Tic Disorders Flashcards
what is the definition of a tic?
a tic is a:
sudden
rapid
recurrent
nonrhythmic
motor movement or vocalization
how many criteria are there for tourettes disorder
4
what is criterion A for tourettes disorder
both motor AND one or more vocal tics have been present at some time during the illness, although not necessarily concurrently
what is criterion B for tourettes disorder
the tics may wax and wane in frequency but have persisted for MORE THAN ONE YEAR since first tic onset
what is criterion C for tourettes disorder
onset BEFORE age 18
what is criterion D for tourettes disorder
disturbance not attributable to the physiological effects of a substance (i.e cocaine) or other medical condition (i.e huntingtons disease, postviral encephalitis)
how many criteria are there for Persistent (Chronic) Motor or Vocal Tic Disorder
5
what is criterion A for Persistent (Chronic) Motor or Vocal Tic Disorder
a single or multiple motor OR vocal tics have been present during the illness (but not both motor and vocal)
what is criterion B for Persistent (Chronic) Motor or Vocal Tic Disorder
the tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset
what is criterion C for Persistent (Chronic) Motor or Vocal Tic
onset before age 18
what is criterion D for Persistent (Chronic) Motor or Vocal Tic Disorder
disturbance not attributable to the physiological effects of a substance (i.e cocaine) or other medical condition (i.e huntingtons disease, postviral encephalitis)
what is criterion E for Persistent (Chronic) Motor or Vocal Tic Disorder
criteria have never been met for tourettes disorder
what are the specifiers for Persistent (Chronic) Motor or Vocal Tic Disorder
specify if:
with motor tics only
with vocal tics only
what are the criteria for Provisional Tic Disorder
A. single or multiple motor and/or vocal tics
B. tics have been present LESS THAN ONE YEAR
C. onset before age 18
D. disturbance not attributable to the physiological effects of a substance (i.e cocaine) or other medical condition (i.e huntingtons disease, postviral encephalitis)
E. criteria have never been met for tourettes or for persistent motor/vocal tic disorder
list tics common across patient populations
eye blinking
throat clearing
what might tics look like
tics can include almost any muscle group or vocalization (but some are more common than others, like eye blinking)
an individual may have various tic symptoms over time, but any any point in time, the tic repertoire recurs in a characteristic fashion
are tics voluntary or involuntary
tics are generally experiences as INVOLUNTARY
but can be voluntarily suppressed for varying lengths of time
what is a quick description of what tics are?
tics are
sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations
that are
involuntary,
suppressible,
wax and wane,
and often accompanied by a premonitory urge
what are the two categories of tics
simple
complex
define simple motor/vocal tic and given an example of each
short duration (milliseconds)
i.e
motor–> eye blinking, shoulder shrugging, extension of extremities
vocal–> throat clearing, sniffing, grunting (often caused by contraction of diaphragm or muscles of the
define complex motor/vocal tics and give an example of each
longer duration (seconds)
often include a combination of simple tics such as simultaneous head turning and shoulder shrugging
can appear purposeful, such as tic-like sexual or obscene gesture or tic-like imitation or someone else’s movements
complex vocal tics can include palilalia or echolalia or coprolalia
define copropraxia
tic-like sexual or obscene gesture
define echopraxia
tic-like imitation of someone else’s movements
define palilalia
repeating one’s own sounds or words
define echolalia
repeating the last hear word or phrase
define coprolalia
uttering socially unacceptable words, including obscenities, or ethnic, racial or religious slurs
how do you distinguish between coprolalia and simply inappropriate/ oppositional/ aggressive speech
coprolalia is an abrupt, sharp bark or grunt utterance that lacks the prosody of similar inappropriate speech observed in human interactions
can tics disappear
tics wax and wane in severity and some individuals may have tic free periods of weeks to months (unlikely to disappear entirely)
when do tic disorders typically begin (average age of onset)
in the prepubertal period, typical age of onset is between 4-6 years
*incidence of new onset tic disorders decreases in teen years
is it common to have new onset tic disorders in adults
no–> this is exceedingly rare
if occurs, is often associated with exposure to drugs or as a result of a CNS insult (i.e post viral encephalitis)
what substance use pattern can result in an adult onset tic disorder
excessive cocaine use
do all children who present with tics go on to develop a tic disorder
no–> tics are COMMON in childhood but TRANSIENT in most cases
what is the estimated prevalence of tourettes disorder in school aged children
3-8 per 1000 kids
which gender tends to be more affected by tic disorders
males more commonly affected (2:1 - 4:1)
in which populations were identified cases of tic disorders lower
in USA, lower amongst african americans and hispanic americans–> DSM postulates this is due to possible differences in access to care
what age is associated with peak severity of tics
