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Tic disorder by Dr. Keerat
- 1. TIC DISORDER Dr. KeeratKaur Post-graduate psychiatry resident MGUMST, Jaipur
- 2.
- 3. INTRODUCTION Tics are definedas: • rapid, recurring • Motor movements (Motor Tics), OR • Vocalisations (Vocal Tics), • Non-rhythmic • involuntary/semivoluntary • sudden in onset 3
- 4. They are complex,heterogenous, neurodevelopmental disorders that are a manifestation of interplay of genes & environment. Tics may change in frequency/anatomical location/number/complexity/severity over time. May even persist during sleep. 4
- 5. FLUCTUATIONS IN COURSE Candecrease during: Can increase during: • Distraction • High concentration job • Cannabis use • Alcohol use • Intentional movements • Stress • Fear • Emotional trauma • Social Pressure • Joy • Tension 5
- 6. HISTORY Jean-Marc Gaspard Itard 1825 1st clinicaldescription of Tourette syndrome Georges Gilles de la Tourette 1885 • Named & described Tourette syndrome & its co-morbid conditions • Coined the term ‘ Coprolalia’ Jean-Martin Charcot Identified disease as progressive & hereditary degenerative disorder 6
- 7. Margaret Mahler 1940 Attributed toinfantilization / parentral overindulgence / sexual conflict Arthur & Elaine Shapiro 1960s-1970s 1st RCT using neuroleptic medications Over last 3 decades Tourette Syndrome Association (TSA) - promoting clinical awareness& research in its causes & t/t 7
- 8. CLASSIFICATION Tics can beclassified as: 1. Simple • inv. 1 muscle/ ms group/sound • meaningless 2. Complex • slower, inv. Coordinated ms groups/ multiple sounds • More purposeful 8 3. Transient 4. Chronic • Tourette’s disorder (has both Motor + Vocal at the same time) • Persistent Motor/ Vocal Tic disorder
- 9. Tics need tobe present for atleast 1 year For tics present for < 1 year - Provisional tic disorder 9
- 10. SIMPLE MOTOR TICS SIMPLE VOCAL TICS COMPLEX MOTORTICS COMPLEX VOCAL TICS Clonic Tics (Brief jerky movt.) Throat clearing Touching objects Palilalia Dystonic Tics (Briefly sustained abnormal posture) Coughing Jumping Echolalia Tonic Tics (isometric contraction) Sniffing Rotating Coprolalia Echopraxia (Imitating others gestures) 10
- 11. MOTOR TICS VOCALTICS Eye blinking Shoulder shrugging Head turning Blephrospasm Ocular deviations Bruxism Mouth opening Torticolis Shoulder rotation Tensing of abdominal ms Echopraxia Throat clearing Coughing Sniffing Echolalia Palilalia Coprolalia Simple Clonic tics Simple Dystonic tics Simple Tonic tic Complex Motor tic Simple Complex 11
- 13. EPIDEMIOLOGY Provisional tic disorder(motor + vocal symptom) • Most common • Prevalence: 2-4% 3-4% are afflicted by Chronic tic disorder Males > Females (3-4 times) 13
- 14. Tics may oftenpersist into adulthood, whereas Tic severity declines in adolescence. Tourette disorder • 1% Prevalence • Average age of onset: 6 years 14
- 15. Tics generally occurfor the 1st time between the ages of 2-15 years However, peak age of onset: 6-8 years 15
- 16. Comorbidity with Tics: 1. ADHD • Most frequent co-occuring condition • ADHD + Tourette disorder = 60-70% 2. OCD • OCD + Tourette disorder = 50% 3. Mood disorders 4. Anxiety disorder 16
- 17. ETIOLOGY 1. Genetic Factors 2.Neurochemical & Neuroanatomical Factors 3. Immunological Factors 17
- 18. Twin studies Bilinear modeof familial transmission First degree relatives of patients with Tic disorder are at risk to develop OCD Rare sequence variant in SLITRK1 on chromosome 13q31.1 (Abelson & colleagues) Functional mutation in the HDC gene encoding l- histidine decarboxylase (Ercan-Sencicek & colleagues) A. GENETIC FACTORS 18
