Incidence of obsessive-compulsive disorder in children with nonmonosymptomatic primary nocturnal enuresis.

INTRODUCTION: Enuresis is defined as the repeated voiding of urine into clothes or bed at least twice a week for at least 3 consecutive months in a child who is at least 5 years of age. The behavior is not due exclusively to the direct physiologic effect of a substance or a general medical condition. Diurnal enuresis defines wetting, whereas awake and nocturnal enuresis refers to voiding during sleep. Primary enuresis occurs in children who have never been consistently dry through the night, whereas secondary enuresis refers the resumption of wetting after at least 6 months of dryness. Monosymptomatic enuresis has no associated daytime symptoms, and nonmonosymptomatic enuresis, which is more common, often has at least one subtle daytime symptom. Monosymptomatic enuresis is rarely associated with significant organic underlying abnormalities. Obsessive-compulsive disorder (OCD) is a chronic disabling illness characterized by repetitive, ritualistic behaviors over which the patients have little or no control. The purpose of this study was to investigate the relationship between OCD and nonmonosymptomatic nocturnal enuresis (NMNE).
MATERIALS AND METHODS: In this case-control study, we evaluated 186 children aged 6-17 years old who were visited in the pediatric clinics of Amir Kabir Hospital, Arak, Iran. The control group included 93 healthy children, and the case group included 93 age- and sex-matched children with stage 1-3 chronic kidney disease (CKD). Then, the children's behavioral status was evaluated using the Children's Yale-Brown Obsessive-Compulsive Scale.
RESULTS: The difference in compulsion was significant (P = 0.021), whereas the difference in obsession was significant between the two groups (P = 0.013). The most common symptom in CKD children with compulsion was silent repetition of words.
CONCLUSION: Compulsive and obsessive are more common in NMNE versus healthy children. The observed correlation between compulsive-obsessive and NMNE makes psychological counseling mandatory in children with NMNE.

Introduction

Obsessive–compulsive disorder (OCD) is characterized by obsessions, compulsions, or both. The most common obsessions are fears of contamination, repeated doubts, need for orderliness, aggressive or horrific impulses, and sexual imagery.[1] The most common compulsions are hand washing, ordering, checking, requesting or demanding reassurance, praying, counting, repeating words silently, and hoarding.[2] Compulsions predominate in children, who often do not complain about the symptoms because they frequently have less insight than adults.[3] In some cases, children show some voluntary control or may hide the symptoms, which may shift over time.[4] Prevalence of OCD in children and adolescents ranges from 1 to 4%, increasing with age. Nearly, 80% of adults with OCD had symptoms in childhood.[5] OCD is more common in boys at a younger age and in girls during adolescence. Family studies reflect a genetic component in OCD, with monozygotic twins affected more commonly than dizygotic twins.[6] By 5 years of age, 90–95% of children are nearly completely continent during the day, and 80–85% are continent at night. Nocturnal enuresis refers to the occurrence of involuntary voiding at night after 5 years, the age when volitional control of micturition is expected.[7] Enuresis may be primary (estimated 75–90% of children with enuresis; nocturnal urinary control never achieved) or secondary (10–25%; the child was dry at night for at least a few months and then enuresis developed). In addition, 75% of children with enuresis are wet only at night, and 25% are incontinent day and night. This distinction is important because children with both forms are more likely to have an abnormality of the urinary tract.[8] Approximately, 60% of children with nocturnal enuresis are boys. Family history is positive in 50% of cases.[9] Although primary nocturnal enuresis may be polygenetic, candidate genes have been localized to chromosomes 12 and 13. If one parent was enuretic, each child has a 44% risk of enuresis; if both parents were enuretic, each child has a 77% likelihood of enuresis. Nocturnal enuresis without overt daytime voiding symptoms affects up to 20% of children at the age of 5 years; it ceases spontaneously in approximately 15% of involved children every year thereafter.[10] Its frequency among adults is <1%.[11] Regarding the prevalence of nonmonosymptomatic enuresis (NMSE) and OCD in children and importance of relationship between nonmonosymptomatic primary nocturnal enuresis and psychiatric disorders and relationship between OCD and chronic diseases in childhood, the hypothesis concerning the relationship between NMSE and OCD in children was discussed. As no study has been conducted on the relationship between NMSE and OCD in children, the aim of this study was to investigate OCD in children with NMSE and compare it with healthy children.

