Feeding, Elimination And Tic Disorders

Feeding and eating disorders, elimination and tic disorders (from the Dr. Vivian Yu lecture of Dra. Yu)

FEEDING DISORDERS Feeding Disorder - persistent symptoms of inadequate food intake - recurrent regurgitation and rechew - repeated congestion of non nutritious food Rumination - repeated regurgitation of food resulting to failure to gain weight and weight loss * reflux- non-projectile vomiting- child cries; projectile rumination- seems to enjoy it, finds satisfaction - not associated with other GI symptoms - males - 3 months-14 months

Psychiatry Third Shifting

Clinical Implication Lead based paint Lead poisoning Animal feces, Intestinal dirt, soil parasitism clay anemia Hair ball, stone, gravel Treatment and Prognosis - determine cause - education and behaviour modification - positive reinforcement - increase parental attention - correction of deficiency - remits spontaneously - limited to the term of pregnancy ELIMINATION DISORDERS

Types • Self-mutilating- mental retardation • Psychogenic- disturbed parent-child relationship o Failure to thrive

• Encopresis • Eneuresis

Treatment - Behavioural modification

Bowel and Bladder Control • Daytime 2 ½ years old • Night time 4 years old • After 5 years old  pathologic

Pica - persistent (>1 month) eating of non-nutritive substances - developmentally inappropriate - not culturally sanctioned - sufficiently severe - onset: 1-2 y/o - male=female Etiology - familial tendency - nutritional deficiency, iron and zinc - parental neglect - mechanism to satisfy oral (blah blah blah..di namin nakuha kasunod, sowi..) Substances ingested: vary according to accessibility, mastery of locomotion Older child: dirt, animal feces, stones, paper

Kibbutz 

Blood lead level Stool exam, hx of passing out worm hemoglobin Abdominal x-ray

Encopresis Classification of encopresis • Primary- has no previous bowel control • Secondary- recurs after successful toilet training • Retentive- associated with constipation and overflow incontinence, 2/3 of cases • Non-retentive- not associated with constipation Etiology - inadequate training - constipated with excess fluid overflow - inadequate sphincter control Diagnosis - repeated passage of feces into inappropriate places, involuntary or intentional - 1 event/month for 3 months 1 of 6

PSYCHIATRY FEEDING AND EATING DISORDERS

Lab Exam • rule-out medical illness (like Hirschsprung and hypothyroidism) • constipation evaluation o PE: rectal exam  (+) feces- chronic constipation  (-) feces- abnormal anal sphincter function • abdominal x-ray Prognosis • depends on cause o presence of anatomical pathology o parental support Treatment • high fiber diet • mineral oil and laxatives • manual disimpaction • family and school support • supportive psychotherapy and relaxation techniques Enuresis - repeated voiding of urine into clothes or bed - involuntary or intentional - 2x/week for 3 months - cause significantly distress or impairment - common in male Epidemiology - decreases with increasing age - 20% are mentally retarded Etiology • normal bladder control • neuromuscular and cognitive development • socioemotional factors • toilet training • difficulty may delay urinary continence • psychosocial • genetic factors o 75% have (+) family history o 7x risk of child • biologic factors o small functional bladder o full bladder + decreased nighttime ADH Classification • Primary/ persistent- never dry at night, 90% of cases Kibbutz 

• Secondary/ regressive- continent for at least 6 months then becomes enuretic again • Nocturnal (night wetting)- most common • Diurnal- wet even when awake; females rarely after 9 years old Differential Diagnosis Anatomic cause (3%) Obstruction, GUT pathology, spina bifida, stress incontinence Medical conditions Infection, DM Disturbances of consciousness and sleep Sleep walking disorder, seizures, intoxication, antipsychotics (thioridazine)

KUB UTZ Pelvic x-ray, VCUG Urinalysis EEG

Course and Prognosis • Usually self-limited • 80% never achieved a 1-yr period of dryness • enuresis after 1-dry-yr occur at 5 to 8 years old o frequently associated with psych factors o decreased self-esteem, social embarrassment o intra-familial conflict Treatment of Enuresis • rule-out medical conditions • review appropriate toilet training • behavioural therapy o classical conditioning o positive reinforcement • psychotherapy • pharmacologic therapy o imipramine (tofranil) o desmopressin (DDAVP)

TIC DISORDERS First part of this ay galing po sa lecture ni doktora..:) thanks sa mga tao sa harap (sila malta) for taking pictures..:) Ung next part po ay galing sa book 

TIC DISODERS - rapid and repetitive muscle contractions - movements and vocalizations - involuntarily - begin in childhood or adolescence - may be suppressed for periods Simple Motor Tics 2 of 6

