Session Ten (Tics and Tourettes) Flashcards
What are tics?
- Involuntary, abrupt, movements or sounds that occur individually or in bouts
- Involuntary, though can be suppressed
- Suggestible
- Range from simple to complex
- Normally preceded by a “premonitory urge”
What is Tourette’s?
- Tourettes is a neuro-developmental disorder with onset in childhood, characterised by multiple motor tics and at least one vocal (phonic) tic.
- These tics characteristically wax and wane
- Largely neuro-developmental in nature but has a significant psychiatric component as well.
Give some examples of Motor Tics (both simple and complex)?
Simple:
- Eye blinking
- Eye movements
- Nose movements
- Mouth movements
- Facial grimaces
- Head jerks
- Shoulder shrugs
- Arm movements
- Hand movements
- Leg/Toe movements
Complex:
- Touching
- Tapping
- Dystonic or Abnormal posture
- Squatting
- Jumping
- Copropraxia (obscene gestures)
- Self-abusive behaviour
Give some examples of phonics tics (complex and simple)?
Simple = mostly sounds and noises:
- Throat clearing
- Sniffing
- Animal noises
Complex = closer to words:
- Syllables
- Words
- Coprolalia (obscene words)
- Echolalia (repeating others words)
- Palilalia (repeating your own words)
What is the difference between Tourette’s and Chronic Tic Disorder?
Tourettes by definition involves multiple motor tics and at least one vocal tic.
CTD can involve just one form, wither as Chronic Motor Tic Disorder or Chronic Vocal Tic Disorder.
(N.B. there also exists a form that lasts less than 1 year, Transient or Provisional Tic Disorder)
Who tends to be affected by tic disorders?
Boys more often than girls.
Mean age of onset is about 5-6.
What exacerbates and lessens tics?
Exacerbated by anxiety, stress, fatigue.
Lessened by mental distraction and attention.
What is the standard progression of tic disorders from diagnosis?
- Diagnosis at age 3-8
- Waxes and waning course from there
- Peaking at around age 10-13
- Remit independent of treatment in late adolescence and early adulthood (for majority of people)
How frequently do tics persist into adulthood?
Reasonably. Of 82 children with significant childhood tic symptoms:
- 37% showed no adult tics
- 18% minimal tics
- 26% showed mild tics
- 19% maintained severe tics
So actually quite a varied picture.
What do tic disorders in adults look like?
- Facial and truncal tics are more common
- Phonic and extremely tics tend to be less common
- Higher chance of having a mood disorder
- Higher risk of substance abuse
(therefore, severe impact on overall health)
What are Echophenomena?
- Echophenomena are automatic imitative actions without explicit awareness or pathological repetitions of external stimuli or activities, actions, sounds, or phrases, indicative of an underlying disorder.
- Seen commonly in tic disorders but also in autism, Sz catatonia, aphasia, epilepsy and dementia
Give 3 common examples of echophenomena?
- Echolalia (repetition of another person’s spoken words)
- Echopraxia (repetition or imitation of another person’s actions)
- Palilalia (involuntary repetition of words, phrases or sentences)
All are reasonably common in tic disorders.
What are some consequences of tic severity?
- Reduced QoL
- Overall impairment in school
- Difficulties with social functioning
- Day to day problems with emotional control
What are some common co-morbidities with Tic Disorders?
- ADHD (very high, over 50%)
- OCD (30-80%)
- Mood disorders
- Anxiety
- Learning disabilities
- ASD
- Aggression
- Impulse Control Disorders
- Suicidal ideation
Why is the overlap between tics and ADHD important?
- 40-90% of child population with TS have ASDH
- ADHD typically precedes onset of tics
- Causes greater stress and poorer overall functioning
- Not associated with increased tic severity
- Causes sleep onset problems
What are Rage Attacks?
- Sudden, explosive episodes of rage
- Out of any proportion with trigger that caused them
- Patient is difficult to calm down
- Rage Attacks increase in frequency with the onset of tic behaviour
- Persists into adolescence and adulthood
- Not related to tic severity
- More commonly seen in individuals with tics and a co-morbidity (e.g. ADHD or OCD)
- Unclear whether caused by TD, TD-Co-M interaction or totally independent
What was the purpose of the 2012 ADHD TACT study?
- Treatment of ADHD in Children with Tics
- Sought to investigate how we should treat ADHD in kids with tourettes
- Long been a concern that treating the hyperactivity symptoms might worsen tic symptoms
Findings:
- MPH did not worsen tics
- Clonidine was effective at treating hyperactivity symptoms
- Outcome measures were best w/ combination
Conclusion: Stimulants should not be avoided due to concerns about worsening tics
What is the link between Tics and OCD?
- 30-50% co-occurence
- Emerges after the onset of tics
- Associated with increased tic severity
- People with both measure higher on measures of psychopathology (e.g. depression, anxiety, psychosocial stress, global functioning)
What is the difference between the Compulsions seen in OCD and the Tics seen in TD?
- Compulsions are performed to reduce anxiety created by Obsessions.
- Tics may create anxiety but are not caused by anxiety themselves.
- However this isn’t black and white, significant grey area (e.g. Tic-related OCD, Tourettic OCD, maybe even PANDAS)
What is the overlap between Depression and Ticking behaviour?
- 20-30% of people with tic disorders have MDD
- Depression symptoms correlate to severity of tics (pain, embarrassment, social isolation, academic failure)
Outline the difference between specific and general memory and how this relates to depression?
- Differences in the way people remember things.
- Can be demonstrated by asking the person to produce a memory e.g. think of a time when you were angry
- General memory = people remember not as specific events but as a category of events (e.g. I’m angry when I have to take the tube)
- Specific memory = people remember specific instances
- More specific memory = Reduced risk of depression
- Overly general memory is one of the most consistent findings about depression
- Theory behind it is that people reduce the specificity of their memories as a protective mechanism, reduced emotional response
- This can be protective against bad memories but also reduces the strength of good memories
- Therapies targeting specific memory have been useful in the treatment of both MDD and TS
What are “Tic attacks”
- Distinct bouts of severe, continuous, disabling tics lasting from 15 minutes to hours
- Often related to anxiety
- Might be panic attacks that present as increased ticking because the person tics anyway
- 8% of people with tics experience them, more common in kids
- Based on misinterpretation of internal body sensations as dangerous, or a tic is about to happen
- Causes increased focus of attention contributing to onset and maintenance of tic attack
- Responds well to external attention focusing and CBT
What is Internal Monitoring and how does it relate to tics?
- Interoceptive accuracy e.g. how aware we are of our own heart beat
- Better you are at monitoring internal sensation, more at risk you are of anxiety
- Some theories suggest people with tics have significantly better internal monitoring due to their premonitory urges.