Materials and Methods

In this case–control study, we selected 125 children with NMSE as the case group and 125 healthy children as the control group, who were all visited in Amir Kabir Hospital, Arak, Iran. The Ethics Committee approved the study. Our exclusion criteria were: (1) Children with psychological disorders and/or mental retardation or nervous system disorders, (2) children whose parents did not fully cooperate, for example, did not fill the forms completely or wished to withdraw from the study. The control group was selected from normal pediatric. After primary evaluation regarding exclusion/inclusion criteria, basic information (age, sex, etc.) was recorded. Then, the children's behavioral status was evaluated using the Children's Yale-Brown Obsessive–Compulsive Scale (C-YBOCS) and Anxiety Disorders Interview Schedule for Children (ADIS-C) which are reliable and valid methods for identifying children with OCD. These questionnaires were tested for reliability in a pilot study by the researchers with 30 patients in each of the case and control groups, and the Cronbach's alpha was 0.89 for C-YBOCS and 0.92 for ADIS-C. The results were analyzed with SPSS version 17 (IBM Corp., NY, US) using descriptive statistics for basic information. P < 0.05 was considered statistically significant.

Results

Overall, 250 children (125 cases and 125 controls) were selected for our study during 2 years. In this study, males comprised 43.3% of the population of whom 49.2% were in the case group and 50.8% were in the control group. Furthermore, females comprised 56.7% of the population of whom 36.9% were in the case group and 63.1% were in the control group. The two groups were matched with no significant difference. On the other hand, 69.3% of the study population lived in urban areas of whom 72.2% were in the case group, and 82.7% were in the control group. Moreover, 30.7% lived in rural areas of whom 27.8% were in the case group, and 17.3% were in the control group. The two groups were matched with no significant difference. The mean age of children in the case and control group was 8.32 ± 2.28 and 7.12 ± 2.11 years, respectively (P = 0.32). There were 58 (62.4%) boys and 35 (37.6%) girls in the case group and 49 (52.6%) boys and 44 (47.4%) girls in the control group (P = 0.38). Compulsive (requesting or demanding reassurance and repeating words silently was the most common symptom) was detected in 21 (33.3%) cases and 7 (7.5%) controls (P = 0.012). Obsession (the fears of contamination was the most common symptom) was detected in 16 (12.2%) cases and 4 (4.3%) controls (P = 0.013).

Discussion

In this article, we compared OCD in children with and without NMSE. To the best our knowledge, it is the first study of OCD in children with NMSE. The data revealed that the incidence of obsessive was fourth time and compulsive was three times higher in NMSE compared to healthy children. Fonseca has reported a high prevalence of lower urinary tract symptoms in children with nocturia, the association of nocturia and one more symptom was usual. In children without nocturia, the symptoms were associated with nocturia, suggesting decreased bladder capacity with an excitatory reaction.[9] Compulsion is more common in chronic kidney disease (CKD) versus non-CKD children. The observed correlation between compulsion and CKD makes psychological counseling mandatory in children with CKD.[6] Considering the results of this study, the higher prevalence of behavioral problems in children with MPNE highlights the importance of early intervention for better treatment and prevention of behavioral problem in children.[7] Child health-care professionals should routinely screen for enuresis and its effects on the emotional health of the child and the family. Assessment of attention-deficit hyperactivity disorder (ADHD) should routinely include evaluation for enuresis and vice versa. Research on the explanations for the association between enuresis and ADHD is indicated.[9] Enuresis is significantly associated with ADHD and conduct disorder, so these conditions must be assessed together during the evaluation of children with enuresis.[10] Children with ADHD are more likely than their peers without ADHD to develop enuresis with a similar trend for encopresis.[11]

Conclusion

Enuresis is a common condition among children in the Iran. Child health-care professionals should routinely screen for enuresis and its effects on the emotional health of the child and the family. Assessment of OCD should routinely include evaluation for enuresis. Research on the explanations for the association between enuresis and OCD is indicated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.