Tourette syndrome: associated symptoms and most disabling features

Sleep and circadian rhythm dysfunctions in movement disorders beyond Parkinson's disease and atypical parkinsonisms

PURPOSE OF REVIEW

This review aimed to comprehensively outline sleep and circadian rhythm abnormalities in hyperkinetic movement disorders beyond Parkinson's disease and atypical parkinsonisms, including tremor, dystonia, choreiform movements, tics, and ataxia disorders.

RECENT FINDINGS

Insomnia, poor sleep quality, and excessive daytime sleepiness (EDS) are commonly reported in essential tremor, Wilson's disease, tics or Tourette's syndrome, and spinocerebellar ataxia (SCA). REM sleep behavior disorder (RBD) have been observed in Wilson's disease and SCA. A combination of REM and non-REM parasomnias, along with nocturnal stridor with the initiation of sleep and re-entering after awakening, are characterized by undifferentiated Non-REM and poorly structured N2 in anti-IgLON5 disease. Restless legs syndrome (RLS) has been reported commonly in SCAs. Sleep-related dyskinesia has been reported in ADCY5-related disease and GNAO1-related movement disorder.

SUMMARY

Sleep problems can manifest as a result of movement disorders, either through direct motor disturbances or secondary nonmotor symptoms. Medication effects must be considered, as certain medications for movement disorders can exacerbate or alleviate sleep disturbances. Distinguishing sleep problems in some diseases might involve pathognomonic symptoms and signs, aiding in the diagnosis of movement disorders.

A qualitative study of Chinese parental perspectives on the causes of Tourette syndrome in children

Parents' beliefs and attitudes toward their children with Tourette syndrome (TS) influence treatment-seeking behaviors. This study aimed to explore and describe the Chinese parents' perspectives on the causes of TS for their children. A qualitative study using semi-structured interviews was conducted with the parents of TS patients from a children's hospital in western China from June to July 2021, and thematic analysis was performed to transcribe interviews and identify themes. A total of 13 participants were interviewed in this study. Five themes were developed in relation to the cognition of the causes of TS in parents, including physical problems, parenting and education problems, mental problems, bad habits, and neurological problems. Due to the insufficient awareness of TS, most parents repeatedly seek medical advice that they regarded the symptoms as physical problems or neurological problems. They generally felt guilty and blamed themselves for their parenting styles and education methods. And some parents attributed it to the poor psychological quality or the bad habits of children. Study findings showed a lack of scientific understanding of the causes of TS among parents further hindered the timely effective treatment for patients and affected the family relationships, which highlights the importance of public education and raising awareness of the disease.

Door-to-door Video-Enhanced Prevalence Study of Tourette Disorder Among African Americans

Tourette syndrome (TS) affects about 0.5% of the population worldwide, but only sparse and conflicting data exist on TS prevalence among minority samples. Here we used VISIT-TS (a survey preceded by a short video showing tic phenomenology) and community outreach to provide estimates of tic disorder prevalence in African Americans. Community health workers (CHWs) left flyers at households in a predominantly minority neighborhood and approached people at a community health fair. Of 606 such contacts, 222 individuals agreed to discuss the study. Of these, 70% enrolled, of whom 82% identified as Black and 64% female. The VISIT-TS was well received. Lifetime prevalence of TS or another chronic tic disorder (TS/CTD) was 3.2%, and 31% endorsed any lifetime simple tic. The number of enrolled Black participants is remarkable compared to earlier TS studies, allowing one of the first prevalence estimates in this population (TS 2.3%, TS/CTD 3.9%). Tic disorders were endorsed only by Black respondents, though the small White sample precluded statistical comparison. Women had higher rates than men of TS (M:F = 0:1) and of any lifetime simple tic (M:F = 0.85), differing significantly from the expected 4:1 ratio (p = .009 and p < .001, respectively). For TS/CTD the ratio was 1.2:1 (p > .15). We conclude that VISIT-TS is a feasible tic screening tool in a minority population, that CHW community outreach increases enrollment of Black participants, that TS/CTD is no less common in this population, and that tics were as common in female as in male respondents.

Sleep Disturbance in Tourette's Disorder: Potential Underlying Mechanisms

Purpose of review

Sleep disturbance is common in TD. However, our understanding of the pathophysiological mechanisms involved is preliminary. This review summarizes findings from neuroimaging, genetic, and animal studies to elucidate potential underlying mechanisms of sleep disruption in TD.

Recent findings

Preliminary neuroimaging research indicates increased activity in the premotor cortex, and decreased activity in the prefrontal cortex is associated with NREM sleep in TD. Striatal dopamine exhibits a circadian rhythm; and is influenced by the suprachiasmatic nucleus via multiple molecular mechanisms. Conversely, dopamine receptors regulate circadian function and striatal expression of circadian genes. The association of TD with restless legs syndrome and periodic limb movements indicates shared pathophysiology, including iron deficiency, and variants in the BTDB9 gene. A mutations in the L-Histidine Decarboxylase gene in TD, suggests the involvement of the histaminergic system, implicated in arousal, in TD.

