[Compulsive phenomena in children with tic disorder and attention deficit-hyperactive disorder]

Challenges in the Diagnosis and Assessment in Patients with Tourette Syndrome and Comorbid Obsessive-Compulsive Disorder

Tourette syndrome (TS) is characterized by the presence of vocal and motor tics with an onset in childhood. In almost 80% of patients psychiatric comorbidities coexist, particularly, attention deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD) or behavior (OCB), depression, anxiety, rage attacks, and self-injurious behaviour (SIB). In this review, we discuss current state of the art regarding diagnosis and assessment of tics and OCD in patients with TS as well as challenges related to differential diagnosis between tics and OCD-related phenomena based on a systematic literature search. While in most cases clinical symptoms can be easily classified as either tics or OCB/OCD, some phenomena lay on the frontier between tics and compulsions/obsessions. For example, compulsions may resemble tics and, vice versa, sequences of motor tics may be misdiagnosed as compulsions. Accordingly, the terms "compulsive tics" and "cognitive tics" have been introduced. The most common and typical OCD symptom in patients with TS are "just right" phenomena, which also may show an overlap with tics, since patients may perform tics repeatedly until this feeling is achieved. Similarly, repetitive behaviors in patients with TS may manifest in a more "tic-like" or a more "OCD-like" type. Furthermore, SIB shows similarities with both tics and OCD. Until today, it is unclear how to classify this symptom best, although from most recent research a closer relationship between SIB and tics is suggested. In this review, in addition, we illustrate differences of the clinical spectrum of OCD in patients with TS compared to those with "pure OCD" without tics. To assess tics, the revised version of the Yale Global Tic Severity Scale (YGTSS-R) should be used, while for the assessment of OCD, the Yale Brown Obsessive Compulsive Disorder Scale (Y-BOCS) is recommended. Finally, we briefly summarize treatment strategies for tics and OCB/OCD in patients with TS.

A Single Case of Tourette's Syndrome Treated with Traditional Chinese Medicine

The objective of this case study was to investigate the effectiveness of Chinese medicine in treating Tourette's syndrome. Tourette's syndrome is a childhood- onset disorder that is characterized by sudden, involuntary movements or tics. The participant in this study was a 33-year-old male who had been diagnosed with Tourette's syndrome at the age of 9 years. His major complaints included facial tics, shoulder shrugging, and clearing the throat. Using a combination of acupuncture, herbs, Gua-Sha, and lifestyle changes once a week for 35 treatments, all the symptoms were reduced by 70%, as reported by the patient. In this case, the results indicated that Chinese medicine was able to minimize the symptoms of Tourette's syndrome. Further investigation is needed to support this argument. Tourette's syndrome, which was first described in 1885 by a French physician named Gilles de la Tourette, is characterized by facial tics, involuntary body movements from the head to the extremities, or vocal tics, and it usually has its onset in childhood. It is a neuropsychiatric disorder. The treatment for Tourette's syndrome is based on pharmacological treatment, behavior treatment, and deep brain stimulation. Unfortunately, none of these could completely control the symptoms; furthermore, antipsychiatric drugs might cause additional side effects, such as Parkinson symptoms, tardive dyskinesia, and metabolic disturbances. Finding acupuncture and oriental medicine literature on treatment of Tourette's syndrome was difficult, especially that written in English. Some research papers that have been translated into English indicated that Chinese herbs and acupuncture could reduce the tics significantly. For example, a study by Dr Pao-Hua Lin reported the significant effects of using acupuncture and oriental medicine in treating 1000 Tourette's syndrome cases. This case was treated to further investigate the principles of Dr Lin's study.

Zwangsstörungen im Kindes- und Jugendalter

Zwangsstörungen zählen mit einer Prävalenz von 1 bis 2 % zu den häufigeren Störungen im Kindes- und Jugendalter. Komorbide Störungen sind regelhaft vorhanden und die psychosozialen Beeinträchtigungen sind oftmals gravierend. Trotz guter Behandelbarkeit der Zwangsstörung gestaltet sich der Langzeitverlauf bei einem bedeutsamen Teil der Betroffenen insgesamt ungünstig. Der vorliegende Beitrag gibt eine selektive Übersicht zu Definition und Klassifikation, Epidemiologie, Symptomatik, Komorbidität, Diagnostik und Verlauf der Zwangsstörung im Jugendalter.