PSYCHIATRY FEEDING AND EATING DISORDERS

- rapid, repetitive contractions of functionally similar muscle groups - eye blinking, neck jerking, shoulder shrugging, facial grimacing Complex Motor Tics - grooming behaviours, echopraxia - smelling of objects - jumping Simple Vocal Tics - coughing - throat clearing - snorting

Differential Diagnosis: - stereotypic movement disorders - stimulant medications - encephalitis - seizure disorders

- barking - sniffing - grunting

Complex Vocal Tics - repeating words or phrases out of context - coprolalia (use of obscene words or phrases) - palilalia (person’s repeating own words) - echolalia (repetition of last words of others) TOURETTE’S DISORDER - George Gilles de la Tourret, 1885 - 5-30 out of 10,000 adults - 1-2 out of 10,000 adults - boys 3x more than grils - multiple motor tics and vocal tics

stimulant

* next part galing na sa book..:)

medications

Anatomical - lack of normal asymmetry in the striatum Immunologic and post-infectious - PANDAS (pediatric autoimmune neuropsychiatric disorder associated with Streptococcal infection) Diagnosis: - both multiple motor and 1 vocal tics present at sometime during illness - tics occur many times a day (bouts), in a year without 3 months that are tic-free - onset before 18 years old - disturbance not due to a substance (stimulant) or general medical condition (Huntington’s or postviral encephalitis) Clinical Features: - face and neck  downward progression Kibbutz 

Treatment: - education of patient and family - behavioral techniques to reduce stress - pharmacotherapy (high potency dopamine receptor antagonists: typical antipsychotics) - haloperidol - pimozide Course and Prognosis: - chronic lifelong - relative remissions and exacerbations

Etiology: Genetics - more common in first-degree relatives Neurochemical - worsening of tics by (dopaminergic involvement)

-eye-blink tic or facial grimace - prodromal behavior symptoms - irritability, poor frustration tolerance - attention difficulties - coprolalia - each adolescence (1/3 of patients) - mental coprolalia

Tics- rapid, repetitive muscle contractions or sounds that usually are experienced as outside volitional control and which often resemble aspects of normal movement or behavior - can be elicited by stimuli or preceded by an urge or sensation Simple motor tics- involve one or a small number of muscle groups (e.g., eyeblinking tic, facial grimace, or shoulder shrug) - can be further subdivided into clonic, tonic, or dystonic types Simple vocal tics- include coughing, throat clearing, grunting, sniffing, snorting, and barking Complex motor tics- may come close to mimicking normal movements of various kinds, through the synchronous contraction of several muscle groups, as in hopping movements, or the simultaneous extension of arms and legs, in knee bends, and rarely, obscene gesturing or copropraxia Complex vocal tics- include repeating words or phrases out of context, coprolalia, palilalia, and echolalia 3 of 6

PSYCHIATRY FEEDING AND EATING DISORDERS

TOURETTE’S DISORDER DSM-IV Diagnostic Criteria for Tourette’s Disorder A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.) 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 years. 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 postviral encephalitis). Epidemiology - lifetime prevalence: 4-5/10,000 - mostly in children (5-30/10,000 affected) than adults (12/10,000) - onset of motor component: 7 years old - vocal: 11 years - 3x more in boys Etiology Genetic Factors - genetic cause - possibly autosomal dominant, bilinear mode - 50% of patients with Tourette’s also have attention deficit/hyperactivity disorder (ADHD) - 40% have obsessive-compulsive disorder Neurochemical and Neuroanatomical Factors - dopamine system - endogenous opioids - noradrenergic system Immunological Factors and Postinfection - secondary to streptococcal infections  genetic variability Pathology and Laboratory Examination - no specific exam - most patients have abnormal electroencephalographic findings (use CT or MRI) Differential Diagnosis of Tic Disorder sori medyo madami..look nalang po sa book  thanks! 

Course and Prognosis - course varies from individual to individual - periods of tic remission followed by exacerbations - severe social, academic, and vocational consequences are frequent sequelae and more severe of these leads to suicide Kibbutz 

Treatment - first step: consideration of a child or adolescent’s overall functioning - comprehensive education for families so that children are not punished for their tic behaviours - behavioural interventions: “habit reversal” techniques - other behavioural interventions: massed (negative) practice, self-monitoring, incompatible response training, presentation and removal of positive reinforcement, as well as habit reversal treatment - pharmacotherapy: historically: high-potency dopamine receptor antagonists (typical antipsychotics), such as haloperidol, tifluoperazine (Stelazine), and pimozide  discontinuation causes extrapyramidal effects and dysphoria CHRONIC MOTOR OR VOCAL TIC DISORDER

A.

B.

C. D.

E.

DSM-IV Diagnostic Criteria for Chronic Motor or Vocal Tic Disorder Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations), but not both, have been present at some time during the illness. The tics occur many times a day 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. The onset is before age 18 years. 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 postviral encephalitis). Criteria have never been met for Tourette’s disorder.