Summary

These biological markers have implications for application of novel, targeted interventions, including noninvasive neuromodulation, iron supplementation, histamine receptor antagonists, and circadian-based therapies for tic symptoms and/or sleep and circadian rhythms in TD.

"Sorry, I Didn't Mean to Kiss at You": A Descriptive Analysis of Tourette Syndrome in Interpersonal Interactions

Recent research has begun to explore the specific social challenges experienced by persons with Tourette syndrome (TS); however, it does not specifically address the challenges that often arise interpersonally as part of people's communicative interactions and these interactions socially construct the individual and collective well-being of all involved. This study conducted semi-structured interviews with 18 adults who identified as having TS in order to investigate the ways in which others respond behaviorally to TS behaviors and the ways TS behaviors are misinterpreted within interpersonal interactions. Thematic analysis was used to identify themes common within participant responses. All participants reported receiving unwanted attention from others in response to their TS symptoms. Unwanted attention was further divided into six emergent subthemes, including verbal harassment, physical abuse, staring, general bullying, getting into trouble, and being kicked out. Three types of misunderstandings were also reported in interpersonal interactions: misunderstanding communicative intention, misunderstanding TS, and misunderstanding the cause of TS behaviors. Applying attribution theory, it is determined that it is ultimately the misattribution of communicative intent to TS behaviors that causes many misunderstandings reported by adults with TS and leads to a plethora of interpersonal, communicative challenges. Importantly, these misunderstandings are what ultimately contribute to much of the unwanted attention described by the participants in this study and documented in previous work, highlighting the value of a greater awareness of how misunderstandings take place with respect to TS.

Sleep Disorders and Sleep Problems in Patients With Tourette Syndrome and Other Tic Disorders: Current Perspectives

Sleep disorders seem to be a frequent complaint of patients diagnosed with Tourette syndrome (TS) or chronic or persistent tic disorders (CTD or PTD). In this review, we expanded a previously used search using 4 well-known databases up to February 15, 2022, looking for the coexistence of global and/or specific sleep disorders and polysomnographic studies performed on patients with TS/CTD/PTD. The references of interest in the topic were selected by hand. Sleep disorders in general, insomnia, different arousal disorders, the persistence of tics during sleep, excessive daytime sleepiness, and periodic limb movements during sleep (PLMS) were very frequent in patients with TS, most of them being more frequent in patients with comorbid Attention Deficit Hyperactivity Disorder. The most frequent results from polysomnographic studies were decreased sleep efficiency and increased sleep onset latency. Many of these findings could be related to medication used for the treatment of tics and comorbid disorders.

Sleep and chronotype in adults with persistent tic disorders

OBJECTIVE

This study examined sleep disorders and sleep medication use rates, nighttime tics, and sleep and chronotype in relation to tic and co-occurring symptoms in adults with persistent tic disorders (PTDs), including Tourette's disorder (TD).

METHODS

One hundred twenty-five adult internet survey respondents rated sleep history, sleep, chronotype, tic severity, impairment, attention deficit hyperactivity disorder, obsessive-compulsive symptoms, anxiety, depression, and emotional and behavioral dyscontrol.

RESULTS

Bruxism, insomnia, tic-related difficulty falling asleep, and melatonin use were commonly endorsed. Sleep disturbance correlated with impairment, obsessive-compulsive symptoms, and emotional and behavioral dyscontrol. Eveningness correlated with vocal and total tic severity only in TD. Controlling for age and sex, age, impairment, and obsessive-compulsive symptoms predicted sleep disturbance, and age and tic severity predicted chronotype.

CONCLUSIONS

Impairment and obsessive-compulsive symptoms play a role in sleep disturbance in adults with PTDs, and may be intervention targets. Eveningness relates to tic severity, which may suggest the utility of interventions to advance chronotype.

Tourette Disorder and Sleep

Healthy sleep is of utmost importance for growth, development, and overall health. Strong evidence shows that sleep is affected negatively in patients and particularly children with Tourette Disorder (TD). There is also a frequent association of TD with Attention Deficit Hyperactivity Disorder (ADHD) which alone has negative effects on sleep and cumulatively worsens the associated sleep findings. The most consistent polysomnographic findings in patients with TD is decreased total sleep time, lower sleep efficiency and an elevated arousal index. Polysomnography studies have confirmed the presence of movements and persistence of tics during both Rapid Eye Movement (REM) and NREM sleep [1]. In general Patients with TD are found to have an increased incidence of sleep onset and sleep maintenance insomnia. Some studies have shown increased incidence of parasomnias (including sleepwalking, sleep talking and night terrors), but this may be confounded by the increased underlying sleep disruptions seen in TD. The hypersomnolence found in patients with TD is also suggested to be secondary to the underlying TD sleep disruption. There is not a significant association with sleep disordered breathing or circadian rhythm disorders and TD. Treatment of underlying TD is important for the improvement of sleep related TD manifestations and is outlined in this review.

Ticked Off: Anger Outbursts and Aggressive Symptoms in Tourette Disorder

Tourette disorder is a complex neuropsychiatric syndrome of childhood onset characterized by multiple motor and phonic tics and is associated with high rates of psychiatric comorbidity. Symptoms of impulsive aggression (explosive outbursts or "rage") are commonly encountered in the clinical setting, cause significant morbidity, and pose diagnostic and treatment challenges. These symptoms may be multifactorial in etiology and result from a complex interplay of illness severity and psychosocial factors. Treatment strategies require careful differential diagnostic evaluation and include both behavioral and pharmacologic interventions.

