Kk&s Ch.46 47 Tic & Elim Disorders

Front 1

Tic Disorder DSM criteria?

Back 1

1. 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.)
2. 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.
3. The onset is before age 18 years.
4. 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).

Front 2

Chronic Motor or Vocal Tic?

Back 2

1. 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.
2. 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.
3. The onset is before age 18 years.
4. 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).
5. Criteria have never been met for Tourette's disorder.

Front 3

Transient Tic Disorder

Back 3

1. Single or multiple motor and/or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations)
2. The tics occur many times a day, nearly every day for at least 4 weeks, but for no longer than 12 consecutive months.
3. The onset is before age 18 years.
4. 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).
5. Criteria have never been met for Tourette's Disorder or Chronic Motor or Vocal Tic Disorder.

Specify if:
Single episode or Recurrent

Front 4

Tics most commonly affect what muscles?

Back 4

face

Front 5

simple def of tic

Back 5

involuntary muscle contraction somewhat suppressible

Front 6

OCD and tourette coexist how often?

Back 6

in up to 2/3's of people with tourettes have OCD

Front 7

The obsessive-compulsive symptoms most likely to occur in those individuals with Tourette's disorder are

Back 7

characteristically related to ordering,
symmetry,
counting and
repetitive touching

Front 8

whereas OCD disorders in the absence of tic disorders are characterized by symptoms more often associated with

Back 8

fears of contamination and
fears of harming others

Front 9

in kids with Tourette's, risk of OCD is worse in who:
a) high IQ above 120
b) Avg IQ

Back 9

high IQ

Front 10

Common (simple or complex) vocal tics include coughing, throat-clearing, grunting, sniffing, snorting, and barking

Back 10

simple vocal

Front 11

Common (simple or complex) motor tics include grooming behaviors, the smelling of objects, jumping, touching behaviors, echopraxia (imitation of observed behavior), and copropraxia (display of obscene gestures).

Back 11

complex motor

Front 12

eye-blinking, neck-jerking, shoulder-shrugging, and facial-grimacing are examples of

Back 12

simple motor

Front 13

epeating words or phrases out of context, coprolalia (use of obscene words or phrases), palilalia (a person's repeating his or her words), and echolalia (repetition of the last-heard words of others)
=

Back 13

complex vocal tics

Front 14

What reduces tics?

Back 14

sleep
relaxation
preoccupation with activity
usually sleep

Front 15

Tourettes and gender?

Back 15

3X more > in boys than girls

Front 16

what usually emerges first, motor or vocal tics?

Back 16

motor age 7
vocal age 11

Front 17

more children or more adults?

Back 17

c- up to 30 per 10, 000
adults 2 per 10, 000

Front 18

Who at highest genetic risk of tourette's

Back 18

son's of mothers with tourettes

Front 19

gene associated with Tourettes?

Back 19

rare sequence variant in SLITRK1 believed to be a candidate gene on chromosome 13q31.

Front 20

up to? patients with Tourette's disorder also have ADHD

Back 20

50%

Front 21

A relation also appears between Tourette's disorder and OCD; up to ? percent of all those with Tourette's disorder also have OCD

Back 21

40%

Front 22

Tourette's more linked to ADHD or OCD?

Back 22

ADHD

Front 23

NT associated with tics? evidence?

Back 23

dopamine
blockers reduce tics
increases of DA increase tics (like stimulants)

Front 24

brain structures associated with tourettes'

Back 24

putamen - less choline & less N-acetylaspartate

frontal cortex less N-acetylaspartate

lower creatine on right brain

lower myoinositol on left side

basal ganglia

Front 25

link of opiates to tourettes?

Back 25

opiate antagonizers like naltrexone reduces tics

Front 26

tourettes and clonidine ... increased or reduced tics?

Back 26

reduced tics

Front 27

Is tic progression upward to face or downward from face?

Back 27

down-ward

Front 28

Order of tic appearnance?

Back 28

The most frequent initial symptom is an eye-blink tic,
followed by a head tic or a facial grimace

Front 29

Scales for tic disorders?

Back 29

Tic Sx Self-Report
Yale Glocal Tic Severity Scale by clinicians

Front 30

OCD and ADHD which comes before, after?

Back 30

ADHD -> Tics -> OCD

Front 31

So how tx ADHD in child with tics? Rx, dosing? monitoring?

Back 31

non-stimulant approach; i.e.,
Guanfacine starting at 0.5mg increasing every week until at 3mg per day in divided doses
Monitor: BP, pulse, sleep, appetite, energy level and tics
Ratiings q1 and 2 months

Front 32

DDX of Tics?

