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Baizabal-Carvallo JF, Cavanna AE, Jankovic J. Tics emergencies and malignant tourette syndrome: Assessment and management. Neurosci Biobehav Rev 2024; 159:105609. [PMID: 38447821 DOI: 10.1016/j.neubiorev.2024.105609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/29/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
Tourette syndrome (TS) is a complex neurodevelopmental disorder characterized by the presence of tics, frequently accompanied by a variety of neuropsychiatric comorbidities. A subset of patients with TS present with severe and disabling symptoms, requiring prompt therapeutic intervention. Some of these manifestations may result in medical emergencies when severe motor or phonic tics lead to damage of anatomical structures closely related to the tic. Examples include myelopathy or radiculopathy following severe neck ("whiplash") jerks or a variety of self-inflicted injuries. In addition to self-aggression or, less commonly, allo-aggression, some patients exhibit highly inappropriate behavior, suicidal tendencies, and rage attacks which increase the burden of the disease and are important components of "malignant TS". This subset of TS is frequently associated with comorbid obsessive-compulsive disorder. Therapeutic measures include intensive behavioral therapy, optimization of oral pharmacotherapy, botulinum toxin injections, and deep brain stimulation.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA; Department of Sciences and Engineering, University of Guanajuato, León, Mexico.
| | - Andrea E Cavanna
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom; Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and University College London, London, United Kingdom; School of Health and Life Sciences, Aston Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom; School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
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Abstract
Tourette syndrome (TS) causes academic, social, emotional, physical, and functional problems. Most TS patients also have comorbid neuropsychological conditions. The purpose of this review is to provide updated information to the clinician about phenomenology, epidemiology, comorbidities, pathophysiology and management strategies for tics (a hallmark of TS) and TS. Recent findings suggest that TS is likely due to a combination of several different genes and environmental factors, with possible involvement of the cortical-basal ganglia-thalamocortical circuit and related multiple neurotransmitters. First-line management includes psychoeducation for families, patients, and school personnel, as well as behavioral therapy. Non-medicine treatment for tics is advancing to include younger children and increase access via remote service applications. Pharmacotherapy is used if appropriate and several new medicines are under investigation (e.g., Tetrabenazine, valbenazine, deutetrabenazine, ecopipam, cannabinoids). Deep brain stimulation and Mouthguard therapy can be used for children with intractable illness.
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Affiliation(s)
- Kallol K Set
- Pediatric Neurologist, Dayton Children's Hospital, Clinical Assistant Professor, Pediatrics, Boonshoft School of Medicine, Wright State University, One Children's Plaza, Dayton, Ohio, 45404-1815, USA.
| | - Jacqueline N Warner
- Pediatric Psychologist, Clinical Assistant Professor, Pediatrics. Boonshoft School of Medicine, Wright State University, Dayton Children's Hospital, One Children's Plaza, Dayton, Ohio, 45404-1815, USA.
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Ueda K, Black KJ. A Comprehensive Review of Tic Disorders in Children. J Clin Med 2021; 10:2479. [PMID: 34204991 PMCID: PMC8199885 DOI: 10.3390/jcm10112479] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 01/13/2023] Open
Abstract
Tics are characterized by sudden, rapid, recurrent, nonrhythmic movement or vocalization, and are the most common movement disorders in children. Their onset is usually in childhood and tics often will diminish within one year. However, some of the tics can persist and cause various problems such as social embarrassment, physical discomfort, or emotional impairments, which could interfere with daily activities and school performance. Furthermore, tic disorders are frequently associated with comorbid neuropsychiatric symptoms, which can become more problematic than tic symptoms. Unfortunately, misunderstanding and misconceptions of tic disorders still exist among the general population. Understanding tic disorders and their comorbidities is important to deliver appropriate care to patients with tics. Several studies have been conducted to elucidate the clinical course, epidemiology, and pathophysiology of tics, but they are still not well understood. This article aims to provide an overview about tics and tic disorders, and recent findings on tic disorders including history, definition, diagnosis, epidemiology, etiology, diagnostic approach, comorbidities, treatment and management, and differential diagnosis.
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Affiliation(s)
- Keisuke Ueda
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA;
| | - Kevin J. Black
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA;
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Neuroscience, Washington University School of Medicine, St. Louis, MO 63110, USA
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Robert Brašić J, Mari Z, Lerner A, Raymont V, Zaidi E, Wong DF. Remission of Gilles de la Tourette Syndrome after Heat-Induced Dehydration. ACTA ACUST UNITED AC 2018; 6. [PMID: 30090843 PMCID: PMC6078428 DOI: 10.4172/2329-9096.1000472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Heat has been reported to exert variable effects on people with Gilles de
la Tourette syndrome (TS). At age 24 years, a 32-year-old right-handed man with
TS experienced a marked reduction in tics for two years after undergoing
dehydration by entering a hot tub at 103°F (39.4°C) to
104°F (40.0°C) for 3 to 4 hours. On the Yale Global Tic Severity
Scale (YGTSS) he scored 55 seven months before dehydration and 13 one month
after dehydration. An intense heat exposure and dehydration led to an apparent
remission in tics. The remission continued without the use of prescribed or
nonprescribed medications or substances for two years until tics returned in the
worst ever exacerbation after a tetanus immunization. The heat exposure may have
altered at least temporarily his thermostat for normal heat-loss mechanisms
through dopaminergic pathways from the anterior hypothalamus to the basal
ganglia and the substantia nigra. Whether or not that mechanism or some other
mechanism relevant to the heat exposure and/or dehydration is at play, the
sudden and marked improvement in his tics needs further attention. Prospective
testing of the heat and dehydration effect on tics should be pursued.
