Developmental psychopathology and neurobiology of Tourette's syndrome

The Impact of Tic Severity, Comorbidity and Peer Attachment on Quality of Life Outcomes and Functioning in Tourette's Syndrome: Parental Perspectives

The aim of this controlled, community-based study based on data from parents of youth (aged 7-16 years) with Tourette's syndrome (TS; n = 86) and parents of age and gender matched peers (n = 108) was to test several hypotheses involving a range of variables salient to the TS population, including peer attachment, quality of life, severity of tics, comorbidity, and psychological, behavioural and social dysfunction. Multivariate between-group analyses confirmed that TS group youth experienced lower quality of life, increased emotional, behavioural and social difficulties, and elevated rates of insecure peer attachment relative to controls, as reported by their primary caregiver. Results also confirmed the main hypothesis that security of peer attachment would be associated with individual variability in outcomes for youth with TS. As predicted, multivariate within-TS group analyses determined strong relationships among adverse quality of life outcomes and insecure attachment to peers, increased tic severity, and the presence of comorbid disorder. Findings suggest that youth with TS are at increased risk for insecure peer attachment and that this might be an important variable impacting the quality of life outcomes for those diagnosed.

The nature and rate of cognitive maturation from late childhood to adulthood

To better understand the nature and rate of cognitive change across adolescence, the Cogstate Brief Battery (CBB) was utilized to assess psychomotor function, attention, working memory, and visual learning in individuals aged 10–18 years old. Since all CBB tasks have equivalent perceptual, motor, and linguistic demands as well as being appropriate for both children and adults, this approach allowed direct across-age comparison of multiple cognitive domains. Exponential decreases in reaction time and linear increases in accuracy were observed across adolescent development in a cross-sectional sample of 38,778 individuals and confirmed in a 5788 individual longitudinal sample with 1-year repeat assessments. These results have important implications for the repeated assessment of cognition during development where expected maturational changes in cognition must be accounted for during cognitive testing.

[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.

High-dose glycine treatment of refractory obsessive-compulsive disorder and body dysmorphic disorder in a 5-year period

This paper describes an individual who was diagnosed with obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) at age 17 when education was discontinued. By age 19, he was housebound without social contacts except for parents. Adequate trials of three selective serotonin reuptake inhibitors, two with atypical neuroleptics, were ineffective. Major exacerbations following ear infections involving Group A β-hemolytic streptococcus at ages 19 and 20 led to intravenous immune globulin therapy, which was also ineffective. At age 22, another severe exacerbation followed antibiotic treatment for H. pylori. This led to a hypothesis that postulates deficient signal transduction by the N-methyl-D-aspartate receptor (NMDAR). Treatment with glycine, an NMDAR coagonist, over 5 years led to robust reduction of OCD/BDD signs and symptoms except for partial relapses during treatment cessation. Education and social life were resumed and evidence suggests improved cognition. Our findings motivate further study of glycine treatment of OCD and BDD.

Validity of the CogState brief battery: relationship to standardized tests and sensitivity to cognitive impairment in mild traumatic brain injury, schizophrenia, and AIDS dementia complex

This study examined the validity of the four standard psychological paradigms that have been operationally defined within the CogState brief computerized cognitive assessment battery. Construct validity was determined in a large group of healthy adults. CogState measures of processing speed, attention, working memory, and learning showed strong correlations with conventional neuropsychological measures of these same constructs (r's = .49 to .83). Criterion validity was determined by examining patterns of performance on the CogState tasks in groups of individuals with mild head injury, schizophrenia, and AIDS dementia complex. Each of these groups was impaired on the CogState performance measures (Cohen's d's = -.60 to -1.80) and the magnitude and nature of this impairment was qualitatively and quantitatively similar in each group. Taken together, the results suggest that the cognitive paradigms operationally defined in the CogState brief battery have acceptable construct and criterion validity in a neuropsychological context.

Is onset of Tourette syndrome influenced by life events?

The aim of this study is to investigate the possible relationship between stressful life events, personality, and onset of Tourette syndrome in children. The study group included 93 subjects aged 7-18 years: 41 with Tourette syndrome (TS), 28 with obsessive-compulsive disorder (OCD), and 24 healthy controls. Diagnoses were based on the Child Schedule for Schizophrenia and Affective Disorders (K-SADS). All children were tested with the Screen for Child Anxiety Related Emotional Disorders, Children's Yale Brown Obsessive Compulsive Scale, Beck Depression Inventory or Children's Depression Inventory, the Life Experience Survey, and the Junior Temperament and Character Inventory. The findings were compared among the groups. Subjects with Tourette syndrome and healthy controls had significantly less stressful life events than subjects with (OCD). There were no significant differences between the TS subjects and the healthy controls. This finding applied to total lifetime events, total lifetime negative events, and events in the year before and after illness onset. Subjects with TS and the healthy controls also showed a significantly lesser impact of life events than subjects with OCD. The Tourette syndrome group showed a significantly lesser impact of stressful life events than controls. Harm avoidance tended to be higher in the patients with Tourette syndrome and comorbid attention deficit hyperactivity disorder and obsessive-compulsive disorder than in patients with Tourette syndrome only. There seemed to be no association between life events, diagnosis, and personality. Although there is some research suggesting that tics can be influenced by the environment, the onset of Tourette syndrome does not seem to be related to stressful life events, nor to an interaction between stressful life events and personality.

