Welcome to Last Minute Lecture.
This free chapter overview is designed to help students review and understand key concepts.
These summaries supplement not replaced the original textbook and may not be redistributed or resold.
For complete coverage, always consult the official text.
Welcome to the Deep Dive.
Today we're getting into a really important chapter from Kaplan and Sadok's comprehensive textbook of psychiatry.
We're focusing on elimination disorders.
Yeah, and our mission here is, well it's pretty crucial.
We're looking at enuresis and encopresis.
These often get misunderstood, don't they?
Seen as just sort of behavioral issues, maybe defiance.
Right, like the child isn't trying hard enough.
Exactly.
But the source material, Kaplan and Sadok, it really emphasizes this complex mix of genetics,
physiology, and yes, psychological factors too.
We want to distill the core concepts for you, the criteria, the treatments.
Okay, let's dive in then starting with enuresis.
That's urinary incontinence.
And it's fascinating.
This isn't new.
The book mentions the Papyrus Ebers like 3 ,550 years ago.
A long history.
But the modern view, the more compassionate one, it really changed when effective treatments came along.
Things like the Bell and Pad, Imipramine, and later DDAVP.
Absolutely.
Those treatments working actually forced a shift.
It moved us away from thinking it was just bad behavior, didn't it?
Away from punishment, towards seeing it as maybe developmental or physiological.
So clinically speaking, how do we define enuresis?
It's that repeated voiding of urine, involuntary or sometimes intentional, into bed or clothes.
And the key starting point is age.
The child needs to be at least five years old.
Or at an equivalent developmental level, right?
Because that's usual incontinence is expected.
Precisely.
And then right away, you have to look at their history.
Kaplan and Sadok points out two really vital subtypes.
First is primary enuresis.
Meaning they've never really been consistently dry for, what, more than a year?
Correct.
Never achieved that milestone for longer than a year.
Then there's secondary enuresis.
This child was dry for a year or more, and then they started wetting again.
And that usually pops up between five and eight years old.
That's the most common onset, yeah.
And knowing that difference, primary versus secondary, it tells you a lot.
Are we looking at a delay or maybe a regression, possibly linked to stress?
And timing matters too, doesn't it?
Nocturnal only, just nighttime wetting that's the most common.
By far.
But you also see diurnal only, so daytime wetting, or a combination of both night and day.
And the DSM -5 -TR criteria, the official diagnosis,
it requires this voiding to happen repeatedly.
So at least twice a week for three months straight.
Yes, that's the frequency guideline.
Or, and this is really important for clinical judgment, even if it happens less often, if it causes significant distress or impairment.
Ah, right, like the social impact, can't go to sleepovers, feeling ashamed.
Exactly.
That level of distress or functional impairment, that alone can warrant the diagnosis and treatment even without hitting that twice a week mark every single week.
Okay, so let's dig into the why.
The etiology, the genetics here seem, well, pretty powerful.
They really are.
The text highlights this.
If the mother had enuresis, the child's risk is over five times higher, 5 .2 times.
Wow, and the father.
Even higher, 7 .1 times greater risk if the father was affected, some very strong familial link.
So more than just coincidence.
Oh, much more.
And the genetic research is fascinating.
It's not pointing to one single enuresis gene.
Instead, it looks like multiple spots on different chromosomes, like 13Q4P22.
Meaning it's heterogeneous.
Different genetic paths can lead to the same outcome.
Precisely.
Multiple ways it can be inherited, leading to different kinds of, say, developmental delays or physiological quirks that all result in wedding.
No simple single cause.
What about development beyond genetics, neurological factors?
Yeah, there's evidence suggesting a link to delayed maturation in parts of the central nervous system.
Studies using things like evoked potentials, looking at brainstem function, they often show slower maturation.
Interesting.
And I think the text also mentioned something about IQ scores.
It did.
Specifically, lower performance IQ scores on tests like the WISC -3.
It's a statistical association suggesting that for some kids, enuresis might be part of a broader picture of slightly delayed CNS development.
And these developmental issues often come with diagnoses, right?
Comorbidity is common.
Very common.
The big one mentioned is ADHD, Attention Deficit Hyperactivity Disorder.
It occurs alongside enuresis, about 30 % more often than you'd just expect by chance alone.
Suggesting some kind of overlapping vulnerability there.
It seems likely, yes.
Either neurological or perhaps developmental.
Now, let's connect this back to one of those treatments we mentioned, DDAVP.
Its effectiveness helps shape a theory about vasopressin, right?
AVP.
That's right.
Arginine vasopressin, the body's natural antidiuretic hormone.
