Psychological and psychiatric comorbid disorders in urinary and
faecal incon6nence Cape Town 2012
Dr. Anne Wright
Introduc6on All forms of incontinence are associated with higher rates of behavioural and emotional disorder compared to possible organic causes
Comparison of percentage organic causes and behavioural comorbidity in normal children and in children with different
types of incon9nence von Gontard A, Neveus T. Mackeith Press 2006
%
Subclinical and clinical emo9onal and behavioural disorders in children with incon9nence
Presenta6on of behavioural and emo6onal disorders
Subclinical symptoms
• Emo6onal distress • Behavioural symptoms • Self esteem • Quality of life • Parental stress and anxiety
• May resolve with treatment
Clinical Psychological disorder
• Clinically significant psychological disorder associated with
– Present distress, disability or impairment
– Poses risk for future development
• Diagnosed according to classified systems
– DSM IV – ICD 10
• Clinical symptom scores (ques6onnaires)
• Do not resolve with treatment • Interfere with compliance and
outcomes
Subclinical symptoms as reported by children
• Popula9on study: BedweJng (ALSPAC, UK n=8209; age 9 years) • Asked children to rate/rank difficulty with 21 situa6ons eg:
• Don’t have friends • Being teased • Being leV out • Being shy • WeXng the bed • Always being in trouble • GeXng into fights • Not liking how they look
• 36.7% perceive bed weXng as being “really difficult” • BedweJng: rank number eight out of 21 for being most difficult situa6on • Boys found bedweXng more difficult than girls • BedweQers (>2x/week) found weJng and not liking their appearance significantly
more difficult than those who were non-‐weders Butler R, Heron J, Child: Care, Health and Dev 2007
Subclinical symptoms in children as reported by parents
• Popula9on study:ALSPAC, UK n= 8000 Age 7.5 years – BedweQers more likely to show:
• Separa9on anxiety • General anxiety • Social fears and sadness • All worsen with severity of bedweJng
Joinson C, J Ped Psychol 2007
• Popula9on study:Finland n= 156 Age 7 years – Day and night weQers showed ff personality traits in rela6on to controls
• More fiZul • More fearful • More impa9ent • More anxious • More inferiority feelings
Moilanen I, JarvelinM et al, Psychiatrica Fennica 1987
• Popula9on study: Sweden n= 75 boys – Faecal incon9nence
• Food refusal, nega9vism, anxiety,stress, difficulty with rela9onships Bellman M, Acta Paed Scand 1966
Impact on Parents • Popula9on study: ALSPAC, UK n=213
– Coping strategies in parents whose children wet bed >2x/week • LiVing 74 % • Fluid restric6on 65 % • Rewards 52 % • Nappies 49 % • Regular day6me toile6ng 34 % • Displeasure 22 %
Butler R Child Care Health Dev 2005
• Popula9on study: America n=1753, age 5-‐13 yrs
– Parental worry in response to child’s bedweJng • 62% reported worry • 17% reported worried a great deal
Foxman B, Valdez B, Brook R Pediatrics 1986
Clinically significant Psychological disorders
Externalising disorders – visible behaviours –eg opposi6onal
defiant disorder (ODD), conduct disorder (CD), Aden6on Deficit Hyperac6vity Disorder (ADHD)
Internalising disorders – inwardly-‐directed – eg. anxiety,
depression, phobias
Other-‐ eg anorexia nervosa, 6c disorders, au6s6c spectrum
disorders
Rela9onships between Psychological disorder and incon6nence
Incon6nence Psychological disorder
Psychological disorder
Gene6c predisposi6on Incon6nence
• Coexist
Incon6nence
• Chance
Psychological disorder
Common neurobiological dysfunc6on
ADHD
Enuresis
NOCTURNAL ENURESIS: Rela9ve risk of clinical behavioural disorders compared to controls: popula9on studies
STUDY AGE yrs N DETAILS RELATIVE RISK Ref
Isle of Wight, UK 5-‐15 4481 Boys 3.2 Ruder 1973
Girls 3.7
Christchurch, NZ 7-‐9 1037 Primary 1.4 McGee 1984
Secondary 2.4
Christchurch FU 11-‐15 1037 Primary 2.5 Feehan 1990
Secondary 4.5
China 6-‐18 3344 4.3 Liu 2000
Netherlands 9 1652 2.3 Hirasing 1997
USA 5-‐17 10960 1.6 Byrd 1996
After von Gontard A ICI
Nocturnal enuresis and psychological disorders
Secondary enuresis >> primary NE
Non-‐monosymptoma9c enuresis > monosymptoma9c enuresis Butler RJ et al Scand J Urol Nephrol 2006
Externalising>>internalising
Most common disorder ADHD
Nocturnal enuresis and ADHD
0 2 4
6
8
10
12
14
16
18
NO WETTING
BEDWETTING
*
* *
* P<0.001
Comparison of percentage behavioural disorders in dry and bedweJng children. N=8242, ALSPAC, UK AGE 7.5 years. Joinson C et al J Pediatr Psychol 2007
ADHD • Diagnosis DSM IV (prevalence 5-‐10%) • Three features:
• Inaden6on/cannot concentrate • Hyperac6vity/cannot keep s6ll • Impulsive/don’t think before they act