Psychopathology in children and adolescents with Tourette's syndrome: a controlled study

OBJECTIVE

Few controlled studies have considered, in paediatric subjects, associations between Tourette's syndrome (TS) and psychiatric/behavioural disorders. We conducted a case-control study to verify the reproducibility of the few data published on this topic to date.

METHOD

Clinicians' impression (i.e. structured interviews and usual history taking), standardized psychiatric and behavioural rating scales (CBCL, TAI, CDI, CRS-R:L, Y-GTSS, CY-BOCS) were used to investigate these associations in 17 youngsters with TS and in 17 age- and sex-matched controls.

RESULTS

The clinician's diagnoses revealed TS alone in 23.5% of the patients (4/17), TS plus attention-deficit/hyperactivity disorder (ADHD) in 11.8% (2/17), TS plus obsessive-compulsive disorder (OCD) in 41.2% (7/17), and TS plus ADHD and OCD in 23.5% (4/17). No control subject presented ADHD and/or OCD. These clinical findings were confirmed by Child Behaviour Check List (CBCL) results. The TS group, compared with the controls, recorded significantly higher CBCL scores in scales relating to the main comorbid conditions. No significant differences emerged on the Children's Depression Inventory or Test Anxiety Inventory.

CONCLUSION

TS patients have a high prevalence of psychiatric and behavioural problems compared with controls. The CBCL is a rapid and useful screening-diagnostic instrument for highlighting the main psychiatric and behavioural problems in TS.

Comorbid behavioural problems in Tourette's syndrome are positively correlated with the severity of tic symptoms

OBJECTIVE

We studied the comorbid behavioural and mood problems in children with non-psychiatric Tourette's syndrome (TS) and their relationship with severity of tic disorder.

METHOD

Sixty-nine TS children and 69 healthy controls were assessed by Child Behavior Checklist (CBCL) and Yale Global Tic Severity Scale (YGTSS). The relationships between behavioural problems and severity of tic symptoms were analysed statistically by comparison, correlation and multiple linear regression.

RESULTS

Tourette's syndrome patients scored significantly lower (p<0.01) on the CBCL competency subscales and total score, and higher on all behavioural problem subscales and total score (p<0.01). Expectedly, the TS children had lower social competence than normal children. Among the TS children, the severity of tic symptoms is positively correlated with the severity of overall impairment in school and social competence. When the behavioural and mood problems commonly associated with TS were studied in detail, we found that delinquent behaviour, thought problems, attention problems, aggressive behaviour and externalizing are positively correlated with severity of tic symptoms.

CONCLUSION

The findings indicated that children with TS-only also had a broad range of behavioural problems, and some of these were related to the severity of tic symptoms.

Effects of donepezil, nicotine and haloperidol on the central serotonergic system in mice: implications for Tourette's syndrome

We have previously reported that acute and chronic donepezil and nicotine administration significantly attenuate DOI-induced head twitch response (HTR) in mice. This behavior, primarily mediated by stimulation of 5-HT2A receptors, has been proposed to model tic symptoms seen in Tourette's syndrome (TS). Haloperidol, a drug widely used to treat symptoms of TS, has also been reported to reduce DOI-induced head shakes in rodents when administered acutely. These findings suggest an inhibitory interaction of these drugs with 5-HT2A receptors. To test this hypothesis, we evaluated the effects of chronic donepezil, nicotine and haloperidol on expression levels of 5-HT2A mRNA and 5-HT2A receptor density in select brain regions. Initially, we established a dose-response relationship for the acute and chronic haloperidol and DOI-induced HTR. Male ICR mice were treated twice daily with donepezil (0.1 mg/kg), nicotine (0.5 mg/kg), and once daily with haloperidol (0.4 mg/kg) for 14 days and were sacrificed 16-18 h after the last injection. These drug regimens were chosen because of their significant effects on DOI-induced HTR. Donepezil significantly increased 5-HT2A mRNA level, but not the receptor density in the striatum. In the midbrain, donepezil significantly decreased the receptor density without affecting the 5-HT2A mRNA level. In the frontal cortex, only haloperidol significantly reduced the 5-HT2A receptor density. The cortex was the only area where donepezil, nicotine and haloperidol significantly reduced the 5-HT2A receptor density. The results suggest that the anti-tic properties of donepezil, nicotine and haloperidol in this paradigm might be due to antagonism of cortical 5-HT2A receptors. Thus, further investigation of involvement of cortical 5-HT2A receptors in TS as well as evaluation of selective 5-HT2A receptor antagonists in this disorder is warranted.

Obsessive-compulsive disorder

Compulsions are meant to relieve anxiety or to prevent a dreaded event. An adolescent or adult may recognize that the ritual is unreasonable or excessive, but that is not necessarily true for the young child. Children and adolescents will attempt to hide their rituals, although with more severe symptoms, this is not usually possible. To meet the diagnostic criteria for the disorder, the person must experience distress, spend more than 1 hour a day in either obsessions or compulsions, or experience significant interference in his/her life. This article reviews the phenomenology, causes, treatment, and outcome of children and adolescents with obsessive-compulsive disorder.

