Child and Adolescent Psych - Tic Disorders, Elimination Disorders, Childhood Anxiety

Question 1

What feeling typically precedes a tic, and what can be done to prevent the tic from occurring? What is the pattern they often occur?

Answer 1

Feeling - premonitory urge
Prevention - via suppression

They often occur in bouts

Question 2

What is a simple vs complex motor tic?

Answer 2

Simple - Only involves 1 muscle group: i.e. Eye blink, nose twitch, jerk, shrug

Complex: Involves many muscle groups, can occur in orchestrated patterns -> gestures or movements

Question 3

What are simple vs complex vocal tics?

Answer 3

Simple - cough, grunt, throat clearing, sniff, etc

Complex - Protracted (prolonged) throat clearing, uttering of meaningful phrases, words, or syllables

Question 4

What are three types of complex vocal tics which may involve speaking? There are three words for these.

Answer 4

1. Palilalia - repeating one’s own words
2. Echolalia - repeating someone else’s words
3. Coprolalia - Obscenities uttered (rare)

Question 5

What are the criteria for Tourette’s Disorder (TS)?

Answer 5

1. 2+ motor AND 1+ vocal tics present during illness, but not necessarily at same time
2. Tics must persist for greater than 1 year since onset (though the tics can change during this time)
3. Must occur before age 18

Question 6

What is the diagnosis if you have ONLY motor or ONLY vocal tics for greater than a year before age 18?

Answer 6

Persistent / Chronic Motor Tic Disorder

or

Persistent / Chronic Vocal Tic Disorder

Question 7

What is a provisional tic disorder?

Answer 7

Single or multiple motor tick and/or vocal tics

Any tics presenting for <1 year since onset, before age 18

Question 8

Who does tic disorder tend to affect, and what types of tics are they?

Answer 8

Males more often

Generally mild, and usually motor ticks (if you have vocal tics, you probably also have motor and a diagnosis of TS)

Question 9

Is there a genetic component with TS? What conditions is it most commonly comorbid with it?

Answer 9

Yes there is

• > OCD & ADHD are most commonly comorbid
• > also anxiety

Question 10

What neuroanatomic abnormalities occur in TS?

Answer 10

Basal ganglia dysfunction, with defective cortical input to striatum, and thalamocortical abnormalities.

-> small caudate volumes, larger PFC, increased dopamine receptor density in striatum in general to make them hypermobile

Question 11

What disorder is characterized by the same anatomic targets as TS, ADHD, and OCD?

Answer 11

Syndenham’s chorea - often comorbid with tics, ADHD, & OCD
-> Follows Group A Streptococcal infection

Question 12

What type of psychological factors tend to exacerbate tic frequency/severity? What will generally make it better?

Answer 12

Increased levels of psychosocial stress, as well as sleeplessness and fatigue

Made better by: Directed, effortful activity (i.e. singing / performing)

Question 13

What is the typical progression of tic disorders?

Answer 13

Simple, transient motor tics arise around age 4-6
Rostrocaudal progression of tics
Phonic tics appear ages 8-15 (does not happen in all, but if you have a phonic tic you most likely have a motor tic)
Tics severity peaks age 10-12
Waxing / waning is normal

Question 14

When is TS typically diagnosed, and when is it most severe?

Answer 14

Diagnosed by age 11 typically, and most severe before mid-teen years, with improvement in lane teens
-> course is chronic and fluctuating

Question 15

On the differential diagnosis for tic disorders, give a possible cause of simple motor tics in each of the following categories.
Genetic:
Structural lesions:
Infectious processes:
Idiopathic:
Pharmacologic agents:

Answer 15

Genetic: Huntington's disease
Structural lesions: Hemiballismus - lesion of STN
Infectious processes: Syndenham's chorea
Idiopathic: Myoclonic epilepsy
Pharmacologic agents: Neuroleptic drugs

Question 16

How are tics differentiated from stereotypies?

Answer 16

Stereotypies - will have onset earlier than tics (before 3 years), and tend to increase when excited. Usually a feature of autism.

Question 17

How are tics different than myoclonus? Compulsions?

Answer 17

Myoclonus - Abrupt jerks, non-suppressible

Compulsions - Done to avoid distress / worry

Question 18

What is the most important thing for diagnosing a tic disorder?

Answer 18

The family history -> need their observation / videos from home. Also, may have not been diagnosed in the past (i.e. thought they were having trouble reading because they were blinking their eyes, brought them to eye doctor and it spontaneously resolved)

Question 19

Why is psychoeducation important for tic disorders?

Answer 19

Alerting parents, teachers, and peers about it will improve acceptance for the condition and allow the child to take control

Question 20

What is the best psychotherapy for tic disorders?

Answer 20

Habit Reversal Training (HRT)
-> Teaches awareness of tic, and “competing response practice” -> channel the urge into a less functionally impairing tic which cannot be seen

Question 21

When is pharmacotherapy used for tic disorders and what drugs should be avoided?

Answer 21

Used when there is a significant impairment due to the tic, i.e. they are being bullied, or they dislocated their shoulder from the movement

Avoid stimulants like methylphenidate when treating co-morbid ADHD, which can exacerbate the tic disorder by increasing dopamine levels

Question 22

What are three classes of drugs used in treatment of tic disorders?

