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Tic disorder

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Clinical Approach to Tic disorder

Clinical Approach to Tic disorder

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    Tic disorder Tic disorder Presentation Transcript

    • TIC DISORDER Dr PS Deb MD, DM
    • TIC  Sudden, rapid, usually stereotyped, predominantly clonic, irresistible movement -> relieve of symptom. Can be controlled by will for short time but reappear as soon as attention is diverted.  They correspond to purposive coordinated act which normally serve the organism  Blinking, sniffing, throat cleaning, neck , shoulder or generalized  Seen transiently in children, mentally retarded  Adult – relieved by sedation, psychotherapy
    • SIMPLE TICS  Motor -- Eye blinking, head jerking, shoulder shrugging and facial grimacing.  Vocal -- Throat clearing, yelping and, noises, sniffing and tongue clicking 8/19/2013
    • COMPLEX TICS  Motor -- Jumping, touching other people or things, smelling, twirling about, and only rarely, self- injurious actions including hitting or biting oneself.  Vocal -- Uttering words or phrases out of context and coprolalia 8/19/2013
    • TIC DISORDERS 8/19/2013 Transient Chronic TS Motor Vocal Simple Complex
    • Georges Gilles de la Tourette (1857-1904
    • GILLES DE LA TOURETTE SYNDROME  Incidence : 0.03 – 0.05% M:F - 3:1  Prevalence: 0.5-1%  Onset - mean 7 y (2-15y) 95% < 11y  1/3rd family members have tics  Motor tics:  Rapid abrupt, intermittent, present in sleep, multifocal simple or complex  Involve face, eyes, and proximal extremities  Vary spontaneously, Echopraxia, Copropraxia  Vocal tics  Involuntary, words, grunts, bark, sniff, snuts, squeals, echolalia, coprolalia
    • COPROLALIA  The uncontrolled, often obsessive use of obscene or scatological language, cursing, ethnic slurs  Thought to possessed by the devil.  Ostracized from their communities or punished for behaviors 8/19/2013
    •  Intellect  Normal, nonspecific right hemispheric dysfunction  Attention disorder, hyperactivity  Personality  Obsessive compulsive  Self deterministic  Anxiety, depression, alcoholism  Modification  Increased by stress, anxiety,  Decreased by relaxation, fever
    •  Course: Natural remission and waxing and waning of severity  Other features: Soft neurological sign  Altered tone  Mild incoordination  Babinski’s sign  No sensory sign  Association  Migraine ( 5HT disorder)  Sec. compressive neuropathy and myelopathy due to violent tics  Sleep disorder – somnambulism, sleep terror, ↓ REM sleep, ↑ stage 3-4 sleep,  EEG and Evoked potential normal  Pre-movement EEG potential absent (subcortical origin)
    • ASSOCIATION  ADHS – 60-80%  OCD  Conduct disorder 8/19/2013
    • PATHOPHYSIOLOGY  Midbrain, basal ganglionic dopaminergic dysfunction (turnover ↓ receptor hypersensitivity)  5HT – Associated with migraine  NA – Improve with clonidine  Cholinergic – Improve with physostigmine  GABA – Clonazepam relieve symptom  Encephalin → dopamine release. Opioid agonist N2O relieve symptom
    • PATHOGENESIS  Anatomical: prefrontal cortex and caudate nucleus  Biochemical: Dopamine  Genetics: AD (Chr 4p and 8p)  Immunological: PANDAS 8/19/2013
    • DIAGNOSTIC CRITERIA  Multiple motor tics  One or more vocal tics  No known cause  Age of onset less than 18 years.  A duration of greater than one year. “Tourette Syndrome Study Group (1993)” 8/19/2013
    • DSM IV CRITERIA OF TOURETTE SYNDROME  Age of onset between 5-15y  Multiple motor tics  Multiple vocal tics  Ability to suppress movement voluntarily for min to hours  Variation in the intensity of symptom over weeks to months  Duration of more than a year
    • DD Clinical Tourette Jumpers (France) Latah (Malacia) Myrichit (Russia) Tics + - - - Startle myoclonus - + + ? Compulsive movement + + + - Echopraxia + + + + Echolalia + + + + Coprolalia + - + -
    • PROGRESSION 8/19/2013
    • PANDAS  OCD/Tic tic disorder  Onset 3-12 years  Episodic course of symptom severity  Association with group A Beta-hemolytic streptococcal infection  Association with neurological abnormalities 8/19/2013
    • TREATMENT  Education  Tic: Anti Dopamine  Associated disorder: ADHS/OCD 8/19/2013
    • PROGNOSIS  Marked improvement in late teens or early twenties.  They get better, not worse, as they mature  TS patients have a normal life span.  1/ 3 of patients experience remission of tic symptoms in adulthood.” 8/19/2013 Samuel Johnson 1709-1784 “Good English Dictionary
    • THANKS