ity of the tics change over time, and the person expe-
riences almost all the possible tics described above
during his or her lifetime. The person has significant
impairment in academic, social, or occupational areas
and feels ashamed and self-conscious. This rare dis-
order (4 or 5 in 10,000) is more common in boys and
usually identified by 7 years of age. Some people have
lifelong problems; others have no symptoms after
early adulthood (APA, 2000).CHRONIC MOTOR OR TIC DISORDER
Chronic motor or vocal tic differs from Tourette’s dis-
order in that either the motor or the vocal tic is seen,
but not both types. Transient tic disorder may in-
volve single or multiple vocal or motor tics, but for no
longer than 12 months.◗ ELIMINATIONDISORDERS
Encopresisis the repeated passage of feces into in-
appropriate places, such as clothing or the floor, by a
child who is at least 4 years of age either chronologi-
cally or developmentally. It is often involuntary, but
it can be intentional. Involuntary encopresis usually
is associated with constipation that occurs for psycho-
logical, not medical, reasons. Intentional encopresis
often is associated with oppositional defiant disorder
or conduct disorder.
Enuresisis the repeated voiding of urine during
the day or at night into clothing or bed by a child at
least 5 years of age either chronologically or develop-
mentally. Most often enuresis is involuntary; when
intentional, it is associated with a disruptive behav-
ior disorder. Seventy-five percent of children with
enuresis have a first-degree relative who had the dis-
order. Most children with enuresis do not have a co-
existing mental disorder.
Both encopresis and enuresis are more common
in boys than in girls; 1% of all 5 year olds have enco-
presis and 5% of all 5 year olds have enuresis. Enco-
presis can persist with intermittent exacerbations for
years; it is rarely chronic. Most children with enure-
sis are continent by adolescence; only 1% of all cases
persist into adulthood.
Impairment associated with elimination dis-
orders depends on the limitations on the child’s social
activities, effects on self-esteem, degree of social os-
tracism by peers, and anger, punishment, and rejec-
tion on the part of parents or caregivers (APA, 2000).
Enuresis can be treated effectively with imipra-
mine (Tofranil), an antidepressant with a side effect
of urinary retention. Both elimination disorders re-
spond to behavioral approaches, such as a pad with a
warning bell, and to positive reinforcement for conti-
nence. For children with a disruptive behavior dis-504 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERSStress exacerbates tics, which diminish during sleep
and when the person is engaged in an absorbing ac-
tivity. Common simple motor tics include blinking,
jerking the neck, shrugging the shoulders, grimac-
ing, and coughing. Common simple vocal tics include
clearing the throat, grunting, sniffing, snorting, and
barking. Complex vocal tics include repeating words
or phrases out of context, coprolalia (use of socially
unacceptable words, frequently obscene), palilalia
(repeating one’s own sounds or words), and echolalia
(repeating the last-heard sound word or phrase)
(APA, 2000). Complex motor tics include facial ges-
tures, jumping, or touching or smelling an object.
Tic disorders tend to run in families. Abnormal
transmission of the neurotransmitter dopamine is
thought to play a part in tic disorders (McCracken,
2000 b). Tic disorders usually are treated with risperi-
done (Risperdal) or olanzapine (Zyprexa), which are
atypical antipsychotics. It is important for clients
with tic disorders to get plenty of rest and to manage
stress, because fatigue and stress increase symptoms.
TOURETTE’S DISORDER
Tourette’s disorderinvolves multiple motor tics
and one or more vocal tics, which occur many times a
day for more than 1 year. The complexity and sever-Oppositional–defiant disorder