Tic Disorders

Question 1

what is the definition of a tic?

Answer 1

a tic is a:

sudden

rapid

recurrent

nonrhythmic

motor movement or vocalization

Question 2

how many criteria are there for tourettes disorder

Answer 2

4

Question 3

what is criterion A for tourettes disorder

Answer 3

both motor AND one or more vocal tics have been present at some time during the illness, although not necessarily concurrently

Question 4

what is criterion B for tourettes disorder

Answer 4

the tics may wax and wane in frequency but have persisted for MORE THAN ONE YEAR since first tic onset

Question 5

what is criterion C for tourettes disorder

Answer 5

onset BEFORE age 18

Question 6

what is criterion D for tourettes disorder

Answer 6

disturbance not attributable to the physiological effects of a substance (i.e cocaine) or other medical condition (i.e huntingtons disease, postviral encephalitis)

Question 7

how many criteria are there for Persistent (Chronic) Motor or Vocal Tic Disorder

Answer 7

5

Question 8

what is criterion A for Persistent (Chronic) Motor or Vocal Tic Disorder

Answer 8

a single or multiple motor OR vocal tics have been present during the illness (but not both motor and vocal)

Question 9

what is criterion B for Persistent (Chronic) Motor or Vocal Tic Disorder

Answer 9

the tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset

Question 10

what is criterion C for Persistent (Chronic) Motor or Vocal Tic

Answer 10

onset before age 18

Question 11

what is criterion D for Persistent (Chronic) Motor or Vocal Tic Disorder

Answer 11

disturbance not attributable to the physiological effects of a substance (i.e cocaine) or other medical condition (i.e huntingtons disease, postviral encephalitis)

Question 12

what is criterion E for Persistent (Chronic) Motor or Vocal Tic Disorder

Answer 12

criteria have never been met for tourettes disorder

Question 13

what are the specifiers for Persistent (Chronic) Motor or Vocal Tic Disorder

Answer 13

specify if:
with motor tics only
with vocal tics only

Question 14

what are the criteria for Provisional Tic Disorder

Answer 14

A. single or multiple motor and/or vocal tics
B. tics have been present LESS THAN ONE YEAR
C. onset before age 18
D. disturbance not attributable to the physiological effects of a substance (i.e cocaine) or other medical condition (i.e huntingtons disease, postviral encephalitis)
E. criteria have never been met for tourettes or for persistent motor/vocal tic disorder

Question 15

list tics common across patient populations

Answer 15

eye blinking

throat clearing

Question 16

what might tics look like

Answer 16

tics can include almost any muscle group or vocalization (but some are more common than others, like eye blinking)

an individual may have various tic symptoms over time, but any any point in time, the tic repertoire recurs in a characteristic fashion

Question 17

are tics voluntary or involuntary

Answer 17

tics are generally experiences as INVOLUNTARY

but can be voluntarily suppressed for varying lengths of time

Question 18

what is a quick description of what tics are?

Answer 18

tics are

sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations

that are

involuntary,

suppressible,

wax and wane,

and often accompanied by a premonitory urge

Question 19

what are the two categories of tics

Answer 19

simple

complex

Question 20

define simple motor/vocal tic and given an example of each

Answer 20

short duration (milliseconds)

i.e
motor–> eye blinking, shoulder shrugging, extension of extremities

vocal–> throat clearing, sniffing, grunting (often caused by contraction of diaphragm or muscles of the

Question 21

define complex motor/vocal tics and give an example of each

Answer 21

longer duration (seconds)

often include a combination of simple tics such as simultaneous head turning and shoulder shrugging

can appear purposeful, such as tic-like sexual or obscene gesture or tic-like imitation or someone else’s movements

complex vocal tics can include palilalia or echolalia or coprolalia

Question 22

define copropraxia

Answer 22

tic-like sexual or obscene gesture

Question 23

define echopraxia

Answer 23

tic-like imitation of someone else’s movements

Question 24

define palilalia

Answer 24

repeating one’s own sounds or words

Question 25

define echolalia

Answer 25

repeating the last hear word or phrase

Question 26

define coprolalia

Answer 26

uttering socially unacceptable words, including obscenities, or ethnic, racial or religious slurs

Question 27

how do you distinguish between coprolalia and simply inappropriate/ oppositional/ aggressive speech

Answer 27

coprolalia is an abrupt, sharp bark or grunt utterance that lacks the prosody of similar inappropriate speech observed in human interactions

Question 28

can tics disappear

Answer 28

tics wax and wane in severity and some individuals may have tic free periods of weeks to months (unlikely to disappear entirely)

Question 29

when do tic disorders typically begin (average age of onset)

Answer 29

in the prepubertal period, typical age of onset is between 4-6 years

*incidence of new onset tic disorders decreases in teen years

Question 30

is it common to have new onset tic disorders in adults

Answer 30

no–> this is exceedingly rare

if occurs, is often associated with exposure to drugs or as a result of a CNS insult (i.e post viral encephalitis)

Question 31

what substance use pattern can result in an adult onset tic disorder

Answer 31

excessive cocaine use

Question 32

do all children who present with tics go on to develop a tic disorder

Answer 32

no–> tics are COMMON in childhood but TRANSIENT in most cases

Question 33

what is the estimated prevalence of tourettes disorder in school aged children

Answer 33

3-8 per 1000 kids

Question 34

which gender tends to be more affected by tic disorders

Answer 34

males more commonly affected (2:1 - 4:1)

