Tic DisordersPsy 610AGary S. Katz, Ph.D.

Tic DisordersTourettes DisorderChronic Motor or Vocal Tic DisorderTransient Tic DisorderTic Disorder Not Otherwise Specified

Tic DisordersTic: a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.Simple motor ticsEye blinking, nose wrinkling, neck jerking, shoulder shrugging, facial grimacing, abdominal tensing.Last less than several hundred millisecondsComplex motor ticsHand gestures, jumping, touching, pressing, stomping, facial contortions, repeatedly smelling an object, squatting, deep knee bends, retracing steps, twirling when walking, assuming/holding unusual posturesCopropraxia sudden, tic-like vulgar sexual, or obscene gesturesEchopraxia involuntary, spontaneous mirroring of anothers behavior.

Tic DisordersTic: a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.Simple vocal ticsThroat clearing, grunting, sniffing, snorting, chirpingComplex vocal ticsInvolve speech or languageSudden spontaneous expressions of single words or phrases, speech blocking, sudden and meaningless changes in pitch, emphasis, or volume of speechPalilalia repeating ones own sounds or wordsEcholalia repeating others sounds or wordsCoprolalia sudden, inappropriate expression of a socially unacceptable word or phrase and may include obscenities as well as specific ethnic, racial, or religious slurs.Found in fewer than 10% of individuals with tic disorders

Tic DisordersTics are generally experienced as irresistable but can be suppressed for periods of time, often leading to excessive discharge later.Many experience a premonitory urge, rising tension prior to the tic expression and a release of tension following the tic expression.Often, individuals with tic disorders describe the tic as falling somewhere between voluntary and involuntary behavior.

Differential DiagnosisAbnormal movements that accompany general medical conditions Huntingtons chorea, stroke, ParkinsonsDirect effects of a substanceTardive DyskinesiaStereotypic Movement DisorderPDDCompulsions (as in OCD)OCD commonly comorbid in tic disordersCompulsions produced in response to an obsession, tics are more due to a perception of physical tension

Differential DiagnosisTic disorders can be differentiated from each other based upon the type of tic and its duration.Transient: lasts 4wks, but no longer than 12mosTourettes requires multiple motor + vocal tics

Tourettes Disorder (307.23)A. Both 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.)

B. 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.

C. The onset is before age 18 years.

D. 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).

Diagnostic Features TourettesLocation, number, frequency, complexity and severity of tics can vary over time.About 50% of individuals with Tourettes see a single tic as the first symptom, usually eye blinking.Sometimes, begins with multiple tics at the same time.

Associated FeaturesMost common: obsessions and compulsions.Hyperactivity, distractibility, and impulsivity also common.Social discomfort, shame, self-consciousness, and demoralization and sadness frequently occur.Younger children may be unaware of their tics as may some adults.Tic thresholds are lowered with the use of some psychostimulant medications. ADHD meds can reveal underlying tic disorders.

Culture and Gender Features and PrevalenceTourettes Disorder has been widely reported in a diverse range of racial and ethnic groups.In clinical samples, 3x to 5x more prevalent in males.In community samples, 2x more prevalent in males.Prevalence related to age:Children: 5-30 per 10,000Adults: 1-2 per 10,000

CourseAge of onset can be as early as 2 years, usually by childhood or early adolescence.Median age for onset of motor tics is 6-7 years.Duration may be lifelong although may have periods of remission.In most cases, severity diminishes during adolescence and adulthood and may disappear in early adulthood.In a few cases, symptoms may worsen in adulthood.Predictors of course are unknown.

Familial PatternTourettes Disorder appears to have genetic transmission; the mode is not known.Pedigree studies suggest that there are genes of major effect.Not everyone who inherits the predisposition for Tourettes will express symptoms of a tic disorderCould be varying levels of tic thresholds

Chronic Motor or Vocal Tic Disorder (307.22)A. Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations), but not both, have been present at some time during the illness.

B. The tics occur many times a day 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.

C. The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.

D. The onset is before age 18 years.

E. 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).

F. Criteria have never been met for Tourette's Disorder.

Transient Tic Disorder (307.21)A. Single or multiple motor and/or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations)

B. The tics occur many times a day nearly every day for at least 4 weeks but for no longer than 12 consecutive months.

C. The onset is before age 18 years.

D. 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).

E. Criteria have never been met for Tourette's Disorder or Chronic Motor or Vocal Tic Disorder.

Specify if:Single Episode or Recurrent

Tic Disorder Not Otherwise Specified (307.20)This 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.

Case MaterialJack E. 8 year old referred because he is having problems academically and is significantly impulsive, inattentive, yet perfectionistic.Teacher reports Jack is very fidgety at school and cannot sustain attention in class, blurts out answers, and is immature.

Case MaterialMedical historyDelivered via c-section 4 weeks early, weighed 5lbs 12ozNo prenatal exposuresHistory of undereating too busy to sit down and eat a full meal.Developmental milestones on time, except some continuing problems with urinary incontinence (will get so occupied in videogames, he will wait just too long to empty his bladder and end up wetting himself on the way to the bathroom).Fair social skills, becomes easily frustrated when friends dont do exactly what he wants to do.

Case MaterialFamily HistoryMom has a history of anxiety disorders, treated medically and with therapy on occasion.Dad was described as moody.Younger brother described as bouncy, just like Jack.School HistoryFidgety in first grade.Second grade continued interpersonal difficulties and low frustration tolerance.Currently in third grade and highly distractible and impulsive.School observation:Facial grimacing, repeated stretching of abdomen, some gruntingCurrent testing observationSee facial grimacing, soft grunting noises.Can inhibit for a while, then they return (after 10min)

Case MaterialIQ Average (VIQ: 110, PIQ: 102, FSIQ: 106)Achievement scores all commensurate.RCMAS (anxiety): social desirability scale at 94th %ile, no other clinical elevations.CPT-II numerous findings suggesting problems with attention, vigilance, and impulse control.Parent and teacher CBCL checklists indicate significant concerns with inattention, impulsivity, and anxiety.

Diagnoses?

Diagnoses

Axis I:Attention-deficit Hyperactivity Disorder, Combined Type

Tourettes Disorder

Adjustment Disorder with Disturbance of Mood and Conduct

Parent/Child Relational Problem

Axis II:No Diagnosis on Axis II

Axis III:No Diagnosis on Axis III

Axis IV:Problems with the school environment, poor academic achievement and distractibility

Axis V:Current estimated GAF: 60

Highest GAF in past year: 60