Epidemiology - 100- 1,000x greater than Tourette’s - high risk: school age boys - prevalence: 1-2% Etiology - aggregate in the same families (hereditary factor) - high concordance in monozygotic twins Course and Prognosis - started between 6-8 years  best outcomes - symptoms usually last for 4-6 yrs and stop in early adolescence - with limbs or trunk tics  do less well than those with only facial tics Treatment 4 of 6

PSYCHIATRY FEEDING AND EATING DISORDERS

- psychotherapy: minimize secondary emotional problems - behavioural techniques: habit reversal joke time muna…..The Jewish and Chinese Pilots A plane leaves Los Angeles airport under the control of a Jewish captain. His copilot is Chinese. It's the first time they've flown together, and an awkward silence between the two seems to indicate a mutual dislike. Once they reach cruising altitude, the Jewish captain activates the auto-pilot, leans back in his seat, and mutters, 'I don't like Chinese.' 'No rike Chinese?' asks the copilot, '....why not?' 'You people bombed Pearl Harbor, that's why !' 'No, no,' the co-pilot protests, 'Chinese not bomb Peahl Hahbah! That Japanese, not Chinese.' 'Japanese, Chinese, Vietnamese... doesn't matter, you're all alike!' There's a few minutes of silence. 'I no rike Jews either!' the copilot suddenly announces. 'Oh yeah, why not?' asks the captain. 'Jews sink Titanic.' 'What? That's insane! Jews didn't sink the Titanic!' exclaims the captain, 'It was an iceberg!' 'Iceberg, Goldberg, Greenberg, Rosenberg ...no mattah... all same.'

TRANSIENT TIC DISORDER

A. B. C. D.

E.

DSM-IV Diagnostic Criteria for Transient Tic Disorder Single or multiple motor and/or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations) The tics occur many times a day, nearly every day for at least 4 weeks, but for no longer than 12 consecutive months. The onset is before age 18 years. 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 postviral encephalitis). Criteria have never been met for Tourette’s disorder or Chronic Motor or Vocal Tic Disorder. Specify if: Single Episode or Recurrent

Epidemiology - common in children - 5-24% school children have history of tics - prevalence: unknown Etiology - either organic or psychogenic or both - organic may lead to Tourette’s - psychogenic most likely remit spontaneously - both: may lead to chronic motor or vocal tic disorder - may be exacerbated by stress and anxiety Course and Prognosis - most do not progress to more serious tic disorder - tics either disappear permanently or recur during periods of special stress Kibbutz 

Treatment - focusing attention may exacerbate tics thus it is recommended that: 1. family disregard the tics as much as possible but if it is severe (impair the patient or accompanied by significant emotional disturbance), complete psychiatric and pediatric neurological examinations are recommended. 2. psychopharmacology is not recommended unless symptoms are severe and disabling - behavioral techniques (habit reversal) may be effective in treating transient tics DSM-IV Diagnostic Criteria for Tic Disorder Not Otherwise Specified This category is for disorders characterized by tics that do not meet criteria for a specific Tic Disorder. Examples include tics lasting less than 4 weeks or tics with an onset after age 18 years. ICD-10 Diagnostic Criteria for Tic Disorders Note: A tic is an involuntary, sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization Transient tic disorders A. Single or multiple motor or vocal tic(s) or both occur many times a day, on most days, over a period of at least 4 weeks. B. Duration of the disorder is 12 months or less. C. There is no history of Tourette’s syndrome, and the disorder is not the result of physical conditions or side effects of medication. D. Onset is before the age of 18 years. Chronic motor or vocal tic disorder A. Motor or vocal tics, but not both, occur many times per day, on most days, over a period of at least 12 months. B. No period of remission during that year lasts longer than 2 months. C. There is no history of Tourette’s syndrome, and the disorder is not the result of physical conditions or side effects of medication. Combined vocal and multiple motor tic disorder [de la Tourette's syndrome] A. Multiple motor tics and one or more vocal tics have been present at some time during the disorder, but not necessarily concurrently. B. The frequency of tics must be many times a day, nearly every day, for more than 1 year, with no period of remission during that year lasting longer than 2 months. C. Onset is before the age of 18 years. Other tic disorders Tic disorder, unspecified A non-recommended residual category for a disorder that fulfills the general criteria for a tic disorder but in which 5 of 6

PSYCHIATRY FEEDING AND EATING DISORDERS

the specific subcategory is not specified or in which the features do not fulfill the criteria for transient tic disorders, chronic motor or vocal tic disorder, combined vocal and multiple motor tic disorder (de la Tourette’s syndrome).

A wedding invitation : Kagaya lng nun sa lecture ni doktora 

enjoy ! 

Kibbutz 

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