- 19. Involvement of cortico-striato-thalami-cortical (CSTC)pathways in frontal lobes & basal ganglia Neurotransmitters involved: 1. Dopamine 2. Serotonin 3. Endogenous opioids B. NEUROCHEMICAL & NEUROANATOMICAL FACTORS 19
- 20. Pathophysiology includes: • Cortical& subcortical impairment • Striatal abnormalities • Disruption of temporo-limbic pathways of CSTC circuits 20
- 21. Voluntary tic suppressioninvolves: • Deactivation of putamen & globus pallidus • Partial activation of prefrontal cortex & caudate nucleus Active suppression of tics requires: Activation of dorsal prefrontal circuits ’s activity in caudate nucleus Inhibiting activity in the putamen 21
- 22. PEDIATRIC AUTOIMMUNE NEUROPSYCHIATRIC DISORDERSA/W STREPTOCOCCAL INFECTION (PANDAS) Post-infectious mechanism for the development of Tics + OCD Diagnostic Criteria for PANDAS: • OCD and/or Tic symptoms • Prepubertal onset • Episodic course • Explosive onset • Temporal relationship with GABHS infection( group A β-hemolytic streptococcus) • Neuropsychiatric symptoms 22
- 23. CLINICAL FEATURES Initial ticsare in the face and neck and then they progress downwards The most commonly described tics affect the face & head, arms & hands, lower extremities, & GIT. The most frequent initial symptom is an eye-blink tic, followed by a head tic or a facial grimace. The complex tics appear many years later 23
- 24. Prodromal symptoms- 1. irritability, 2.attention difficulties, 3. poor frustration tolerance (diagnosed as ADHD for which stimulants are started 25% end up with Tourette’s) Attention difficulties often precede the onset of tics, whereas obsessive-compulsive symptoms often occur after their onset 24
- 25. TICS • Yale GlobalTic Severity Scale (YGTSS) • Abnormal Involuntary Movement Scale (AIMS) • Tic Symptom Self-Report ADHD • Swanson, Nolan, & Pelham-IV (SNAP-IV) • Abbreviated Conners Questionnaire OCD • Yale-Brown Obsessive Compulsive Scale (YBOCS) • Children’s YBOCS • National institute of Mental Health Global MOOD & ANXIETY DISORDERS • Children’s Depression Inventory (CDI) • Children’s Depression Rating Scale (CDRS) • Multidimensional Anxiety Scale for Children (MASC) GENERAL • Achenbach Child Behavior Checklist (CBCL) • Clinical Global Impressions Scale (CGI) 25
- 26. Yale Global TicSeverity Scale: • 6-17 years of age • Divided into 3 parts- 1. Symptoms of motor & phonic tics, severity & age of onset 2. OCD symptoms, severity & Age pf onset 3. Environmental effects on symptoms 26
- 27.
- 28. Abnormal involuntary movementscale (AIMS) • 12 items • Rated on 5 point severity scale {0(none)-4(severe)} • Scoring: >2 - Tardive Dyskinesia 28
- 29. DIAGNOSIS Detailed medical history Standardizedquestionnaires • Child Behaviour checklist • Strengths & Difficulties questionnaire Interviews • Yale Global Tic Severity Scale • Tourette’s Syndrome Severity Scale Parenteral/ Self Rating Scales • Yale Tourette syndrome Symptom List Physical & Neurological Examination EEG 29
- 30. ICD-10 DSM-IV DSM-V F95.0Transient tic disorder 307.21 Transient Tic disorder 307.21 Provisional Tic dsiorder F95.1 Chronic Motor/ Vocal tic disorder 307.22 Chronic Motor/ Vocal Tic disorder 307.22 Persistent Motor/Vocal Tic disorder F95.2 Combined Vocal & multiple motor tic disorder (Gilles-de-la-Tourette syndrome) 307.23 Tourette’s disorder 307.23 Tourette’s disorder F95.8 Other Tic disorder 307.20 Tic disorder NOS 307.20 Other specified Tic disorder F95.9 Unspecified 307.20 Unspecified 30
- 31.
