Mental Retardation Tic Disorders Psy 610A by mikesanye

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									Tic Disorders
     Psy 610A
 Gary S. Katz, Ph.D.
                Tic Disorders
   Tourette’s Disorder
   Chronic Motor or Vocal Tic Disorder
   Transient Tic Disorder
   Tic Disorder Not Otherwise Specified
                      Tic Disorders
   Tic: a sudden, rapid, recurrent, nonrhythmic,
    stereotyped motor movement or vocalization.
       Simple motor tics
          Eye blinking, nose wrinkling, neck jerking, shoulder
           shrugging, facial grimacing, abdominal tensing.
          Last less than several hundred milliseconds
       Complex motor tics
          Hand gestures, jumping, touching, pressing, stomping,
           facial contortions, repeatedly smelling an object, squatting,
           deep knee bends, retracing steps, twirling when walking,
           assuming/holding unusual postures
          Copropraxia – sudden, tic-like vulgar sexual, or obscene
           gestures
          Echopraxia – involuntary, spontaneous mirroring of
           another’s behavior.
                           Tic Disorders
   Tic: a sudden, rapid, recurrent, nonrhythmic,
    stereotyped motor movement or vocalization.
       Simple vocal tics
            Throat clearing, grunting, sniffing, snorting, chirping
       Complex vocal tics
            Involve speech or language
            Sudden spontaneous expressions of single words or phrases, speech
             blocking, sudden and meaningless changes in pitch, emphasis, or
             volume of speech
            Palilalia – repeating one’s own sounds or words
            Echolalia – repeating other’s sounds or words
            Coprolalia – sudden, inappropriate expression of a socially
             unacceptable word or phrase and may include obscenities as well as
             specific ethnic, racial, or religious slurs.
                  Found in fewer than 10% of individuals with tic disorders
                 Tic Disorders
   Tics are generally experienced as irresistable but
    can be suppressed for periods of time, often
    leading to excessive discharge later.
   Many experience a premonitory urge, rising
    tension prior to the tic expression and a release
    of tension following the tic expression.
   Often, individuals with tic disorders describe the
    tic as falling somewhere between voluntary and
    involuntary behavior.
             Differential Diagnosis
   Abnormal movements that accompany general medical
    conditions
       Huntington’s chorea, stroke, Parkinson’s
   Direct effects of a substance
       Tardive Dyskinesia
   Stereotypic Movement Disorder
   PDD
   Compulsions (as in OCD)
       OCD commonly comorbid in tic disorders
       Compulsions produced in response to an obsession, tics are
        more due to a perception of physical tension
          Differential Diagnosis
   Tic disorders can be differentiated from each
    other based upon the type of tic and its
    duration.
     Transient: lasts 4wks, but no longer than 12mos
     Tourette’s requires multiple motor + vocal tics
       Tourette’s Disorder (307.23)
A. Both multiple motor and one or more vocal tics have been present at some
   time during the illness, although not necessarily concurrently. (A tic is a
   sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or
   vocalization.)

B. The tics occur many times a day (usually in bouts) nearly every day or
   intermittently throughout a period of more than 1 year, and during this period
   there was never a tic-free period of more than 3 consecutive months.

C. The onset is before age 18 years.

D. The disturbance is not due to the direct physiological effects of a substance
   (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or
   postviral encephalitis).
Diagnostic Features – Tourette’s
   Location, number, frequency, complexity and
    severity of tics can vary over time.
   About 50% of individuals with Tourette’s see a
    single tic as the first symptom, usually eye
    blinking.
   Sometimes, begins with multiple tics at the same
    time.
            Associated Features
   Most common: obsessions and compulsions.
   Hyperactivity, distractibility, and impulsivity also
    common.
   Social discomfort, shame, self-consciousness, and
    demoralization and sadness frequently occur.
   Younger children may be unaware of their tics as may
    some adults.
   Tic thresholds are lowered with the use of some
    psychostimulant medications. ADHD meds can reveal
    underlying tic disorders.
        Culture and Gender Features and
                   Prevalence
   Tourette’s Disorder has been widely reported in
    a diverse range of racial and ethnic groups.
   In clinical samples, 3x to 5x more prevalent in
    males.
   In community samples, 2x more prevalent in
    males.
   Prevalence related to age:
     Children: 5-30 per 10,000
     Adults: 1-2 per 10,000
                       Course
   Age of onset can be as early as 2 years, usually by
    childhood or early adolescence.
   Median age for onset of motor tics is 6-7 years.
   Duration may be lifelong although may have periods of
    remission.
   In most cases, severity diminishes during adolescence
    and adulthood and may disappear in early adulthood.
   In a few cases, symptoms may worsen in adulthood.
   Predictors of course are unknown.
                  Familial Pattern
   Tourette’s Disorder appears to have genetic
    transmission; the mode is not known.
   Pedigree studies suggest that there are genes of
    major effect.
   Not everyone who inherits the predisposition
    for Tourette’s will express symptoms of a tic
    disorder
       Could be varying levels of tic thresholds
 Chronic Motor or Vocal Tic Disorder (307.22)
A. Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent,
   nonrhythmic, stereotyped motor movements or vocalizations), but not both,
   have been present at some time during the illness.