The Role of Obsessive-Compulsive Symptoms

Objective: The study examines the role of obsessive-compulsive symptoms (OCS) as a part of the psychopathology of children with chronic tic disorders (CTD) and/or attention-deficit hyperactivity disorder (ADHD). Method: We assessed the psychopathology of four large patient groups without further psychiatric disorders: CTD (n = 112), CTD + ADHD (n = 82), ADHD (n = 129), and controls (n = 144)) by implementing the Child Behavior Checklist (CBCL). We compared the main effects for CTD and ADHD with and without including OCS as covariates. Results: Including OCS led to substantially different main effects for CTD on seven out of eight CBCL subscales. Slightly different main effects for ADHD were determined with respect to ADHD, mainly on the subscale withdrawn. Conclusions: OCS are closely related to CTD-associated psychopathology and – to a lesser extent, but nevertheless of importance in daily clinical practice – on ADHD-related symptoms. This information can be helpful in implementing more precise diagnostics and treatment in daily routine care.

[Changes in comorbid symptoms and subjective interference in a habit reversal therapy in children with chronic tic disorder - a pilot study]

OBJECTIVE

This pilot study investigates the effects of habit reversal training in a German-speaking population of children and young adults with chronic tic disorders on comorbid symptoms and subjective interference.

METHODS

16 children were treated using a manualized program. Comorbid-symptoms (ADHD, anxiety and OCD, depression) were assessed using parent and self-ratings. Additionally, the correlation of tic symptoms with comorbid symptoms at the beginning of the therapy was analyzed.

RESULTS

We obtained positive results in reducing comorbid symptoms during a primary treatment of tic symptoms. We further found a correlation of tic symptoms and comorbid symptoms especially in parent ratings.

CONCLUSIONS

These first findings show that a primary treatment of tics may be indicated in patients with comorbid symptoms, because a therapy of tic symptoms has also positive effects on comorbid symptoms.

Relationship of obsessive-compulsive disorder to age-related comorbidity in children and adolescents with Tourette syndrome

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are the 2 most frequent psychiatric disorders co-occurring with Tourette syndrome (TS). Both usually cause greater impairment in psychosocial functioning than the tics themselves. In a previous study, we examined the relationship of attention-deficit/hyperactivity disorder to other comorbid conditions in TS. The relationship of OCD to other comorbidities in TS still remains unclear and is the focus of the present study.

METHODS

Pearson's χ tests and logistic regressions (year-wise) were used to examine a cross-sectional sample of children and adolescents (n = 5060) diagnosed with TS, taken from the Tourette Syndrome International Database Consortium. We explored the relationship of OCD to other comorbid conditions in TS across different age groups.

RESULTS

In children (ages 5-10 y) with TS, higher rates of comorbidities were found in the presence compared with the absence of OCD. Adolescents (ages 11-17 y) with TS + OCD showed higher rates of internalizing (i.e., anxiety and mood) disorders when compared with those with TS - OCD. A year-wise increase of coexisting mood disorders was found for subjects with TS with and without OCD.

CONCLUSIONS

Overall, children and adolescents with TS + OCD showed higher rates of comorbid disorders compared with those with TS - OCD. This underlines the necessity for a comprehensive assessment of additional comorbidities even if the 2 disorders (TS + OCD) have already been diagnosed.

Obsessive-compulsive disorder in children and adolescents

BACKGROUND

Early-onset obsessive-compulsive disorder (OCD) is one of the more common mental illnesses of children and adolescents, with prevalence of 1% to 3%. Its manifestations often lead to severe impairment and to conflict in the family. In this review, we summarize the manifestations, comorbidity, pathophysiology, and course of this disease as well as current modes of diagnosis and treatment.

METHODS

We selectively review the relevant literature and the German-language guidelines for the diagnosis and treatment of mental illnesses in children and adolescents.

RESULTS

Obsessive-compulsive manifestations are of many types and cause severe impairment. Comorbid mental disturbances are present in as many as 70% of patients. The disease takes a chronic course in more than 40% of patients. Cognitive behavioral therapy is the treatment of first choice, followed by combination pharmacotherapy including selective serotonin reuptake inhibitors (SSRI) and then by SSRI alone.