Neuropsychologic characteristics of children with attention-deficit hyperactivity disorder (ADHD), learning disorder, and tic disorder on the Rey-Osterreith Complex Figure

This study examined the performance of Korean children diagnosed with attention-deficit hyperactivity disorder (ADHD), learning disorder, ADHD with learning disorder, and tic disorder on the Rey-Osterreith Complex Figure. The clinical group consisted of 57 children between the ages of 6 and 13 years (15 with ADHD, 13 with learning disorder, 15 with ADHD + learning disorder, and 15 with tic disorder), and the control group included 20 children recruited from an elementary school. Rey-Osterreith Complex Figure productions were scored according to the Developmental Scoring System. The children in the control group showed a clear developmental trend--organization score increasing with age--that was similar to the performance of American children. No such age-related effect was found in the three clinical groups. The organization scores of the children with ADHD were lower than those of other groups, suggesting an organizational deficit in ADHD. Performance on the immediate recall condition was poorest in the tic disorder and ADHD + learning disorder groups, suggesting the presence of nonverbal memory problems in those groups.

Translocation breakpoint in two unrelated Tourette syndrome cases, within a region previously linked to the disorder

Tourette syndrome (TS) is a complex neuropsychiatric disorder characterized by both motor and vocal tics. The etiology of TS is poorly understood; however, evidence of genetic transmission arises from family and twin studies. A complex mode of inheritance has been suggested, likely involving contributions of several genes with different effect size. We describe here two unrelated families wherein balanced t(6;8) chromosomal translocations occur in individuals diagnosed with TS. In one of these families, the transmission of the translocation is associated with learning and behavioral difficulties; in the other family, one parent is unaffected and the other cannot be traced, thus transmission cannot be demonstrated and it is possible that the translocation may have occurred de novo. The breakpoint on chromosome 8 occurs within the q13 band in both families, suggesting that a gene or genes in this region might contribute to the TS phenotype. Existing linkage and cytogenetic data, suggesting involvement of chromosome 8 in TS families and individuals, further support this hypothesis. We have identified two YAC clones mapping distal and proximal to the chromosome 8 translocation site, as determined by fluorescent in situ hybridization (FISH). PCR amplification of genetic markers in this region, using isolated chromosomes from one of the patients, followed by BAC screening with the closest flanking genetic markers, has identified a 200-kb BAC, which, by FISH, we have demonstrated encompasses the chromosome 8 breakpoint in both families. The fact that the chromosomal breaks in the TS cases from both families occur within such a small region of chromosome 8 further supports the hypothesis that disruption of a gene or genes in this part of chromosome 8 contributes to the clinical phenotype.

Executive function profile of children with attention deficit hyperactivity disorder

We explored the neuropsychological profile for executive functions of children with attention deficit hyperactivity disorder (ADHD) to assess whether problems associated with the two most cited relevant processes--inhibition and attentional problems--were the core of any executive function difficulty. A battery of executive function tests was administered to 31 children with a clinical diagnosis of ADHD and to 33 normal control participants, all aged between 7 and 12. The executive function battery encompassed a number of tasks, selected because each had multiple measures: a sustained attention reaction time task, a related vigilance task, an adaptation of the Hayling Sentence Completion Test, an adaptation of the Brixton Spatial Rule Attainment Test, a Letter Fluency task, a number Stroop task, and an "n-back" working memory task. The overall pattern of the results fit well with those obtained in previous studies as far as abnormalities of the ADHD group in the domain of inhibitory processes, attentional functions, and executive functions. The children with ADHD, although performing well on baseline tasks, performed more poorly than the controls on all the experimental tasks with one borderline exception: Letter Fluency, where the children with ADHD showed a very different pattern than most adult frontal lobe subgroups. However, there was no specific impairment on measures of inhibitory processes. In addition, strategy generation and use were severely affected in the ADHD group. Particular findings fitted well with disorders of a high-level effort system and of a monitoring system.

Tourette syndrome associated with body temperature dysregulation: possible involvement of an idiopathic hypothalamic disorder

Tourette syndrome is a neuropsychiatric disorder that holds the potential to afflict the emotional, familial, social, or scholastic performances of patients with Tourette syndrome in day-to-day life functioning. The disorder is today characterized mainly and diagnosed by clinical observations, yet false-negative results obtained in the diagnosis of Tourette syndrome are numerous and well documented. There is still no laboratory or imaging technique available for the diagnosis of Tourette syndrome. This article reports on changes of the ambient thermal perception (38%) and a circadian dysregulation of the body-temperature profile present in Tourette syndrome probands, irrespective of their chronologic age, sex, or comorbid symptoms. An involvement of idiopathic hypothalamic dysfunctions associated with Tourette syndrome is proposed. Such a phenomenon, if substantiated, could lead to a better understanding of Tourette syndrome and the development of unbiased physical diagnostic criteria of Tourette syndrome and potentiate possible production of novel therapeutic possibilities.