- 32. More precise definitionof motor & vocal tics Simplification of duration criteria for tic disorders Term ‘Transient Tic disorder’ ‘Provisional Tic disorder’ Removal of Tic disorder NOS Includes a specifier - Motor Tics only/ Vocal Tics only CHANGES IN DSM-V 32
- 33.
- 34. DIFFERENTIAL DIAGNOSIS 1) Abnormalmovements: • Myoclonus • Tremors • Chorea • Athetosis • Dystonia • Akathisia • Compulsive rituals 34
- 35.
- 36. 2) Sydenham’s chorea 3)Post-streptococcal neurological complications: • choreiform, writhing & truncal movements 4) Huntington disease • Autosomal dominant d/o • Dementia • onset: 4th-5th decade 36
- 37. 5) Parkinson disease •Late onset • Flatened facies • Bradykinesia • Rigidity • ‘pill-rolling’ resting tremors • cog-wheeling 6) Wilson’s disease • Autosomal recessive d/o copper metabolism • Liver inv • Neurological symp: dementia, mood symp, psychosis • Asterixis (flapping tremors of hand) 37
- 38. 7) Structural disease Hemiballismus:sub-thalamic nucleus impairment Neuroacanthocytosis: • muscle weakness & atrophy • Cognitive loss • Chorea • Acanthocytosis • Facial tics 8) Neuroleptic- related dyskinesia • Tardive & withdrawal dyskinesias 38
- 39. CORMORBID PSYCHIATRIC DISORDERS CORMORBID DISORDERS %OF CHILDREN WITH TIC DISORDER AFFECTED ADHD 40-60% OCD 40-70% Anxiety disorders 25-40% Mood symptoms 50% Sleep disorders 12-44% 39
- 40. ADHD is diagnosedby developmentally inappropriate inattention &/or hyperactivity &impulsive behaviour Bidirectional relationship Tourette + ADHD: • Academic difficulties • Peer rejection • Family conflicts ADHD + TIC DISORDER • Disruptive behavior • Poor t/t adherence 40
- 41. OCD is characterisedby • Obsessions- recurrent, intense, intrusive ideas, thoughts, impulses or images that cause anxiety or distress • Compulsions- repetitive behaviors or mental acts sought to prevent anxiety or distress caused by an obsession Bidirectional relationship If anxiety relief or prevention is the case, it is more likely a compulsion than tic. OCD + TIC DISORDER 41
- 42. TREATMENT Not to interprettic as behavioral problem Family psychoeducation Mild cases: no t/t required Severe cases: 1. Pharmacotherapy 2. Behavioural therapy 42
- 43. CBIT(Comprehensive Behavioral Intervention forTics) is the initial t/t approach for Tic disorder in pt. with Tourette syndrome and Chronic Tic d/o who do not choose watchful waiting & have no functional impairment, a/c to a new practice guideline from American Academy of Neurology (AAN) 43
- 44. Cognitive Behavioral Methods: •Habit Reversal Training • Exposure Response Prevention • Masses (Negative) Practice • Relaxation Training • Contingency Management • Family Therapy PSYCHOTHERAPY 44 CBIT
- 45. PHARAMACOTHERAPY α-adrenergic agonists 1st generation Antipsychotics 2nd generation Antipsychotics Benzamides ClonidineHaloperidol Aripiprazole Sulpride Guanfacine Pimozide Olanzapine Tiapride Risperidone Ziprasidone 45
- 47. Deep brain stimulation,repetitive magnetic stimulation, special diets, and dietary supplements lack empirical support for the treatment of CTD/TD and are not recommended. 47
- 48. REFERENCES Kaplan & Sadock’sComprehensive Textbook Of Psychiatry Kaplan & Sadock’s Synopsis Of Psychiatry Tourette’s disorder and other tic disorders in DSM-5: a comment Eur Child Adolesc Psychiatry. 2013 February; 20(2): 71–74 Practice Parameter for the Assessment and Treatment of Children and Adolescents With Tic Disorders. Journal of the American Academy of Child & Adolescent Psychiatry, volume 52 number 12 december 2013. 48
- 49.