A novel local field potential-based functional approach for targeting the centromedian-parafascicular complex for deep brain stimulation

BACKGROUND

The centromedian-parafascicular (Cm-Pf) complex of the thalamus is a common deep brain stimulation (DBS) target for treatment of Tourette syndrome (TS). Currently, there are no standardized functional intraoperative neurosurgical targeting approaches. Collectively, these issues have led to variability in DBS lead placement. Therefore, more defined methods are needed to improve targeting accuracy.

OBJECTIVE

The objective of this observational study was to develop and to verify a functional mapping task capable of differentiating the Cm-Pf region from the nearby ventral intermediate (Vim) nucleus region of the thalamus. The overarching goal was to improve the reproducibility of DBS targeting in the Cm-Pf region.

METHODS

Seven TS patients completed a modified Go/NoGo task (five in the post-operative setting and two in the intra-operative setting). Post-operative neural signals from Cm-Pf region were collected using sensing-enabled implanted neural stimulators, and intraoperative neural signals from the Cm-Pf region were collected using an external amplifier. Event-related potential (ERP) features were identified by using the grand-average of stimulus onset signals derived from the postoperative participants. These features were correlated with anatomical locations for the specific electrode recordings. The same features were extracted from the intraoperative patients in order to verify electrode positions in the operating room environment.

RESULTS

Two features - a positive and a negative deflection - were identified in the average ERP from the post-operative participants. The peak amplitudes of both features were significantly correlated with the electrode depth position (p = 0.025 for positive deflection and p = 0.039 for negative deflection). The same result was reproduced intra-operatively in the two most recent patients, where more ventral electrode contacts revealed stronger peak amplitudes in comparison to the dorsal electrode contacts.

CONCLUSION

This process was used to physiologically confirm accurate lead placement in the operating room setting. The modified Go/NoGo task elicited robust neural responses in the Cm-Pf region however the signal was not present in the Vim nucleus region of thalamus along the DBS electrode trajectory. We conclude that the differences in ERP responses may be a potentially novel LFP based functional approach for future targeting of the Cm-Pf complex for TS DBS.

Rage attacks in Tourette Syndrome and Chronic Tic Disorder: a systematic review

Tourette syndrome (TS) and chronic motor/vocal tic disorder (CTD) are neurodevelopmental conditions defined by the occurrence of multiple tics. Besides the well-known association with attention deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD), rage attacks (RA) represent common and detrimental symptoms for patients. Inorder to explore prevalence of RA in tic disorders, relation to tic severity/comorbidities and available treatments, we performed a systematic literature review based on PRISMA Guidelines. 32 studies published between January 2008 - December 2019 were deemed suitable for the analysis and provided a prevalence of 20-67 %. Most findings showed a direct correlation with tic severity and a significant impact on psychosocial functioning. Although apparently related to comorbid ADHD, RA also frequently occur as independent manifestations. Association with other comorbidities, such as OCD, impulse control and mood disorders has also been reported, not yet fully established. Behavioral interventions appear to be effective, whereas there is limited evidence concerning the efficacy of medication. In TS/CTD, RA may be regarded as a major comorbidity that requires clinical investigation in order to develop personalized treatments.

Sleep disorders in tourette syndrome

Sleep disorders are very common in patients diagnosed with Tourette syndrome (TS). The present review focuses on sleep disorders and the results of polysomnographic studies performed in patients with TS. We made a search using the PubMed, Embase, MedLine, and Web of Science Databases, from 1966 until November 14, 2019, crossing the search term "Tourette syndrome" with "sleep", "sleep disorders", "sleep disturbances", and "polysomnography", and with each of the specific sleep disorders listed according to the International Classification of the Sleep Disorders-Third Edition. Then we identified the references of interest for the topic. Insomnia, excessive daytime sleepiness, disorders of arousal (sleepwalking, sleeptalking, sleep terrors, and enuresis), the persistence of tics during sleep, and presence of periodic limb movements during sleep (PLMS) were very frequent in patients with TS. These disturbances were more frequent in children and in patients with comorbid Attention Deficit Hyperactivity Disorder. Decreased sleep efficiency, decreased percentage of delta sleep, increased nocturnal awakenings and increased PLMS were the most consistent findings in the polysomnographic studies.

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.

