Tourette Disorder

Ajit Jetmalani, MDDirector, Division of Child and Adolescent Psychiatry

Clinical ProfessorOHSU Doernbecher Children’s Hospital

Disclosure

I have no relevant financial interest arrangement or affiliation with any organizations related to commercial products or services to be disclosed at this program.

Pre Talk Questions:

Tics may be differentiated from other movement disorders as they are frequently painful. T F

Common reason to treat tics: Impaired ambulation parental frustration sleep interruption functional impairment

Pre Talk Questions:

Known cardiac conduction delay would lead to preferential use of Pimazide (Orap) and Ziprasidone (Geodon) in a patient with tics. TF

Talk Outline Clinical Features Diagnostic Criteria Epidemiology Clinical Course Differential Diagnosis Comorbid conditions Assessment Treatment

Clinical Features: Tics Defined Sudden movements or sounds Voluntary movement disorder

(suppressable) Repetitious Sporadic and clustered Non rhythmic

Clinical Features: Tics Defined: Rostral to Caudal Premonitory sensation Wax and wane Change with stress

Simple Tic eye blinking, jaw thrusting, throat

clearing

Complex Tic multiple organized contractions which

mimic contextual speech or movement

obscene gestures such as “the finger” [copropraxia], obscene utterances [coprolalia], or repetition of others speech and movement [echolalia, echopraxia]

Diagnostic Criteria:onset before age 18 and not due to other cause

DISORDER TYPE OF TIC DURATION OF SYMPTOMS Tourette’s Disorder

Motor and one or more vocal tics at some point in the illness but not necessarily concurrently Nearly every day for more than a year with no greater than 3 months tic free Chronic Motor or vocal Tic Disorder Motor or Vocal Tics Nearly every day for more than a year with no greater than 3 months tic free Transient Tic Disorder Motor or Vocal Tics Between 4 weeks and one year

Disorder Type of Tic Duration of Symptoms

Tourette’s disorder Motor and one or more vocal tics at some point in the illness but not necessarily concurrently

Greater than 12 months

Persistent or Chronic motor or vocal tic disorder

Motor or Vocal Tics Greater than 12 months

Provisional Tic disorder

Motor or Vocal Tics Up to 12 months

Course of tics over the lifespanLeckman, J. F. et al. Pediatrics 1998;102:14-19

“BOUTS” LECKMAN ET AL . Advances in Neurology: Tourettes Syndrome 2001

Differential Diagnosis of Tics: SECONDARY: (Zebra?)

Inheritable syndromes: Huntington’chorea, Wilson’s disease, Hallervorden-Spatz,

Tuberous Sclerosis, Neuroacanthocytosis Infections:

PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptoccocal infection), Acute viral encephalitis, Chronic Encephalitis (HIV, CJD)

Toxins: Medications and Drugs of Abuse (partial list): Amphetamines,

methylphenidate, tricyclic antidepressants, L-dopa, carbodopa, carbamazepine, cocaine, antipsychotic medication (withdrawal).

Environmental: carbon monoxide, organopestacides, and volatile aromatic compounds.

Other: MRDD, Autism, head trauma, stroke, tumor, and Multiple

Sclerosis.

Video Clips: Tourette Disorder (Tourette foundation)

Factors suggesting secondary or other movement disorder: Movement disorder presenting in mid to late

adolescence Temporal relationship of symptom onset to

head injury, illness, medication or drug use Family history of Neurodegenerative disorder Cognitive decline Rigidity Tremor Dysarthria Dysphagia Weakness

Factors suggesting secondary or other movement disorder: Lateralizing findings Abnormal reflexes Seizures Recurrent GABHS Substantial symptoms during sleep Abrupt and severe onset Perceived as purely involuntary Non-suppressible motor symptoms No family history of tic disorder Child has no premonition of tic Movements are painful

Co morbidity (“TOURETTES PLUS”)

Anxiety 25 % *OCD Separation Other

*ADHD 50 % Learning Disability Pervasive Developmental Disorder ODD\CONDUCT DISORDERS 20% Mood disorder 20%

TREATMENT Inform the family and child of the waxing and waning course of

tics. Support acceptance of tics in the family through reassurance

and education. Treat tics with medication only if there is pain, physical

dysfunction, or marked social impact. Set realistic targets and goals prior to beginning medical

treatment. If medication is used, start low and go slow; consider the

natural flux in tics, and medication side effects when evaluating titration outcomes (including discontinuation rebound symptoms).

