Phenomenology of tics: psychological and psychiatric approach

The association of involuntary motor disturbances and psychic symptoms is a salient feature of Gilles de la Tourette's disease. The frequency of the association is supported by recent epidemiological data. However, a clear distinction must be made between psychic symptoms dependent of the pathological process and psychological reactions to the disease. The link between motor and psychic symptoms raises a crucial and yet controversial question. Etiology, and particularly the role of psychological and social factors, is discussed. But mechanisms must be studied independently. Is there a causal relationship between motor and psychic symptoms? Is there a common neuro-chemical alteration? There is no evidence for clear conclusion but this questions must be clarified.     

Social deficits in children with chronic tic disorders: Phenomenology,clinical correlates and quality of life

Youth with chronic tic disorders (CTD) experience social problems that have been associated with functional impairment and a diminished quality of life. Previous examinations have attributed social difficulties to either tic severity or the symptom severity of coexisting conditions, but have not directly explored performance deficits in social functioning. This report examined the presence and characteristics of social deficits in youth with CTD and explored the relationship between social deficits, social problems, and quality of life. Ninety-nine youth (8–17 years) and their parents completed a battery of assessments to determine diagnoses, tic severity, severity of coexisting conditions, social responsiveness, and quality of life. Parents reported that youth with CTD had increased social deficits, with 19% reported to have severe social deficits. The magnitude of social deficits was more strongly associated with inattention, hyperactivity, and oppositionality than with tic severity. Social deficits predicted internalizing and social problems, and quality of life above and beyond tic severity. Social deficits partially mediated the relationship between tic severity and social problems, as well as tic severity and quality of life. Findings suggest that youth with CTD have social deficits, which are greater in the presence of attention-deficit hyperactivity disorder and obsessive compulsive disorder. These social deficits play an influential role in social problems and quality of life. Future research is needed to develop interventions to address social performance deficits among youth with CTD.     

Therapy of tic disorders

Tremendous progress has taken place in the last 8 years since the publication of our review on ?Therapy of Tic Disorders? in the Zeitschrift für Kinder- und Jugendpsychiatrie. Several steps in treatment have been specified. For example, consensus-based indications for treatment have been published, and a detailed manual for a so-called habit-reversal training program has been developed and evaluated. In addition, new treatment options such as aripiprazole and deep-brain stimulation have been implemented. Increasing attention is being given to the disabling consequences of the commonly co-occurring psychiatric conditions known as ADHD or OCD. Nevertheless, there is still much to be learned about the treatment of tic disorders; standardized and sufficiently large drug trials in patients with tic disorders fulfilling evidence-based medicine standards are still scarce. The same is true for direct comparisons of different agents as well as of medication versus behavioral treatment. Finally, the question of how to predict the individual course of tics and how best to deal with the problems of waxing and waning of tics in this context still limits evidence base for treatment decisions. Large clinical experience is still a pre-requisite for making optimal decisions for the treatment of individual patients suffering from a tic disorder.     

Development and natural history of mood disorders.

To expand and accelerate research on mood disorders, the National Institute of Mental Health (NIMH) developed a project to formulate a strategic research plan for mood disorder research. One of the areas selected for review concerns the development and natural history of these disorders.The NIMH convened a multidisciplinary Workgroup of scientists to review the field and the NIMH portfolio and to generate specific recommendations. To encourage a balanced and creative set of proposals, experts were included within and outside this area of research, as well as public stakeholders.The Workgroup identified the need for expanded knowledge of mood disorders in children and adolescents, noting important gaps in understanding the onset, course, and recurrence of early-onset unipolar and bipolar disorder. Recommendations included the need for a multidisciplinary research initiative on the pathogenesis of unipolar depression encompassing genetic and environmental risk and protective factors. Specifically, we encourage the NIMH to convene a panel of experts and advocates to review the findings concerning children at high risk for unipolar depression. Joint analyses of existing data sets should examine specific risk factors to refine models of pathogenesis in preparation for the next era of multidisciplinary research. Other priority areas include the need to assess the long-term impact of successful treatment of juvenile depression and known precursors of depression, in particular, childhood anxiety disorders. Expanded knowledge of pediatric-onset bipolar disorder was identified as a particularly pressing issue because of the severity of the disorder, the controversies surrounding its diagnosis and treatment, and the possibility that widespread use of psychotropic medications in vulnerable children may precipitate the condition. The Workgroup recommends that the NIMH establish a collaborative multisite multidisciplinary Network of Research Programs on Pediatric-Onset Bipolar Disorder to achieve a better understanding of its causes, course, treatment, and prevention. The NIMH should develop a capacity-building plan to ensure the availability of trained investigators in the child and adolescent field.Mood disorders are among the most prevalent, recurrent, and disabling of all illnesses. They are often disorders of early onset. Although the NIMH has made important strides in mood disorders research, more data, beginning with at-risk infants, children, and adolescents, are needed concerning the etiology and developmental course of these disorders. A diverse program of multidisciplinary research is recommended to reduce the burden on children and families affected with these conditions.     

