Tics and Tourettes Flashcards
Describe and give examples of the different types of tics
Motor tics: sudden, rapid, non-rythmic motor movements. They can be simple ( eye blinking, mouth twitching) or complex (repetitive or compulsive nature such as certain ways of touching an object or elaborate sequences of movements copropraxia).
Phonic/vocal tics: flow of air through vocal cords, nose or mouth (throat clearing, grunts, coprolalia and echolalia)
What are compulsions and what is their link to tics and tourettes
Movements or ritualistic behaviours used to reduce stress (hand washing, counting). Fear of impending doom if not carried out (obsessive).
Unlike tics, movements are purposeful and not stereotyped.
Family history of obsessive/compulsive behaviour linked to childhood motor sstereotypies and tics…
Outline childhood motor stereotypies
DSM-IV-TR it is a repetitive, non functional motor disorder which interferes with normal activities or results in injury. However, in clinical setting children are not aware of actions.
Common: hand flapping, head banging, face or mouth stretching.
25% of children have affected relative and family history of obsessive tendencies.
Aetiology: not understood.
Lesions of basal ganglia, excess dopamine in ascending pathways. NB: seems to be genetic predisposition likely, combo.
Treatment:
Usually behavioural strat unless self injury or severe = drugs, SSRIs.
Co-morbidities are common in 80% of childhood motor stereotypies. What are these?
Autism, sensory impairment, social isolation, learning disability.
What is the difference between primary and secondary motor stereotypies?
Primary: observed in neurotypical children. Remain stable or regress with age as children become more aware of social surroundings.
Secondary: additional developmental delay or neurological disorder, may persist over time (characteristic hand movements in Rett’s)
State the difference between tourettes and chronic tic disorder
Chronic must have phonic or motor.
Tourettes must have both.
To be diagnosed both must have persisted for over a year and patient must have multiple tics per day.
How many children are affected by tics?
10%
Outline progression of tics
Begin as simple motor, progress to complex motor and phonic tics over 1-2 year period.
Most difficult period with maximum tic severity is 8-12 years.
18+ tics often wane and impairments due to tics documented to reduce with either no or mild tics in adulthood. For small % will go into adulthood with debilitating tics and associated mood disorders.
State key features of a tic
Ability to suppress tics temporarily
Suppression may lead to discomfort or urge may precede the tic
Active participation is required in performing the tic
Often highly suggestible (depend on environment, tic at home vs not).
Define Tourettes Syndrome
Multiple tics per day, both phonic and motor that must have first presented under the age of 18 and lasted over a year, not be related to a medical condition or substance use.
More males than females diagnosed, 3:1.
Known to be underdiagnosed so there is inadequate care. Average 5 yrs from onset to diagnosis.
Outline management of tic disorders.
Aim to diminish tic severity and frequency. Education and reassurance followed by watchful waiting.
Behavioural: habit reversal training, exposure and response prevention as well as relaxation training.
Pharmacological: reserved for severe cases, used for symptomatic control (lack of long term data to address side effects).
*Clonidine: most common and useful in coexisting behaviours such as sleep probs and ADHD.
*Risperidone alongside SSRI also used.
Surgery: Deep Brain Stimulation, evidence is limited. Only recommended for adult, treatment resistant, severly impacted patients where tics present for 5+ yrs.
What makes tics severe?
1) Causing pain or discomfort: musculoskeletal or neuropathic, can lead to injuries.
2) Social stimga: social isolation, bullying.
3) Psychological probs: negative peer interation can lead to reactive depression, anxiety and social phobia.
4) Functional impairment: can impact concentration as tic suppression is tiring. Phonic tics can impair pronounciation and ability to interact in the classroom.
Define stereotypie
Rhythmic, fixed movements that do not seem to have a purpose, but are predictable in pattern and location on the body.
Give some examples of differential diagnosis of motor disorders
Tic diorder, Tourette Syndrome, compulsions, dystonia, seizures…
State differences between tics and stereotypies
Onset: 5-7yrs for tics, over 2 years for stereo.
Patterns: t-variable, s-foreseeable, identical, fixed.
Movement: t-quick and sudden, s-rhythmic and prolonged.
Pre-movement: t- sensorimotor phenomena, s-nothing.
Supress: t-self directed and uncomfortable, s-external distraction, no conscious effort.
Treatment: t responsive to neuroleptics and s rarely are.
Define copropraxia:
Obscene movements or gestures
Define echopraxia
mimicking actions or gestures of others.
Coprolalia
Vocalisation of expletives or insults.
Palilalia
Repeating what oneself has just said
Echolalia
Repeating what another person has just said
Akathisia
Restlessness, compulsion to move ore walk around to alleviate perceived discomfort
Hyperekplexia
excessive startle resulting from hypertonicity. Thought to be hereditary and due to mutation of glycine receptor.
PANDAS?
PAEDIATRIC AUTOIMMUNE NEUROPSYCHIATRIC DISORDER ASSOCIATED WITH STREPTOCOCCAL INFECTION
Evidence that disorders are autoimmune and mediated by antibodies that bind to and cause dysfunction within CNS (esp basal ganglia).
These antibodies are universal in acute Sydenham’s chorea and post-streptococcal dystonia. The hypothesis is that an antecedent group A Haemolytic streptococcal infection could lead to molecular mimicry at the basal ganglia and then produce a neuropsychiatric manifestation.
Recent large cohort found no link.
What are paroxysmal dyskinesias?
Hyperkinetic movement disorders; abnormal repetitive involuntary movements. Episodic where abnormal only present at certain times and between attacks people are well. Can be inherited.
Encompasses tics, chorea, dystonia.
Phenotypically linked by excess of unwanted movements and thought to share common neural pathways (basal ganglia, thalamus and cerebellum).
