TIC DISORDERSKaplan & Sadocks Synopsis of PsychiatryBehavioral Sciences/ Clinical PsychiatryBetita, Durell S.Oliveros, Vanessa D.

TICSdefined as rapid and repetitive muscle contractions resulting in movements or vocalizations that are experienced as involuntaryabnormal movements or vocalizations that most commonly affect the muscles of the face & neck eye-blinking, head-jerking, mouth-grimacing, head-shakingVocal Tics: throat-clearing, grunting, snorting, and coughing

Children and adolescentsoccur after a stimulus or in response to an internal urgewith a stable or fluctuating course in childhood and generally wane by adolescenceGilles de la Tourette syndrome (aka Tourettes disorder) as most widely known & most severe tic disorder: exhibit reduction or complete remission of tic symptoms during adolescence by half or two-thirdsExacerbated by STRESS and ANXIETY

Obsessive-Compulsive Symptoms (OCD) coexist in one third to two thirds of children with Tourettes1/3 of adults with Tourettes with persisting OCDTourettes + OCD:OrderingSymmetryCountingRepetitive TouchingOCD without Tourettes:Fears of contamination Fears of harming others

Children with Tourettes with higher IQ (above 120), have higher risk of developing OCD in early adulthood, compared to those with average IQ of 100.Tics suppressed for minutes or hoursTics attenuated by sleep (may disappear but not always), relaxation, absorption in an activity

Diagnostic & Statistical Manual of Mental Disorders (DSM-IV-TR)Chronic Motor/ Vocal Tic DisorderTransient Tic DisorderTic Disorder Not Otherwise Specified

MOTOR TICSSimple Motor Tics repetitive, rapid contractions of functionally similar muscle groups (eye-blinking, neck-jerking, shoulder shrugging, facial-grimacing)Complex Motor Tics purposeful, ritualistic than simple tics (grooming behaviors, smelling of objects, jumping, touching behaviors, echopraxia or imitation of observed behavior, copropraxia or display of obscene gestures

VOCAL TICSSimple Vocal Tics coughing, throat-clearing, grunting, sniffing, snorting, barkingComplex Vocal Tics repeating of words or phrases out of context, coprolalia or use of obscene words or phrases, palilalia or repeating own words, echolalia or repetition of last-heard words of others

Tourettes DisorderMultiple Motor & one or more Vocal TicsCauses distress or significant impairment in important areas of functioningOnset before 18 years oldNot caused by a substance or by general medical conditionGeorges Gilles de la Tourette (1875-1904) first described a patient with this disorder and noted syndrome that included multiple motor tics, coprolalia & echolalia

EPIDEMIOLOGY4-5 per 10,000More in children than adultsOnset of motor component occurs at 7 years old; vocal tics emerge at 11 years oldMore often in boys than girls

ETIOLOGYGenetic Factors more in monozygotic twins than dizogytic, transmission in autosomal dominant fashion, relation to ADHD (half of all Tourettes patients)Neurochemical & Neuroanatomical Factors dopamine system involvementImmunological Factors & Postinfection autoimmune process secondary to Streptococcal infections as potential mechanism , also associated in OCD development

DSM-IV-TR Diagnostic Criteria for Tourette's DisorderBoth multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.) The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.

DSM-IV-TR Diagnostic Criteria for Tourette's DisorderThe onset is before age 18 years. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).

(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed.)

PATHOLOGY & LAB EXAMNo specific lab diagnostic testNonspecific abnormal EEGCT/ MRI revealed no specific structural lesions10% of patients with nonspecific abnormality on CT scans

DIFFERENTIALSDisordered Movements (Dystonic, Choreiform, Athetoid, Myoclonic, Hemiballismic)Tremors, mannerisms, stereotypic movement disorder (head-banging, body rocking)

COURSE & PROGNOSISChildhood-onset neuropsychiatric disorderMotor & Vocal TicsMay decrease, persist, or increase, & old symptoms replaced by new onesMay have serious emotional problems (depression), academic, occupationalCoexistence of OCD and/or ADHD

CHRONIC MOTOR OR VOCAL TIC DISORDERDefined as presence of either Motor Tics or Vocal Tics but not bothOther features same as TourettesCannot be diagnosed if criteria for Tourettes have ever been met

EPIDEMIOLOGY100 1,000 X greater than Tourettes School boys at higest risk, unknown incidenceRare, 1-2% of population

ETIOLOGYHigh concordance in monozygotic twins

DX & CLINICAL FEATURESEarly childhoodChronic Vocal tics considerably rarer than Chronic Motor tics

DIFFERENTIAL DIAGNOSISMotor movementsInvoluntary Vocal Utterances (Huntingtons, Parkinsons)

COURSE & PROGNOSISStarts between 6 & 8 years oldSymptoms last for 4-6 years, stops in early adolescenceTics involving limbs or trunks do less well than those with only facial tics

TREATMENTPsychotherapyReversal TreatmentsAnxiolytic Agents

TRANSIENT TIC DISORDERPresence of single tic or multiple motor or vocal tics or bothOccur many times a day for at least 4 weeks, no longer than 12 monthsCommon in children (5-24% of all school-age children), unknown prevalenceProbably has organic origins, with some tics-combining psychogenic contributions

Occur many times a day nearly every day for at least 4 weeks, no longer than 12 monthsNo Hx of Tourettes or Chronic Motor/ Vocal TicsFrequent among young children, not associated with severe impairmentDoesnt necessarily progress to Chronic Motor/ Vocal Tics, even TourettesPsychopharmacology is recommended only in debilitating symptomsHabit Reversal Treatment seen effective in Transient Tics

DSM-IV-TR Diagnostic Criteria for Tic Disorder Not Otherwise SpecifiedThis category is for disorders characterized by tics that do not meet criteria for a specific tic disorder. Examples include tics lasting less than 4 weeks or tics with an onset after age 18 years.