Fluphenazine and multifocal tic disorders

In a five-year study, 21 patients with multiple tic disorder intolerant of haloperidol therapy were treated with fluphenazine hydrochloride. Sixteen of these patients had fewer side effects with fluphenazine and had either equivalent (five patients) or better (11 patients) tic control. Fluphenazine can be an effective treatment for multiple tics in patients with dose-limiting side effects related to haloperidol.     

Adult onset tic disorders

BACKGROUND: Tic disorders presenting during adulthood have infrequently been described in the medical literature. Most reports depict adult onset secondary tic disorders caused by trauma, encephalitis, and other acquired conditions. Only rare reports describe idiopathic adult onset tic disorders, and most of these cases represent recurrent childhood tic disorders. OBJECTIVE: To describe a large series of patients with tic disorders presenting during adulthood, to compare clinical characteristics between groups of patients, and to call attention to this potentially disabling and underrecognised neurological disorder. METHODS: Using a computerised database, all patients with tic disorders who presented between 1988 and 1998 to the movement disorders clinic at Columbia-Presbyterian Medical Center after the age of 21 were identified. Patients' charts were retrospectively reviewed for demographic information, age of onset of tics, tic phenomenology, distribution, the presence of premonitory sensory symptoms and tic suppressibility, family history, and associated psychiatric features. These patients' videotapes were reviewed for diagnostic confirmation and information was obtained about disability, course, and response to treatment in a structured follow up interview. RESULTS: Of 411 patients with tic disorders in the database, 22 patients presented for the first time with tic disorders after the age of 21. In nine patients, detailed questioning disclosed a history of previous childhood transient tic disorder, but in 13 patients, the adult onset tic disorder was new. Among the new onset cases, six patients developed tics in relation to an external trigger, and could be considered to have secondary tic disorders. The remaining patients had idiopathic tic disorders. Comparing adult patients with recurrent childhood tics and those with new onset adult tics, the appearance of the tic disorder, the course and prognosis, the family history of tic disorder, and the prevalence of obsessive-compulsive disorder were found to be similar. Adults with new onset tics were more likely to have a symptomatic or secondary tic disorder, which in this series was caused by infection, trauma, cocaine use, and neuroleptic exposure. CONCLUSIONS: Adult onset tic disorders represent an underrecognised condition that is more common than generally appreciated or reported. The clinical characteristics of adults newly presenting to a movement disorder clinic with tic disorders are reviewed, analysed, and discussed in detail. Clinical evidence supports the concept that tic disorders in adults are part of a range that includes childhood onset tic disorders and Tourette's syndrome.     

The natural history of anxiety disorders.

The article reviews research and presents our results on the natural history of 2 forms of anxiety disorder, panic disorder and generalized anxiety disorder. Data from our epidemiological cohort study give evidence of premorbid anxiousness and overadaptation already in childhood. Distressing conditions in the family are more prevalent among subjects with anxiety disorders or major depression than among controls. Anxiety disorders frequently begin between age 20-30 and can be triggered by life events. The course is often characterized by a certain chronicity that manifests itself in residual symptoms and mild impairment in social roles even after many years and is frequently complicated with depression. The best predictors are severity and duration of symptoms, as well as comorbidity with depression. Future studies of the natural history should take into account these factors in multivariate approaches.     

Adult-onset tic disorders.