peak severity of tics usually between ages 10-12 (with onset around age 4-6)
how do tics changes in severity over time
tend to get less severe during adolescence
many adults with tic disorders experience diminished symptoms
*small percentage will have persistently severe or worsening symptoms in adulthood
what is a premonitory urge
a somatic sensation that preceeds the tic, with a feeling of tension reduction following the expression of the tic
*usually not expressed until child is older
*tics that have a premonitory urge may not be experiences as completely “involuntary” in that the urge and the tic can be resisted
*an individual may also feel the need to perform a tic in a specific way or repeat it until he or she achieves feeling it has been done “JUST RIGHT”
what co-occurring disorders are kids more likely to develop if they are prepubertal when they develop their tic disorder
prepubertal children with tic disorders are more likely to experience ADHD, OCD, and separation anxiety disorder
what co-occurring disorders are kids more likely to develop if they are a teen or an adult with a tic disorder
more likely to develop new onset MDD, substance use disorder, bipolar disorder
list temperamental risk factors for tic disorders
tics are worsened by anxiety, excitement, exhaustion
what makes tics better
tend to be better during calm, focused activities i.e people may have fewer tics when engaged in schoolwork or tasks at work rather than when relaxing at home after school or in the evening
is tourettes disorder heritable
there have been important risk alleles identified for tourettes disorder
there are also rare genetic variants identified in families with tic disorders
what risk factors are associated with worse tic severity
obstetrical complications
older paternal age
lower birth weight
maternal smoking during pregnancy
though there are differences in prevalence between males and females, are there gender differences in kinds of tics, age at onset or course of disorder?
no
ddx list for tourettes/tic disorder
- abnormal movements that may accompany other medical conditions
- stereotypic movement disorder
- substance induced and paroxysmal dyskinesias
- myoclonus
- OCD and related disorders
define motor stereotypies
involuntary rhythmic*, repetitive, and predictable movements that appear purposeful but serve no obvious adaptive function or purpose and stop with distraction
*=unlike tics
–> motor stereotypies have earlier age of onset (below 3 years), prolonged duration, repetitive fixed form and location, unlike tics
define chorea
rapid, random, continual, abrupt, irregular, unpredictable, nonstereotyped actions that are usually BILATERAL and affect all parts of the body
the timing, direction and distribution of movements varies from moment to momemt and movement typically worsen during voluntary action
define dystonia
simultaneous sustained contracture of both agonist and antagonist muscles, resulting in a distorted posture or movement of parts of the body –> not seen during sleep, and are often triggered by attempts at voluntary movement
define myoclonus and distinguish it from tics
myoclonus = sudden unidirectional movement that is often nonrhythmic, may be worsened by movement and occur during sleep
differentiated from tics by rapidity, LACK of suppressibility and absence of premonitory urge
what clues may favor a diagnosis of OCD vs tics
OCD–> include a cognitive-based drive (i.e fear of contamination) and the need to perform the action in a particular fashion a certain number of times, equally on both sides of the body or until a “just right” feeling is obtained
impulse control problems and other repetitive behaviours, such as persistent hair pulling, skin picking and nail biting appear more goal directed and complex than tics
which disorders are most commonly comorbid with tic disorders
OCD and related
ADHD
what impact does a co occurrence of tics and OCD have on treatment
the OC symptoms seen in tic disorder tend to be characterized by more aggressive symmetry and order symtpoms and POORER RESPONSE to pharmacotherapy with SSRIs
when should you use “other specified tic disorder” as your diagnosis
presentation in which symptoms characteristic of a tic disorder that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet full criteria for a tic disorder or any of the disorders in the neurodevelopmental disorders dx class
use this when you want to communicate the specific reason that the presentation does not meet criteria for a tic disorder etc –> must record a reason
when should you use “unspecified tic disorder” as your diagnosis
presentations in which symtpoms characteristic of a tic disorder that causes clinically significant distresss and impairment predominate but do not meet full criteria for a tic disorder / other neurodevel. disorder and may include times when there is insufficient info to make the dx
how do you treat tics (psych DB)
*guidelines on other slides
- education and support for patients family and school = first line treatment
- Habit Reversal Therapy –> behavioural treatment used to reduce repetitive behaviours = second line for tourettes (after providing education about the disorder)
- pharmacotherapy with either alpha-2 agonists or AAPs
do stimulants exacerbate tics
previously thought so
newer evidence suggests they do NOT exacerbate tics –> can use if there is tics and comorbid ADHD