CONCLUSION

OCD often begins in childhood or adolescence. There are empirically based neurobiological and cognitive-behavioral models of its pathophysiology. Multiaxial diagnostic evaluation permits early diagnosis. Behavioral therapy and medications are highly effective treatments, but the disorder nonetheless takes a chronic course in a large percentage of patients.

[Aripiprazole - a medical treatment alternative for Tourette Syndrome in childhood and adolescence]

OBJECTIVE

We report a case-series of seven patients with a medical history of at least two years of tic disorder treated with the partial dopamine agonist aripiprazole to illustrate its efficacy as a treatment alternative for motor and vocal tics in children and adolescents.

METHOD

A case series of five patients with Tourette Syndrome (TS) and two with chronic motor tic disorder (age range 8; 7-18; 1 year), the majority of whom had been refractory to treatment with other neuroleptics or had ceased treatment due to intolerable side effects, were treated for eight weeks with aripiprazole. Before and after treatment, parents rated the severity of motor and vocal tic symptoms on the Yale Tourette Syndrome Checklist.

RESULTS

Within eight weeks mean motor tic symptoms decreased by 66% and mean vocal tic symptoms decreased by 26%. Mean effective dosage was 14.3 mg/day (min. 5 mg, max. 30 mg). Symptoms of comorbid ADHD or Obsessive Compulsive Disorder were not significantly influenced. During medication only mild side effects were observed, e.g., abdominal pain, fatigue and increased emotional sensitivity. No patient dropped out of treatment due to side effects.

CONCLUSIONS

Aripiprazole may be an effective pharmacologic treatment alternative for individuals with chronic motor tic disorder and TS. It induces quick, significant and sustained effects with few generally mild and transient side effects, if anything. Its effectiveness, especially relative to comorbidities, should be verified in double-blind, placebo-controlled studies.

Children and adolescents with obsessive-compulsive disorder and comorbid attention-deficit/hyperactivity disorder: preliminary results of a prospective follow-up study

In the present study, we have investigated the influence of comorbid attention deficit hyperactivity disorder (ADHD) on early onset obsessive compulsive disorder (OCD). For that purpose, we compared 20 patients with "OCD with ADHD" and 20 randomly selected patients with "OCD without ADHD". "OCD with ADHD" patients tended to show an earlier age of OCD onset, a higher severity of symptoms and a higher persistence rate than OCD patients without ADHD. Both groups appear to develop different patterns of comorbid disorders.

Effects of atomoxetine and methylphenidate on attention and impulsivity in the 5-choice serial reaction time test

Deficits in attention and response inhibition are apparent across several neurodegenerative and neuropsychiatric disorders for which current pharmacotherapy is inadequate. The 5-choice serial reaction time test (5-CSRTT), which originated from the continuous performance test (CPT) in humans, may serve as a useful translational assay for efficacy in these key behavioral domains. The selective norepinepherine reuptake inhibitor, atomoxetine, represents the first non-stimulant based drug approved for Attention Deficit Hyperactivity Disorder (ADHD) and has replaced methylphenidate (Ritalin) as the first line in pharmacotherapy for the treatment of ADHD. Methylphenidate and atomoxetine have different cortical and sub-cortical neurochemical signatures that could predict differences in cognitive and non-cognitive functions. The present experiments investigated the effects of acute methylphenidate and atomoxetine in male long Evans rats in the 5-choice serial reaction time (5CSRT) test that is hypothesized to serve as a model of vigilance and impulsivity behaviors associated with ADHD. Long Evans rats were trained to perform at 75% correct responses with fewer than 20% missed trials in the 5CSRT test (500 ms stimulus duration, 5 s inter-trial interval (ITI)). By varying the ITI (10, 7, 5, and 4 s) on drug test days, impulsivity (as defined by premature responses) was dramatically increased with a concomitant decrease in attention (percent correct). Subsequently, animals were treated with methylphenidate (2.5 and 5 mg/kg, i.p.) or atomoxetine (0.1, 0.5 and 1 mg/kg, i.p.) using this design. In Experiment 1, treatment with methylphenidate modestly improved overall attention but the highest dose of methylphenidate (5.0 mg/kg) significantly increased impulsivity. In contrast, treatment with atomoxetine induced a marked decrease in impulsivity whilst modestly improving overall attention. Interestingly, no effect was observed on measures of performance (e.g. motivation/sedation) with atomoxetine, whilst moderate hyperactivity (faster overall response latencies; magazine, correct, incorrect) was observed in the methylphenidate group. Those data suggest that the 5CSRT test can be used to differentiate stimulant and non-stimulant pharmacotherapies on measures of impulsivity.

