Tourette Syndrome: Tackling a noisy tic disorder (with just a whisper about medication) Samuel H. Zinner, M.D. Assistant Professor of Pediatrics & Developmental- Behavioral Pediatrician University of Washington, Seattle http://depts.washington.edu/dbpeds Conference on Early Learning Sept 24, 2007
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Tourette Syndrome:Tackling a noisy tic disorder
(with just a whisper about medication)
Samuel H. Zinner, M.D.Assistant Professor of Pediatrics & Developmental-Behavioral Pediatrician
University of Washington, Seattle
http://depts.washington.edu/dbpeds
Conference on Early LearningSept 24, 2007
Tourette Syndrome:Tackling a noisy tic disorder
(with just a whisper about medication) Samuel H. Zinner, M.D. discloses no relevant financial relationships with
any commercial interests.
This presentation will reference unlabeled/unapproved uses of medications and products, and will be identified as such.
"I Have Tourette's but Tourette's Doesn't
Have Me"premieres Saturday, November 12, 2005at 7:30 p.m. ET/PT
– family, twin and adoption studies• Non-genetic factors also present
– Gestational exposure?– Perinatal?– Hormonal?
Geneticsbarriers to identifying genes
• Diagnosis based on behaviors• Defining the TS phenotypic spectrum
– “endophenotypes”• Family pedigree problems• Environmental influences• Combinations of genes may be involved• Symptoms decrease with age• Transient tics
Differential Diagnosis of tics
• Sydenham’s chorea• Compulsions• Blepharospasm• Other hyperkinetic disorders• Stereotypies• Allergies
Diagnostic Pitfalls 101
• Subject or clinician unaware of tics• Waxing and waning nature of tics• Tics are suppressible
Diagnostic Pitfalls 102
• T.S. is not rare• T.S. is usually not catastrophic• Few have coprolalia• You may not see the tics
• Hyperactivity often precedes tics• Head and neck tic onset age 6 to 7• Vocal tics age 8 to 9• Obsessive-Compulsive symptoms 11-12• Peak tic severity age 10 to 11• Often see decrease in tics• Tics lifelong in 50% to 90%
Quality of Life?
Quality of Life?“Tourette differs from other
neuropsychiatric disorders in one simple way: It is largely the disease of the onlooker. When I tic, I am usually
not the problem. You are.”
Peter Hollenbeck, Ph.D.(a neuroscientist with TS)
-Cerebrum (2003)
Management
• General Guidelines– Education – Monitoring (tics and non-tics)– Containment
Identification
• Clinical aspects of tics• Comorbid conditions• Emotion and behavior
Identification – comorbid conditions
KEY POINT!Always assess for non-tic comorbidity
* 90% occurrence if tics mild* 100% occurrence if tics severe
TRICHOTILLOMANIA: moth-eaten appearance to hair and
scalp excoriations
David Sedaris
a plague of tics
from “Naked”Little, Brown and Company, 1997
Clinical Course
• Hyperactivity often precedes tics• Head and neck tic onset age 6 to 7• Vocal tics age 8 to 9• Obsessive-Compulsive symptoms 11-12• Peak tic severity age 10 to 11• Often see decrease in tics• Tics lifelong in 50% to 90%
Management
• Is additional treatment needed:– for tics?– for co-morbid conditions?
Management
• Perspectives:– The child– The parent– The school– You
Managementparent perspective
• Most Important– Episodic rage– Attention deficit– Learning difficulties
• Least Important– Motor tics– Vocal tics
Management:“co-morbid” conditions
– OCD & other anxiety disorders– ADHD – Learning difficulties– Behavioral Disorders– Sleep disturbances– Other self-injurious behaviors– Family dysfunction