 5-year-olds, 3 to 5 percent among 10-year-olds, and1.1 percent among children age 15 or older. An epidemiologicalstudy in China reported a 4.3 percent prevalence, with a significantlyhigher percentage of boys than girls. Medical Treatment for enuresis typically centers on using medicationssuch as the antidepressant drug imipramine. The mechanismunderlying the action of the drug is unclear, but it maysimply lessen the deepest stages of sleep to light sleep, enablingthe child to recognize bodily needs more effectively. An intranasal desmopressin (DDAVP) is also used to treatchildren to help them manage urine more effectively. Thismedicine is a hormone replacement treatment and is said to increases urineconcentration, decreases urine volume which reduces theneed to urinate. The use of this medication to treat enuretic childrenis no panacea, however. Disadvantages of its use include itshigh cost and the fact that it is effective only with a small subset ofenuretic children, and then only temporarily. Conditioning procedures have proved to be highly effectivetreatment for enuresis. Mowrer and Mowrer, in their classic research that is still relevant today, introduceda procedure in which a child sleeps on a pad that is wired to abattery-operated bell. At the first few drops of urine, the bell is set off,thus awakening the child. Through conditioning, the child comes toassociate bladder tension with awakening. Some evidence suggeststhat a bio behavioral approach—that is, using the urine alarm alongwith desmopressin—is most effective. Encopresis as classified in DSM-5, under elimination disorders,is less common than enuresis.However, the estimates based on DSM are that about 1% of 5yearold children haveencopresis. A study of 102 cases of children with encopresis foundthe following list of characteristics: The average age of childrenwith encopresis was 7years, with a range of ages from 4 years to 13 years. Many children with encopresis may also suffer from constipation. Hence, animportant element duringthe diagnosis should include a physical examination in orderto determine whether or not physiological factors are contributing tothe disorder. The Treatment for encopresis usually involves bothmedical and psychological aspects. Many research studies related to the usingconditioning procedures for children with encopresis have reportedmoderate treatment success. They have shown that there was no additional incidents’occurring within 6 months following treatment. 218 CU IDOL SELF LEARNING MATERIAL (SLM)
However, research has shown that a minority of children(11 to 20 percent) do not respond to learning-based treatmentapproaches. 14.8 KEY WORDS Behaviour modification: The deliberate changing of a particular pattern of behaviour by behaviorist methods. Enuresis: Involuntary release of urine, such as bed-wetting in children, usually from emotional disturbance rather than organic causes. Psychotherapy: The use of psychological techniques to treat psychological disturbances. Psychological debriefing: A type of crisis intervention that requires individuals who have recently experienced a traumatic event to discuss or process their thoughts and feelings related to the traumatic event, typically within 72 hours of the event Psychological model:Psychological model includes personality, learning, stress, self- efficacy, cognition and early life experiences and the way in which they affect mental illness Psychological tests:Psychological tests are used for assessment of different attributes personality, social skills, intelligence, cognitive abilities, emotional responses, behavioral responses and interests. They can be administered either individually or to groups using pen and paper or oral method. Psychopathology: The scientific study and research on psychological disorders Public stigma: When peoplein a society approve negative stereotypes towards a person with a mental disorder and discriminate against them. 14.9 LEARNING ACTIVITY 1. Explain the process of assessment undertaken in order to diagnose a child with elimination disorder? ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain the process of treatment provided to a child with elimination disorder? ___________________________________________________________________________ ___________________________________________________________________________ 14.10 UNIT END QUESTIONS 219 A. Descriptive Questions Short Questions CU IDOL SELF LEARNING MATERIAL (SLM)
1. What is the incidence of elimination disorder? 2. What is the prevalence of enuresis? 3. What is the prevalence of encopresis? 4. Explain the prognosis for enuresis. 5. Explain the prognosis for encopresis. 6. What is Ultrasonic Bladder Volume Alar? 7. What is biofeedback? Long Questions 1. Explain the process of assessment for enuresis. 2. Explain the process of assessment for encopresis. 3. Explain the pharmacological treatment for enuresis. 4. Explain the psychological treatment for enuresis. 5. Explain the treatment for encopresis. B. Multiple Choice Questions 1. DSM-IV-TR defines enuresis as the repeated, usually involuntary voiding of urine during the day or at night into either bed or clothes. To qualify for a diagnosis, the voiding of urine must occur at least twice a week for at least 3 months, and the child must be at least 5-years of age. Enuresis can be divided into primary and secondary. Which of the following describes secondary enuresis? a. When bladder control is still problematic, but the child has been dry for a period of up to 6 months b. When the child experiences loss of bladder control at night c. When the child has never experienced a lengthy spell of bladder control d. When the child loses bladder control at school 2. According to von Gontard, Hollman, Eiberg, Benden et al. (1997), secondary nocturnal enuresis is frequently associated with a higher incidence of which of the following factors? a. Pre-natal malnutrition b. Parental separation c. Gender d. Diet 3. Which of the following is a widely-used classical conditioning method for treating nocturnal enuresis? a. Bell-and-whistle technique 220 CU IDOL SELF LEARNING MATERIAL (SLM)