• Three subtypes • Pred inaden6ve • Pred hyperac6ve-‐impulsive • Combined
• Comorbid condi6ons; ODD, CD, Tic disorder,Depression, Anxiety, Specific developmental disorder
ADHD and Nocturnal enuresis • Lower compliance with treatment
– More difficult to treat – Worse outcome on alarm – Less dry at 6 and 12 months – Less compliant
• Both condi6ons require treatment • Imipramine has been shown to be effec6ve for enuresis in ADHD
• Atomoxe6ne used in treatment of ADHD has resulted in resolu6on of enuresis
Day6me weXng
NO WETTING
DAY AND NIGHT WETTING 0
5
10
15
20
25
NO WETTING
BEDWETTING
DAY AND NIGHT WETTING
* P<0.001
*
*
Comparison of percentage behavioural disorders in dry, bedwetting and day and night wetting children.N=8242, ALSPAC, UK AGE 7.5 years. Joinson, C.Pediatrics 118, 1985-1993, 2006
* *
Day9me weJng
• Externalising disorders predominate
• Sep anxiety, aQen9on deficit, opp behav, conduct problems
• No popula9on data on different subgroups • Selec9ve clinic-‐based studies show:
– Urge incon.nence assoc with only slightly increased rates – of disorder with mostly internalising problems Von Gontard A, ICI – Voiding postponement 37.3% of children had psychological disorder with predominantly externalising symptoms par9cularly ODD Von Gontard A et al, BJU 1998, Ledgen B et al Acta Paediatrica 2002
• LiQle data available on other subtypes of day9me weJng
Psychological disorders in Faecal incon9nence
Joinson C et al Pediatrics 117, 1575-1584, 2006
STUDY AGE yrs N DETAILS RELATIVE RISK
ALSPAC, UK 7-‐8 8242 Separa6on anxiety 5.4
Specific phobia 4.3
Generalised anxiety 8.5
ADHD 4.8
ODD 6.3
• Characterised by both internalising and externalising disorders
ICCS Recommenda6ons
Screening for emo6onal and behavioural disorders in all children with any form of incon6nence • Acquire basic knowledge, observe, ask relevant ques6ons and explore
• Screen with validatd ques6onnaires • For children with clinically relevant scores obtain child psychological or psychiatric assessment
• Counselling and treatment in appropriate cases
Screening all children • History, observa6on, explora6on
• Short screening ques9onnaires
• Problem items/behaviours present?
• Standard long ques9onnaires
• Problem items/behaviours present?
• Full child psychiatric/ psych assessment
• Child psychiatric disorder present?
• Treatment of disorder • In addi6on to NE/incon6nence
• YES
• YES
• YES
• Treatment of • enuresis/incon6nence only
• NO
• NO
• NO
• Counselling in addi6on to • treatment of • enuresis/incon6nence
• A • L • T • E • R • N • A • T • I • V • E
Ques9onnaires
• Short – Short screening instrument for psychological problems in enuresis. SSIPPE (Van Hoecke 2007) Validated. 13 items. Yes/No
• Standard long CBCL (Achenbach 1991) 113 items
• Any validated parental ques6onnaire on children’s behaviour
• QoL –generic, disease specific eg PinQ (Bower et al. 2006)
• Van Hoecke, E,: Journal of Urology 178, 2611-2615, 2007 • Achenbach, T.M.: Manual for the child behavior checklist / 4-18 and 1991 profile. Burlington, University of Vermont, 1991 • Bower WF,Neurourology and Urodynamics 25: 221-227, 2006
Psychiatric assessment
• Professional procedure to arrive at a diagnosis according to standardised classifica6on schemes
• Detailed developmental, behavioural and family history • Child and parent-‐child observa6on • Ques6onnaires • IQ test not rou6ne as this is normal range for most children
with i/c –if indicated • Disorders of speech/language/ dyslexia etc as necessary
Treatment • Before –is treatment necessary at all?
• OVen counselling of parents and child is all that is necessary, or perhaps changing the environment
• Detailed psychiatric treatment–eg pharmacotherapy, psychotherapy, CBT, psychodynamics therapy, social competence training, combina6ons
• Other therapies-‐eg speech, support for specific learning impairment etc
Conclusion • Counselling and child psychiatric/psychological treatment is
offered in addi6on to treatment of incon6nence
• ......... “comorbid disorders interfere with treatment for enuresis/incon4nence. Affected children show lower compliance and treatment results are lower. Therefore, children with incon4nence should be screened for psychological disorders even in pediatric and urological se?ngs. Children with a severe condi4on should be referred to the mental health service (child psychiatrists and child psychologists).An interdisciplinary approach is needed for op4mal care in day4me we?ng children.” Kuhn S: Journal of Urology, 182(4 Suppl), 1967-‐1972, 2009.
Thank you