Neuropsychiatric assessment of Gilles de la Tourette patients: comparative study with other hyperkinetic and hypokinetic movement disorders

The role of the basal ganglia in conditions with co-occurring movement disorders and neuropsychiatric symptoms is not well known. It has been hypothesized that hyperkinesia -disinhibited behaviors and hypokinesia-inhibited behaviors result from an imbalance between the direct and indirect striatal output pathways, and that differential involvement of these pathways could account for the concurrent abnormalities in movement and behavior observed in these disorders. This study aimed to evaluate whether the pattern and the extent of the neuropsychiatric manifestations of patients with GTS, a hyperkinetic movement disorder of basal ganglia origin, differs from that of patients with other basal ganglia hyperkinetic (e.g., HD) or hypokinetic (e.g., PSP) movement disorders, and to determine whether patients with GTS show a greater frequency of hyperactive behaviors (e.g., agitation, irritability, euphoria, or anxiety) than PSP patients, and are comparable to patients with HD. The Neuropsychiatric Inventory (NPI), a scale with established validity and reliability, was administered to 26 patients with GTS (mean age, 30.2 +/- 2.2 years), and the results were compared with that of 29 patients with HD (mean age, 43.8 +/- 2 years) and 34 with PSP (mean +/- S.D. age, 66.6 +/- 1.2 years). There was no difference between the groups in the total NPI scores. However, there was a double dissociation in behaviors: patients with hyperkinetic disorders (HD and GTS) exhibited significantly more agitation, irritability, anxiety, euphoria, and hyperkinesia, whereas hypokinetic patients (PSP) exhibited more apathy. Patients with GTS showed greater scores than HD patients in all those scores differentiating HD and GTS from PSP patients (e.g., agitation, irritability, anxiety and euphoria), and were differentiated in a logistic regression analysis from both HD and PSP patients in having significantly more anxiety. We found that patients with GTS manifested predominantly hyperactive behaviors similar but more pronounced than those presented by patients with HD, while those with PSP manifested hypoactive behaviors. Based on our findings and the proposed models of basal ganglia dysfunction in these disorders, we suggest that the hyperactive behaviors in GTS are comparable to those observed in HD, being both secondary to an excitatory subcortical output through the medial and orbitofrontal cortical circuits, while in PSP the hypoactive behaviors are secondary to hypostimulation of these circuits. Abnormalities of other brain structures (e.g., amygdala, brainstem nuclei) may account for the significantly higher anxiety scores differentiating GTS from HD patients.

Tics and its disorders

Tourette syndrome (TS) is familial neuropsychiatric disorder that is characterized by motor and phonic tics that begin in childhood. Once thought of as a rare and debilitating disorder, in the last decade new scientific knowledge suggests that TS and related tic disorders are more common and less debilitating for the majority of individuals. Evidence points toward a spectrum of TS symptomatology that extends beyond the tics disorder to probably include obsessive-compulsive disorder, attention deficit hyperactivity disorder, and mood disorders. Tourette syndrome and its differential diagnosis are discussed in this article with a focus on new developments in classification, etiology, epidemiology, genetics, pathophysiology, and clinical management.

Childhood-onset obsessive-compulsive disorder: a tic-related subtype of OCD?

Obsessive-compulsive disorder (OCD) is a psychiatric condition characterized by recurrent obsessions or compulsions that cause significant impairment or distress. Although OCD was once perceived to be relatively rare in childhood, current estimates suggest that as many as half of all adult OCD cases may have their onset in childhood or adolescence. In general, there appears to be a great deal of continuity between the clinical presentation of OCD in children and that in adults. Yet, numerous differences have also been found between child and adult OCD, including differences in sex distribution, patterns of comorbidity, and degree of familial loading. These differences raise the issue of whether obsessive-compulsive symptoms that have their onset in childhood, but perhaps persist into adult life, are meaningfully different from those that emerge de novo in adulthood. In this article, current research on child- and adult-onset OCD is critically reviewed. It is proposed that child-onset OCD represents a phenomenologically and etiologically distinct subtype of OCD, bearing a close genetic relationship to tic-disorders and possibly sharing a common or similar pathogenesis. Clinical implications of the child- versus adult-onset OCD distinction are discussed.

Informativeness of structured diagnostic interviews in the identification of Tourette's disorder in referred youth

Although specialized programs have greatly advanced the treatment of youth with Tourette's disorder (TD), not all children with TD reach such programs, raising questions as to whether TD is adequately identified outside specialized settings. There is thus a need for evidence that cases identified in the nonspecialty setting are "true cases." Because structured diagnostic interview methodology can reduce errors of omission, this approach can facilitate the identification of TD in referred youth outside specialized programs. Similarities between cases ascertained in specialty and nonspecialty settings would suggest that those identified in the nonspecialty setting were indeed "true cases." Comparisons were made between youth with TD ascertained through a specialized TD program who had both a structured diagnostic interview-derived diagnosis of TD plus an expert evaluation of TD (N = 103), with youth ascertained through a non-TD specialized pediatric psychopharmacology program who had a structured diagnostic interview-derived diagnosis of TD (N = 92). Irrespective of ascertainment source, children with structured interview-derived diagnosis of TD shared similar correlates in terms of tic severity, mean age of onset and duration of tics, as well as patterns of comorbidity well known to be associated with TD in clinical samples. Children meeting diagnostic criteria for TD on structured diagnostic interviews share similarities and patterns of clinical correlates, irrespective of ascertainment through a specialized TD or non-TD specialized clinic. These findings support the usefulness of structured diagnostic interview methodology as a diagnostic aid for the identification of TD in non-TD specialized settings and facilitate delineation of patterns of comorbidity.

Clocks, engines, and quarks--love, dreams, and genes. What makes development happen?

