Tourette's syndrome

Question 1

learning objectives

• Understand the definitions of the Syndrome
• Understand the role of psychological factors in tics and the historical context
• Understand the complexities of comorbidities

Answer 1

• Be aware of aspects of the underlying neurobiology
• Understand the pharmacological and behavioural treatment options

Question 2

what are the diagnostic criteria for tourettes syndrome

Answer 2

• both multiple motor and one or more vocal tics
• tics may wax and wane in frequency but persist for more than a year since onset
• onset before 18 years old
• not due to substances or other medical conditions

Question 3

what is the male to female ratio

Answer 3

2:1 to 4:1

Question 4

what is a tic

Answer 4

a semi purposeful brief movement or vocalisation that may be simple or complex

Question 5

which factors are increased in tic patients

Answer 5

mortality
suicide
cardiovascular risk

Question 6

what are psychiatric common comorbidites of TS

Answer 6

ADHD
obsessive compulsive behaviour

Question 7

what are comorbidities associated with

Answer 7

anger control problems
sleep difficulties
coprolalia
self injurious behaviour

Question 8

which obsessive symptoms are commonly seen in TS

Answer 8

• sexual
• violent
• aggressive
• religious

Question 9

which compulsions are commonly seen in TS

Answer 9

• touching
• counting
• hoarding
• symmetry
• checking
• ordering

Question 10

what percentage of TS patients have one or more psychiatric comorbidites?

Answer 10

86%

Question 11

what percentage of TS patients haev two or more psychiatric comorbidities?

Answer 11

58%

Question 12

which psychiatric disorders have the highest occurence in TS

Answer 12

OCD
ADHD
mood
anxiety disorders
disruptive behaviour disorders

Question 13

which perinatal factors are associated with increased TS prevalence

Answer 13

poor maternal weight gain
alcohol
cannabis
parity

Question 14

which perinatal factors are not associated with increased TS prevalence

Answer 14

birth weight
smoking

Question 15

what is the relationship between maternal mood and TS prevalence

Answer 15

prevalence is associated with pre and post natal anxiety and depression

Question 16

which rare single genes are associated with tourettes

Answer 16

SLITRK1 proximal to chromosome 13 inversion
L-histidine decarboxylase

Question 17

which susceptibility gene has been identified

Answer 17

NRXN1

Question 18

what is the neuropathophysiology of TS

Answer 18

altered density of parvalbumin positive interneurons in the internal and external globas palliduds compared to controls

Question 19

where is atrophy seen in TS

Answer 19

subtle atrophy of the striatothalamo-cortical system

Question 20

what are the treatment modalities for tics

Answer 20

cbt
drugs
botox
deep brain stimulation
non invasive brain stimulation

Question 21

how can tics be treated using behavioural strategies

Answer 21

exposure and response prevenetion and habit reversal training

Question 22

the stimulus refers to…

Answer 22

the premonitroy urge

Question 23

the repsonse refers to…

Answer 23

the tic

Question 24

the consequence refers to

Answer 24

the relief

Question 25

what is CBIT

Answer 25

comprehensive behavioural interventions for tics

Question 26

what are the components of CBIT

Answer 26

psychoeducation awareness training habit reversal traning functional intervention reward system/ contingency management relaxation training | 50/50 success rate in adults and children

Question 27

which drug classes may have a short term benefit

Answer 27

antipsychotics noradrenergic

Question 27

which treatment is favoured by the AAN practice guidelines

Answer 27

CBIT

Question 28

# AAN practice guidelines which treatments are moderately favourable

Answer 28

aripiprazole clonidine botox

Question 29

# AAN practice guidelines which treatments are only slightly favourable

Answer 29

pimozide topiramate

Question 30

which pharmacological treatments are considered for mx of tics

Answer 30

*neuroleptics such as* - **aripiprazole** - risperidone - sulpiride *other drugs* - clonidine - topiramate - tetrabenazine - botox

Question 31

which pharmacological treatments are considered for mx adhd in tics

Answer 31

clonidine stimulants such as methylphenidate atomoxetine

Question 32

what treatments are used for OCD and depression in TS

Answer 32

SSRIs

Question 33

which factors need to be monitored in patients on neuroleptics

Answer 33

weight ecg lipids glucose prolactin extrapyramidal symptoms

Question 34

evidence for DBS for TS

Answer 34

unknown optimal target site in one case there was improvement in tics no cases of improvement for urges

Question 35

which target areas have there been positive trials in for tics

Answer 35

thalamus internal globus pallidus

Question 36

which area has there been a negative trial for tics

Answer 36

anterior internal globus pallidus

Question 37

what is the role of non invasive brain stimulation

Answer 37

alterns synaptic excitability and intracortical inhibition increases gain of sensory input to motor areas increases cortico-cortical coherence

Question 38

what are methods of non invasive brain stimulation

Answer 38

TMS tDCS peripheral nerve stimulation vibration

Question 39

how do smartwatches for ts work

Answer 39

Pulse trains of rhythmic median nerve stimulation delivered at 12 Hz, entrain sensorimotor mu-band oscillations, whereas pulse trains of arrhythmic MNS do not.

Question 40

what are risk factors for tourette syndrome

Answer 40

family history male

Question 41

what are clinical features of tourettes

Answer 41

childhood onset clonic tics rostrocaudal tic distribution waxing and waning

Question 42

what are the risk factors for functional tics

Answer 42

trauma alexythymia female

Question 43

what are the overlapping risk factors between tourettes and functional tics

Answer 43

anxiety obsessionality low interoceptive accuracy impulsivity life events

Question 44

what are the clinical features of functional tics

Answer 44

adult onset tics mainly trunk and arms common intereference with voluntary actions atypical response to anti-tic medication other fnd signs

Question 45

what are the overlapping clinical features between tourettes and functional tics

Answer 45

echo/paliphenomena coprophenomena sensory antecedents of movement suppresibility

Question 46

what increased during the pandemic

Answer 46

tic like presentation in teenage girls

Question 47

why is clinical information important to dx

Answer 47

without it it is hard for clinicans to distinguish between primary and functional tics

Question 48

what other features are suggestive of functional tics

Answer 48

lack of simple or facial tics abrupt onset rapid development completely symptom free periods varied and complex vocalisations tic attacks throwing breaking things