Sleep difficulties in children with Tourette syndrome and chronic tic disorders: a systematic review of characteristics and associated factors

Sleep difficulties are common in children and young people with Tourette syndrome and chronic tic disorders (TS/CTD). However, it is unclear whether sleep problems can be considered typical of the TS/CTD phenotype or whether they reflect concomitant factors such as individual patient characteristics (e.g. medication use), underlying neurodevelopmental disorders and/or co-occurring psychiatric symptoms. To help address this question, this review systematically explored types and frequency of sleep problems in children and young people with TS/CTD, while also examining the heterogeneity and methodological quality of studies. Psycinfo, Ovid Medline, Embase, and Web of Science databases were searched using a range of terms relating to tics, sleep and co-occurring psychopathology. Studies were considered that included a sample of children with TS/CTD (n &gt; 5) for whom sleep difficulties were measured. Eighteen studies met criteria for inclusion in the review. Findings supported the high prevalence of sleep difficulties in children with TS/CTD, though estimates of sleep difficulties ranged from 9.7% to 80.4%. Twelve studies reported on other factors affecting sleep in this patient group including tic severity, comorbid psychopathological or neurodevelopmental disorders and medication use. Studies varied in terms of methodology, sample characteristics and research quality, but most concluded that children with TS/CTD experienced high levels of sleep difficulties with children with co-occurring anxiety most at risk. The current review highlights the need for further empirical investigation of sleep in children with TS/CTS, with a view to informing understanding and clinical management.

Outpatient Treatment of Tic Disorders Among Children and Adults

Introduction

Limited information is available regarding treatment practices in applied settings for children and adults with tic disorders (TDs). We describe, for the first time, the treatment of TDs in U.S. children and adults in the outpatient setting.

Methods

Data from the 2003-2010 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey were used. Descriptive statistics for modality of treatment and class of pharmacological medications were reported by patient and visit characteristics. Separate multivariable logistic regression models were used to examine associations between patient and visit characteristics and classes of medications prescribed.

Results

One third (n = 99) of the sample did not receive any psychiatric or psychological treatment. Nearly two-thirds received a psychotropic medication. The most common class of medication was alpha-2 agonists (25%), followed by stimulants (23%), serotonin-reuptake inhibitors (SRIs) (19%), atypical antipsychotics (18%), anxiolytics (14%), anticonvulsants (11%), and typical antipsychotics (8%). Comorbid disorders and chronicity of problems were significantly associated with the receipt of certain classes of medications. Relatively few patients (18%) received psychotherapy.

Conclusions

If the decision is made to treat tic disorders, the choice of medication is dependent on the primary complaints, severity, chronicity, and the presence of comorbid psychiatric disorders. In general, comorbid externalizing, anxiety and mood disorders appear to influence treatment decisions in addition to TDs.

Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette syndrome

IMPORTANCE

Tourette syndrome (TS) is characterized by high rates of psychiatric comorbidity; however, few studies have fully characterized these comorbidities. Furthermore, most studies have included relatively few participants (<200), and none has examined the ages of highest risk for each TS-associated comorbidity or their etiologic relationship to TS.

OBJECTIVE

To characterize the lifetime prevalence, clinical associations, ages of highest risk, and etiology of psychiatric comorbidity among individuals with TS.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional structured diagnostic interviews conducted between April 1, 1992, and December 31, 2008, of participants with TS (n = 1374) and TS-unaffected family members (n = 1142).

MAIN OUTCOMES AND MEASURES

Lifetime prevalence of comorbid DSM-IV-TR disorders, their heritabilities, ages of maximal risk, and associations with symptom severity, age at onset, and parental psychiatric history.

RESULTS

The lifetime prevalence of any psychiatric comorbidity among individuals with TS was 85.7%; 57.7% of the population had 2 or more psychiatric disorders. The mean (SD) number of lifetime comorbid diagnoses was 2.1 (1.6); the mean number was 0.9 (1.3) when obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD) were excluded, and 72.1% of the individuals met the criteria for OCD or ADHD. Other disorders, including mood, anxiety, and disruptive behavior, each occurred in approximately 30% of the participants. The age of greatest risk for the onset of most comorbid psychiatric disorders was between 4 and 10 years, with the exception of eating and substance use disorders, which began in adolescence (interquartile range, 15-19 years for both). Tourette syndrome was associated with increased risk of anxiety (odds ratio [OR], 1.4; 95% CI, 1.0-1.9; P = .04) and decreased risk of substance use disorders (OR, 0.6; 95% CI, 0.3-0.9; P = .02) independent from comorbid OCD and ADHD; however, high rates of mood disorders among participants with TS (29.8%) may be accounted for by comorbid OCD (OR, 3.7; 95% CI, 2.9-4.8; P < .001). Parental history of ADHD was associated with a higher burden of non-OCD, non-ADHD comorbid psychiatric disorders (OR, 1.86; 95% CI, 1.32-2.61; P < .001). Genetic correlations between TS and mood (RhoG, 0.47), anxiety (RhoG, 0.35), and disruptive behavior disorders (RhoG, 0.48), may be accounted for by ADHD and, for mood disorders, by OCD.

CONCLUSIONS AND RELEVANCE

This study is, to our knowledge, the most comprehensive of its kind. It confirms the belief that psychiatric comorbidities are common among individuals with TS, demonstrates that most comorbidities begin early in life, and indicates that certain comorbidities may be mediated by the presence of comorbid OCD or ADHD. In addition, genetic analyses suggest that some comorbidities may be more biologically related to OCD and/or ADHD rather than to TS.