Tic- und Zwangsstörungen

Zusammenfassung. In diesem Übersichtsartikel werden die Gemeinsamkeiten und Unterschiede von Tic- und Zwangsstörungen auf verschiedenen Ebenen dargestellt. In der Psychopathologie unterscheiden sich beide Phänomene zunächst deutlich - Tics sind plötzlich auftretende, unwillkürliche, motorische Bewegungen oder Vokalisationen. Zwänge sind wiederholte, zweckmäßige und beabsichtigte Verhaltensweisen. Es gibt jedoch fließende Übergänge, die sich vor allem bei den Just-Right-Zwängen manifestieren, die bei Tourette-Störungen gehäuft auftreten. Die diagnostischen Strategien und die dabei hilfreichen Instrumente werden vorgestellt. In der Therapie haben sich bei beiden Störungen sowohl verhaltenstherapeutische als auch pharmakotherapeutische Verfahren bewährt. Es wird eine Übersicht über den Stand der empirischen Evidenz gegeben. Die Behandlung von kombinierten Tic- und Zwangsstörungen wird speziell erörtert.

Tic disorders and obsessive compulsive disorder: where is the link?

Over the last years evidence on the overlap between tic-disorders (TD) and obsessive compulsive behavior/disorder (OCB/OCD) has increased. The main focus of research have been the phenomenological and epidemiological similarities and differences in samples of different age, primary diagnosis (TD vs. OCD) including the co-occurrence of both. Unfortunately, only a minority of studies included all three groups (TD, TD + OCD, OCD). Nevertheless, new insight concerning possible subtypes for both TD and OCD has been gained. While some authors concentrated on OCD with/without tics we will summarize the field of TD and OCB/OCD from the viewpoint of tics, since OCB plays an important role in patients with TD. Thereby we will not only sharpen the clinicans' awareness of known differences in phenomenology, epidemiology, genetics and neurobiology, aimed to improve their diagnoses and treatment but also highlight the gaps of knowledge and discuss possibilities for further research in this field.

Aripiprazole for the treatment of Tourette's disorder

OBJECTIVE

Tourette's disorder is a neuropsychiatric syndrome that manifests with motor and vocal tics, including coprolalia. This article presents a report of successful treatment of these tics with aripiprazole in 2 consecutive patients with Tourette's disorder.

METHOD

After an informed consent was obtained from the subjects, approval for this retrospective case series was sought from the Institutional Review Board. A detailed history was obtained and physical and mental state examination was performed for each patient. Tic severity was assessed using the Yale Global Tic Severity Scale. Aripiprazole was started at a low dose (5 mg/day) and titrated. The severity of tics was monitored during follow-up.

RESULTS

The 2 individuals presented in these case reports tolerated aripiprazole well and showed a clinically significant decrease in tic frequency and severity.

CONCLUSIONS

Aripiprazole, a newer atypical antipsychotic with a unique pharmacodynamic profile, appears to be efficacious in treatment of tics in Tourette's disorder, thus impressing upon the need for placebo-controlled trials in the management of this neuropsychiatric syndrome.

Co-existing disorders in ADHD -- implications for diagnosis and intervention

BACKGROUND

It is only recently that "comorbidity" in ADHD has come to the forefront as one of the most important aspects of the disorder. It is agreed that, often, these problems are at least as important as ADHD in contributing to the longer term outcome in the individual child.

OBJECTIVE

To provide the reader with basic information about clinics and treatment of "comorbidity" in ADHD.

METHOD

Review of the empirically based literature.

RESULTS

ADHD exists in a surprisingly high frequency together with a broad range of child neuropsychiatric disorders. This is accompanied with many still unresolved treatment problems.

CONCLUSION

It would not be appropriate to develop ADHD-services where clinicians would only have expertise in ADHD as such. Anyone working with children, adolescents and adults with ADHD would need to have training in general neuropsychiatry. Further research in this field is urgently needed.