We report on 8 patients with adult-onset motor tics and vocalisations. Three had compulsive tendencies in childhood and 3 had a family history of tics or obsessive-compulsive behaviour. In comparison with DSM-classified, younger-onset Gilles de la Tourette syndrome, adult-onset tic disorders are more often associated with severe symptoms, greater social morbidity, a potential trigger event, increased sensitivity, and poorer response to neuroleptic medication.     

抽动障碍的家系研究

目的从家系研究的角度分析遗传印迹是否与抽动障碍的垂直传递有关.方法采用Tourette综合征及其相关行为障碍定式检查提纲、美国精神障碍诊断与统计手册第4版诊断标准和美国抽动障碍联合会制定的抽动障碍诊断标准,对171例抽动障碍先证者进行评定和诊断;采用标准化表型评定程序,收集先证者及其一级亲属(342人)、二级亲属(1283人)、三级亲属(2310人)的表型资料;根据父亲或母亲的患病情况,将先证者分为母系传递者和父系传递者.结果母系传递对于先证者复杂运动性抽动症状的影响较为显著(偏回归系数=6.6,P=0.01);父系传递的先证者则更容易表现注意问题(t=2.78,P=0.01);由母系传递先证者的发病年龄[(5.6±0.8)岁]早于父系传递的先证者[(6.1±1.1)岁;t=2.34,P=0.02].结论抽动障碍的垂直传递存在亲源特异性表达,遗传印迹机制可能参与了抽动障碍的发病.     

Pharmacologic treatment of tic disorders

The approach to treating children and adolescents with tic disorders has evolved in recent years such that complete elimination of tics is no longer the primary goal of treatment. Indeed, given the high frequency of psychiatric comorbidity in TS, treatment planning begins with identification of target symptoms. Although traditional neuroleptics still represent standard treatment for tics, many families and clinicians are reluctant to use these agents because of concern about the potential for short- and long-term side effects. Thus, there is great interest in the newer atypical neuroleptics. Interest in the atypical neuroleptics is understandable, but much more study is needed before these agents can become first-line treatments for tics. A small group of non-neuroleptic medications have been used in the treatment of tics. Of these, clonidine, guanfacine, tetrabenazine, pergolide, and botulinum toxin injections have shown some promise for suppressing tics. To date, however, only clonidine has been evaluated in randomized, controlled trials, and the results are not consistent across studies. Although comorbid ADHD is common in children with TS, treatment with stimulant medications was not recommended in children with tics. Recent data suggest that stimulants may be used in some children with TS without adverse effects. Until more is known about which children with ADHD and tic disorders can be safely treated with stimulants, however, the use of stimulants in this population should be undertaken with caution. A handful of nonstimulant medications have been used in the treatment of ADHD with some success, but more study is needed for most of these agents. Evaluation of the stimulants and nonstimulants for the treatment of ADHD in children and adolescents with tic disorders is an area worthy of large controlled trials.     

Phenomenology and treatment of tremor disorders

Tremor is classified according to anatomic distribution among body parts, and by frequency and amplitude during rest, postural maintenance, movement, intention, and the performance of specific tasks. Key historical features include age at onset, progression over time, family history, exacerbating and remitting factors and behaviors, response to alcohol and medications, and additional neurological signs and symptoms. Accurate diagnosis is a critical factor in predicting the natural history and response to treatment.     

抽动障碍儿童亲子依恋特点的初步研究

目的：探讨抽动障碍儿童的亲子依恋特点。方法：采用儿童依恋量表对47名抽动障碍儿童与83名正常儿童进行测试,对比各维度评分;采用耶鲁综合抽动严重程度量表（YGTSS）对抽动障碍儿童进行症状评估;将抽动障碍儿童的依恋评分与抽动严重程度进行相关分析和比较。结果：抽动障碍组儿童的父亲依赖度（3．05±0．67）分、母亲依赖度（3．13±0．61）分、母亲亲近度（2．71±0．54）分、父子安全性依恋（2．80±0．56）分及母子安全性依恋（2．93±0．47）分总分均低于对照组（P〈0．05或P〈0．01）;抽动严重程度与依恋量表各维度未见明显相关性。结论：抽动障碍儿童亲子安全性依恋水平低于正常儿童。     

