Child and Adolescent Psych - Tic Disorders, Elimination Disorders, Childhood Anxiety Flashcards
What feeling typically precedes a tic, and what can be done to prevent the tic from occurring? What is the pattern they often occur?
Feeling - premonitory urge
Prevention - via suppression
They often occur in bouts
What is a simple vs complex motor tic?
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
What are simple vs complex vocal tics?
Simple - cough, grunt, throat clearing, sniff, etc
Complex - Protracted (prolonged) throat clearing, uttering of meaningful phrases, words, or syllables
What are three types of complex vocal tics which may involve speaking? There are three words for these.
- Palilalia - repeating one’s own words
- Echolalia - repeating someone else’s words
- Coprolalia - Obscenities uttered (rare)
What are the criteria for Tourette’s Disorder (TS)?
- 2+ motor AND 1+ vocal tics present during illness, but not necessarily at same time
- Tics must persist for greater than 1 year since onset (though the tics can change during this time)
- Must occur before age 18
What is the diagnosis if you have ONLY motor or ONLY vocal tics for greater than a year before age 18?
Persistent / Chronic Motor Tic Disorder
or
Persistent / Chronic Vocal Tic Disorder
What is a provisional tic disorder?
Single or multiple motor tick and/or vocal tics
Any tics presenting for <1 year since onset, before age 18
Who does tic disorder tend to affect, and what types of tics are they?
Males more often
Generally mild, and usually motor ticks (if you have vocal tics, you probably also have motor and a diagnosis of TS)
Is there a genetic component with TS? What conditions is it most commonly comorbid with it?
Yes there is
- > OCD & ADHD are most commonly comorbid
- > also anxiety
What neuroanatomic abnormalities occur in TS?
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
What disorder is characterized by the same anatomic targets as TS, ADHD, and OCD?
Syndenham’s chorea - often comorbid with tics, ADHD, & OCD
-> Follows Group A Streptococcal infection
What type of psychological factors tend to exacerbate tic frequency/severity? What will generally make it better?
Increased levels of psychosocial stress, as well as sleeplessness and fatigue
Made better by: Directed, effortful activity (i.e. singing / performing)
What is the typical progression of tic disorders?
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
When is TS typically diagnosed, and when is it most severe?
Diagnosed by age 11 typically, and most severe before mid-teen years, with improvement in lane teens
-> course is chronic and fluctuating
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:
Genetic: Huntington's disease Structural lesions: Hemiballismus - lesion of STN Infectious processes: Syndenham's chorea Idiopathic: Myoclonic epilepsy Pharmacologic agents: Neuroleptic drugs
How are tics differentiated from stereotypies?
Stereotypies - will have onset earlier than tics (before 3 years), and tend to increase when excited. Usually a feature of autism.
How are tics different than myoclonus? Compulsions?
Myoclonus - Abrupt jerks, non-suppressible
Compulsions - Done to avoid distress / worry
What is the most important thing for diagnosing a tic disorder?
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)
Why is psychoeducation important for tic disorders?
Alerting parents, teachers, and peers about it will improve acceptance for the condition and allow the child to take control
What is the best psychotherapy for tic disorders?
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
When is pharmacotherapy used for tic disorders and what drugs should be avoided?
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
What are three classes of drugs used in treatment of tic disorders?
- Alpha-2 receptor agonists - first line (clonidine, guanfacine)
- D2 receptor antagonists - neuroleptic drugs like haloperidol, risperidone, and pimozide (typical antipsychotics mostly)
- Botox - for very severe motor / vocal
What is the typical progression of bowel control and what determines it?
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
What are the words for not controlling your pee and your poop?
Pee - Enuresis - lack of bladder control
Poop - Encopresis - lack of bowel control
What are the typical etiologies of primary vs secondary enuresis and what does this mean? Which is more common?
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
Is enuresis genetic? Who tends to get it more?
Yes, most people have a first degree relative with a history of this. especially the father
Tends to affect boys more than girls
What is the DSM diagnosis of enuresis? What developmental must be met?
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)
What is enuresis co-morbid with?
Actually few co-morbid conditions, less than 20% of kids have co-morbidity - ADHD / anxiety most common
What conditions must be ruled out in enuresis ddx?
UTI’s, structural abnormalities leading to UTIs, Diabetes mellitus / insipidus
What is the supportive pretreatment for enuresis?
Charting enuresis with rewards, restricting fluids late at night, and awakening child to void 2 hours after they go to bed
What is the most successful treatment for enuresis?
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
What are the pharmacotherapies available for enuresis if there is a major functional impairment? Major risks?
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
Why does encopresis typically arise?
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.
What condition must be ruled out before making a diagnosis of encopresis and starting normal treatment?
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
What is the DSM criteria for encopresis? What must you specify?
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
What does encopresis without constipation / overflow incontinence usually present with in terms of child behavior?
Smearing or intentional depositing
(this is less common than constipation)
-> smearing may also be due to attempt to clean or hide evidence
How is psychogenic megacolon differentiated from Hirschsprung’s disease?
Hirschsprung’s is aganglionic megacolon, with symptoms appearing shortly after birth (vs age 4-5)
What is related to poorer prognosis in encopresis?
Nighttime soiling, nonchalant attitude, and soiling as an expression of aggression
-> most will respond to treatment or spontaneously remiss by age 16
What is the treatment for encopresis?
Use laxatives to disimpact bowel
Develop a supportive, nonpunitive atmosphere with timed toileting and positive reinforcement
If intentional: use psychodynamic evaluation
At what age is fear of the dark normal?
Around 7 years old
What are the DSM criteria of separation anxiety disorder (SAD)?
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.
What is commonly co-morbid with SAD, and what will result in adult life?
Co-morbid: GAD, specific phobia, social phobia, ADHD
Adult life: Anxiety / depression
When does SAD usually start / originally develop?
Starts after a life stress, usually ages 7-9 years.
What is the DSM criteria for selective mutism?
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
Who tends to get selective mutism and what is it co-morbid with?
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