Post-operative Adult Onset Tic Disorder: A Rare Presentation

Tics are rapid and repetitive muscle contractions resulting in stereotype movements and vocalizations that are experienced as involuntary. Onset before 18-year is a diagnostic criterion for tic disorders. Children and adolescents may exhibit tic behaviors after a stimulus or in response to an internal urge. Tic behaviors increase during physical or an emotional stress. Adult onset tic disorders are reported by infections, drugs, cocaine, toxins, chromosomal disorders, head injury, stroke, neurocutaneous syndromes, neurodegenerative disorders and peripheral injuries. Only few cases have yet been reported having onset after surgery though surgery brings both physical and emotional stress to the patient. We report a case of a 55-year-old lady who developed tic disorder as post-operative event of cataract surgery. Our patient had a dramatic response to haloperidol which is in contrast to all earlier reports.

Does it help to talk about tics? An evaluation of a classroom presentation about Tourette syndrome

BACKGROUND

Tourette syndrome (TS) is a poorly understood condition characterised by motor and vocal tics. It may affect children's social functioning at school. This study examined the impact of a psychoeducational intervention (classroom presentation) from multiple perspectives.

METHOD

We used a mixed-methods, multiple case-study design with interviews, focus groups and self-report questionnaires. Four children with TS, their parents, teachers and classmates (n = 100) took part.

RESULTS

Questionnaire data showed an increase in classmates' knowledge and positive attitudes about TS postintervention. Qualitative data revealed two overarching themes: the impact on classmates in terms of enabling prosocial behaviours, and the impact on the child in terms of their embracing having TS.

CONCLUSION

A brief psychoeducational intervention enhances knowledge and attitudes of classmates towards children with TS, and improves how children with TS feel about the condition. Further research is needed to evaluate this approach with larger samples of children and to identify mechanisms of change.

'Everybody just thinks I'm weird': a qualitative exploration of the psychosocial experiences of adolescents with Tourette syndrome

BACKGROUND

Research suggests Tourette syndrome (TS) can have a negative impact on quality of life. To date, little research has examined the perspectives of young people with this condition in depth.

METHODS

Six 14- to 16-year-olds with TS took part in semi-structured interviews to explore the perceived impact of this condition on self and on relationships with others. The transcripts were analysed using interpretative phenomenological analysis.

RESULTS

The young people felt that TS was a constant presence in their lives, but one they have learnt to cope with well. Most had developed supportive friendships but encountered problems when interacting with the wider peer network. Specific concerns around meeting new people and future employment were voiced.

CONCLUSIONS

The adolescents described specific ways in which TS affects quality of life and social interactions, and the effort it can take to cope effectively with this condition.

European clinical guidelines for Tourette syndrome and other tic disorders. Part III: behavioural and psychosocial interventions

This clinical guideline provides recommendations for the behavioural and psychosocial interventions (BPI) of children and adolescents with tic disorders prepared by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain an update on the efficacy of BPI for tics. Relevant studies were identified using computerised searches of the Medline and PsycINFO databases and the Cochrane Library for the years 1950-2010. The search identified no meta-analyses, yet twelve (systematic) reviews and eight randomised controlled trials provided evidence for the current review. Most evidence was found for habit reversal training (HRT) and the available but smaller evidence also supports the efficacy of exposure with response prevention (ERP). Both interventions are considered first line behavioural treatments for tics for both children and adults and should be offered to a patient, taking into account his preference. Treatments that are considered second line or add-on behavioural treatments are contingency management, function based interventions and relaxation training. Neurofeedback is still experimental. Almost no research was identified that examined the efficacy of psychosocial interventions, e.g., psychoeducation and group work. Based on clinical practice, this guideline recommends behavioural treatment as first line offer to patients in most cases. It should be embedded within a psychoeducational and supportive context and can be combined with drug treatment.

Tourette syndrome in children and adolescents: special considerations

Tourette syndrome (TS) affects people of all ages, with onset in early childhood and continuing through the different stages of the life cycle into adolescence and adults. This review focuses on barriers to diagnosis and challenges in the management of young patients with TS. Barriers to identification occur at multiple levels, including detection in the community setting (including schools), parents' help-seeking behavior, and cultural influences on such behavior, as well as diagnosis by the medical provider. Challenges to management include unfamiliarity of primary care providers, inconsistencies in the diagnosis and management plan, and failure to recognize comorbid conditions, as well as inadequate knowledge and lack of resources to effectively deal with comorbidities. In addition to the complexities posed by pharmacological interactions, there are unique psychosocial challenges experienced by young people with TS and their families. Effective communication and collaboration between families, health care providers, and school personnel, as well as supportive communities, are essential components of comprehensive management.

Aripiprazole in children and adolescents with Tourette disorder with and without explosive outbursts

OBJECTIVE

We conducted a retrospective, observational study of aripiprazole for the treatment of tics and/or co-morbid explosive outbursts in 37 children and adolescents with Tourette disorder (TD).

METHOD

Thirty seven children and adolescents with TD, with and without explosive outbursts, and refractory to previous treatment were treated at one of two university affiliated specialty clinics. All diagnoses were made using Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) criteria. Tic severity was rated using the Clinical Global Impressions Scale for tics (CGI-Tics) and frequency of explosive outbursts was assessed using the CGI-Rage; both measures were obtained at pretreatment baseline and at posttreatment follow up.

