Tourette Syndrome Enuresis Enkopresis

1. Yeditepe Üniversitesi Hastanesi Çocuk ve Ergen Psikiyatrisi Anabilim Dalı 2015 TouretteSyndromeEnuresisEnkopresis

2. Tourette Syndrome • an inherited neuropsychiatric disorder with onset in childhood, characterized by the presence of multiple physical (motor) tics and at least one vocal (phonic) tic • Genetic studies have shown that the overwhelming majority of cases of Tourette's are inherited, although the exact mode of inheritance is not yet known, and no gene has been identified. • Gender appears to have a role in the expression of the genetic vulnerability: males are more likely than females to express tics.

3. Tourette Syndrome • Non-genetic, environmental, infectious, or psychosocial factors—while not causing Tourette's—can influence its severity. • In 1998, a team at the US National Institude of Mental Health proposeda hypothesis that both obsessive–compulsive disorder (OCD) and tic disorders may arise in a subset of children as a result of a poststreptocoocal autoimmune process • Children who meet five diagnostic criteria are classified, according to the hypothesis, as having Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). • Tics are believed to result from dysfunction in cortical and subcortical regions, the thalamus,basal ganglia and frontal cortex.

4. Tourette Syndrome • Diagnostic CriteriaA) Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. B) The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.C) The onset is before age 18. D) The disturbance is not due to the direct physiological effects of a substance (e.g. stimulants) or a general medical condition (e.g. Huntington's disease or post-viral encephalitis).

5. Tourette Syndrome • Although the word "involuntary" is used to describe the nature of the tics, this is not entirely accurate. • People with TS feel an irresistable urge to perform their tics, much like the need to scratch a mosquito bite. • Some people with TS are able to hold back their tics for up to hours at a time, but this only leads to a stronger outburst of tics once they are finally allowed to be expressed. • coprolalia has been sensationalized by the media, it is actually rare, occuring in less than 30% of people who have a severe case. • Coprolalia does not have to be exclusively swear words. Many times coprolalia manifests itself as socially inappropriate or unacceptable words or phrases

6. Tourette Syndrome • it is believed that an abnormal metabolism of the neurotransmitters dopamine and serotonin are involved with the disorder. • It is genetically transmitted; parents having a 50% chance of passing the gene on to their children. • Girls with the gene have a 70% chance of displaying symptoms, boys with the gene have a 99% chance of displaying symptoms. • Between 1 and 10 children per 1,000 have Tourette's • People with Tourette's have normal life expectancy and intelligence.

7. The severity of the tics decreases for most children as they pass through adolescence, and extreme Tourette's in adulthood is a rarity. • There is no effective medication for every case of tics, but there are medications and therapies that can help when their use is warranted. • Explanation and reassurance alone are often sufficient treatment; education is an important part of any treatment plan

8. Enuresis • A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional). • B. The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupa­tional), or other important areas of functioning. • C. Chronological age is at least 5 years (or equivalent developmental level). • D. The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition ( e.g., diabetes, spina bifida, a seizure disorder).

9. Two physical functions prevent bedwetting. • 1)The first is a hormone that reduces urine production at night. • 2)The second is the ability to wake up when the bladder is full. • Children usually achieve nighttime dryness by developing one or both of these abilities. • There appear to be some hereditary factors in how and when these develop. • At about sunset each day, the body releases a minute burst of antidiuretic hormone(also known as arginine vasopressin or AVP). • This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of puberty, and some not at all. • The second ability that helps people stay dry is waking when the bladder is full. This ability develops in the same age range as the vasopressin hormone, but is separate from that hormone cycle.

10. Enuresis • Most bedwetting is a developmental delay, not an emotional problem or physical illness. Only a small percentage (5% to 10%) of bedwetting cases are caused by specific medical situations. • Bedwetting is frequently associated with a family history of the condition. • Bedwetting children can suffer emotional stress or psychological injury if they feel shamed by the condition. • most treatment plans aim to protect or improve self esteem • Treatment guidelines recommend that the physician counsel the parents, warning about psychological damage caused by pressure, shaming, or punishment for a condition children cannot control.

11. epidemiology • Age 5: 20% • Age 6: 10 to 15% • Age 7: 7% • Age 10: 5% • Age 15: 1-2% • Males make up 60% of bedwetters overall and make up more than 90% of those who wet nightly

12. Medical definitions: primary vs. secondary enuresis • Primary nocturnal enuresis (PNE) is the most common form of bedwetting. • Secondary nocturnal enuresis occurs after a patient goes through an extended period of dryness at night (roughly 6 months or more) and then reverts to nighttime wetting. Secondary enuresis can be caused by emotional stress or a medical condition, such as a bladder infection. • Psychological issues (e.g., death in the family, sexual abuse, extreme bullying) are established as a cause of secondary nocturnal enuresis (a return to bedwetting),

13. Psychological-social impact • a bedwetting child is not at fault for the situation. • Many medical studies state that the psychological impacts of bedwetting are more important than the physical considerations. “It is often the child's and family member's reaction to bedwetting that determines whether it is a problem or not • Whether bedwetting causes low self-esteem remains a subject of debate, but several studies have found that self-esteem improved with management of the condition. • Children questioned in one study ranked bedwetting as the third most stressful life event, after parental divorce and parental fighting.

14. Treatment • Waiting • delaying treatment until the child is at least six or seven years old. • Bedwetting alarms • DDAVP (Desmopressin) • a synthetic replacement for antidiuretic hormone • Tricyclic antidepressants • with anti-muscarinic properties have been proven successful in treating bedwetting

15. Encopresis • A. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional. • B. At least one such event a month for at least 3 months. • C. Chronological age is at least 4 years (or equivalent developmental level). • D. The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation.

16. Encopresis • in 5-year-olds is ~1-3%. • The disorder is thought to be more common in males than females, by a factor of 6 to 1. • In the type without constipation, the feces are usually well-formed, soiling is intermittent, and feces are usually deposited in a prominent location. This form may be associated with oppositional defiant disorder or conduct disorder