Tic Disorders Complete

Tic Disorders
Iqra Tariq
Qureshi
Clinical Psychologist &
Senior Demonstrator
Dept. Behavioral
Sciences
Objective
• To recognize tics and ticsdisorders
• To identify the differential diagnosis and medical workup for tics
• To explain treatment options for tics to patients/families, including therapy
and medication options
• To apply knowledge about differential diagnosis and treatment options to
patient cases
Tics
• Tic: A sudden, rapid, recurrent, non-rhythmic movement or
vocalization.
• Premonitory urge: sensory phenomena (itch, tingle, vague
discomfort) that precede and trigger the urge to tic
• Suggestible and suppressible
• Exacerbating factors: psychosocial stress, temperature changes,
illness, fatigue
• Rarely occur during sleep
• Natural course: waxing and waning symptoms.
• Genetic: first degree relative with TD = 5-15x increased risk. Can
also be sporadic
Types of Tics
• Simple motor tics • Simple vocal tics
• Fast, brief, involving 1-2 muscle groups • Solitary, meaningless sounds and noises
• Eye blinking, shoulder shrugs, head jerks, • Grunting, sniffing, snorting, throat
facial grimaces, abdominal tensing clearing, humming, coughing, barking or
screaming.
• Complex motor tics
• Larger muscle groups, last longer,
• Complex vocal tics
Sequentially and/or simultaneously • Linguistically meaningful utterances
produced, coordinated
• Partial words, words out of context (oh
• hand gestures, jumping, touching, boy!), repeated sentences, coprolalia,
pressing, palilalia or echolalia
repeatedly smelling an object.
Tic Disorders DSM
5
• Tourette’s Disorder
• Both multiple motor and one or more vocal tics present at some
time during the illness
• May wax and wane in frequency but persist at least a year since
first tic onset
• Not attributable to effects of a substance or another medical
condition.
• Onset before age 18
• Persistent (Chronic) Motor or Vocal Tic Disorder
• Provisional tic disorder
Chronic Tic Disorders
• Average age of onset: 7 years
• Prevalence/severity peak: 9-12 years
• Remission/marked attenuation: 65% by 18-20
years
• Male-female ratio of 2:1—4:1
• Prevalence
• CTD: 1-3%, TD: 1%
• Transient tic disorders: 20% life time prevalence
Co-
• Obsessive-Compulsive Disorder
•
morbidities
20%-60% of TD patients meet criteria for
• Learning disabilities
• 23%
OCD
• High rates of school-related problems.
• 30%-28% of OCD patients report co- Especially if co-morbid ADHD
morbid tics
• Male gender and history of perinatal
problems increase risk
• Attention-Deficit/Hyperactivity • Autism Spectrum Disorder
Disorder
• Careful assessment to differentiate primary
• Up to 50% of children with TD, primary ASSD or ASD with co-occurring
CTD tics.
• TD: as high as 60-80% • 4.6% of youth with TD had comorbid ASD
• Co-occurrence = disruptive • Anxiety and Depression
behaviors, learning disorders and
academic difficulties (4x) • Especially if tics persist into adulthood
• ADHD diagnosis often precedes onset
of tics.
Medical Work-up
• Organic process: sudden onset of severe tics, atypical tics, mental
status change
• Consider CO poisoning, stroke, CNS infection,
PANDAS/PANS
• Labs: Hemoglobin, renal/hepatic function, thyroid panel, ferritin,
UDS
• If indicated, tests for co-occurring infection: culture, rapid viral
tests
• EEG and brain imaging NOT routinely recommended unless
neurological findings.
Treatmen
t
• Decision to treat based on level of impairment and distress caused by tics
• Often comorbid condition causes more functional impairment/impacts quality of life
• Behavioral interventions
• Habit Reversal Training (HRT)
• C-BIT
• Medications
• Not many rigorous studies in children
• Considered for moderate to severe tics causing severe impairment in quality of life or when
medications target both tics and co-morbidities.
Behavior
therapy CBIT
• Comprehensive Behavioral Intervention for Tics (
for diagnosis of tics or Tourette’s Disorder
): evidenced-based behavioral intervention
• Adults and children studied 30+ years

