Encopresis DSM-5 307.7 (F98.1)

Introduction

Encopresis is essentially a repeated passage of feces into inappropriate places, such as on clothing or the floor. While typically the passage is involuntary in nature, it can be intentional in some cases. If the passage is involuntary, it is often related to constipation, impaction and retention with a resultant overflow (Klyko & Kay 2012).

Encopresis Symptoms

There are a number of key symptoms to keep in mind in the diagnosis of encopresis. Included in this list are the following

• Occasional passage of very large stools;
• Secretive behavior associated with the act of having a bowel movement;
• Inability to retain feces (bowel incontinence);
• The passage of stool in inappropriate places (for example in the child’s clothing);
• Constipation and/or hard stools (MedlinePlus 2012).

Diagnostic Criteria

According to DSM-5, there are 4 features that must be present to support a diagnosis of encopresis:

1. Patient’s chronological age must be at least 4 years;
2. A repeated passage of feces into inappropriate places, e.g., clothing or floor. This can be either intentional or involuntary;
3. At least one such event must occur every month for at least 3 months;
4. The behavior is not attributable to the effects of a substance, e.g., laxative, or another medical condition, with the exception of a mechanism involving constipation.

In making the diagnosis, it is critical that the clinician, specify which of the following is present:

• With constipation and overflow incontinence: through physical examination or medical history, there is evidence of constipation.
• Without constipation and overflow incontinence: through physical examination or medical history, there is no evidence of constipation (American Psychiatric Association, 2013).

Whenever possible, a parent should complete an encopresis frequency calendar to help clarify the frequency of and any associated symptoms. As part of the history, it is critical to assess the mental status. For example, “what is the child’s level of distress concerning encopresis?” In order to make a definitive diagnosis, a complete medical examination must be conducted. Features of this exam must include: gait abnormalities; general strength; reflexes, coordination, abdomen for presence of stool masses/discomfort and rectal examination for tone and presence of impaction. Lastly, some laboratory assessments as well as imaging modalities may be required (Klyko & Kay 2012).

Prevalence, Development and Course of Disease

It is estimated that about 1% of 5-year olds have encopresis, and that the disorder is more commonly observed in males than in females. It cannot be properly diagnosed until a mental age of four years is reached. If inadequate, inconsistent toilet training is employed, or psychosocial stresses are encountered, children may be at higher risk of developing encopresis. Primary encopresis is observed when an individual has never established fecal continence, while secondary encopresis is a type of disturbance that develops after a period of established fecal continence. In either case, encopresis can persist for many years (American Psychiatric Association, 2013).

In some cases, encopresis can be volitional in nature. Children presenting with oppositional defiant disorder and/or conduct disorder may use inappropriate soiling as a form of retaliation or as a way to demonstrate the anger that they feel towards their parents and other authority figures. Further, while not common in older children, younger children or infants may find it interesting to play with or smear their feces, if given the opportunity. Children who do engage in this practice may have further psychiatric issues that should be explored. In other cases, fecal smearing may result when an embarrassed child attempts to hide or clean up feces that were involuntarily passed. Due to the variability of causes leading to this activity, a full investigation and psychological work up may be warranted (Klyko & Kay 2012).

Risk Factors

Although every case is different, a number of risk factors are known to be associated with the development of encopresis. Examples include:

• Abuse or neglect;
• Diet that is rich in fat and/or sugar;
• Inadequate water intake;
• Presence of chaos or unpredictability in the patient’s life;
• Lack of physical exercise;
• Refusal to use the bathroom, especially public restrooms;
• Presence of a neurological impairment;
• History of constipation or painful defecation;
• Cognitive delays, such as autism or mental retardation;
• Presence of obsessive/compulsive disorders;
• ADHD or difficulty focusing;
• Learning disabilities (Cohen 2011).

Treatment

Punishment is not typically effective, and usually increases, rather than decreases the frequency of soiling. A more effective approach is to try and help the child better understand the problem and helping to maintain regular bathroom routines. Enhancements in diet and exercise are often useful, and some children may benefit from developing a method of tracking their successes (Cohen 2011).

A recent review of the literature examined systemic psychological interventions for families of children and adolescents with a variety of difficulties, to include conduct problems, emotional problems, eating disorders and somatic problems, to include encopresis. Interventions studied included family therapy as well as other family-based methods such as parental training. The evidence discovered demonstrated the potential effectiveness of such approaches (Carr 2014).

In many cases, encopresis may be the result of anxiety. Even if it is not, the presence of this disorder can often lead to anxiety. In many cases, a warm bath may calm the child, and the value of routine cannot be overlooked. As such, routine bathroom times are recommended. If there are comorbid mental health disorders (anxiety, depression, etc), these disorders must be addressed. Encopretic children with comorbid mental health issues often have poorer outcomes in toilet training. Cognitive Behavioral Therapy and psychotherapy can help decrease the symptoms of anxiety and/or depression associated with encopresis. Biofeedback may also be useful in teaching the child enhanced sphincter control. In many cases the combination of biofeedback with other treatment modalities can have additional benefits (Klyko & Kay 2012).

Although behavior modification appears to be the mainstay for therapy, the literature does contain a case report describing the success of sertraline in the treatment of encopresis in a 11 year old girl also afflicted with ADHD (Gupta 2010). Less aggressive pharmacological approaches might include the use of fiber supplements, stool softeners, osmotic or stimulant laxatives (Klyko & Kay 2012).

No matter which treatment modality is chosen (dietary changes, behavioral strategies, biofeedback, psychotherapy or medications), it remains a fact that if the bowel is kept empty, soiling cannot occur. As a result, all efforts should be focused on achieving between one to three bowel movements per day (Klyko & Kay 2012).

References

American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders (5^th ed.). Arlington, VA: American Psychiatric Publishing.

Carr, A. 2014. The evidence base for family therapy and systemic interventions for child-focused problems. Journal of Family Therapy, DOI: 10.1111/1467-6427.12032

Cohen, D.P. 2011. Encopresis: A medical and family approach. Pediatric Nursing, 37, 107-112.

Klyko, W.M. & Kay, J. (Ed.). 2012. Clinical Child Psychiatry. (3^rd Ed.) Oxford, UK. Wiley Blackwell.

Medhekar, D. & Gupta, N. 2010. Use of sertraline in childhood retentive encopresis. The Annals of Pharmacotherapy, 44, 395. doi: 10.1345/aph.1M280

U.S. National Library of Medicine, MedlinePlus (2012). Encoporesis. nlm.nih.gov. Retrieved 24 February 2014 from http://www.nlm.nih.gov/medlineplus/ency/article/001570.htm