09 10 2014 Tic disorders Flashcards
Tic
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.
What are the two types of tics?
- Motor
- simple motor tics (blinking)
-Complex motor tics (more than one muscle
group)
- simple motor tics (blinking)
- Vocal
- Simple vocal tics (sounds)
- Complex vocal tics (words)
Associated symptoms or disorders with tic disorders?
Attention problems Learning difficulties/disabilities Anxiety Obsessions and compulsions Depression Emotional lability Irritability Impulsivity Aggression Disruptive and self-injurious behaviors
Tourette’s Diagnosis criteria
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)
Persistant (chronic) motor or Vocal tic disorder
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.
Prevalence of Tourette’s and related chronic tic disorders
0.5-3%
Generally male to female ratio is > or equal to 2:1
More frequent in caucasian than African American
Genetics of Dic disorders?
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
Tic Characteristics
- 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%
Tourette’s Disease course
- 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.
Environmental Influences
- Sensitivity to array of stimuli exacerbate
- temp changes
- Illness
- Fatigue
- Stress - 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.
Differences found in magnitude of regional brain activation when study compared tourette’s syndrome patients (66) with healthy controls (70)
Lag in TS subjects to deactivate prefrontal and cingulate cortex with increasing age.
Activation increase in other areas
Factors impacting Symptom Severity
-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)
Tourette’s disorder w/o Comorbidity
Comorbidity: the simultaneous presence of two chronic diseases or conditions in a patient
- IQ benefits:
- higher IQ
- fewer learning disabilities
- Athletic advantages
- faster on timed motor tasks
- continue into adulthood
Tourette’s disorder Comorbidity
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
Approach of treatment of patient with ADHD and Tourette’s Syndrome
use stimulant medication to decrease ADHD. Stress and tics are gone for a period of time.
TS treatment
- 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
- tics severity will general decrease
- Educational interventions
- Encourage participation in extra-curricular activities
- Psychotherapy can improve family strain, social coping, self-esteem, school adjustment.
Tic Disorder treatment
- Education interventions
- Behavioral and cognitive therapies
- Habit reversal training – mirror to see tic
- Cognitive Behavioral Therapy
- Exposure and response prevention
- Anger management training
- Parent training
- Medication
Medication
- Alpha-adrenergic agents
- Clonidine, guanfacine
- Neuroleptics – typicals
- Haloperidol, pimozide
- Neuroleptics– atypicas
- Risperidone, ziprasidone, olanzapine, aripirazole.
ADHD as a diagnosis:
- 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
Attention-Deficit/ Hyperactivity Disorder (ADHD)
- 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
ADHD–Inattention
- 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
ADHD- Hyperactivity/ Impulsiveness
- 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)
Executive functions
- Activation– organizing/prioritizing and activating work
- Focus
- Effort
- Emotion– impulsiveness
- Memory
- Action – monitoring and self-regulating action– impulsiveness
Basal Ganglia and ADHD?
Basal ganglia development is delayed in ADHD
- progressive, atypical contraction of the ventral stratal surfaces
- reward processing regions
- non-progressive fixed contraction of dorsal stratal surfaces localized to executive function and motor planning supported regions
ADHD group on psychostimulants vs. unmedicated
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
Other organs which have a different shape in ADHD vs. general population
- Thalamus
- medication helped alter shape –>normal
-thinning of cerebral cortex!
When to think of ADHD– Child who has:
- Problems paying attention
- Problems with increased activity/impulsive
- Duration, Dysfunction, Differential diagnosis
Screening tools for ADHD
- Conners Scales
- Swanson, NOlan and Pelham-IV (SNAP-IV)*
- Vanderbilt scales*
*– DSM-5 revised 10 item modification
Medical disorders presenting with ADHD symptoms
- Sleep Apnea
- Diabetes
- Thyroid – Hyper, resistance to TH with ADHD
- Elevated lead levels
- Neurological diseases
- Seizure disorder
- Tumor and unusal syndromes
ADHD Course
- 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.
ADHD management
- Biopsychosocial approach
- Medication
- Psychological factors : learning ability, cognitive distortions, social skills and self-control strategies
- Social factors in home and school/
