This is an informative chapter about elimination and tic disorders. None of this information in here or other chapters can be used to diagnose people. Only psychiatry professions are obligated to diagnose. Psychopathology chapters are review and summary of Textbook “David H. Barlow, V. Mark Durand (2014) Abnormal Psychology: An Integrative Approach” and lecture notes.
Elimination Disorders
Enuresis: Voluntarily or involuntarily urinate into their clothing or beds after the age of 5 can be diagnosed as suffering from enuresis.
*Occur at least twice a week for a period of 3 months.
*Urinations are not just accidents.
*7% of males, 3% of females.
Encopresis: Voluntary or involuntary passage of feces in inappropriate places, such as in clothing or onto the floor.
*Starts at least 4 years old.
*Occur at least once a month for a period of 3 months.
*1% of five year old children.
*More in boys than in girls.
Elimination Disorders (Enuresis) Explanation.
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Primary enuresis is a physiological problem but, “wetting” is so embarrassing for children-families, it leads to many psychological problems.
Primary enuresis leads anxiety, shame, withdrawal.
Elimination Disorders (Enuresis) Treatment
Behavioral approaches;
- Sun and rain charts >>> reward.
- Bell-and-bed procedure.
Helps the child to recognize the signals of a full bladder before it's too late.
- Bell-and-bed procedure is effective with about 75%.
- Relapse rate 40% but 30% regain if the treatment is reinstituted.
A synthetic form of ADH (nasal spray before bedtime);
- 70% stop immediately, 10% substantial reductions.
Case Work: Tim
Tim, age 6, was referred to the clinic by his general practitioner because of persistent soiling. A medical workup revealed no general medical condition that could account for these symptoms.
Tim had never gained control of his bowel habits. He was not constipated as an infant; but after a febrile illness at age 2, he had become constipated. Six months later he had impacted feces, and was seen by a surgeon, who prescribed laxatives and suppositories.
Following this, there was a pattern of alternating constipation, when he did not go to the toilet for several days, and runny diarrhoea, then he soiled his pants many times a day.
At age 4, Tim took laxatives regularly, and his stool became softer and more regular. At about the same time, his mother first attempted to toilet train him. He was made to sit on the toilet every evening until he "performed."
Although he usually managed this, producing a tiny amount or, rarely, a normal stool, he continued to soil his pants frequently during the day. His mother said that within half an hour of changing his pants, he would be soiled again, and this pattern has continued until the present time.
Tim himself has been distressed about the soiling since starting school. He hates taking his clothes off for gym or on the beach. He worries that people will notice if, as occasionally happens, feces drop out of his pants.
He is anxious when sitting on the toilet in the evenings, and at first would do so only if bribed. Now he insists his mother stay in the bathroom with him.
Tim is also enuretic at night. He became dry by day at age 3.5, but has continued to wet at night; because waking him at night has not prevented his wetting, his mother still puts him in diapers.
For the last month, since seeing a puppet show, Tim has awakened frequently with nightmares about witches.
He often asks about witches, and his mother has tried to assure him that they do not exist. He has had a light on all night in his room for the past month. He never goes into his parents' bed, as they do not allow this because of his being wet.
His mother says that Tim has seemed rather preoccupied with death. He often asks why people have to die and if he or his parents will die first. He then works out how old he might be when his parents die. He has said that he doesn't want to be buried because then people would walk over him.
Apart from the problems of soiling and wetting, his mother feels he is a normal little boy who is happy and outgoing. He is very affectionate with his mother and likes to receive lots of kisses and hugs. His mother implied that this might be excessive for a boy.
He is attached to his father, but not as much as to his mother. He likes to play and go out with his father, but with his mother he is clinging and likes to stay close to her.
Up until age 4, Tim had worried his parents because of seeming rather effeminate. He liked to dress in girl's clothes and talked of "when I grow up to be a girl." Now when playing he likes to take traditionally male roles, such as policemen or bus conductors.
There was initially some difficulty in Tim's adjustment at school. He used to scream when his mother left him, and he was reported to be very timid and afraid of other children. This lasted most of the first term; but he eventually began "to stand up for himself," and has been quite happy at school since then. He has several friends there, and the school is satisfied with his progress.