RESULTS

High rates of psychiatric co-morbidity were observed in these subjects: 31 of 37 (84%) subjects met criteria for obsessive-compulsive disorder (OCD), and 31 of 37 (84%) met criteria for attention-deficit/hyperactivity disorder (ADHD). Twenty nine of 37 (78%) subjects met criteria for intermittent explosive disorder (IED) minus criterion C; the remaining 8 subjects had TD only. Eight subjects (22%) discontinued treatment before 12 weeks due to inability to tolerate the drug. At follow up, tics reduced at a mean daily dose of 12.3 (7.50) mg in 29 of 29 (100%) subjects who completed the study, and explosive outbursts improved in 24/25 subjects (96%) who completed the study. Aripiprazole was tolerated reasonably well, although 8/37 (22%) subjects discontinued treatment; most common side effects included weight gain, akathisia, and sedation.

CONCLUSION

Aripiprazole should be investigated further as a treatment option for TD with and without co-morbid explosive outbursts.

Mood disorders and Gilles de la Tourette's syndrome: An update on prevalence, etiology, comorbidity, clinical associations, and implications

Gilles de la Tourette's syndrome (GTS) consists of multiple motor tics and one or more phonic tics. Psychopathology occurs in approximately 90% of GTS patients, with attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) being common. Depression is common, with a lifetime risk of 10% and a prevalence of between 1.8% and 8.9%. Depression and depressive symptoms are found to occur in 13% and 76% of GTS patients attending specialist clinics, respectively. In controlled studies embracing over 700 GTS patients, the patients were significantly more depressed than controls in all but one instance. In community and epidemiological studies, depression in GTS individuals was evident in two of five investigations. Clinical correlates of depression in people with GTS appear to be: tic severity and duration, the presence of echophenomena and coprophenomena, premonitory sensations, sleep disturbances, obsessive-compulsive behaviors/OCD, self-injurious behaviors, aggression, conduct disorder (CD) in childhood, and, possibly, ADHD. Depression in people with GTS has been shown to result in a lower quality of life, potentially leading to hospitalization and suicide. The etiology of depression appears to be multifactorial. Bipolar affective disorder (BAD) and GTS may be related in some individuals. However, it is noted that sample sizes in most of these studies were small, and it is unclear at the present time as to why BAD may be overrepresented among GTS patients.

The Tourette's Disorder Scale (TODS): development, reliability, and validity

To address the lack of a simple and standardized instrument to assess overall illness severity of Tourette's disorder (TD), the authors developed and tested a 15-item scale to measure a broad range of common symptoms including tics, inattention, hyperactivity, obsessions, compulsions, aggression, and emotional symptoms. Independent investigators used the 15-item Tourette's Disorder Scale (TODS) to assess 60 TD patients who were taking part in a double-blind placebo-controlled multicenter 8-week treatment study. Interrater reliability, internal consistency, convergent and discriminant validity, and sensitivity to change were examined. The TODS was associated with good interrater reliability, excellent internal consistency, and favorable levels of validity and sensitivity to change. Individual TODS items showed good convergent and discriminant validity against other measures. The TODS is a simple, efficient way for clinicians and parents to rate the severity of multiple symptoms commonly found in patients with Tourette's disorder.

Clinical phenomenology of episodic rage in children with Tourette syndrome

OBJECTIVE

Episodic rage of unknown etiology causes significant morbidity in children with Tourette's syndrome (TS). Using modified Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for intermittent explosive disorder (IED), we developed a screen and symptom questionnaire to explore rage attack phenomenology and to preliminarily investigate whether symptom clusters can identify clinical subgroups of TS children with rage attacks.

METHODS

48 children with TS between ages 7 and 17 years consecutively presenting with rage attacks completed the Rage Attacks Screen and Questionnaire. Data was subjected to factor analysis. Cluster analytic procedures were used to identify clinical subgroups.

RESULTS

Final cluster solution revealed four homogeneous subgroups of TS children with rage who were differentiated by predominant clinical characteristics: specific urge resolution, environmentally secure reactivity, nonspecific urge resolution or labile nonresolving.

CONCLUSION

Episodic rage in TS has stereotypic features, but diverse and complex etiologies. Identifying particular symptom clusters may facilitate improved treatment strategies.

Schlafstörungen bei kinder- und jugendpsychiatrischen Erkrankungen

Zusammenfassung: Schlafstörungen als Symptom zahlreicher kinder- und jugendpsychiatrischer Störungsbilder komplizieren häufig den Verlauf und die Behandlung der Grunderkrankung. Organische Störungen wie die Narkolepsie oder das Kleine-Levin-Syndrom können zu differentialdiagnostischen Schwierigkeiten und Fehleinschätzungen führen. Unklar ist, ob spezifische Veränderungen der Schlafarchitektur bereits im Kindes- und Jugendalter bestehen und damit als biologischer Trait-Marker für psychiatrische Erkrankungen zu verstehen sind. Während für das Erwachsenenalter die Bedeutung von Schlafstörungen vor allem für die Entwicklung späterer depressiver Störungen belegt werden konnte, ist derzeit offen, ob es sich bei persistierenden Schlafstörungen im Kindesalter um Vulnerabilitätsmarker für psychiatrische Erkrankungen handelt. In der vorliegenden Literaturübersicht sollen Wechselwirkungen zwischen Schlafstörung und psychischer Störung aufgezeigt und die Bedeutung der Berücksichtigung von Schlafstörungen für Diagnostik und Therapie kinder- und jugendpsychiatrischer Störungsbilder unterstrichen werden.

