Tourette' Syndrome

Corporalia

Uttering of obscene words (most distressing and recognizable symptoms affecting about 10% of patients)

Tics Categorization (2) - based on duration

(1) Transient - mildest and most common Single or multiple motor tics - for over 4 weeks but less than 12 months (2) Chronic - present for more than 12 months Tics are ether entirely motor or solely vocal tics (less common)

Habit Reversal

1) Awareness of behaviour (sensations) 2) Self monitoring for short periods of time until the entire day is monitored to find a pattern 3) Develop a competing response - another behaviour (same muscles) to replace tic 4) Competing response for at least a minute 5) Practice and praise

Pathogenesis/Neuropathology

Cause is unknown but appears to be inherited (genetic) Neuroimmunology - exacerbated of symptoms at same time as streptococcal infection Cortico-striatal-thalamocortical pathways

Tourette's Syndrome

Chronic Tic disorder characterized by involuntary motor and phonic tics

Behavioural Treatment

Conditioning technqiues - respond to a stimulus with a particular behaviour Awareness Training - educate child and parents Relaxation Training Biofeedback Hypnosis

Treatment

Create a suitable environment for the affected individual Give scheduled break for an opportunity to release the tics

Characteristics of Tics

Exacerbated during periods of anticipation, emotional upset, or fatigue; Subside when - absorbed in activity, concentrating, pleased, asleep Associated with premonitory sensation or discomfort - can be suppresed in many cases Severity waxes and wanes - episodes of repeated tic execution mixed with tic-free periods (can last minutes to hours) Psychosocial stress and adversities prominent in children with TS

Simple Motor Tic

Few muscles of a single body part Brief, rapid movements that typically involve only one muscle group, thus restricted to a specific body part ex: eye blinking, shoulder shrugging, face grimacing, neck stretching, mouth movements, jaw clenching, spitting

Epidemiology Tics

Higher in winter Higher in males Higher in children with ADHD Higher in children attending special education programs

Tic

Involuntary, sudden, rapid repetitive, non-rhythmic, stereotyped movements (motor) or vocalizations (phonic)

Tourettes Syndrome

Multiple motor and at least one vocal tic Waxing and waning increase in severity over time Tic symptoms lasting at least a year Symptom Onset: before age 21 No preceipitating illness or drugs

Pharmacotherapy

No cure, therefore regarded as symptomatic (alleviate symptoms) Focus of medical therapy relies on decreasing impairment Mainstay treatment - dopamine receptor blocking agents

OCD

Occur in 20-60% of patients Generally seen after tic onset Self Injurious behaviour - related to OCD - reported in up to 53% of all patients - common form is damage of skin by: biting, scratching, cutting, engraving, or hitting

Tics usually begin during childhood

Onset: 6-7 years of age Most severe at age 10, decreases in frequency to the point that age 18, 50% are tic free TS incidence higher in males

Palilalia

Repetition of one's own words

Echolia

Repetition of other's words

ADHD

Reported in 50% of TS patients Characterised by impulsivity, hyperactivity, and decreased ability to maintain attention Begins at 4-5 years of age Precedes the onset of tics by 2-3 years

Complex Motor Tic

Several muscle groups, resembled normal movements or gestures Abrupt movements that involve either a cluster of simple movements or a more coordinated sequence of movements Serve no purpose, even when they seem purposeful Ex: touching, hitting, smelling, jumping, or obscene gestures Inappropriately intense and timed

Classification (4)

Simple Motor Complex Motor Simple Vocal Complex Vocal

Simple Vocal Tic

Single vocalisations, no meaning Consists of sounds that do not form words Ex: throat clearing, grunting, coughing, sniffling, and barking

Comorbidity

There are 2 common behavioural features associated with TS: (1) ADHD (2) OCD - self inujurious behaviour Higher incidence of depression and anxiety Migraine in 25% of patients Sleep problems

Complex Vocal Tics

Words/sentences with meaning Include syllables, phrases, and echolia, palilia, and corporalia Improperly intense and timed