TouretteTicDisorders
Tourette’s and other Tic Disorders
The Mind Body Interface-Psychiatry Meets Neurology
No 14 in the series ”I want you to know what I know.”
Mental Health Problems that Shouldn’t be Missed and their Treatments
First do no harm, teach what is known, and treat as if treating yourself.
1. Definition of Tic: A tic is sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization. They are experienced as irresistible but can be suppressed for varying lengths of time. People with tics feel they are between voluntary and involuntary, similar to giving into to the tension that precedes a sneeze, or the urge to scratch and itch. Tics may be simple like eye blinking or throat clearing, or complex like a hand gesture or saying words. There may be a repeating or imitation of someone else’s gesture or words, called echopraxia and echolalia. Copropraxia or coprolalia which only occurs in less than 10% of people and tends to be mild , is the repetition of socially inappropriate and unacceptable gestures and words.
2. Expression and Types of Tic Disorders: Tics occur in bouts or episodes of several tics at once separated by non-tic behavior lasting from seconds to hours. They can vary greatly in severity and duration, usually made worse by periods of excitement good or bad, yet may have a life of their own sometimes changing for no apparent reason. They may also get worse when he person relaxes in private. If there are both multiple vocal and motor tic lasting for at least a year, with no tic free period greater than 3 months, with onset before 18 years of age, the criteria are met for Tourette’s Disorder or Syndrome [TS]. If there are only motor or vocal tics but not both then the diagnosis is Motor Tic or Vocal Tic Disorder. If the tic occur nearly every day for at least 4 weeks, but not greater than 12 months is would be a Transient Tic Disorder. One needs to rule out other causes such as induced by a substance or a drug, and medical conditions especially of a neurological nature. One also has to differentiate between tics and other movements such as stereotypic movements, habit disorders, and compulsions.
3. Tourette’s Disorder: The essential feature of TS is multiple motor tics and one or more vocal tics. About one half of people with TS the first symptoms are episodes of a single motor tic such as eye blinking, followed by progression to nose wrinkling, neck jerking, shoulder shrugging, facial grimacing and abdominal tensing, lasting about one second. Complex motor tic include hand gestures, touching, repeatedly smelling an object, squatting , retracing steps, twirling when walking, holding unusual postures. One can see how these can be confused for habits and compulsions. Simple vocal tics are throat clearing, grunting, sniffing, snorting, yelps, barking and chirping. Complex vocal tics involve expression of single words or phrases, speech blocking, and sudden and meaningless changes in pitch, emphasis or volume of speech, and there may be echolalia repeating the last heard sound, coprolalia may be present but is rare. Motor tic may begin as early as 2 years of age, the median being 6-7 years , with vocal tic occurring a year or two later.
4. Associate Features and Disorders: The most common associated symptoms are obsessions and compulsions, followed by hyperactivity, impulsivity and distractibility. Often children with TS are also prone to mood swings and are highly anxious. One must attempt to differentiate these symptoms from ADHD , OCD, Mood and Anxiety Disorders for many reasons especially so that the right medication is chosen. This can become a very complex diagnostic and therapeutic problem. The brain chemistry that causes TS leads to urges to move, to do and to talk that can easily be confused with ADHD and OCD, and also causes an emotional excitability that can mimic mood and anxiety disorders. In TS there tends to be a progression from the preschool age of very mild tic, and perhaps even more mild compulsive tendencies, that are often not thought of, and not looked for and are in fact are primary , and at the root of what appears to be the other diagnoses. As the child gets l older child they may develop more complex motor and vocal tics , and last to develop are compulsions as symptoms of TS, not necessarily true OCD. Sometimes the child is aware of these tendencies and symptoms and hides and disguises them. By definition the tics and compulsions will be episodic and thus with hiding and disguising are easy for the parent or the evaluator to miss. If one is suspicious of this based on the child’s history and family history one may need to teach the parent or significant other what to look for. The motivating factors of the compulsions in TS are more based on need to do something, a motor urge like to count or order to dispel the tension associated with the urge, rather than based on an emotional fear such as contamination, and to do a ritual like hand washing to get rid of the anxiety associated with the obsessional fear. The child with an anxiety disorder will generally be pervasively fearful and anxious, not just around their specific compulsion, and the child with a mood disorder will have more intense mood changes, irritability, and rage attacks accompanied by the other symptoms of mood disorders, Unipolar or Bipolar. ADHD can be ruled out or in by the episodic nature of core symptoms being driven by tics and localized to specific domains, rather than being continuous and relatively the same across domains when one factors in differences caused by milieu, motivation and mood. To further add complexity all diagnosis may be present in the same person especially the triad of TS, ADHD, and OCD. Again there tends to be an age related developmentally progression with ADHD being the first, followed by TS, and then OCD, and if these are missed and not treated properly Anxiety and Mood Disorder, Unipolar or Bipolar may follow as complications that could have been prevented. Often a carefully done medication trial is needed to help clarify the diagnoses.