Tim's developmental milestones were all a little behind those of his two older sisters, but his mother could not recall them exactly. He sat at about 6 months, shuffled about on his bottom and did not crawl, and walked at 18 months. He spoke his first words at about that same time.
Tim's mother is a smartly dressed, 35-year-old; laboratory technician who seems timid and speaks quietly, but at the same time is quite forceful and articulate in what she says.
She seems to feel unsure of herself with Tim and thinks that bringing up a boy is much more difficult than bringing up her daughters. She is embarrassed, as a professional person, not to have sought help earlier. She recalls how she, too, had in childhood hated to use lavatories away from home.
Tim's father is a 40-year-old, intelligent, distinguished-looking contractor. He was reticent during the interview. He readily admitted that he did not take an active part in the rearing of the children, but enjoyed them and was very fond of them. He explained that he was rather disgusted by the soiling and tried to keep out of the situation for fear of being too punitive.
Tim was small for his age and had a babyish, full face. In the interview he was at first very timid and shy and clung to his mother. However, he did allow his mother to leave the room after a short period and became much more assertive and outgoing once she had left.
He played with family figures in the dollhouse and soon had the little boy figure on the toilet and all the other members of the family watching him. His speech was immature and difficult to understand, but his vocabulary was extensive.
Tim was also seen by a paediatrician. On physical examination, a fecal mass the size of a melon could be palpated in the lower abdomen, and soft feces could be felt in his rectum.
Encopresis can sometimes be caused by general medical conditions, such as a ganglionic megacolon and anal fissure. Because these have been ruled out in Tim's case, the diagnosis of Encopresis (Not Due to a General Medical Condition) is appropriate.
Because Tim's fecal incontinence was apparently associated with constipation and overflow incontinence, this would also be noted with the diagnosis.
In addition, he continues to have night-time wetting, warranting an additional diagnosis of Enuresis (Not Due to a General Medical Condition). Because the enuresis occurs only during sleep, Nocturnal Only is specified.
For the last month, Tim has had nightmares about witches and has been scared of the dark and preoccupied with death. Because this is likely to be only a transient reaction, it does not warrant an additional diagnosis.
If it persists or becomes more severe, however, then an additional diagnosis, such as Adjustment Disorder with Anxious mood, should be considered.
Tim apparently went through a phase during which he showed some signs of possible disturbance in gender identity but now seems to have a clear sense of himself as a male.
He also showed some signs of separation anxiety when he began school, but they were insufficient for a diagnosis of Separation Anxiety Disorder.
Tic Disorders
Tic:
- Recurrent involuntary movement from small twitches of the mouth or eye blinking to large movements of the body.
- Can consciously be suppressed for short periods of time, but as soon as the attention is turned away the tics return.
- Can lead to serious psychological and physiological problems.
Tourette`s Disorder:
Involves numerous motor and vocal tics.
Motor tics: Blinking, facial grimaces, movements of large parts of the body.
Vocal tics: A sudden involuntary contraction of the muscles of the diaphragm forces air pass the vocal cords.
Grunts, yelps, barks, says or yells words.
Coprolalia: In the absence of any reason for doing so, yelling out words that most people find shocking.
The involuntary yelling of obscenities.
30% in Tourette`s Disorder.
Very disruptive of psychosocial functioning.
- The symptoms may get worse in vicious circle.
- Usually begins around age 7.
- 3 times more in males than females.
- Lasts throughout adulthood.
- Comorbidity with ADHD and OCD.
Physiological dysfunction of the brain;
Oversensitivity of the dopamine receptors in the basal ganglia (where motor behavior is controlled).
This oversensitivity leads to excessive firing in the brain, which triggers tics.
Evidence;
Drugs increase dopamine activity increase tics.
Drugs decrease dopamine activity decrease tics.
The reasons for increased dopamine activity:
1.Genetics;
*In family members: 7.4%.
*In general population: .05%.
*Co-occurrence in identical twins higher than non-identical twins.
2.Abnormal reactions of the immune system due to infections.
- Drugs to reduce dopamine activity (Haloperidol, olanzapine etc.).
Case Work: Compulsion
Alan, a 1O-year-old boy, is brought for a consultation by his mother because of "severe compulsions."