Answer 22

1. Alpha-2 receptor agonists - first line (clonidine, guanfacine)
2. D2 receptor antagonists - neuroleptic drugs like haloperidol, risperidone, and pimozide (typical antipsychotics mostly)
3. Botox - for very severe motor / vocal

Question 23

What is the typical progression of bowel control and what determines it?

Answer 23

Nocturnal fecal control -> diurnal fecal control -> diurnal bladder control -> nocturnal bladder control

Weird that you can control your poops at night before during the day

Determined by intellectual and social maturity, as well as psychological interactions

Question 24

What are the words for not controlling your pee and your poop?

Answer 24

Pee - Enuresis - lack of bladder control

Poop - Encopresis - lack of bowel control

Question 25

What are the typical etiologies of primary vs secondary enuresis and what does this mean? Which is more common?

Answer 25

Primary - never gained continence -> usually due to maturational delay. Represents 80% of patients.

Secondary enuresis - lost continence after at least 1 year of continence -> usually due to a stressor. Less common, starts between 5-8

Question 26

Is enuresis genetic? Who tends to get it more?

Answer 26

Yes, most people have a first degree relative with a history of this. especially the father

Tends to affect boys more than girls

Question 27

What is the DSM diagnosis of enuresis? What developmental must be met?

Answer 27

Involuntary or intentional voiding into bed or clothes, at least 2x a week for >=3 consecutive months, or presence of distress / impairment

Developmental age >= 5 years (better than 90% will have bladder control by this point)

Question 28

What is enuresis co-morbid with?

Answer 28

Actually few co-morbid conditions, less than 20% of kids have co-morbidity - ADHD / anxiety most common

Question 29

What conditions must be ruled out in enuresis ddx?

Answer 29

UTI’s, structural abnormalities leading to UTIs, Diabetes mellitus / insipidus

Question 30

What is the supportive pretreatment for enuresis?

Answer 30

Charting enuresis with rewards, restricting fluids late at night, and awakening child to void 2 hours after they go to bed

Question 31

What is the most successful treatment for enuresis?

Answer 31

Enuresis alarm - pad which detects first drop of liquid expelled and wakes up the child when they do they, helps child improve awareness of urination

Question 32

What are the pharmacotherapies available for enuresis if there is a major functional impairment? Major risks?

Answer 32

Imipramine - tricyclic with anticholinergic properties, cardiac arrhythmia is a concern

DDAVP - desmopressin - reduces urine production, may lead to hyponatremia and seizure due to water intoxication

Question 33

Why does encopresis typically arise?

Answer 33

Again more common in boys

Arises usually as secondary encopresis (>1 yr of continence) with constipation and excessive fluid overflow (overflow incontinence) -> will be small liquid stool. Often precipitated by life events and in reaction to a stressor / anxiety.

Can also be primary due to lack of proper toilet training.

Question 34

What condition must be ruled out before making a diagnosis of encopresis and starting normal treatment?

Answer 34

Psychogenic megacolon

pathology:

• > children hold feces voluntarily or because of defecation pain
• > rectal distention leads to loss of rectal tone / desensitization
• > children do not need to defecate -> leads to OVERFLOW encopresis
• > need GI to decompact the bowel for treatment

Question 35

What is the DSM criteria for encopresis? What must you specify?

Answer 35

Involuntary or intentional passage of feces at least 1x per month for at least 3 months
-> chronological age of at least 4 (vs 5 with enuresis)

-> must specify if due to overflow incontinence or not

Question 36

What does encopresis without constipation / overflow incontinence usually present with in terms of child behavior?

Answer 36

Smearing or intentional depositing

(this is less common than constipation)

-> smearing may also be due to attempt to clean or hide evidence

Question 37

How is psychogenic megacolon differentiated from Hirschsprung’s disease?

Answer 37

Hirschsprung’s is aganglionic megacolon, with symptoms appearing shortly after birth (vs age 4-5)

Question 38

What is related to poorer prognosis in encopresis?

Answer 38

Nighttime soiling, nonchalant attitude, and soiling as an expression of aggression

-> most will respond to treatment or spontaneously remiss by age 16

Question 39

What is the treatment for encopresis?

Answer 39

Use laxatives to disimpact bowel
Develop a supportive, nonpunitive atmosphere with timed toileting and positive reinforcement

If intentional: use psychodynamic evaluation

Question 40

At what age is fear of the dark normal?

Answer 40

Around 7 years old

Question 41

What are the DSM criteria of separation anxiety disorder (SAD)?

Answer 41

Inappropriate, excessive anxiety concerning separation from attachment figures (i.e. Meghan), lasting for >4 weeks.

Distress from separation, worry about attachment figure, refusal or fear to leave home or be alone, refusal to sleep away from home or without attachment figure. Nightmares w/separation themes common.

Question 42

What is commonly co-morbid with SAD, and what will result in adult life?

Answer 42

Co-morbid: GAD, specific phobia, social phobia, ADHD

Adult life: Anxiety / depression

Question 43

When does SAD usually start / originally develop?

Answer 43

Starts after a life stress, usually ages 7-9 years.

Question 44

What is the DSM criteria for selective mutism?

Answer 44

For >1 month (not the first month of school), failure to speak in specific social situations despite speaking in others. Interferes with function, not simply due to language / developmental issue

Question 45

Who tends to get selective mutism and what is it co-morbid with?

Answer 45

Typically girls > boys

Co-morbid with anxiety, may be associated with social phobia.

Kids tend to be shy, socially isolated, clingy, and compulsive. Teased by peers