Comorbid conditions or psychological issues may cause greater dysfunction than tics, and should be weighted accordingly in the treatment plan

Habit Reversal Training (HRT)(competitive response training) Tic description Awareness of tics, through feedback, video tape, etc. Acknowledging tics when they happen, by documenting or

labeling with a letter T verbalized after each tic Learning a competitive response, i.e., a motor behavior

that is close to the opposite of the muscle contractions, that occur in the tic, and rehearsing it with the therapist

Learning relaxation techniques, such as breathing techniques and/or muscle relaxation techniques, to assist in carrying out a competitive response

Applying the competitive response when the patient feels a tic coming or for 1-2 minutes after a tic or series of tics

Great praise for the child when he/she follows through with the process

Feedback to the child regarding observed improvements

When to use medication Be certain the symptom is persistent. Try to not treat if possible

Functional impairment Social impairment Pain

How to use medication Define Goals of treatment Identify target symptoms Set expectations Single agent preferred over

polypharmacy Start low, go slow…tics wax and

wane!

Risks of treating tics Primary side effects Complexity of waxing and waning

syndrome and impact of medication tolerance and withdrawal

Unknowns of influence on brain development

Over reliance on medical intervention

PSYCHOPHARMACOLOGY(all dosages are

total daily) Tics OnlyMedication mg/day divided Comments

Alpha Two Agonists Clonidine 0.025-0.4 bid-qid 1,3 Guanfacine 0.5-4.0 bid-qid 1,3

NeurolepticsTypical Pimazide 0.5-4.0 qd-tid 1,4 Haloperidal 0.5-4.0 qd-tid 1,4Atypical Risperidone 0.25-4.0 qd-tid 1,2,4 Olanzepine 2.5-10 qd 2,4 Ziprasidone 20-160 bid 1,2,4

_________________________________________________________Comments:

1. Cardiovascular side effects2. Metabolic monitoring necessary / weight gain3. Severe withdrawal cardiovascular side effects4. Risk of tardive dyskinesia, withdrawal dyskinesia

Tics plus ADHD First Line: atomoxetine, buproprion, guanficine

Second Line Stimulants: Long acting Adderall XR, Concerta, Ritalin LA, Metadate CD,

Adderall. Stimulants: Short acting dextroamphetamine, methylphenidate,

dexmethlyphenidate Third Line Tricyclic Antidepressants:

imipramine, nortriptylin

Risks of Stimulants: ?onset or increase tics? Increase in anxiety / rigidity Decrease appetite / calories / growth Agitation Insomnia ?addiction risk?

Tics plus Anxiety, OCD Depression

First line SSRI’s: fluoxetine, fluvoxamine,

sertraline, (escitalopram, citalopram paroxetine not approved under 18).

Second line TCA’s Clomipramine, imipramin, nortriptylin

Pre Talk Questions:

Tics may be differentiated from other movement disorders as they are frequently painful. T F

Common reason to treat tics: Impaired ambulation parental frustration sleep interruption functional impairment

Pre Talk Questions:

Tics may be differentiated from other movement disorders as they are frequently painful. False, tics should not generally be painful

Common reason to treat tics: Impaired ambulation No parental frustration No sleep interruption No functional impairment Yes

Pre Talk Questions:

Known cardiac conduction delay would lead to preferential use of Pimazide (Orap) and Ziprasidone (Geodon) in a patient with tics. TF

Pre Talk Questions:

Known cardiac conduction delay would lead to preferential use of Pimazide (Orap) and Ziprasidone (Geodon) in a patient with tics. TF

False, Both drugs have the potential of lengthening the QTc and would be contraindicated