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Neurology 1- M2 > 09 10 2014 Tic disorders > Flashcards

09 10 2014 Tic disorders Flashcards

1
Q

Tic

A

sudden, rapid, recurrent, non-rhythimc sterotypes motor movement OR vocalization causing distress or significant impairment

-invluntary or response to irresistible urge

Onset: before the age of 18.

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2
Q

What are the two types of tics?

A
  1. Motor
    • simple motor tics (blinking)
      -Complex motor tics (more than one muscle
      group)
  2. Vocal
    • Simple vocal tics (sounds)
    • Complex vocal tics (words)
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3
Q

Associated symptoms or disorders with tic disorders?

A 
Attention problems
Learning difficulties/disabilities
Anxiety
Obsessions and compulsions
Depression
Emotional lability
Irritability
Impulsivity
Aggression
Disruptive and self-injurious behaviors
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4
Q

Tourette’s Diagnosis criteria

A

Multiple motor AND one or more vocal tics present some time during the illness

Wax and wane – Not necessarily concurrent (happening at same time)

Occur several times/day over > 1 year since tic onset.

Onset before age of 18

Not due to physiologic effects of a substance (e.g. cocaine) or medical condition (e.g. Huntington’s or post viral encephalitis)

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5
Q

Persistant (chronic) motor or Vocal tic disorder

A

Single or multiple motor OR vocal tics present some time during the illness.

wax and wane – not necessarily concurrent (happening at same time).

Onset before the age of 18

Not due to physiologic effects of a substance OR condition

Tourette disorder criteria were never met.

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6
Q

Prevalence of Tourette’s and related chronic tic disorders

A

0.5-3%

Generally male to female ratio is > or equal to 2:1

More frequent in caucasian than African American

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7
Q

Genetics of Dic disorders?

A

Autosomal dominant

  • 1st degree relatives of those with TD have an 10-100x increased risk of getting it.
  • 94% chance for monozygotic twins to have concordance
  • Dizygotic twins 23% concordance for CTD
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8
Q

Tic Characteristics

A
  • Antecedent sensory feeling – itch to scratch
  • Often irresistible
  • sometimes painful or source of mental impairment
  • possible sensory cues prompt particular tic (e.g. grunt, throat clearing)
  • Coprolalia (involuntary swearing) in 10%
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9
Q

Tourette’s Disease course

A
  • tics decrease in intensity through adolescence and may be gone in adulthood.
  • Tic anatomic location, frequency, and severity can and usually do change over time.
  • Severity worse between 9-12 yrs
  • Often see hyperactive behavior from age 3 or more years
  • Simple motor tics of eyes, face, and head… followed by neck and shoulders… then arms and hands, then by age 6 – tics in trunks and legs.
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10
Q

Environmental Influences

A
  1. Sensitivity to array of stimuli exacerbate
    - temp changes
    - Illness
    - Fatigue
    - Stress
  2. PANDAS (Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection)
    - Group A Beta hemolytic Streptococcus (GABHS) preceded tics in 44% of children with symptoms
    - few had antibodies to GABHS
    - associated with wide range of other disorders.
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11
Q

Differences found in magnitude of regional brain activation when study compared tourette’s syndrome patients (66) with healthy controls (70)

A

Lag in TS subjects to deactivate prefrontal and cingulate cortex with increasing age.

Activation increase in other areas

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12
Q

Factors impacting Symptom Severity

A

-psychological stress

  • Infections disease
    • PANDAS, lyme, mycoplasma pneumonia
    • noninfections immunologic response
  • Deficits in procedural learning, fine motor control, visual motor integration and motor inhibition.
  • Inability of basal ganglia to suppress motor neural areas that initiate tics
  • Abnormal dopamine modulation (though not 100% sure about this yet)
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13
Q

Tourette’s disorder w/o Comorbidity

Comorbidity: the simultaneous presence of two chronic diseases or conditions in a patient

A
  1. IQ benefits:
    • higher IQ
    • fewer learning disabilities
  2. Athletic advantages
    • faster on timed motor tasks
    • continue into adulthood
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14
Q

Tourette’s disorder Comorbidity

A

Overlap with:

  • ADHD
  • Oppositional defiant disorder
  • OCD
  • Major depression and Dysthymic disorder
  • Anxiety disorders
  • Learning disorders
  • Sensory integraiton (processing) disorder

Treatment must consider comorbid disorders

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15
Q

Approach of treatment of patient with ADHD and Tourette’s Syndrome

A

use stimulant medication to decrease ADHD. Stress and tics are gone for a period of time.