That psychological growth and maturation throughout the lifespan involve progressive linear processes is an implicit assumption of all models of development. Within psychoanalysis, a particular focus has been those processes that hinder forward development and manifest themselves as regressions or fixations or in character structure. However, the implicit assumption of progressive, linear development leaves unexplored the central question of what are the processes that govern developmental progressions. What makes psychological development happen in more or less predictable ways and yet allows for considerable individual variability? And are those developmental progressions inevitably forwardly progressive? Questions regarding what regulates and integrates development are relevant not only for understanding the normal building up of the internal world and of childhood psychopathology but also for those times of dramatic mental reorganization in adulthood surrounding events such as pregnancy and aging and for issues of psychological change during and after an analysis. Clinical material from analyses with a child and an adult and from interviews with four- to five-year-old children is used to explore individual fantasies of how development and change happens. The central role of internalization and object relations in regulating psychological development is emphasized.

Distinguishing illness severity from tic severity in children and adolescents with Tourette's disorder

OBJECTIVE

To examine whether tic severity, comorbid disorders, or both are associated with illness morbidity in youths with Tourette's disorder (TD).

METHOD

Subjects were 156 consecutively referred youths (aged 5-20 years) who met DSM-III-R criteria for Tourette's disorder at a major academic medical center. All subjects were evaluated with a clinical interview by a child and adolescent psychiatrist and an assessment battery that included the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version. Statistical analysis used chi 2 and multivariate logistic regression.

RESULTS

Nineteen (12%) of the 156 youths with TD required psychiatric hospitalization. Current age, TD severity, TD duration, obsessive-compulsive disorder, psychosis, major depression, bipolar disorder, panic disorder, and overanxious disorder were significant univariate predictors of psychiatric hospitalization (p < .01). While tic severity was marginally significant as a predictor of psychiatric hospitalization (p < .05), major depression (p < .016) and bipolar disorder (p < .001) were robust predictors of psychiatric hospitalization, even after statistical adjustment for collinearity and correction for all other variables assessed.

CONCLUSION

The findings indicate that comorbid mood disorders are strongly associated with illness morbidity in youths with TD, highlighting the importance of attention to comorbidity in patients with TD.

Anxiety disorders and tic severity in juveniles with Tourette's disorder

OBJECTIVE

It was hypothesized that comorbidity with anxiety disorders would predict tic severity in youths with Tourette's disorder (TD).

METHOD

Subjects were 190 youths meeting DSM-III-R diagnostic criteria for TD who were consecutively referred to a pediatric psychopharmacology program between 1994 and 1997. Subjects were initially evaluated with a clinical interview and the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version. Statistical analysis used t tests, chi 2 tests, and logistic regression analysis.

RESULTS

One hundred thirty-four subjects were classified as mild/moderate and 56 as severe TD cases. No meaningful differences were found in socioeconomic status, gender distribution, or age at onset of TD between the 2 groups. The 2 groups could not be differentiated by the presence of comorbid mood or disruptive behavior disorders including attention-deficit hyperactivity disorder. Although obsessive-compulsive disorder (OCD) was overrepresented among the severe TD cases, the difference failed to reach statistical significance. Excluding social and simple phobias, all other anxiety disorders were more clearly overrepresented among subjects with severe TD; separation anxiety disorder most robustly predicted tic severity, irrespective of the presence of OCD or other anxiety disorders.

CONCLUSION

Findings suggest that non-OCD anxiety disorders in general and separation anxiety disorder in particular may be significantly associated with tic severity in referred TD patients.

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.

Bilateral globus pallidus lesions in a patient with Tourette syndrome and related disorders

BACKGROUND

The neuroanatomic and pathologic basis of Tourette's syndrome or related disorders such as obsessive-compulsive disorder and attention deficit-hyperactivity disorder remains unknown. Although a substantial body of neuroimaging and other data implicate basal ganglia and some point out specifically the globus pallidus in the etiopathogenesis of these three related disorders, no clear or pathologically significant isolated lesions restricted to this region have yet been demonstrated, with the exception of obsessive-compulsive disorder.

METHODS

A seventeen-year-old male case of Tourette syndrome with comorbid obsessive-compulsive disorder, attention deficit-hyperactivity disorder, stuttering and gait disturbance, who had negative family history is presented.

RESULTS

The patient has failed to respond to drug treatment and his MRI scan revealed bilateral and symmetrical globus pallidus lesions with specific "tiger's eye" appearance of unknown etiology.

CONCLUSIONS

Well-localized lesions in the globus pallidus support growing data suggesting the involvement of this brain region in Tourette syndrome and related disorders.

Bilineal transmission in Tourette syndrome

OBJECTIVE

To investigate the frequency and pattern of bilineal transmission in families of patients with Tourette syndrome (TS) compared with normal control subjects.

METHODS

The study population consisted of two groups: 1) consecutive patients with TS with both parents (51 family sets; 153 individuals), and 2) normal control subjects randomly selected from public schools (20 family sets; 60 individuals). All patients with TS, normal control subjects, and their parents were evaluated for evidence of TS and associated features. Structured interviews and detailed questionnaires designed to assess tics, obsessive-compulsive behavior (OCB), and attention deficit disorder (ADD) were administered to all people in both groups.