Question 35

in which populations were identified cases of tic disorders lower

Answer 35

in USA, lower amongst african americans and hispanic americans–> DSM postulates this is due to possible differences in access to care

Question 36

what age is associated with peak severity of tics

Answer 36

peak severity of tics usually between ages 10-12 (with onset around age 4-6)

Question 37

how do tics changes in severity over time

Answer 37

tend to get less severe during adolescence

many adults with tic disorders experience diminished symptoms

*small percentage will have persistently severe or worsening symptoms in adulthood

Question 38

what is a premonitory urge

Answer 38

a somatic sensation that preceeds the tic, with a feeling of tension reduction following the expression of the tic

*usually not expressed until child is older

*tics that have a premonitory urge may not be experiences as completely “involuntary” in that the urge and the tic can be resisted

*an individual may also feel the need to perform a tic in a specific way or repeat it until he or she achieves feeling it has been done “JUST RIGHT”

Question 39

what co-occurring disorders are kids more likely to develop if they are prepubertal when they develop their tic disorder

Answer 39

prepubertal children with tic disorders are more likely to experience ADHD, OCD, and separation anxiety disorder

Question 40

what co-occurring disorders are kids more likely to develop if they are a teen or an adult with a tic disorder

Answer 40

more likely to develop new onset MDD, substance use disorder, bipolar disorder

Question 41

list temperamental risk factors for tic disorders

Answer 41

tics are worsened by anxiety, excitement, exhaustion

Question 42

what makes tics better

Answer 42

tend to be better during calm, focused activities i.e people may have fewer tics when engaged in schoolwork or tasks at work rather than when relaxing at home after school or in the evening

Question 43

is tourettes disorder heritable

Answer 43

there have been important risk alleles identified for tourettes disorder

there are also rare genetic variants identified in families with tic disorders

Question 44

what risk factors are associated with worse tic severity

Answer 44

obstetrical complications

older paternal age

lower birth weight

maternal smoking during pregnancy

Question 45

though there are differences in prevalence between males and females, are there gender differences in kinds of tics, age at onset or course of disorder?

Answer 45

no

Question 46

ddx list for tourettes/tic disorder

Answer 46

1. abnormal movements that may accompany other medical conditions
2. stereotypic movement disorder
3. substance induced and paroxysmal dyskinesias
4. myoclonus
5. OCD and related disorders

Question 47

define motor stereotypies

Answer 47

involuntary rhythmic*, repetitive, and predictable movements that appear purposeful but serve no obvious adaptive function or purpose and stop with distraction

*=unlike tics

–> motor stereotypies have earlier age of onset (below 3 years), prolonged duration, repetitive fixed form and location, unlike tics

Question 48

define chorea

Answer 48

rapid, random, continual, abrupt, irregular, unpredictable, nonstereotyped actions that are usually BILATERAL and affect all parts of the body

the timing, direction and distribution of movements varies from moment to momemt and movement typically worsen during voluntary action

Question 49

define dystonia

Answer 49

simultaneous sustained contracture of both agonist and antagonist muscles, resulting in a distorted posture or movement of parts of the body –> not seen during sleep, and are often triggered by attempts at voluntary movement

Question 50

define myoclonus and distinguish it from tics

Answer 50

myoclonus = sudden unidirectional movement that is often nonrhythmic, may be worsened by movement and occur during sleep

differentiated from tics by rapidity, LACK of suppressibility and absence of premonitory urge

Question 51

what clues may favor a diagnosis of OCD vs tics

Answer 51

OCD–> include a cognitive-based drive (i.e fear of contamination) and the need to perform the action in a particular fashion a certain number of times, equally on both sides of the body or until a “just right” feeling is obtained

impulse control problems and other repetitive behaviours, such as persistent hair pulling, skin picking and nail biting appear more goal directed and complex than tics

Question 52

which disorders are most commonly comorbid with tic disorders

Answer 52

OCD and related

ADHD

Question 53

what impact does a co occurrence of tics and OCD have on treatment

Answer 53

the OC symptoms seen in tic disorder tend to be characterized by more aggressive symmetry and order symtpoms and POORER RESPONSE to pharmacotherapy with SSRIs

Question 54

when should you use “other specified tic disorder” as your diagnosis

Answer 54

presentation in which symptoms characteristic of a tic disorder that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet full criteria for a tic disorder or any of the disorders in the neurodevelopmental disorders dx class

use this when you want to communicate the specific reason that the presentation does not meet criteria for a tic disorder etc –> must record a reason

Question 55

when should you use “unspecified tic disorder” as your diagnosis

Answer 55

presentations in which symtpoms characteristic of a tic disorder that causes clinically significant distresss and impairment predominate but do not meet full criteria for a tic disorder / other neurodevel. disorder and may include times when there is insufficient info to make the dx

Question 56

how do you treat tics (psych DB)

*guidelines on other slides

Answer 56

1. education and support for patients family and school = first line treatment
2. Habit Reversal Therapy –> behavioural treatment used to reduce repetitive behaviours = second line for tourettes (after providing education about the disorder)
3. pharmacotherapy with either alpha-2 agonists or AAPs

Question 57

do stimulants exacerbate tics

Answer 57

previously thought so

newer evidence suggests they do NOT exacerbate tics –> can use if there is tics and comorbid ADHD