5. Medication Based on GAF for Triad of Tourette’s, ADHD , OCD vs. Symptom Clusters: The GAF standing for Global Assessment of Functioning uses symptom severity/distress and impairment of functioning at home, work, socially, school, in relationships to determine over all degree of severity. One uses this concept of distress and impairment to choose what of the multiple symptoms and clusters to treat in Tourette’s Disorder, based on underlying biochemical causes. This triad is more common than appreciated and often mismanaged with medication, because the primary Dx or Dxs are missed and the symptoms are treated rather than medicating the underlying biochemical cause of the symptoms based on severity and impairment. The diagnostic and medication management involved can be used as a model that can be applied to any [A.]other situations where there are possibly multiple diagnoses and symptom clusters. It also is a good model for the [B.] Dx and Rx of episodic symptoms vs. continuous symptoms in mental health with an extremely strong biological basis. Thirdly it demonstrates the need [C.] to medicate based on symptom severity , distress and impairment rather than the actual presenting symptom cluster or diagnostic label. Fourthly this demonstrates[D.] the necessity of adequate treatment to prevent relapses and complications, like a mood disorder. First one must differentiate between the symptom cluster and the underlying actual diagnosis. Are all three Dxs present or are the symptoms representing only one or two Dxs. One medicates the underlying cause of the symptom cluster, not the symptoms. Whatever the presentation or symptom cluster one treats the underlying cause. If the underlying cause is Tourette’s brain chemistry then one uses a dopamine antagonist medication like Haldol or Risperdal. Prozac for the same symptoms caused by the serotonin based OCD , and Adderal if caused by the dopamine problem of ADHD. The Tics of Tourette’s , the vocalizations and motor movements may not get worse with a stimulant alone the 1/3 rd rule applying, equal chance of getting better, worse, or being neutral. Tics similar to the compulsions of OCD are episodic, where as the hyperactivity, impulsiveness, and anxiety are continuous, to make matter even more complex there may be a complicating mood disorder present also that may be either episodic or continuous. What to treat and when to treat again is based on symptom severity, distress and impairment.
6. Specific Treatment of Symptom Clusters-Motor & Vocal Tics: The tics that characterize the disorder are often not causing excessive distress or impairment and therefore specifically may not be the targets of medication management. However if it is determined that the underlying brain chemistry that is causing the tics, the imbalances of dopamine, is driving the tics and the other symptoms such as the ADHD, OCD, Anxiety, or Mood clusters, then they would be treated with the same medications used for the tics. The primary group of medication are the low dose potent neuroleptic medications, Risperdal, Haldol, Orap and others, and a second group are the alpha agonists, clonidine and guanficene. Risperdal has the advantage of helping anxiety and depression better than the others, and Orap has the disadvantage of increasing certain ECG waves, called the QT, which can in certain individuals predispose to bad heart rhythms, and Haldol the most potent and perhaps the best for the tics alone, may cause other movement problems as side effects which can be confused with the very tics one is trying to treat. Clonidine and guanficene both can be very sedating and making the person too tired, also may lower the blood pressure, and may not be as effective to control the tics. Often if properly adjusted one medication such as Risperdal may treat adequately regardless of the symptom clusters present. If not an adjunctive medication may have to be added, like Dexidrine for symptoms of ADHD, Prozac for OCD symptoms, and Depakote or Lithium if there is Bipolar symptoms.