Phenomenology and history of the origin of exhibitionism

Exhibitionism should not be misunderstood as a throw back into phylogenetically highly primitive "sexual advertising". The issue is also missed if one shares the widespread belief that at least some of the cases could be explained by an abnormally increased sexual drive. This sexual deviation mostly appears for the first time at the turn of the second to the third decade of life. The relatively close association with age is not conspicuous when we take a look at first police reports or at the sum total of culpable criminal offences. Only about one-tenth of the cases concern late delinquency beyond 35 or 40 years of age. More than 75% of the adult delinquents had married. Marriage practically never implied a turning-point within the sexual maldevelopment, perhaps also largely due to the specific choice of the spouse. It is more likely that the original conflicts are even aggravated as a result of the confrontation with the marriage partner. There is a sharp contrast between the general tendency on the part of the exhibitionists to follow a set behavioural pattern which is stereotyped and rather mechanical, on the one hand, and the wide variety of "victims" selected by many of these delinquents on the other. There is also a noticeable affinity to theft and misappropriation of property--a criminologically interesting aspect. Among the factors contributing to a lack of self-concept and deficient feeling of male identity, the following have been determined to act in combination with other negative influences: The delinquents grow up in a large family comprising many brothers and sisters, a highly significant factor being a predominance of boys among the siblings; often, there is no positive male reference person as would be represented by the father; or the patient is himself an illegitimate offspring. There may often be a physical malformation or handicap acting as a kind of social stigma. This can result in amplifying the subjective feeling of rejection or non-acceptance. Conflicts of the type of a dysmorphophobia were in far more than one-third of the examined 40 patients contributory to the prerequisites of sexual anomaly. Lack of confidence in one's own capacities is one of the main factors in preventing the delinquents from being professionally as successful as their fathers--which would offer a chance of raising their self-esteem. Self-limitation because of strong aggressive inhibition seems to be the main reason for the albeit slight deterioration in status-determined behaviour and hence social status.(ABSTRACT TRUNCATED AT 400 WORDS)     

Fragile X syndrome associated with tic disorders

Movement disorders other than late onset tremor‐ataxia in association with fragile X syndrome, the most common identifiable cause of inherited mental retardation, seem to be rare. Here we describe five male patients from three unrelated families with fragile X syndrome that presented with motor and phonic tics. Clinically, 4 patients fulfilled diagnostic criteria for Gilles de la Tourette syndrome (GTS) while 1 patient would have been diagnosed with an adult onset tic disorder. However, in all patients onset of tics was considerably later than in typical GTS. Three patients had atypical tics and two patients reported waxing and waning of tic intensity over time. Four of the 5 patients showed clinical signs typical of fragile X syndrome, in particular dysmorphic features, learning difficulties and speech and language problems that required special treatment. All patients had co‐morbidities common to both GTS and fragile X syndrome. We suggest considering fragile X syndrome in GTS complicated by co‐morbidity with late onset of atypical tics, in particular when learning disability and dysmorphic features are present. © 2008 Movement Disorder Society     

Aggressive symptoms in children with tic disorders

Episodes of explosive anger and aggression are reported in patients with tic disorders and probably contribute to psychosocial stress and low quality of life. The source of these symptoms is controversial. The objective of the study was to study the relationship between tic disorders, their associated comorbidities, and aggressive behavior. The cohort included 47 children and adolescents (age 7–17 years) with Tourette syndrome or other chronic tic disorders attending a tertiary pediatric Tourette clinic. Associated psychopathology was assessed with the Yale Global Tic Severity Scale, Yale Brown Obsessive Compulsive Scale, Conners ADHD Rating Scale, Screen for Child Anxiety-Related Emotional Disorders, and Child Depression Inventory. Aggression was assessed with the Overt Aggression Scale and scores were compared with a group of 32 healthy age- and sex-matched children. There were no significant differences in aggression scores between the children with tic disorders and controls. Verbal aggression was the most prevalent type of aggression, found in 70% of the patients with tic disorders. The level of aggression was not correlated to tic severity. Comorbid attention-deficit hyperactivity disorder and obsessive–compulsive disorder increased the probability of aggressive behavior in patients with tic disorders. On regression analysis, the only significant predictor of aggression was the severity of attention-deficit hyperactivity disorder. This study suggests that there is no difference in aggressive behavior between children with tics without comorbidities and healthy children. It is possible that aggressive behavior in children with tic disorders is predominantly associated with comorbid attention-deficit hyperactivity disorder.