B. The tics occur many times a day nearly every day or intermittently throughout
   a period of more than 1 year, and during this period there was never a tic-free
   period of more than 3 consecutive months.

C. The disturbance causes marked distress or significant impairment in social,
   occupational, or other important areas of functioning.

D. The onset is before age 18 years.

E. The disturbance is not due to the direct physiological effects of a substance
   (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or
   postviral encephalitis).

F. Criteria have never been met for Tourette's Disorder.
       Transient Tic Disorder (307.21)
A. Single or multiple motor and/or vocal tics (i.e., sudden, rapid, recurrent,
   nonrhythmic, stereotyped motor movements or vocalizations)

B. The tics occur many times a day nearly every day for at least 4 weeks but for
   no longer than 12 consecutive months.

C. The onset is before age 18 years.

D. The disturbance is not due to the direct physiological effects of a substance
   (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or
   postviral encephalitis).

E. Criteria have never been met for Tourette's Disorder or Chronic Motor or
   Vocal Tic Disorder.

Specify if:
    Single Episode or Recurrent
    Tic Disorder Not Otherwise
         Specified (307.20)
This category is for disorders characterized by
tics that do not meet criteria for a specific Tic
Disorder. Examples include tics lasting less than
4 weeks or tics with an onset after age 18 years.
                 Case Material
   Jack E. – 8 year old referred because he is
    having problems academically and is
    “significantly impulsive, inattentive, yet
    perfectionistic.”
   Teacher reports Jack is very fidgety at school
    and cannot sustain attention in class, blurts out
    answers, and is “immature.”
                      Case Material
   Medical history
       Delivered via c-section 4 weeks early, weighed 5lbs 12oz
       No prenatal exposures
       History of “undereating” – too busy to sit down and eat a full
        meal.
       Developmental milestones on time, except some continuing
        problems with urinary incontinence (will get so occupied in
        videogames, he will wait “just too long” to empty his bladder
        and end up wetting himself on the way to the bathroom).
   “Fair” social skills, becomes easily frustrated when
    friends don’t do exactly what he wants to do.
                             Case Material
   Family History
        Mom has a history of anxiety disorders, treated medically and with therapy on
         occasion.
        Dad was described as moody.
        Younger brother described as “bouncy”, just like Jack.
   School History
        Fidgety in first grade.
        Second grade continued interpersonal difficulties and low frustration tolerance.
        Currently in third grade and “highly distractible” and “impulsive.”
        School observation:
             Facial grimacing, repeated stretching of abdomen, some grunting
   Current testing observation
        See facial grimacing, soft grunting noises.
        Can inhibit for a while, then they return (after 10min)
                 Case Material
   IQ Average (VIQ: 110, PIQ: 102, FSIQ: 106)
   Achievement scores all commensurate.
   RCMAS (anxiety): social desirability scale at 94th
    %ile, no other clinical elevations.
   CPT-II numerous findings suggesting problems
    with attention, vigilance, and impulse control.
   Parent and teacher CBCL checklists indicate
    significant concerns with inattention,
    impulsivity, and anxiety.
Diagnoses?
                           Diagnoses
Axis I:     Attention-deficit Hyperactivity Disorder, Combined Type
            Tourette’s Disorder
            Adjustment Disorder with Disturbance of Mood and Conduct
            Parent/Child Relational Problem

Axis II:    No Diagnosis on Axis II

Axis III:   No Diagnosis on Axis III

Axis IV:    Problems with the school environment, poor academic achievement and
            distractibility

Axis V:     Current estimated GAF: 60
            Highest GAF in past year: 60

								
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