Gilles de la Tourette syndrome: symptomatic treatment based on evidence

The treatment of the Gilles de la Tourette syndrome has evolved from case reports, clinical experience and more recently blinded trials usually in small numbers of patients. We have reviewed the evidence available to clinicians. The oldest and still most widely prescribed drug, haloperidol, should now not be considered the first-line agent in children as other agents have superior adverse effects profiles. Symptomatic treatment should be targeted to the specific additional psychopathologies seen in the syndrome. For the treatment of tics, sulpiride, tiapride, possibly pimozide and in some cases clonidine may be considered first-line agents. Although a body of data supports pimozide, caution has to be exercised in relation to possible cardiac effects. Antidepressants and stimulants have an important place in the management of depression, obsessionality and attention deficit hyperactivity disorder. The latter also responds to clonidine making it a rational first choice where ADHD coexists with GTS. There are a multitude of other drugs advocated in the literature in addition to reports of neurosurgery and the novel use of immune modulation. Therapeutic trials for GTS are challenging. However, further data from blinded trials are required before many of these treatments can be considered to be mainstream treatment options.

Explosive outbursts in children with Tourette's disorder

OBJECTIVE

Sudden, explosive outbursts of behavior occur in some children with Tourette's disorder (TD). The etiology of these symptoms is unknown. This study investigated the relationship between explosive outbursts, TD, and its comorbid disorders.

METHOD

Tic type and severity and the presence of specific comorbid disorders were compared in 37 children with TD and explosive outbursts and 31 children with TD who did not have such symptoms.

RESULTS

Children with TD and explosive outbursts were more likely to demonstrate significant comorbid conditions, particularly attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, and oppositional defiant disorder. Tic type and severity did not appear related to the presence of explosive outbursts. A highly significant relationship was demonstrated between the number of comorbid psychiatric diagnoses and explosive outbursts.

CONCLUSIONS

Explosive outbursts in children with TD resemble intermittent explosive disorder and may reflect dysregulation of diverse domains of brain function. The presence of such symptoms should alert the clinician to underlying comorbid conditions.

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.

Aggressive behaviour in children with Tourette syndrome and comorbid attention-deficit hyperactivity disorder and obsessive-compulsive disorder

BACKGROUND

Aggressive behaviour, defined as sudden, explosive outbursts of rage, has been reported as a clinical problem in approximately 23% to 40% of Tourette syndrome (TS) patients (1-5). Attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are also reported in 50% to 70% of TS patients (6).

OBJECTIVE

To investigate whether aggressive behaviour was associated with TS directly or found primarily in TS with comorbid ADHD or OCD.

METHOD

Aggressive behaviour in 33 nonmedicated patients with TS (ages 6 to 14 years) and 6 healthy control subjects (ages 7 to 12 years) was examined by semistructured interview and multiinformant questionnaires.

RESULTS

Aggression subscales on Achenbach's Child Behavior Checklist (CBCL) completed by parents and Teacher's Report Form (TRF) completed by teachers distinguished the TS-only and control groups from the group with TS + Comorbidity (P < 0.046, and P < 0.016) after adjusting for tic severity and age. The conduct disorder subscale on the Conners Parent Rating Scale (CPRS) was also significantly higher (P < 0.005) in the TS + comorbidity group than in the TS-only or control groups, with more problems reported in the older children.

CONCLUSIONS

These findings provide additional evidence that aggressive behaviour observed in children with TS may be associated with comorbid ADHD or OCD (6), independent of tic severity or age. This is consistent with the clinical observation that most TS patients have only minimal symptoms, which do not interfere with their daily functioning.

Orphan neurones and amine excess: the functional neuropathology of Parkinsonism and neuropsychiatric disease

The aetiology and treatment of Parkinsonism is currently conceptualised within a dopamine (DA) deficiency-repletion framework. Loss of striatal DA is thought to cause motor impairment of which tremor, bradykinaesia and rigidity are prominent features. Repletion of deficient DA should at least minimise parkinsonian signs and symptoms. In Section 2, based on extensive pre-clinical and clinical findings, the instability of this approach to Parkinsonism is scrutinised as the existing negative findings challenging the DA deficiency hypothesis are reviewed and reinterpreted. In Section 3 it is suggested that Parkinsonism is due to a DA excess far from the striatum in the area of the posterior lateral hypothalamus (PLH) and the substantia nigra (SN). This unique area, around the diencephalon/mesencephalon border (DCMCB), is packed with many ascending and descending fibres which undergo functional transformation during degeneration, collectively labelled 'orphan neurones'. These malformed cells remain functional resulting in pathological release of transmitter and perpetual neurotoxicity. Orphan neurone formation is commonly observed in the PLH of animals and in man exhibiting Parkinsonism. The mechanism by which orphan neurones impair motor function is analogous to that seen in the diseased human heart. From this perspective, to conceptualise orphan neurones at the DCMCB as 'Time bombs in the brain' is neither fanciful nor unrealistic [E.M. Stricker, M.J. Zigmond, Comments on effects of nigro-striatal dopamine lesions, Appetite 5 (1984) 266-267] as the DA excess phenomenon demands a different therapeutic approach for the management of Parkinsonism. In Section 4 the focus is on this novel concept of treatment strategies by concentrating on non-invasive, pharmacological and surgical modification of functional orphan neurones as they affect adjacent systems. The Orphan neurone/DA excess hypothesis permits a more comprehensive and defendable interpretation of the interrelationship between Parkinsonism and schizophrenia and other related disorders.

