Exacerbation Of Tics Research Articles

Psychosocial stress in children with Tourette syndrome and chronic tic disorder

BackgroundThis study aimed to understand the longitudinal relationship between psychosocial stress with tic exacerbation in children with Tourette syndrome (TS) and chronic tic disorder. MethodsConsecutive ratings of tic severity as well as child and parental reports of psychosocial stress were obtained for 373 children (296 males, 77 females; mean age 9y 5mo; SD 3y 3mo) with TS and chronic tic disorder between January 2018 and December 2020. The Yale Global Tic Severity Scale (YGTSS) global severity score, total tic score, and impairment rating were calculated. The stressful events and YGTSS measurements were used and treated as time-varying variables in the analyses. Models that controlled for non-independence among the repeated observations using a random intercept and random slope model were employed. Each participant was treated as a random factor in the modelling. ResultsFamily-related stress, personal relationship stress and school-related stress were independently associated with increasing YGTSS global severity, total tic score, and impairment rating over time. An increased number of stressful events were associated with increased severity of tics. ConclusionFamily, personal relationships, and school-related stress were consistently associated with the exacerbation of tics. Managing these stressful events is important in the treatment of TS and chronic tic disorder.

Extended-Release Viloxazine Compared with Atomoxetine for Attention Deficit Hyperactivity Disorder.

In our outpatient pediatric and adult psychiatry centers, we reserve psychostimulants for predominantly inattentive attention deficit hyperactivity disorder (ADHD) due to the potential for appetite and growth suppression, insomnia, wear off, exacerbation of mood, anxiety, and tics, or misuse. We utilize extended-release (ER) alpha-2 agonists primarily for hyperactivity/impulsivity but find them less effective for inattention, and they can cause sedation and hypotension. Oftentimes, we need to combine an alpha-2 agonist for behavior with psychostimulants for inattention. We employ atomoxetine or viloxazine ER (VER) for combined ADHD. However, our patients' insurers mandate a trial of generic atomoxetine prior to covering branded VER. The objective of this study was to determine whether pediatric and adult patients taking atomoxetine for DSM-5-TR ADHD combined type would experience improvement in ADHD symptoms following voluntary, open-label switch to VER. 50 patients (35 children) received mean doses of atomoxetine 60 mg (25-100 mg once daily) followed by VER 300 mg (100-600 mg once daily) after a 5-day atomoxetine washout. Both atomoxetine and VER were flexibly titrated according to US Food and Drug Administration (FDA) guidelines. The pediatric ADHD-Rating Scale-5 (ADHD-RS-5) and the Adult Investigator Symptom Rating Scale (AISRS) were completed prior to starting atomoxetine, and 4 weeks after treatment with atomoxetine or upon earlier response or discontinuation due to side effects, whichever occurred first; the same protocol was used after treatment with VER. We conducted a blinded, de-identified, retrospective review of charts from these 50 patients in the regular course of outpatient practice. Statistical analysis was performed using a within-subject, 2-tailed t-test with significance level of p < 0.05. From the baseline total ADHD-RS-5 mean score (40.3 ± 10.3), improvements were greater on VER (13.9 ± 10.2) than atomoxetine (33.1 ± 12.1; t = - 10.12, p < 0.00001) in inattention (t = - 8.57, p < 0.00001) and in hyperactivity/impulsivity (t = - 9.87, p < 0.00001). From the baseline total AISRS mean score (37.3 ± 11.8), improvements were greater on VER (11.9 ± 9.4) than atomoxetine (28.8 ± 14.9; t = - 4.18, p = 0.0009) in inattention (t = - 3.50, p < 0.004) and in hyperactivity/impulsivity (t = - 3.90, p < 0.002). Of patients on VER, 86% reported positive response by 2 weeks versus 14% on atomoxetine. A total of 36% discontinued atomoxetine for side effects, including gastrointestinal (GI) upset (6 patients), irritability (6), fatigue (5), and insomnia (1), versus 4% who discontinued VER due to fatigue. A total of 96% preferred VER over atomoxetine, with 85% (22 out of 26) choosing to taper psychostimulants following stabilization on VER. Pediatric and adult ADHD patients who have experienced less than optimal response to atomoxetine demonstrate rapid improvement in inattention and in hyperactivity/impulsivity with greater tolerability on extended-release viloxazine.

PANDAS/PANS in the COVID-19 Age: Autoimmunity and Epstein-Barr Virus Reactivation as Trigger Agents?