b. Bell-and-battery technique c. Alarm system technique d. Bell book and candle technique 4. Drug used for Treatment for nocturnal enuresis is? a. Trazodone b. Imipramine c. Chlorpromazine d. Sertraline 5. Identify one method of preventing encopresis. a. Discipline the child b. Eat a diet high in fat c. Drink plenty of fluids d. Eat a diet high in salt Answers 1-a, 2-b, 3-b, 4-b, 5-b 14.11 REFERENCES Textbooks Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. American PsychiatricAssociation (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc. Clifford Morgan, Richard King, John Weisz, John Schopler (2004) Introduction to Psychology, McGraw-Hil, New Delhi Domjan Michael (2010). The Principles of Learning and Behavior (6th Edt) Wadsworth, Cengage Learning. Hergenhahn B R (2008). An introduction to the history of psychology, Wadsworth, Cengage Learning. Robert S. Feldman (2011) Understanding Psychology, McGraw-Hil, New Delhi. Robert. A. Baron, Psychology, (2008) Prentice Hall India. 221 CU IDOL SELF LEARNING MATERIAL (SLM)
Reference books Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. Emery, R.E., &Oltmans, T.F. (1998). Abnormal Psychology (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc. Kay J, Tasman A. (2006) Essentials of Psychiatry, Chichester, John R. Wiley and Sons. Sadock, Benjamin, J., & Virginia A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams &Wilkins. Levine MD (1975) Children with encopresis: A descriptive analysis. Pediatrics 56, 412–416. Loening-Baucke VA (1995) Biofeedback treatment for chronic constipation and encopresis in childhood: Long-term outcome. Pediatrics 96, 105–110. March JS, Parker JDA, Sullivan K et al. (1997) The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability and validity. J Am Acad Child Adolesc Psychiatr 36, 554–565. Mikkelsen EJ and Rapoport JL (1980) Enuresis: Psychopathology sleep stage and drug response. Urol Clin N Am 7, 361–377. Nolan T, Debelle G, Oberklaid F et al. (1991) Randomized trial of laxatives in Treatment for childhood encopresis. Lancet 338, 523–527. Pretlow RA (1999) Treatment for nocturnal enuresis with an ultrasound bladder volume controlled alarm device. J Urol 162, 1224–1228. Rutter M, Tizard J and Whitmore K (eds) (1970) Education, Health and Behavior. Longman, London. Rutter ML, Yule W and Graham PJ (1973) Enuresis and behavioral deviance: Some epidemiological considerations in Bladder Control and Enuresis. Clinics in Developmental Medicine, Nos. 48/49. (eds Kolvin I, MacKeith R, and Meadow SR). Heinemann/Spastics International Medical Publications, London, pp. 137–147. Serel TA, Perk H, Koyuncuoglu HR et al. (2001) Acupuncture therapy in the management of persistent primary nocturnal enuresis – preliminary results. Scand J Urol Nephrol 35(1), 40–43. Shaffer D, Stephenson JD and Thomas DV (1979) Some effects of imipramine on micturition and their relevance to their antienuretic activity. Neuropharmacology 18, 33–37. Shaffer D, Gardner A and Hedge B (1984) Behavior and bladder disturbance in enuretic children: A rational classification of a common disorder. Dev Med Child Neurol 26, 781–792. 222 CU IDOL SELF LEARNING MATERIAL (SLM)
Stein Z and Susser M (1967) Social factors in the development of sphincter control. Dev Med Child Neurol 9, 692–700. Steinhausen HC and Gobel D (1989) Enuresis in child psychiatric clinic patients. J Am Acad Child Adolesce Psychiatry 28, 279–281. Taylor E and Hersov L (1994) Fecal soiling, in Child and Adolescent Psychiatry: Modern Approaches, 3rd edn. (Eds Rutter M, Taylor E, Hersov L et al.) Blackwell Scientific, London. van Ginkel R, Benninga MA, Blommaart PJ et al. (2000) Lack of benefit of laxatives as adjunctive therapy for functional non retentive fecal soiling in children. J Pediatry 137(6), 808–813. Wilkins R (1985) A comparison of elective mutism and emotional disorders in children. Br J Psychiatry 146, 198–203. Woodmansey AC (1967) Emotion and the motions: An inquiry into the causes and prevention of functional disorders of defecation. Br J Med Psychol 40, 207–223. Sarason I., G & Sarason B. R. (2005).Abnormal psychology: The problem of maladaptive behavior. (11th edn). PHI Learning Private limited. World Health Organization (1993). The ICD-10 Classification of Mental and Behavioral Disorders Websites www.simplypsychology.com http://www.human-memory.net www.simplypsychology.org https://psychcentral.com https://courses.lumenlearning.com https://www.sparknotes.com 223 CU IDOL SELF LEARNING MATERIAL (SLM)
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