• highly effective
• quick response rate.
• Superior in comparison to Supportive Therapy and psychoeducation
• CBIT/HR considered first line of non-pharmaceutical treatment for TS.
• Studies completed include the following: HRT vs. Supportive Therapy (Wihelm et al., 2003; Am J Psychiatry), HRT vs. Supportive therapy
(Deckersbach et al., 2006; Behav Res Ther), Behavior Therapy for Children With Tourette’s Disorder: A Randomized Controlled Trial (John
Piacentini; Douglas W. Woods; Lawrence Scahill; et al., JAMA2010;303(19): 1929-1937 (dol: 10. 1001/jama.2010.607) http://jama.ama-
assn.org/cgi/content/full/303/19/1929
Habit reversal Training/CBIT:
a multicomponent
treatment
• HABIT REVERSAL
• Psychoeducation
• Creating a Tic Hierarchy and Inconvenience Review
• Motivation -developing a behavioral reward program for the client
• Social Support
• Functional-Based Assessment/Interventions
• HR (Awareness/Competing Response)
• Relaxation Techniques
• Relapse Prevention
• CBIT interventions are focused on management rather than a cure to Tic/Tourette’s Disorder.
Psychoeducation
Teaching the patient and family more about tic
disorders, including the following:
• What are tics and what is a tic disorder?
• How common are they and what contributes to
their development?
• How do we treat tic disorders (CBIT)?
• What are common social struggles and
comorbidities with tic disorder?
Tic hierarchy
• The tic hierarchy is based on the client’s view point due to it being a self-
management intervention. It is important to have the client motivated and identify
the tic that is most bothersome to them.
• The clinician will want to start with the most bothersome tic and work down the
client’s list. The clinician can be flexible on the list with the client’s wishes. This will
also help the client be motivated in therapy to decrease their tics.
• When explaining to parents, it is important for them to be aware that what tic is
most important or impairing to their child may not be the same tic for the parent
and that is ok.
Functional-based
Assessment/Intervention
s
• The purpose of the FBA is to identify the internal and external environmental variables that may be
increasing or maintaining the client’s tics. Habit Reversal addresses internal environments and
Functional Assessment/Interventions address external environments.
• These environments or factors are individualized for each client.
• It is important to address both of these environments for treatment to be effective.
• Internal factors: premonitory urge, anxiety, or boredom
• External Factors: loud noises, social bullying, bright lights, chaos, etc.
• These variables are then modified for the purpose of reducing tics.
• The client’s reactions to the variables are also modified to reduce tics.
• This is where relaxation techniques can be introduced to the client.
Relaxation
• Diaphragmatic Breathing
• Client learns to breathe from their diaphragm, rather from their chest.
The training does include awareness of inhaling and exhaling slowly.
• Progressive Muscle Relaxation
• The client’s body is divided up into a series of large muscle groups, each
group is tensed and then relaxed. This method usually starts with the
head and ends with the feel (not mandatory). Tension usually is
maintained for 5 seconds and relaxation for about 10-15 seconds.
Awareness Training
• The purpose of awareness training is to get the client to verbally
acknowledge when their tics are happening and when they are about to
happen. This is considered one of the most important processes of
HRT.
• Parents should be informed that this can cause stress within their
relationship with their child. The child may not want to be made aware
of their tics, but it is important to continue with the training.
Medications
• Typical antipsychotics • Haloperidol (Haldol)
• Starting dose: 0.25-0.5 mg
• Range: 1-4 mg
• FDA-approved medications: haloperidol • Side effects: extrapyramidal symptoms (EPS), anxiety
and pimozide flares
• Pimozide better than haloperidol—more • Pimozide (Orap)

effective, better tolerated • Starting dose: 0.5-1 mg
• Lower doses required (compared to • Range: 2-8 mg
psychosis). Careful risk/benefit • Side effects/considerations: EPS, EKG monitoring, 2D6
assessment interaction
Medications
• Guanfacine (Tenex)
• Alpha-2 Agonists • Starting dose: 0.5-1 mg
• More favorable side effect profile • Dose range: 1-4 mg
compared to antipsychotics
• Guanfacine ER (Intuniv)
• Effect size 0.5 (medium)
• Starting dose: 1 mg; dose range: 1-4 mg
• Works better when co-morbid
ADHD • Clonidine
• Side effects: sedation, • Starting dose: 0.5 mg
hypotention, bradycardia, • Dose range: 0.1-0.4 mg
rebound effects if discontinued
abruptly • Clonidine ER (Kapvay)
• Starting dose: 0.1 mg; dose range: 0.1-0.4 mg
NOT RECOMMENDED
• Deep brain stimulation
• Repetitive magnetic stimulation
• Special diets
• Dietary supplements
• Antibiotics or immunomodulatory treatments
Reference
s
• Practice Parameter for the Assessment and Treatment of Children and Adolescents With Tic Disorders.
Murphy, Tanya K. et al. Journal of the American Academy of Child & Adolescent Psychiatry , Volume 52 , Issue 12
, 1341 - 1359
• Bestha, et al. Management of tics and Tourette’s disorder: an update. Expert Opin. Pharmacother. (2010) 11(11).
• Treatment of ADHD in children with tics: A randomized controlled trial (TACT). Neurology. 2002. Feb
26;58(4):527-36.
• Clinical evaluation of Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Recommendations from the PANS
2013 PANS Consortium Conference
Chang Kiki, Frankovich Jennifer, Cooperstock Michael, Cunningham Madeleine W., Latimer M. Elizabeth, Murphy Tanya K.,
Pasternack Mark, Thienemann Margo, Williams Kyle, Walter Jolan, Swedo Susan E., and From the PANS Collaborative Consortium.
Journal of Child and Adolescent Psychopharmacology. February 2015, 25(1): 3-13. doi:10.1089/cap.2014.0084.
Thank
• If you have any furtheryou!
questions on CBIT therapy, please feel free to email
me at:
• Psy.iqra@gmail.com

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Tic Disorders

• Adults and children studied 30+ years

• Pimozide better than haloperidol—more • Pimozide (Orap)

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