COVID-19 impacted the entire world's population, frequently resulting in long-lasting neuropsychiatric complications. Furthermore, social distancing, lockdowns and fear for one's personal health worsen individual psychological wellbeing, especially in children and adolescents. Herein, we discuss the results of studies that specifically reported data about the impact of the COVID-19 pandemic or infection on children with Pediatric Acute-Onset Neuropsychiatric Disorders (PANS). Furthermore, we present the cases of five adolescents with PANS whose symptomatology increased following SARS-CoV-2 infection. What emerged from this study was that COVID-19 resulted in the exacerbation of obsessions, tics, anxiety and mood symptoms and decreased wellbeing. Moreover, new symptoms, as well as new PANS cases, are reported to have arisen after COVID-19 infection. Here, we hypothesize that the pathogenic mechanisms of silent viruses, such as the Epstein-Barr virus, are related to neuroinflammation, immune responses and reactivation, with additional roles played by social-isolation-related inflammatory processes. The discussion of PANS, which represents a model of immune-mediated neuropsychiatric manifestations, is particularly relevant, with the aim of uncovering the mechanisms that lead to neuropsychiatric Post-Acute COVID-19 Syndrome (PACS). Prospects for future studies and treatment implications are discussed.

TikTok and tics: the possible role of social media in the exacerbation of tics during the COVID lockdown

Over the past year, many cases with newly onset or significantly exacerbated tic disorders were observed worldwide, where some aspects of the clinical presentation or the symptomatology were atypical for established tic diagnoses. Our purpose was to describe the atypical cases and raise relevant diagnostic issues. Consecutive cases with atypical tic presentations were documented. Five atypical tic cases are described. These cases shared some common characteristics, most notably the fact that all of them had been exposed to online presentation of ticking behaviour on social media platforms prior to the de novo development or exacerbation of their tics. Even though the order of events suggests causality and therefore the diagnosis of a functional tic disorder, unambiguous criteria for classifying atypical tics as functional symptoms are lacking. Differentiating neurodevelopmental and functional tics in childhood is currently problematic. Based on the currently unresolved issues in differential diagnosis, the importance of watchful waiting and behavioural interventions is highlighted to avoid unwarranted pharmacotherapy.

Reader Response: Association of Group A Streptococcus Exposure and Exacerbations of Chronic Tic Disorders: A Multinational Prospective Cohort Study.

The European Immuno-Neuropsychiatric Association Scientific and Medical Advisory Group welcomes this study that considered associations between exposure to group A streptococcus (GAS) and chronic tic disorders.1 This well-conducted study, with a balanced discussion, found no significant association between GAS and exacerbation of tics in children with chronic tic disorders. It is important that the study population was composed mainly of patients with a previous diagnosis of Tourette syndrome (90.8%). Thus, it is likely that the vast majority did not meet the diagnostic criteria for immune-mediated conditions, such as pediatric acute-onset neuropsychiatric syndrome/pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANS/PANDAS), which is differentiated from Tourette syndrome by presenting with an acute onset of several neuropsychiatric symptoms that may include tics or movement disorders. The results and conclusions should not therefore be used to refute the existence of immune-mediated conditions, including PANS/PANDAS, or to imply that these conditions do not similarly have an association with GAS infection. It is also interesting that an association between exacerbation of attention-deficit/hyperactivity disorder symptoms and GAS exposure was found, which we agree should be further investigated. The value of looking for GAS immune-mediated changes in the context of acute-onset tic disorders is not delineated by this study, and we feel that point should be highlighted.

Anti-dopamine D2 receptor antibodies in chronic tic disorders.

To investigate the association between circulating anti-dopamine D2 receptor (D2R) autoantibodies and the exacerbation of tics in children with chronic tic disorders (CTDs). One hundred and thirty-seven children with CTDs (108 males, 29 females; mean age [SD] 10y 0mo [2y 7mo], range 4-16y) were recruited over 18 months. Patients were assessed at baseline, at tic exacerbation, and at 2 months after exacerbation. Serum anti-D2R antibodies were evaluated using a cell-based assay and blinded immunofluorescence microscopy scoring was performed by two raters. The association between visit type and presence of anti-D2R antibodies was measured with McNemar's test and repeated-measure logistic regression models, adjusting for potential demographic and clinical confounders. At exacerbation, 11 (8%) participants became anti-D2R-positive ('early peri-exacerbation seroconverters'), and nine (6.6%) became anti-D2R-positive at post-exacerbation ('late peri-exacerbation seroconverters'). The anti-D2R antibodies were significantly associated with exacerbations when compared to baseline (McNemar's odds ratio=11, p=0.003) and conditional logistic regression confirmed this association (Z=3.49, p<0.001) after adjustment for demographic and clinical data and use of psychotropic drugs. There is a potential association between immune mechanisms and the severity course of tics in adolescents with CTDs.