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16
Q

TS treatment

A
  1. Basis for instituting treatment
    -treat comorbid conditions first
    • tics severity will general decrease
      -Can often manage without using medication
    • Family sometimes hurting more than the
      patient.
      -Waxing and waning occurs
  2. Educational interventions
  3. Encourage participation in extra-curricular activities
  4. Psychotherapy can improve family strain, social coping, self-esteem, school adjustment.
17
Q

Tic Disorder treatment

A
  1. Education interventions
  2. Behavioral and cognitive therapies
    • Habit reversal training – mirror to see tic
    • Cognitive Behavioral Therapy
      - Exposure and response prevention
      - Anger management training
      - Parent training
  3. Medication
18
Q

Medication

A
  1. Alpha-adrenergic agents
    • Clonidine, guanfacine
  2. Neuroleptics – typicals
    • Haloperidol, pimozide
  3. Neuroleptics– atypicas
    • Risperidone, ziprasidone, olanzapine, aripirazole.
19
Q

ADHD as a diagnosis:

A
  • Spectrum of symptoms
  • found across many psychologic disorders/medical diseases.
  • Complex genetic disorder resulting from combined effects of several polygenic genes
    • starts in the womb
  • Diagnosis by applying validated criteria
    • well established biological correlates
20
Q

Attention-Deficit/ Hyperactivity Disorder (ADHD)

A
  • Inattention (6 or more symptoms for 6 or more months) and/or Hyperactivity- Impulsiveness (6 or more symptoms for 6 or more months).
  • Symptoms > server than normally seen for comparable developmental level.
  • 5 symptoms in either or both for those 17 or older.
  • Symptoms negatively impact social and academic/occupational activities
  • Several symptoms of inattentive and or hyperactive impulse inattentive behavior have been present before age 12 years AND AT LEAST 2 settings.

** must cause impairment

21
Q

ADHD–Inattention

A
  • Makes careless mistakes
  • Difficulty sustaining attention
  • Doesn’t seem to listen when directly spoken to
  • Fails to finish things
  • Difficulty organizing activités and tacts
  • Avoids tasks requiring sustained mental effort
22
Q

ADHD- Hyperactivity/ Impulsiveness

A
  • Fidgets or squirms
  • leaves seat when should be seated
  • Inappropriately runs around or climbs excessively (restlessness in older teens and adults)
  • Difficulty playing quietly
  • On the go, acts as if driven by a motor
  • Talks excessively
  • blurts out an answer
  • Difficulty waiting for turn
  • Intrudes or interrupts others (games or conversations)
23
Q

Executive functions

A
  1. Activation– organizing/prioritizing and activating work
  2. Focus
  3. Effort
  4. Emotion– impulsiveness
  5. Memory
  6. Action – monitoring and self-regulating action– impulsiveness
24
Q

Basal Ganglia and ADHD?

A

Basal ganglia development is delayed in ADHD

  1. progressive, atypical contraction of the ventral stratal surfaces
    • reward processing regions
  2. non-progressive fixed contraction of dorsal stratal surfaces localized to executive function and motor planning supported regions
25
Q

ADHD group on psychostimulants vs. unmedicated

A

Medicated ADHD had no significant difference on basal ganglia shape when compared to controls

Unmedicated showed inward deofmraiton of Putamen. This drived the finding of ADHD

26
Q

Other organs which have a different shape in ADHD vs. general population

A
  • Thalamus
  • medication helped alter shape –>normal

-thinning of cerebral cortex!

27
Q

When to think of ADHD– Child who has:

A
  1. Problems paying attention
  2. Problems with increased activity/impulsive
  3. Duration, Dysfunction, Differential diagnosis
28
Q

Screening tools for ADHD

A
  • Conners Scales
  • Swanson, NOlan and Pelham-IV (SNAP-IV)*
  • Vanderbilt scales*

*– DSM-5 revised 10 item modification

29
Q

Medical disorders presenting with ADHD symptoms

A
  1. Sleep Apnea
  2. Diabetes
  3. Thyroid – Hyper, resistance to TH with ADHD
  4. Elevated lead levels
  5. Neurological diseases
    • Seizure disorder
    • Tumor and unusal syndromes
30
Q

ADHD Course

A
  • Deficit areas persist into adulthood
  • less educational achievement
  • Problems with social skills
  • lower occupational status
  • Risk developing antisocial personality
  • mixed results about continuity of ADHD diagnosis into adulthood.
31
Q

ADHD management

A
  • Biopsychosocial approach
  • Medication
  • Psychological factors : learning ability, cognitive distortions, social skills and self-control strategies
  • Social factors in home and school/

Neurology 1- M2 (22 decks)

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