The theory is that some children, especially with nocturnal enuresis, don't concentrate their urine properly at night, maybe because of irregularities in how AVP is secreted.
Leading to too much urine being produced overnight.
Exactly.
High nocturnal urine volume.
And DDAVP essentially mimics AVP's effect.
Now, this all is true for a good number of kids who well to DDAVP.
But not all.
Well, the research gets complex.
AVP secretion is postal.
It comes in bursts.
So, studies trying to find consistent differences in AVP levels between all responders and non -responders.
It's been tricky.
It works for many, but the exact why might still vary.
Okay.
The good news, though, is that enuresis often resolves on its own.
It does.
There's a pretty high spontaneous remission rate, maybe 5 % to 10 % each year after age 5.
But waiting isn't always the best option, especially if there's distress.
So for those needing treatment, where do we start?
The textbook points strongly to behavioral therapy first, doesn't it?
Yes, absolutely.
The gold standard is the bell and pad method.
It's a conditioning approach.
An alarm wakes the child as soon as wedding starts.
And the success rate is high, around 75%.
Reported success is around 75%, yes.
And the big advantage over medication is the long -term outcome.
Kids tend to stay dry more consistently after successful bell and pad treatment.
But there's a catch, isn't there?
Implementation can be tough.
That's the major hurdle.
The source mentions a high dropout rate, maybe up to a third of families finding it too difficult to manage consistently over weeks or months.
It takes a lot of parental effort and motivation.
Which often leads clinicians towards medication, then.
It often does.
And the first line pharmacologic choice now is DDAVP, or desmopressin.
It works fast, which families appreciate.
But there's a really critical safety warning we need to highlight.
Extremely important.
The FDA warning.
The nasal spray form is no longer indicated for childhood enteresis.
Too much risk of hyponatremia, low sodium, and seizures.
So it's oral tablets now, and with strict fluid restriction.
Crucial.
Restrict fluid significantly.
The text suggests no more than 8 ounces total, from one hour before taking the pill until 8 hours after.
It has to be managed carefully.
Are there clues about who might respond best to DDAVP?
Yes.
The source notes a few positive predictors.
Being a bit older, having a larger functional bladder capacity, and interestingly having that positive family history of enteresis we talked about earlier.
What about other medications?
Amitopramine is still mentioned.
It is.
Amitopramine, a tricyclic antidepressant.
It's still relevant, maybe for cases where DDAVP doesn't work, or if cost is a major issue.
But it comes with its own set of warnings.
Like needing an ECG beforehand.
Yes, due to potential cardiac effects.
And very careful dose titration.
But the biggest clinical warning is about overdose risk.
Ah, that point about magical thinking in children.
Exactly.
The text specifically mentions this risk.
A child thinking, well if one pill helps a little, maybe taking a lot more pills will cure me instantly.
It's a scary thought, but a real risk that parents must be warned about requires very safe storage.
That's a sobering reminder of the child's perspective and potential desperation.
Okay, let's shift gears.
Let's talk about the second disorder in this chapter.
Encopresis, or fecal incontinence.
Right.
So for encopresis, the diagnosis involves repeated passage of feces into inappropriate places, clothes, floor, etc.
It has to happen at least once a month for three months or more.
And the age threshold is different here, isn't it?
It's four years old.
Correct.
At least four years old developmentally.
And just like with enuresis, subtyping is absolutely key for understanding and treating it.
So what are the main types described in the text?
There are two main subtypes outlined in table 48 .3.
By far the most common is encopresis with constipation and overflow incontinence.
This is called the retentive type.
Retentive meaning they're holding stool.
Exactly.
Chronically constipated, often developing a large hard mass of stool and impaction.
Then looser liquid stool leaks out around that blockage.
That's the soiling parents usually see.
Okay, so that's the retentive type.
What's the other one?
That's encopresis without constipation and overflow incontinence, the non -retentive type.
Here, there's no constipation or impaction.
The soiling is usually linked more directly to, say, psychological issues or maybe problems with synchter control itself.
Got it.
And epidemiologically, encopresis is much less common than enuresis.
Much less common, yeah.
The text cites figures around 1 .5 % in seven to eight year old boys.
And there's a noticeable male predominance about three boys affected for every girl.
When we look at the causes, the why for encopresis, the thinking has shifted too, hasn't it?
Away from older psychological theories.
It really has.
Earlier psychodynamic ideas haven't held up well in systematic studies.
Instead, research points to clear physiological findings in many kids, especially those with a retentive type.
Like what kind of findings?
Things like abnormal anal sphincter dynamics.
For instance, some children actually tighten their external sphincter when they're trying to defecate.