RESULTS

In addition to tics, 43 (84.3%) patients with TS had ADD, 33 (64.7%) had OCB, and 31 (60.8%) had both ADD and OCB. In 42 (82.4%) of the 51 patients, at least one parent exhibited features of TS; unilineal transmission (only one parent with tics, OCB, or ADD) was present in 29 (56.9%) TS families and an additional 13 (25.5%) TS families manifested evidence of bilineal transmission (both parents affected). More fathers than mothers of patients with TS had tics (31.4% versus 15.7%), whereas more mothers had OCB than did fathers (33.3% versus 15.7%). Features of ADD were equally distributed among fathers (35.3%) and mothers (33.3%) of patients with TS. Eight of 1,142 (0.7%) children in the general school population had some evidence of TS. One of 40 parents of the normal control subjects (2.5%) had symptoms of ADD, but none of the parents of normal control subjects manifested any features of TS or OCB.

CONCLUSIONS

This study found evidence for bilineal transmission in one fourth of TS families. Features of the TS spectrum were rare in normal control families. Evidence of tics, OCB, and ADD should be investigated in both parents of patients with TS.

A child with severe head banging

We present a 7-year-old boy with a developmental disorder presenting with severe head banging. Clinical evolution was consistent with diagnosis of autistic spectrum disorder, obsessive compulsive disorder, stuttering, and Tourette's syndrome. This report emphasizes the overlap between developmental disorder phenotypes. There is a need to understand the natural history and relationship of specific symptoms that occur in developmental disorders to devise effective and appropriate intervention strategies.

Tics in Tourette syndrome: new treatment options

Tourette Syndrome is a familial neurobehavioral disorder characterized by fluctuating involuntary motor and/or vocal tics. The most commonly used medications to treat Tourette's syndrome are haloperidol, pimozide, fluphenazine, and clonidine, all of which may have considerable side effects. We enrolled 450 patients with tics/Tourette's syndrome to be treated with baclofen/botolinum toxin type A for their symptoms. Global severity of tic symptoms was rated by the Yale Global Tic Severity Scale and a quantified videotaped micro-structured analysis of tics. We found that baclofen/botolinum toxin type A are very effective, safe, and reliable in the treatment of tics/Tourette's syndrome. It is worthwhile considering this treatment approach in patients with tics/Tourette's syndrome in order to reduce or avoid the side effects of other medications. Further studies, however, are required.

Saccadic performance characteristics and the behavioural neurology of Tourette's syndrome

OBJECTIVE

To better understand the neuropathological correlates of Tourette's syndrome (TS), measures of saccadic eye movement performance were examined among patients with TS.

METHODS

A case-control design was used. Twenty one patients with DSM-IV TS (mean age 40.6 years (SD 11.0); 38% female) mainly recruited from UCSD Psychiatry Services, and a community based sample of 21 normal subjects (mean age 34.6 years (SD 13.4); 43% women) participated in this study. Participants were administered ocular motor tasks assessing visual fixation, and the generation of prosaccades, predictive saccades, and antisaccades. Saccadic reaction time, amplitude, duration, and mean and peak velocity were computed. Intrusive saccades during visual fixation and the proportion of correct antisaccade responses were also evaluated.

RESULTS

The groups had similar visual fixation performance. Whereas patients with TS generated prosaccades with normal reaction times and amplitudes, their saccade durations were shorter and their mean velocities were higher than in normal subjects. During a prosaccade gap task, patients with TS exhibited an increased proportion of anticipatory saccades (RTs<90). The proportion of "express" saccades (90<RTs<135) did not differ between groups. Patients with TS had fewer correct antisaccade responses than did normal subjects, an effect accounted for by 19% of the patients. Antisaccade reaction times among patients with TS were increased during an overlap version of the task.

CONCLUSION

These findings suggest that TS mildly affects the ocular motor control circuitry associated with saccade inhibition.

Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. AACAP

These practice parameters describe the assessment and treatment of obsessive-compulsive disorder based on a detailed literature review and expert consultation. Obsessive-compulsive disorder is a disorder of heterogeneous origin characterized by intrusive thoughts or compulsive urges or behaviors that are distressing, time-consuming, or functionally impairing. In children and adolescents, the disorder often is accompanied by a wide range of comorbidity, including mood, anxiety, attentional, and learning difficulties, and/or tic disorder. These parameters describe the relevant areas of assessment, especially symptomatology, onset, and course, other associated psychopathology, and developmental, family, and medical history (including postinfectious onset or exacerbations). Two modalities have been systematically assessed and empirically shown to ameliorate core symptoms: cognitive-behavioral therapy (primarily exposure/response prevention) and serotonin reuptake inhibitor medication. Data regarding the indications, efficacy, and implementation of these modalities are reviewed. Because OCD frequently occurs in the context of other psychopathology and adaptive difficulties, additional individual and family psychotherapeutic, pharmacological, and educational interventions often are necessary. Treatment planning guidelines are provided.

Bipolar disorder in adult patients with Tourette's syndrome: a clinical study

BACKGROUND

Although recent clinical and epidemiological studies indicate that Tourette's syndrome (TS) is associated with a higher than expected rate of bipolar disorder (BPD), the clinical characteristics of BPD in patients with TS have not been widely investigated.

METHODS

Thirty adult TS patients with comorbid BPD were selected from a consecutive series of 90 referred TS patients and examined using structured psychiatric rating scales.