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Affiliation(s)
- James Robert Brašić
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Section of High Resolution Brain Positron Emission Tomography Imaging, Johns Hopkins Outpatient Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zoltan Mari
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, Maryland, USA
| | - Alicja Lerner
- Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, Maryland, USA
| | - Vanessa Raymont
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Section of High Resolution Brain Positron Emission Tomography Imaging, Johns Hopkins Outpatient Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eram Zaidi
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Section of High Resolution Brain Positron Emission Tomography Imaging, Johns Hopkins Outpatient Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dean F Wong
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Section of High Resolution Brain Positron Emission Tomography Imaging, Johns Hopkins Outpatient Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Robertson MM, Eapen V. The Psychosocial Aspects of the Gilles de la Tourette Syndrome: Empirical Evidence from the Literature. Curr Behav Neurosci Rep 2017. [DOI: 10.1007/s40473-017-0107-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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A personal 35 year perspective on Gilles de la Tourette syndrome: prevalence, phenomenology, comorbidities, and coexistent psychopathologies. Lancet Psychiatry 2015; 2:68-87. [PMID: 26359614 DOI: 10.1016/s2215-0366(14)00132-1] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 09/15/2014] [Indexed: 02/07/2023]
Abstract
This Series is a personal narrative of my experience with patients with Gilles de la Tourette syndrome and covers its definition and history since the first description in 1825. Controversy entered the prevalence debate early. Although originally considered very rare, in the 1980s, Tourette's syndrome was reported to be common. However, Tourette's syndrome has been shown to occur at a prevalence of about 0·85% to 1%. Tourette's syndrome is more common in the male population, more prominent during childhood, and usually improves, but does not disappear with age. Tourette's syndrome is considered less common in people of sub-Saharan black African, African-American, and American Hispanic ethnic origin. The phenomenology is similar worldwide, indicating a biological basis. The hallmark characteristics are multiple motor and one or more vocal/phonic tics. Other associated features include premonitory urges, a waxing and waning course, and to a much lesser degree, coprolalia. Comorbid disorders are common and are suggested to include obsessive-compulsive disorder and behaviours, attention deficit hyperactivity disorder, and autistic spectrum disorder. Coexistent psychopathologies are suggested to include depression and conduct and personality disorders. Importantly, I argue that Tourette's syndrome is not a unitary condition. Finally, I offer suggestions for future research.
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Cavanna AE, Ali F, Leckman JF, Robertson MM. Pathological laughter in Gilles de la Tourette syndrome: An unusual phonic tic. Mov Disord 2010; 25:2233-9. [DOI: 10.1002/mds.23216] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Weil RS, Cavanna AE, Willoughby JMT, Robertson MM. Air swallowing as a tic. J Psychosom Res 2008; 65:497-500. [PMID: 18940380 DOI: 10.1016/j.jpsychores.2008.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Revised: 12/18/2007] [Accepted: 04/01/2008] [Indexed: 10/21/2022]
Abstract
The authors present a patient with Gilles de la Tourette syndrome who developed abdominal distension and bloating due to air swallowing. We suggest that this air swallowing may have been due to a tic.
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Affiliation(s)
- H S Singer
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
The constellation of motor and vocal tics and certain of the other neuropsychiatric symptoms seen in Tourette syndrome are thought to have an organic basis, although the nature of the neurobiological lesion is uncertain. The syndrome is usually familial but the presumed genetic substrate has not been identified. A number of models currently under debate include a proposed autoimmune contribution.
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Affiliation(s)
- M M Robertson
- Academic Department of Psychiatry and Behavioural Sciences, University College London Medical School, UK
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Abstract
Neuropsychiatric disorders of childhood include autism spectrum disorders, disorders comprising attention deficits (attention-deficit-hyperactivity disorder and deficits in attention, motor control and perception), tics (motor or vocal, or both), and obsessions and compulsions (obsessive-compulsive disorder). They affect a small proportion of the child population. They can now reliably be diagnosed, and are valid and clinically meaningful conditions. Effective interventions are available for most of these disorders.
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Affiliation(s)
- C Gillberg
- Department of Child and Adolescent Psychiatry, Sahlgren University Hospital, Annedals Clinics, Göteborg, Sweden
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