Back 32

Huntington's disease,
parkinsonism,
Sydenham's chorea, and
Wilson's disease
Tremors,
mannerisms, and
stereotypic movement disorde

Front 33

Difference between steteotypica mvmt disorders like rocking, hand-gazing and tics?

Back 33

voluntary and produce comfort while tics do not

Front 34

Tourettes also seen more often with?

Back 34

autism
bipolar ds

Front 35

before starting antipsychotic what do?

Back 35

rule out td

Front 36

as tic severity increases what happens?

Back 36

get more internalizing ... depression and externalizing (agression) sx

Front 37

Tourette's disorder is associated with reduced ? volume

Back 37

caudate nucleus

Front 38

prediction onto adulthood?

Back 38

MRI showing small caudate nucleus volume

Front 39

T or F: severity always predicts persistence into adulthood

Back 39

False

Front 40

Tx tics psycho?

Back 40

Pscho:
psycho-ed - not punish
including massed (negative) practice, self-monitoring, incompatible response training, presentation and removal of positive reinforcement, as well as habit reversal treatment

Front 41

Rx most used for tics?

Back 41

haloperidol and
pimozide (orap)

Front 42

problems with pimozide/haldol?

Back 42

long qt
td
little experience in kids<12

Front 43

common atypicals used?

Back 43

risp 1-6
olanz

Front 44

Other rx for tics?

Back 44

alpha 2 adrenergic agonists:clonidine and gaunfacine

Front 45

Clonidine/Gaunfacine dosing?

Back 45

Clonidine has generally been used in dosages ranging from 0.05 mg orally thrice daily to 0.1 mg four times daily; and guanfacine is usually used in dosages ranging from 1 to 4 mg per day.

Front 46

adverse effects of the α-adrenergic agents include

Back 46

drowsiness,
headache,
irritability, and
occasional hypotension

Front 47

atomoxetine and tics?

Back 47

may reduce

Front 48

buproprion and tics?

Back 48

worsened

Front 49

what is more common chronic tic ds or tourettes?

Back 49

chronic tics 100 to 1000 times more common = 1 to 2% prev

Front 50

which is more rare - chronic motor or vocal tics?

Back 50

vocal more rare

Front 51

ddx of chronic vocal tics?

Back 51

Involuntary vocal utterances can occur in certain neurological disorders, such as Huntington's disease and Parkinson's disease

Front 52

ddx of chronic motor tics?

Back 52

choreiform movements, myoclonus, restless legs syndrome, akathisia, and dystonias

Front 53

Children whose tics involve the limbs or trunk tend to do (better or worse) than those with only facial tics.

Back 53

worse

Front 54

The treatment of chronic motor or vocal tic disorder depends????

Back 54

on the
severity and
frequency of the tics; the patient's
subjective distress; the
effects of the tics on school or work, job performance, and socialization; and the presence of any other concomitant mental disorder.

Front 55

tx of chronic tics?
what not work?

Back 55

psychotx to minimize 2ndary problems
habit reversal
habit reversal
antipsychotics

anti-anxiety rx (i.e., ssri's)

Front 56

Which comes first usually, bowel or bladder control?

Back 56

The ability to have muscular control over the bowel occurs even before bladder control for most toddlers

Front 57

The normal sequence of developing control over bowel and bladder functions is the development of

Back 57

nocturnal fecal continence,
diurnal fecal continence,
diurnal bladder control, and
nocturnal bladder control.

Front 58

These disorders are considered after age ? years, for encopresis, and after age ? years for enuresis, when a child is chronologically, developmentally, and physiologically expected to be able to master these skills.

Back 58

4
5

Front 59

Encopresis is defined as a pattern of passing feces in inappropriate places, such as in clothing or other places, at least ? per month for ? consecutive months, whether the passage is involuntary or intentiona

Back 59

once per month for 3 months

Front 60

Enuresis time criteria?

Back 60

2x/week
for at least 3months
ORRRRRR
dysfxn if less than that

Front 61

Although the diagnosis is not made until after age 4 years, encopretic behavior is present in ? percent of 3 year olds, ? percent of 5 year olds, and ?percent of 10 to 12 year olds.

Back 61

Although the diagnosis is not made until after age 4 years, encopretic behavior is present in 8.1 percent of 3 year olds, 2.2 percent of 5 year olds, and 0.75 percent of 10 to 12 year olds.

Front 62

In Western cultures, bowel control is established in more than ? percent of children by their fourth birthday and in ? percent by the fifth birthday.