RESULTS

The full clinical spectrum of BPD was found, including bipolar I disorder, schizoaffective bipolar disorder, bipolar II disorder, and cyclothymic disorder. Atypical vegetative depressive symptoms, rapid cycling patterns, and seasonal patterns of recurrence were also documented. In the present clinical sample, BPD mainly occurred in patients with mild tic symptoms and was invariably associated with a high lifetime prevalence of general psychopathology, including generalized anxiety disorder, obsessive-compulsive disorder, panic, phobias, eating disorders, self-injurious behavior, attention-deficit hyperactivity disorder, impulse control disorders, and personality disorders.

CONCLUSIONS

The results of this clinical study indicate that BPD and nonaffective psychopathology may be prominent comorbid disorders in a subpopulation of patients with TS.

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.

Childhood Tourette's syndrome and the Thematic Apperception Test: is there a recognizable pattern?

26 children, one-half of whom were diagnosed with Tourette's syndrome, were administered the Thematic Apperception Test. A pilot investigation suggested that children with Tourette's syndrome produced high rates of responses in four categories: references to physical aggression, supernatural power, character names, and specific quantities. When compared with other children treated for emotional and behavioral problems at the same facility and matched on demographic variables and IQ, children with Tourette's syndrome were not more likely to produce Thematic Apperception Test responses in any of the four categories. This study shows that a recognizable pattern on projective testing was not easily established among these 13 children with Tourette's syndrome and further highlights the importance of using mental health comparison groups when investigating clinical disorders.

Rates for tic disorders and obsessive compulsive symptomatology in families of children and adolescents with Gilles de la Tourette syndrome

The aim of this study was to assess rates for tic disorders and obsessive compulsive psychopathology in families of children and adolescents with Gilles de la Tourette syndrome (TS). Diagnoses were based on the DSM III-R criteria. Obsessive compulsive psychopathology, that did not fulfill the criteria for obsessive compulsive disorder (OCD) was additionally assessed and termed obsessive compulsive symptoms (OCS). The authors hypothesized that comorbid OCD or OCS in TS patients predicts a higher familial loading with obsessive compulsive symptomatology. The study cohort included 87 patients with TS who were evaluated clinically and with the use of a structured psychiatric interview. All available parents (152/174; 87%), several sibs (49/93; 53%) and some second degree relatives (27/659; 4.1%) were also interviewed. For other first and second degree relatives the family history method was used. Familial rates for TS were clearly elevated. Rates for chronic tic disorders (CT) were considerably lower than in previous studies. Additionally, tic disorders not otherwise specified (TDNOS) were diagnosed in a substantial number of first degree (15/267; 5.6%) and second degree relatives (36/659; 5.5%). OCD in parents (4/174; 2.3%) did not occur in an above baseline rate. However, both OCD (14/87; 16.1%) and OCS (15/87; 17.2%) were frequently associated with TS in index patients. Interestingly, 10 of 16 fathers with OCS also had a tic disorder. Obsessive compulsive psychopathology clustered in families. It is concluded that genetic studies in TS could profit from adhering to a conservative diagnostic approach to both tic disorders and OCD. The familial clustering of OCS/OCD in conjunction with the elevated paternal rate for the co-occurrence of tic disorders and OCS might indicate heterogeneity of TS.

Neuropsychiatric disorders of childhood: Tourette's syndrome as a model

Neuropsychiatric disorders of childhood include conditions such as autism, pervasive developmental disorder and attention deficit hyperactivity disorder. Tourette's syndrome (TS) of chronic, multiple, motor and vocal tics is a model neuropsychiatric disorder with a childhood onset and long-term, and sometimes life-long, course. Symptoms and signs change during the course of maturation, and include obsessions, compulsions, attentional difficulties and psychological responses to the disability. These clinical features reflect the interaction between genetic and environmental factors. The localization and cloning of the genetic substrate will allow for detailed study of the pathways from molecular vulnerability to clinical syndrome.

Tourette syndrome. Phenomenology and classification of tics

Motor and phonic tics represent the clinic hallmark of Tourette syndrome. Since there is no diagnostic test for tics, the clinical recognition of phenomenology is essential for proper diagnosis. Some, and possibly most, motor tics are preceded by a premonitory urge or sensation that is relieved by the execution of the tic and thus can be difficult to differentiate from compulsions, hence the term compulsive tic. In the schema of categorization of movements, most tics can be classified as either unvoluntaryin response to an inner sensory stimulus or to an unwanted feeling compulsionor involuntarytics that are usually suppressible. Further studies are needed to elucidate the clinical, anatomical, and physiologic substrates for the different forms of tics. Finally, the relationship between tics and comorbid conditions, such as obsessive-compulsive disorder and attention deficit with hyperactivity needs to be further explored.

Behavioral and emotional aspects of Tourette syndrome

This article reviews the behavioral and emotional aspects of Tourette syndrome with a focus on behavioral phenomenology and psychiatric comorbidity. Tourette syndrome is a complex neuropsychiatric disorder characterized by disinhibition and dysfunction of the regulation of motor, cognitive, affective, and behavioral functions. Although multiple motor and vocal tics are the key diagnostic phenomena, hyperactivity, impulsivity, inattention, obsessive-compulsive, and emotional symptoms are common in many patients. Evaluation and treatment should take into account the behavioral and emotional symptoms as well as the tics. Treatment should incorporate multimodal strategies so as to address both the tics and symptoms.

