09 10 2014 Tic disorders

Question 1

Tic

Answer 1

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.

Question 2

What are the two types of tics?

Answer 2

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

Question 3

Associated symptoms or disorders with tic disorders?

Answer 3

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

Question 4

Tourette’s Diagnosis criteria

Answer 4

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)

Question 5

Persistant (chronic) motor or Vocal tic disorder

Answer 5

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.

Question 6

Prevalence of Tourette’s and related chronic tic disorders

Answer 6

0.5-3%

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

More frequent in caucasian than African American

Question 7

Genetics of Dic disorders?

Answer 7

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

Question 8

Tic Characteristics

Answer 8

• 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%

Question 9

Tourette’s Disease course

Answer 9

• 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.

Question 10

Environmental Influences

Answer 10

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.

Question 11

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

Answer 11

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

Activation increase in other areas

Question 12

Factors impacting Symptom Severity

Answer 12

-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)

Question 13

Tourette’s disorder w/o Comorbidity

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

Answer 13

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

Question 14

Tourette’s disorder Comorbidity

Answer 14

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

Question 15

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

Answer 15

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

Question 16

TS treatment

Answer 16

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.

Question 17

Tic Disorder treatment

Answer 17

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

Question 18

Medication

Answer 18

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

Question 19

ADHD as a diagnosis:

Answer 19

• 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

Question 20

Attention-Deficit/ Hyperactivity Disorder (ADHD)

Answer 20

• 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

Question 21

ADHD–Inattention

Answer 21

• 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

Question 22

ADHD- Hyperactivity/ Impulsiveness

Answer 22

• 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)

Question 23

Executive functions

Answer 23

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

Question 24

Basal Ganglia and ADHD?

Answer 24

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

Question 25

ADHD group on psychostimulants vs. unmedicated

Answer 25

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

Question 26

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

Answer 26

- Thalamus - medication helped alter shape -->normal -thinning of cerebral cortex!

Question 27

When to think of ADHD-- Child who has:

Answer 27

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

Question 28

Screening tools for ADHD

Answer 28

- Conners Scales - Swanson, NOlan and Pelham-IV (SNAP-IV)* - Vanderbilt scales* *-- DSM-5 revised 10 item modification

Question 29

Medical disorders presenting with ADHD symptoms

Answer 29

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

Question 30

ADHD Course

Answer 30

- 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.

Question 31

ADHD management

Answer 31

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