Back 62

95%
99%

Front 63

encopresis and gender?

Back 63

males >females

Front 64

pattern of holding, impaction, then overflow occurs what %?

Back 64

75%

Front 65

encopresis > or < or no diff in sexual abuse; psych disorders,

Back 65

>in abuse
not a specific indicator of sexual abuse, because it also occurs with increased frequency in nonabused children with other behavioral problems
> in psych disturb

Front 66

encopresis linked to bipolar ds?

Back 66

yes

Front 67

can you have encopresis as secondary problem (i.e., after being continent) ?

Back 67

yes, with stressor

Front 68

what happens with chronic constipation?

Back 68

rectal distension from large, hard massses ->loss of tone and desensitization to pressure -->less aware of need to defecate

Front 69

does being punitive during accidents => risk of encopresis?

Back 69

yes

Front 70

Studies have indicated that children with encopresis who (have or not have) gastrointestinal illnesses have high rates of abnormal anal sphincter contractions.

Back 70

NOT having; i.e., gi illness lower rates

Front 71

DDx of encopresis with constipation and overflow incontinence?

Back 71

Hirschprung's disease or aganglionic megacolin ... overflow of feces even though rectum empty and no desire to defecate
Rule out Sexual abuse

Front 72

tx of encopresis?

Back 72

1. medical assessment
2. decrease negative affect assoc with all bowel behaviours/routines
3. daily mineral oil with regular scheduled sits

Front 73

what % of 5 years have enuresis?
teens and beyond?

Back 73

7%
1%

Front 74

Nocturnal enuresis is about ? percent more common in boys and accounts for about ? percent of children with enuresis

Back 74

50%
80%

Front 75

What is more likely to be associated with a GMC: normal amounts, large or small amounts of nocturnal enuresis?

Back 75

small

Front 76

The most severe form of dysfunctional voiding is called ?, and is thought of as a non-neurogenic neurogenic bladder resulting from habitual, voluntary tightening of the external sphincter during urges to urinate.

Back 76

Hinman's syndrome
sensation to urinate decrases

Front 77

(few, some, most) children are not enuretic by intention or even with awareness until after they are wet.

Back 77

most

Front 78

what starts off enuresis, what maintains it?

Back 78

Physiological factors often play a role in the development of enuresis, and behavioral patterns are likely to maintain the maladaptive urination

Front 79

A longitudinal study of child development found that children with enuresis were about twice as likely to have concomitant ? as those who did not have enuresis.

Back 79

developmental delays

Front 80

About ? percent of children with enuresis have a first-degree relative who has or has had enuresis.

Back 80

75%

Front 81

A child's risk for enuresis has been found to be more than ? times greater if the father was enuretic

Back 81

7

Front 82

Studies indicate that children with enuresis with a normal anatomic bladder capacity report urge to void with (more, less) urine in the bladder than children without enuresi

Back 82

less

Front 83

studies report that nocturnal enuresis occurs when the bladder is full because of lower than expected levels of nighttime ?

Back 83

antidiuretic hormone

Front 84

what stage of sleep is enuresis associated with

Back 84

nil

Front 85

can stress precip enuresis?

Back 85

yes

Front 86

Children with enuresis are at higher risk for ? compared with the general population

Back 86

ADHD
encopresis

Front 87

enuresis lab workd?

Back 87

rule out it

Front 88

enuresis + what = greater likelihood of gmc?

Back 88

day and night enuresis+
frequency+
urgency

Front 89

enuresis ddx gmc?

Back 89

he organic features include genitourinary pathology—structural, neurological, and infectious—such as obstructive uropathy, spina bifida occulta, and cystitis;

other organic disorders that can cause polyuria and enuresis, such as diabetes mellitus and diabetes insipidus;

disturbances of consciousness and sleep, such as seizures, intoxication, and sleepwalking disorder, during which a child urinates; and adverse effects from treatment with antipsychotics (e.g., thioridazine [Mellaril]).

Front 90

Tx enuresis

Back 90

1. review toilet training
2. star chart
3. restrict hs fluid
4. increase hs urination, including waking up at night
5. bell and pad

Front 91

how effective is bell and pad?

Back 91

50%

Front 92

rx for enuresis
efficacy?

Back 92

desmopressin
10 to 90%

Front 93

desmopressin side fx?

Back 93

headache
nasal congestion
epistaxis
stomaches
serious: hyponatremia and seizure that goes with it

Front 94

promising rx?

Back 94

reboxetine, NE reuptake inhibitor