7. Specific Treatment-ADHD cluster: The triad of inattention , impulsivity, and over activity may represent associated symptoms of Tourette’s or the disorder of ADHD. Many time only a treatment trial will help clarify the diagnosis. If the symptoms are severe, with anxiety, moodiness, with or without compulsions it is best to start with a neuroleptic, like Risperdal, which may treat the symptom triad of ADHD sufficiently, but if not a stimulant like Dexidrine may be added. In by GAF the ADHD triad is what needs treatment, and the tics, anxiety, moods, and OCD symptoms are minimal a stimulant alone may be sufficient. The rule with stimulants and tics, and sometimes OCD symptoms is the 1/3 rd rule where there is an equal 1/3 rd chance that the stimulant may make the other symptoms better, worse , or the same that is neutral. So in reality using this rule of thumb there is a 2/3 rd chance that the tics or compulsions may not be aggravated. If either are aggravated one would add the appropriate medication watching for aggravation of the ADHD symptoms, Prozac for the compulsions, and Risperdal for moods and the tics. One regulates by treatment response, what is helped, what might be aggravated, and the GAF.
8. Specific Treatment- OCD symptoms: If symptoms of OCD are primary or aggravated by other medications, and by GAF should be the target of treatment a serotonin agent such as Prozac, or one that also may involve norepinephine also like Effexor will be needed to control compulsions, anxiety, and ADHD symptoms, and Tics if driven by the underlying OCD brain chemistry. The stimulants if used may have to be adjusted or stopped, and sometimes using Welbutrin for the ADHD is helpful. Adjusting the neuroleptic or changing to one with different properties like Zyprexa or Abilify may help by a trial and error process.
9. Mood Complications: Unipolar or Bipolar mood disorders may accompany and complicate the treatment of TS. In Unipolar states the antidepressant or anti compulsive medication used often when adjusted will help this depression. However these same medications may aggravate and fuel a Bipolar process and may have to be discontinued with one relying on other traditional mood stabilizers, Lithium and anticonvulsants if the atypical neuroleptic aren’t sufficient.
10. Realistic Complexity Requires Following Sound General Principles with Consistency: General medication concerns and guidelines were discussed in section 5 above. The actual medications chosen are less important than the class, the underlying biochemistry causing the target symptoms, and adjusting, starting and stopping base on treatment response balancing good vs. negative effects. This may take much time, patience, education and clinical judgment, with availability for more than usual face to face evaluations, so the actual effects can be observed, though phone calls may suffice in certain situations. Based on GAF treat the symptoms clusters underlying biochemistry, giving sufficient time for the medications to work, and not responding to shifting symptoms that may have nothing to do with the underlying brain chemistry, to avoid chasing variably episodic less severe, distressing and impairing symptoms, that may be unpredictable rather than more consistent trends based on history and treatment response.
Symptoms of Tourette’s Disorder:
[ ] Simple Motor Tics- rapid meaningless muscle contraction of few muscles like eye blinking
[ ] Simple Vocal Tics - sniffs, snorts, clicks, throat clearing, grunts, coughs, barks, yelps, giggle
[ ] Complex Motor- touching, squatting, twirling & retracing steps when walking, repeating
[ ] Complex Vocal- saying and repeating words, phrases, part of songs
[ ] Motor Driven Compulsions- doing things over and over, rituals driven by tics
[ ] Motor Driven “ADHD type symptoms”- over active, impulsive, inattention driven by tics