The mother reports that the child at various times has to run and clear his throat, touch the doorknob twice before entering any door, tilt his head from side to side, rapidly blink his eyes, and suddenly touch the ground with his hands by flexing his whole body.
These "compulsions" began 2 years ago. The first was the eye blinking, and then the others followed, with a waxing and waning course. The movements occur more frequently when he is anxious or under stress. The last symptom to appear was the repetitive touching of the doorknobs.
The consultation was scheduled after the child began to make the middle finger sign while saying, "fuck."
When examined, Alan reported that most of the time he did not know in advance when the movements were going to occur except for the touching of doorknobs.
Upon questioning, he said that before he felt he had to touch a doorknob, he got the thought of doing it and tried to push it out of his head, but he couldn't because it kept coming back until he touched the doorknob several times; then he felt better.
When asked what would happen if someone did not let him touch the doorknob, he said he would just get mad; once his father had tried to stop him and Alan had had a temper tantrum. Alan explained that the touching of the doorknobs didn't really bother him what did was all the "other stuff' that he couldn't control.
During the interview the child grunted, cleared his throat, turned his head, and rapidly blinked his eyes several times. At times he tried to make it appear as if he had voluntarily been trying to perform these movements.
Personal history and physical and neurological examination were totally unremarkable except for the abnormal movements and sounds. The mother reported that her youngest uncle had had similar symptoms when he was an adolescent, but she could not elaborate any further. She stated that she and her husband had always been "very compulsive," by which she meant only that they were quite well organized and stuck to routines.
The mother describes Alan's difficulties as "compulsions," and Alan's description of what goes on his mind before he touches door knobs seems to describe a obsession with an accompanying compulsion. He first gets the intrusive thought of touching the door knob. He tries to resist the thought but is unable to do so; in response to this obsession, he then touches the doorknob twice. He acknowledges that if he resisted the compulsion to touch doorknobs, he would be extremely uncomfortable.
However, because these obsessions and compulsions apparently do not cause marked distress; do not significantly interfere with his functioning, and are not particularly time consuming the diagnosis of Obsessive-Compulsive Disorder is not given.
Alan is most disturbed by his motor tics. (e,g., tilting his head from side to side, blinking his eyes, flexing his whole body) and yerbal tics (eg., " clearing throat, saying “fuck”).
Because the motor tics involve a series of coordinated movements, they are considered "complex motor tics." The combination of motor and verbal tics with a duration of over 1 year establishes the diagnosis of Tourette's Disorder.
It is sometimes difficult to distinguish a complex motor tic from a compulsion because the observed behavior can be similar. A tic is an involuntary, sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization. In contrast, a compulsion is an intentional voluntary act that is either performed in response to an obsession or according to rules that must be applied rigidly.
Alan, like many patients with Tourette's Disorder, also has obsessions and compulsions, even if not sufficiently impairing to warrant the additional diagnosis of Obsessive-Compulsive Disorder.
Table of Contents
1.Introduction and Historical Issues
Normality and Abnormality in Clinical Psychopathology
2.Diagnostic Systems and Techniques
Interviews, Observations and Tests
3.Anxiety Disorders I
Symptoms of Anxiety, Phobic Disorders, Generalized Anxiety Disorders, Panic Disorder
4.Anxiety Disorders II
Obsessive-Compulsive Disorders, Post-Traumatic and Acute Stress Disorders.
5.Mood Disorders I
Major Depressive Disorder and Dysthymia.
6.Mood Disorders II
Bipolar Disorder and Cyclothymic Disorder.
7.Schizophrenia I
Symptoms and Issues.
8.Schizophrenia II
Explanations and Treatments.
9.Disruptive Behavior Disorders-I
Attention Deficit/Hyperactivity Disorder.
10.Disruptive Behavior Disorders-II
Conduct Disorder and Oppositional Defiant Disorder.
11.Pervasive Development Disorders
Autistic Disorder, Asberger`s and other Developmental Disorders.
12.Elimination Disorders and Tic Disorder.
13.Mental Retardation.
14.Cognitive Disorders
Amnesia Disorders, Dementia Disorders, Delirium Disorders.
15.Suicide.
16.Substance-related disorders.
17.Sexual Dysfunctions.