DSM-5 Diagnostic Criteria
Encopresis 307.7 (F98.1)
A. Repeated excretion of feces in inappropriate places (e.g., on clothing, on the floor), whether involuntary or voluntary.
B. At least one of these episodes occurs each month for a minimum of three months.
C. Chronological age is at least 4 years (or an equivalent level of development).
D. The behavior cannot be attributed to the physiological effects of a substance (e.g., laxatives) or another medical condition except for a mechanism related to constipation.
Specify if:
With constipation and overflow incontinence:
There is evidence of constipation on physical examination or history.
No constipation and overflow incontinence: There is no evidence of constipation on physical examination or history.
The essential characteristic of encopresis is the repeated passage of feces in inappropriate places (eg, clothing or the floor). In most cases this emission may be involuntary, but sometimes it is intentional. The event must occur at least once a month for at least 3 months, and the child’s chronological age must be at least 4 years. Fecal incontinence cannot be due exclusively to the direct physiological effects of a substance (eg, laxatives) or a medical illness, except by some mechanism involving constipation.
When the emission of feces is more involuntary than intentional, it is usually associated with constipation, wind and retention with the consequent overflow. Constipation may occur for psychological reasons (e.g., anxiety about defecating in a particular location or a more general pattern of anxiety or oppositional behavior), leading to avoidance of defecation. Physiological predispositions to constipation include dehydration associated with a febrile illness, hypothyroidism, or the side effect of medication. Once constipation is established, it can be complicated by an anal fissure, painful defecation, and subsequent fecal retention. The consistency of stool may vary. In some children they are of normal or almost normal consistency. In others they are liquid, specifically when there is overflow incontinence, secondary to fecal retention.
The child with encopresis often feels embarrassed and may want to avoid situations (eg, camp or school) that could cause pregnancy. The significance of the disturbance depends on its effect on the child’s self-esteem, the degree of social ostracism determined by peers, and the anger, punishment, and rejection expressed by caregivers. Smearing with feces can be deliberate or accidental, resulting from the child’s attempt to clean or hide the feces that she involuntarily expelled. When incontinence is clearly deliberate, features of defiant disorder or conduct disorder may be observed. Many children with encopresis also have enuresis.
Encopresis is not diagnosed until a child has reached a chronological age of at least 4 years. Inadequate and inconsistent toilet training and psychosocial stress (eg, starting school or the birth of a sibling) may be predisposing factors.
Treatments
The treatments used in encopresis are medical, psychological and mixed (medical-psychological).
Medical treatment consists of the use of imipramine combined with other treatments. In the case of encopresis due to constipation, enemas or laxatives are used to decongest the colon so that the intestine can return to normal.
Among the psychological approaches, we highlight:
-Reinforcement techniques.
-Techniques to reduce anxiety and phobia of defecation.
-Training and psychoeducation with parents.