Tourette's syndrome and psychopathology in a child psychiatry setting

Prior investigations of psychopathology among children with Tourette's syndrome (TS) have rarely used child psychiatry samples and sophisticated personality instruments.

OBJECTIVE

To produce an objectively derived composite TS personality profile and to determine the rate of particular problems in a TS psychiatry sample compared with children with out TS from the same clinical practice.

METHOD

Children (n = 33) referred to child psychiatrists because of emotional and behavior problems who were subsequently also found to meet DSM-III-R criteria for TS were assessed by the Personality Inventory for Children.

RESULTS

Children with TS expressed high rates of psychopathology overall (composite 2.7 SD elevated) with depression, anxiety, and peculiar behavior having the highest values; depression occurred most frequently (73%), and attention-deficit hyperactivity disorder (55%) was no more common than among comparison group children and conduct problems (18%) were rarer. "Depression, anxiety, tension, and excessive worry" were characteristic of the actuarially derived modal TS personality.

CONCLUSIONS

The prevalence and manifestations of psychopathology of children with TS in a child psychiatry practice are not identical with those reported in the literature. Child psychiatrists should be particularly vigilant of depressive symptoms and expect to encounter relatively few conduct problems compared with children without TS. Establishing "local prevalence rates" for children with TS seeking psychiatric evaluation can help guide the diagnostician and make diagnosis more assured.

NREM sleep parasomnias

The three states of mammalian being--wakefulness, REM sleep, and NREM sleep--are not mutually exclusive and may occur simultaneously, oscillate rapidly, or appear in dissociated or incomplete form to produce primary sleep parasomnias. Dysfunctions of a wide variety of organ systems may take advantage of the sleeping state to declare themselves, resulting in the secondary sleep parasomnias. Contrary to popular opinion, most of these often bizarre and frightening experiences are not the manifestation of underlying psychological or psychiatric conditions. Formal study in an experienced sleep disorders center usually reveals a diagnosable and treatable condition. Various parasomnias may result in injurious or violent behavior. The forensic science implications are beyond the scope of this article but have been reviewed extensively elsewhere. Continued study of unusual sleep-related events undoubtedly will reveal more fascinating conditions, expanding our knowledge of sleep physiology and strengthening the bonds between clinicians and basic science sleep researchers.

Role of genetic factors in depression based on studies of Tourette syndrome and ADHD probands and their relatives

Tourette syndrome (TS) is a common, neuropsychiatric disorder which has many similarities to attention deficit hyperactivity disorder (ADHD). TS probands have a high frequency of a variety of behavioral disorders including depression. The depression may be due to a pleiotrophic effect of the Gts genes, proband ascertainment bias, or a result of coping with the chronic tics. To distinguish between these hypotheses we examined the responses to 17 Diagnostic Interview Schedule questions to evaluate the 9 DSM-III-R criteria for major depressive episode in 1,080 adults consisting of TS and ADHD probands, their relatives and controls. Using a Bonferonni corrected p there was a significant progressive increase in 16 of 17 depressive symptoms and for a life time history of a major depressive episode in groups with increased genetic loading for Gts genes. Similar trends were seen in the small number of ADHD probands and their relatives. There was also a significant increase for these variables in non-proband TS relatives versus non-TS relatives, indicating the association of depression with Gts genes was not due to ascertainment bias or the inappropriate choice of controls. Multiple linear regression analysis indicated that obsessive-compulsive behaviors, sex, ADHD, drug abuse, and age all showed a more significant effect on depressive symptoms than the number of tics. The presence or absence of TS in the relatives had a much greater effect on risk for depression than the presence or absence of an episode of major depression in the proband. These results are consistent with the hypothesis that Gts and ADHD genes play a major role in depression.

Clinical predictors of psychopathology in children and adolescents with Tourette Syndrome

Tourette Syndrome (TS) is a neuropsychiatric disorder of childhood onset characterized by vocal and motor tics and associated psychopathologies. The current study was undertaken to explore the associations between tic symptomatology, related clinical variables and behavioral dysfunction within a cohort of TS subjects. Ninety-two child and adolescent TS subjects were rated through self-measure, and by parents on measures of tic symptomatology, OC characteristics, and dysfunctional behaviors including learning difficulties and attention deficits. Statistical modeling revealed associations among tic clusters, clinical items and behavioral measures, which were unique for the child and adolescent subgroups.