48 Assessment Methods and Techniques: Elimination Disorders

Source of information about DSM diagnoses: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.

overview

Elimination disorders are characterized by inappropriate elimination of urine or feces, typically diagnosed during childhood or adolescence. These behaviors are developmentally inappropriate and may be voluntary or involuntary. This category of disorders encompasses enuresis, which involves urinating in unsuitable places repeatedly, and encopresis, which refers to the repeated passing of stool in inappropriate locations.

Important Features:

• Diagnosis is based on developmental level, not just chronological age.

• Disorders may appear independently or co-occur.

• Often associated with psychosocial stressors or developmental delays.

• Rule out medical conditions (e.g., urinary tract infections, neurological issues) before diagnosing.

enuresis

Enuresis is characterized by repeated urination into bed or clothing, whether during the day (diurnal) or at night (nocturnal). Although most episodes are involuntary, some may be intentional.

Associated Features:

• Nocturnal Enuresis:

  • May occur during REM sleep, sometimes accompanied by dreams about urination.

• Diurnal Enuresis:

  • Often involves postponing urination due to factors like social anxiety, school-related distraction, or preoccupation with play.

  • More common in the early afternoon, especially on school days or shortly after returning home.

• Neurodevelopmental Correlates:

  • Children with executive functioning difficulties or neurological issues may be at higher risk.

  • Some cases persist even after infections are treated, particularly in mixed (diurnal and nocturnal) subtypes.

Criteria:

A. There is a repeated pattern of urinating in inappropriate places, such as in bed or clothing. This can happen either involuntarily or on purpose.
B. The behavior is considered clinically important if it happens at least twice a week for three months in a row, or if it leads to noticeable distress or problems in social life, school/work performance, or other key areas of functioning.
C. The individual is at least 5 years old or has reached a comparable developmental level.
D. The issue cannot be explained by the effects of medications (e.g., diuretics, antipsychotics) or medical conditions like diabetes, neurological disorders, or congenital abnormalities.

Subtypes:

• Nocturnal only: Urination occurs exclusively during sleep at night.

• Diurnal only: Urination happens only during waking hours.

• Nocturnal and Diurnal: Urination occurs both during the night and the day.

encopresis

Encopresis involves the repeated passing of stool in inappropriate places, such as in clothing or on the floor. While these episodes are usually involuntary, they can occasionally be intentional.

Associated Features:

• Emotional and Social Impact:

  • Children may experience shame, low self-esteem, and avoidance of social settings (like school or camp).

  • Parental reactions may involve anger, punishment, or rejection, which can intensify the child’s distress.

• Smearing of feces may be either accidental (in attempts to hide or clean up) or intentional.

• When defecation is clearly deliberate, this may suggest oppositional defiant disorder or conduct disorder.

• Encopresis often co-occurs with enuresis and may lead to urinary complications such as infections or reflux, especially when constipation is untreated.

Criteria:

A. The child repeatedly passes stool in places that are not appropriate, such as in clothing or on the floor. These incidents may happen unintentionally or deliberately.
B. This behavior must occur at least once a month for a period of three months or longer.
C. The child must be at least 4 years old, or have a developmental level equivalent to that age.
D. The behavior is not due to the effects of substances (like laxatives) or a medical condition, unless the medical issue contributes to the problem through constipation.

Subtypes:

• With constipation and overflow incontinence: Signs of constipation are found either through medical history or physical examination.
• Without constipation and overflow incontinence: No evidence of constipation is found on exam or in the child’s history.

other specified elimination disorder

Other specified elimination disorder refers to conditions where problems with elimination (such as urination or defecation) cause significant distress or difficulties in important areas of life, like social relationships, work, or daily activities, but the symptoms do not fully match the criteria for any specific elimination disorder diagnosis. This category is used when the clinician wants to explain why the individual’s symptoms do not fit into a specific disorder. In such cases, the diagnosis is labeled “other specified elimination disorder,” along with a brief description of the reason (for example, “low-frequency enuresis”).

unspecified elimination disorder

This diagnosis is used when a person shows symptoms related to elimination that cause significant distress or problems in important areas of life, such as social relationships, work, or daily activities, but the symptoms do not fully match any specific elimination disorder. This category is chosen when the clinician decides not to explain why the full criteria for a specific disorder are not met. It can also be used when there is not enough information available to make a more precise diagnosis, such as in emergency situations.

Self-check