Instead of relaxing it, they paradoxically contract.
Wow.
So physically working against themselves?
In effect, yes.
And also, many show slow colon transit time stool just moves very slowly through their large intestine.
So it's often a physiological issue of motility and coordination, not just willful withholding.
And does ADHD pop up here too?
It does.
Encopresis is also linked with a statistically significant increased risk for ADHD, similar to enuresis.
Another point, secondary encopresis, where a child was toilet trained and then starts soiling again.
That's more likely a link to stress.
Is more strongly associated with psychosocial stressors, yes.
Things like parental divorce, loss of a parent, major family disruptions.
That brings up the question of intention.
Most soiling isn't deliberate, right?
That's a critical point.
The vast majority, especially in the retentive type, is involuntary leakage due to the constipation and overflow.
However, intentional soiling, where the child consciously chooses to soil.
That signals something different.
Almost certainly, yes.
The text suggests intentional soiling is usually a sign of a significant psychological disturbance, maybe oppositional defiant disorder or conduct disorder.
Differentiating that is key.
So given all that, what's the recommended treatment approach for encopresis, particularly the common retentive type?
The source material strongly advocates for a combined approach, which has a really high success rate reported around 78%.
It involves three main parts.
Okay, what are they?
First, educational interventions.
You have to talk to the child and the parents, correct misconceptions about how the bowels work, why this is happening, demystify it.
Makes sense.
Reduce blame and confusion.
What's second?
Second is the physiological component.
This usually starts with an initial throw -bowel clean -out, sometimes called catharsis, to get rid of any impacted stool.
This can involve enemas or strong oral laxatives.
That sounds intense, but necessary to sort of reset the system?
Exactly.
You need a clean slate.
Then that's followed by daily maintenance with stool softeners or mineral oil to keep stools soft and prevent re -impaction.
Okay, education physiology.
What's the third part?
The third is the behavioral element.
This involves scheduled toilet sets, usually after meals, to take advantage of the body's natural gastrocolic reflex.
And importantly, using positive reinforcement rewards,
star charts for effort and success.
So it's a package deal.
Education, clearing the blockage and keeping things moving, and then retraining bowel habits with positive reinforcement.
That's the core of the conventional, successful approach.
What about other things people have tried, like biofeedback?
Interestingly, the text mentions that controlled studies have shown biofeedback training, trying to teach kids better sphincter control,
actually does not seem to add significant benefit beyond that standard combined treatment package we just discussed.
So stick with the proven three -part plan.
Is there any role for medication beyond laxatives?
Generally, not much.
Pharmacologic treatment beyond the laxatives for the retentive type is rarely needed, though imipramine, which we discussed for inuresis, has apparently shown some effectiveness in case reports for the rarer, non -retentive type of encopresis.
But overall, the focus is non -pharmacological for encopresis.
Primarily, yes.
Except, of course, it's always crucial to address any underlying psychological issues,
especially if you suspect intentional soiling, or if the encopresis started after a major stressor or trauma.
Okay, so wrapping this up, this deep dive into elimination disorders really highlights that while they have clear diagnostic criteria, age, frequency, duration,
the causes are really varied.
Absolutely.
It's this mix of biology, genetics, development,
physiology, and sometimes psychological stressors or disturbances.
It's not one -size -fits -all.
And that's why subtyping is so critical, right?
Primary versus secondary inuresis, nocturnal versus diurnal, retentive versus non -retentive encopresis.
Knowing those subtypes makes all the difference.
It guides whether you emphasize conditioning or maybe medication like DDAVP, or if you need that intensive bowel cleanout and behavioral retraining for encopresis, it dictates the treatment plan.
It's the roadmap to effective help, rather than just trying things randomly.
Precisely.
Avoiding a lot of frustration for the child, the family, and the clinician.
So here's a final thought for you, building on what we've discussed from Kaplan and Sadok.
We know the Bell & Pad works really well long -term for enuresis, and that combined therapy is highly effective for encopresis.
But we also noted the implementation challenges, especially for the Bell & Pad.
Right, the dropout rate.
So the question is, how might developing better support systems for families, helping them successfully implement these effective behavioral methods, how might that change clinical practice?
Could it reduce our tendency to perhaps jump to pharmacological options quite so quickly?
That's a really provocative question.
Focusing on making the best behavioral treatments more accessible and sustainable for families?
Definitely something worth considering.
Something for you to think about.
Thank you for joining us on this deep dive into elimination disorders.
We hope this exploration of the Kaplan and Sadok chapter leaves you feeling more informed and confident about this important area of child psychiatry.