Pathogenesis of Tourette's syndrome

This review presents a models of disease pathogenesis in the context of CNS development. It begins with an exploration of the clinical features and natural history of Tourette's syndrome. This is followed by a consideration of the role of genetic and nongenetic factors. An effort is then made to review the anatomical organization of the basal ganglia and related cortical sites. These circuits are intimately involved in the normal processing of sensorimotor, cognitive, and emotionally laden information. Evidence implicating these circuits in the pathobiology of Tourette's syndrome is then considered. The review closes with the prospects for advances in interdisciplinary research and therapeutics using this model as a guide.

Tourette's syndrome in the year 2000

OBJECTIVE

To examine the current status of knowledge of Tourette's syndrome (TS) and to highlight those areas of research that are most likely to have the most significant advances in the next few years into the 21st century.

METHOD

Index Medicus was consulted from its beginning in 1885 until 1964 (inclusive), looking initially under the title 'tics' and subsequently under 'Tourette's Disorder'. From 1965 and the advent of MEDLINE, a search was performed looking for 'Tourette's'. A chronological examination of TS in the medical literature is presented. Some issues surrounding Huntington's Disease (HD) research are pertinent to TS and may serve as a guide in the future direction of TS research; these issues have been identified and illustrated in the context of TS. Where relevant, other medical disorders are also commented on.

RESULTS

There has been a steady increase in the volume of TS literature since 1885, with a marked increase since 1980, changing in focus from a psychological to a neurobiological viewpoint. Current areas of interest include genetics, comorbid psychopathologies, neuroimaging, treatments, epidemiology and educational considerations. Issues raised by HD and other movement disorders such as Parkinson's Disease (PD) are predictive testing, gene therapy and neural transplants.

CONCLUSIONS

The year 2000 is likely to herald a significant increase in our knowledge of the genetics and neuroimaging of TS, with new developments in therapy. A broadening of awareness of TS among health workers and teachers in particular is likely to increase the number of diagnosed patients and, hence, new challenges will be posed to existing resources for health and educational provision.

Obsessive-compulsive disorder in children and adolescents: a review of the past 10 years

OBJECTIVE

To review the literature on pediatric obsessive-compulsive disorder (OCD) from the perspective of information relevant to American Board of Psychiatry and Neurology recertification in child and adolescent psychiatry.

METHOD

The clinical and research literatures were systematically searched or articles that address the diagnosis and treatment of pediatric OCD.

RESULTS

Drawing from the literature and their own clinical experience, the authors note that (1) OCD is a common neuropsychiatric disorder; (2) comorbidity is common, especially with tic, attention-deficit, anxiety, and affective disorders; (3) OCD following group A beta-hemolytic streptococcal infection may define an autoimmune sub-grouping calling for immunomodulatory treatments; and (4) OCD-specific cognitive-behavioral psychotherapy and pharmacotherapy with a serotonin reuptake inhibitor define the psychotherapeutic and pharmacotherapeutic treatments of choice, respectively.

CONCLUSION

Child psychiatrists should be familiar with the differential diagnosis and treatment of OCD.

The clinical features of Tourette's disorder with obsessive-compulsive symptoms

Twenty-three patients with Tourette's disorder (13 with obsessive-compulsive symptoms [OCS] and 10 without) were comparatively investigated. In contrast to OCS-free Tourette's disorder patients, those with OCS were found to be characterized by (i) a higher incidence of volatile temper, (ii) a higher incidence of compulsive tics, (iii) a higher incidence of perinatal disorders and brain wave abnormalities, (iv) a higher severity as rated using the Severity Scale, and (v) a higher prevalence of complications, especially of developmental disorders. Of the subjects with OCS-accompanied Tourette's disorder, approximately half had developed OCS by the onset of tics. These findings suggest the likelihood that OCS-accompanied Tourette's disorder is more strongly associated with organic cerebral disorders, independently of sites of tic disorders, than is OCS-free Tourette's disorder.

Auditory event-related potentials (ERPs) and mismatch negativity (MMN) in healthy children and those with attention-deficit or tourette/tic symptoms

The study compares 5 auditory event-related potential (ERP) components (P1 to P3) after 3 tones differing in pitch and rarity, and contrasts the mismatch negativity (MMN) between them in 12 children with attention-deficit hyperactivity disorder (ADHD; mean 10.2 years of age), 12 healthy controls pairwise matched for age (controls), and 10 with Chronic Tic or Tourette Syndrome (TS). Topographic recordings were derived from 19 scalp electrodes. Four major effects are reported. (a) Shorter latencies in ADHD patients were evident as early as 100 ms. (b) Both ADHD and TS groups showed very large P2 components where the maxima were shifted anteriorly. The differences in the later potentials were of a topographical nature. (c) Frontal MMN was non-significantly larger in the ADHD group but normalized data showed a left rather than a right frontal bias as in control subjects. Maxima for TS were usually posterior. (d) ADHD patients did not show the usual right-biased P3 asymmetry nor the frontal versus parietal P3 latency difference. From these results it is suggested that ADHD patients process perceptual information faster from an early stage (N1). Further, along with the TS group, ADHD patients showed an unusually marked inhibitory phase in processing (P2), interpreted as a reduction of the normal controls on further processing. Later indices of stimulus processing (N2-P3) showed a frontal impairment in TS and a right hemisphere impairment in ADHD patients. These are interpreted in terms of the difficulties in sustaining attention experienced by both ADHD and TS patients.