Trastornos de eliminacion Flashcards
14.1.
The diagnosis of encopresis in the DSM-5 includes which of
the following symptoms as a specifier?
A. Abnormal sphincter tone
B. Anger
C. Anxiety
D. Constipation
E. Laxative responsive
14.1. D. Constipation
Either constipation or overflow incontinence are specifiers that
should be used in the DSM-5 when making a diagnosis of encopresis.
Patients without abnormalities in sphincter tone are more likely to
respond to laxatives, though it is not included as a specifier. Anger
and anxiety can be emotional factors that contribute to encopresis,
though are not included as specifiers in the DSM.
14.2.
Which of the following children would meet DSM-5 criteria
for encopresis?
A. An 8-year-old child who soils himself when he has major
school examinations
B. A 5-year-old child with constipation, diarrhea, and soiling
himself for 3 months
C. A 7-year-old child who soiled his pants once after going to
the bathroom
D. A 10-year-old child who soils himself each time after having
caffeinated tea at lunch
E. A 3-year-old child who smears feces on his carpet weekly
14.2. B. A 5-year-old child with constipation, diarrhea, and
soiling himself for 3 months
For a diagnosis of encopresis to be made, eliminating feces on the
clothes or floor, whether voluntary or unintentional, must occur in
someone who is greater than or equal to 4 years old and the episodes
have to occur at least once a month for a period of 3 or more months
14.3.
Which treatment should be the initial step in treating a child
with encopresis without evidence of constipation?
A. Family-based treatment
B. Fluoxetine
C. Polyethylene glycol (PEG)
D. Surgical disimpaction
E. Timed, regular toileting intervals
14.3. E. Timed, regular toileting intervals
For encopresis with constipation, often daily laxatives, such as PEG
are utilized and in severe cases, surgical disimpaction under general
anesthesia is initiated prior to the laxative use. When encopresis
without constipation is noted, the typical first step is a cognitive
behavioral intervention to help institute regular, timed intervals on
the toilet. This can also be helpful in cases of encopresis with
constipation. Supportive psychotherapy can be helpful in children
with comorbid anxiety and self-esteem issue. Family interventions
can help when children are smearing feces.
14.4.
Which of the following causes of encopresis is most common?
A. Behavioral and conduct problems
B. Hirschsprung disease
C. Sexual abuse
D. Specific toilet phobia
E. Withholding feces via sphincter tightening due to pain
14.4. E. Withholding feces via sphincter tightening due to
pain
In 90% of cases of childhood encopresis, children will withhold feces
by contracting their gluteal muscles, holding their legs, and then
tightening their external anal sphincter, typically as a response to
previously painful bowel movements due to constipation. A specific
phobia of using the toilet is a less common cause of encopresis. In
only about 5% to 10% of cases are medical conditions, such as
Hirschsprung disease and spinal cord damage, contributing factors.
One study found sexual abuse is higher in a sample of children with
encopresis compared to healthy controls, though this disorder is by
no means a specific indicator of sexual abuse
14.5.
A 5-year-old child has been bed-wetting most nights of the
week for the past year. Which of the following psychiatric
disorders are they at increased risk of getting compared to the
general population?
A. Attention deficit hyperactivity
B. Anxiety
C. Depressive
D. Eating
E. Oppositional defiant
14.5. A. Attention deficit hyperactivity
The patient described above has enuresis, which is defined in DSM-5
as episodes of urinating onto the bed or clothing, either voluntarily
or unintentionally for at least 2 weeks for 3 or more months in
children 5 years or older. Nocturnal, diurnal, or both should be
indicated as specifiers. Children with enuresis are at a higher risk of
attention-deficit/hyperactivity disorder (ADHD) compared to the
general population.
14.6.
Which of the following outcomes is the most typical course
for a child with enuresis?
A. Development of an oppositional defiant
disorder
B. Occurrence after 1 year of dryness
C. Progression to a chronic cystitis
D. Relapse in adulthood
E. Spontaneous remission
14.6. E. Spontaneous remission
Medical causes of enuresis should be ruled out including urinary
tract infections, bladder dysfunction, spina bifida, cystitis, etc.
However, most sophisticated radiographic medical tests are deferred
unless there are signs of repeat infections. The most common
scenario is that enuresis is self-limited and spontaneous remission is
seen. Enuresis most commonly occurs in those without ever having a
period of dryness first (80%). The age of onset is older (i.e., 5 to 8) in
those in which a year period of dryness occurred first. Relapses can
occur. The course is often complicated in those with comorbid
ADHD
14.7.
What is the minimum age a child can respond to use of a bedwetting
alarm for enuresis?
A. 2
B. 4
C. 6
D. 8
E. 10
14.7. C. 6
A bed alarm has been the mainstay of treatment for enuresis. It
alerts a child when they start to void during sleep. The device is
attached to the child’s underwear and then sounds a loud noise to
awaken the child to go to the toilet. At the age of 6 or 7 years, it is
thought that the child is old enough to respond optimally to the
alarm.
14.8.
Use of the bell and pad alarm for the treatment of bedwetting
is a form of which type of behavioral therapy?
A. Classical conditioning
B. Operant conditioning
C. Positive reinforcement
D. Punishment
E. Negative reinforcement
14.8. A. Classical conditioning
Classical conditioning in this case involves associating the
involuntary response of nocturnal enuresis with the unconditioned
stimulus, the alarm, training the child to get up and go to the
bathroom (unconditioned response). It is the mainstay treatment for
nocturnal enuresis and typically more effective than bladder training
(i.e., delayed urinating for increased times during the day).
14.9.
Though rare, which is the most severe side effect documented
with the use of desmopressin in the treatment of enuresis?
A. A cardiac arrest
B. Agranulocytosis
C. A hyponatremic seizure
D. Liver failure
E. Renal failure
14.9. C. A hyponatremic seizure
Desmopressin, a nasal spray that acts as an antidiuretic compound,
is used to treat enuresis when it is causing significant social or
functional impairment for the child. The most common side effects
of desmopressin are headaches, nasal congestion, epistaxis, and
stomachaches. A rare complication of a hyponatremic seizure has
been documented with use of desmopressin for enuresis treatment.
14.10.
Which neurotransmitter reuptake inhibitor is thought to be
a safer alternative to imipramine for the treatment of
enuresis?
A. Desipramine
B. Duloxetine
C. Reboxetine
D. Strattera
E. Tranylcypromine
14.10. C. Reboxetine
Antidepressants with anticholinergic side effects, such as
imipramine, were initially used for the
treatment of enuresis.
However, due to its considerable side effect profile, such as
cardiotoxicity, it has fallen out of favor. Reboxetine, though not
currently available in the United States, is a norepinephrine reuptake
inhibitor that is a safer alternative to imipramine for the treatment of
enuresis, without the potential for cardiac toxicity.
14.11.
Which type of enuresis is most commonly diagnosed?
A. Adolescent onset
B. Combination (diurnal and nocturnal)
C. Diurnal
D. Nocturnal
E. Structural/anatomical defect
14.11. D. Nocturnal
The three main types of enuresis are diurnal, nocturnal, and a
combination of diurnal and nocturnal. In general, enuresis is most
commonly present in 5-year-olds (i.e., 5% to 10%). Among the types,
nocturnal enuresis accounts for about 80% of children with enuresis.
Adolescent onset is rare around 1%. Structural abnormalities, such as
genitourinary pathology, are less common and typically present with
both diurnal and nocturnal enuresis