Efectos secundarios del metilfenidato en población infantil y juvenil

The use of psychostimulants has been present in common medical practice since the 20th century and has undergone an exponential growth in terms of the number of prescriptions. To review the current state of knowledge about the side effects of psychostimulants in the child and teen populations. A review was performed by searching in different databases and included clinical analyses, observational prospective studies and systematic reviews. A minimum increase in blood pressure and heart rate are observed, but some studies highlight an underestimation of the long-term risk. As regards appetite and growth, almost all the current literature points to a slowing of the rate of growth, which is regained on interrupting treatment. One important factor, as is the parallel evolution of bone age, has not been evaluated in most of the studies carried out to date. No significant worsening of sleep was noted in patients treated with psychostimulants with respect to those who are not being treated. With regard to the central nervous system, there does not seem to be any evidence of an increased risk of the appearance or exacerbation of tics following introduction of the treatment. Affect and emotion are areas that have been barely explored. It is important to have more evidence on the safety of these drugs. It is therefore essential to have access to studies that cover a period of time consistent with the duration of these treatments.

The Modulating Role of Stress in the Onset and Course of Tourette’s Syndrome

Accumulating data indicate a common occurrence of tic exacerbations and periods of psychosocial stress. Patients with Tourette's syndrome (TS) also exhibit aberrant markers of hypothalamic-pituitary-adrenal (HPA) axis activation. Based on these findings, a functional relationship between stress and tic disorders has been suggested, but the underlying mechanism of how stress may affect tic pathology remains to be elucidated. We suggest that dopaminergic and noradrenergic neurotransmission as well as immunology play a crucial role in mediating this relationship. Two possibilities of causal direction might be assumed: (a) psychosocial stress might lead to an exacerbation of tics via activation of HPA axis and subsequent changes in neurotransmission or immunology and (b) TS-related abnormalities in neurotransmission or immunology result in a higher vulnerability of affected patients to respond to psychosocial stress with a strong activation of the HPA axis. It may also be the case that both assumptions hold true and interact with each other.

Management of severe pediatric tourette syndrome resistant to drug treatment.

Tourette syndrome (TS) is a neurodevelopmental disorder with chronic and disabling impacts on multiple domains of functioning in children. Treatment of TS is often complicated by comorbid conditions. We present a 12-year-old boy with severe symptoms of Tourette syndrome (TS), with prominent and markedly disabling vocal tics, who failed to respond to substantial doses of risperidone and haloperidol, given for a prolonged period. Satisfactory outcome was achieved with exposure and response prevention, adjunct to medication. Comorbid ADHD was treated with stimulants with no exacerbation of tics.

Oral Δ9-Tetrahydrocannabinol Improved Refractory Gilles de la Tourette Syndrome in an Adolescent by Increasing Intracortical Inhibition

To describe the clinical course of the Delta 9-tetrahydrocannabinol (Delta 9-THC) treatment of a boy with Gilles de la Tourette Syndrome (TS) and comorbid attention-deficit/hyperactivity disorder (ADHD) in relation to Delta 9-THC plasma levels and intracortical inhibition measured by transcranial magnetic stimulation. The clinical course and pharmacological and neurophysiological measures are reported in a 15-year-old boy with treatment refractory TS plus ADHD leading to severe physical and psychosocial impairment. Administration of Delta 9-THC improved tics considerably without adverse effects, allowing parallel stimulant treatment of comorbid ADHD. Along with the Delta 9-THC treatment, intracortical inhibition was increased, reflected in the enhanced short-interval intracortical inhibition and the prolongation of the cortical silent period. Our observation suggests that Delta 9-THC might be a successful alternative in patients with severe TS refractory to classic treatment. Particularly in the case of stimulant-induced exacerbation of tics, Delta 9-THC might enable successful treatment of comorbid ADHD. The enhancement of intracortical inhibition might be mediated by modulating release of several neurotransmitters including dopamine and gamma-aminobutyric acid. Further studies are needed to substantiate our findings.

Crack dancing in the United Kingdom: Apropos a video case presentation

We report an adult patient presenting with choreiform movements 4 days after a large intravenous dose of cocaine. These movements were transitory and they normalized a week after admission. We believe this to be the first video case of acute chorea secondary to cocaine--a phenomenon popularly known as "crack dancing. " Cocaine abuse is associated with a wide range of movement disorders, including dystonia and exacerbation of Tourette's syndrome, multifocal tics, opsoclonus-myoclonus, choreiform movements, and stereotyped behavior known as "punding." Transient choreiform movements with a typical duration of 2 to 6 days are recognized by cocaine abusers themselves as crack dancing, but are infrequently reported. We present a video report of a patient with cocaine dependency and choreiform movements that normalized within a week of admission.

Exacerbation of vocal tics after temporal lobectomy

We describe a woman with intractable temporal lobe epilepsy secondary to dysgenesis of the left temporal lobe who had a marked and long-term exacerbation of her preexisting vocal tics after a temporal lobectomy that completely controlled her seizures. The patient was determined to have right-sided speech dominance by the Wada test. This is, to our knowledge, only the second reported case of exacerbation of tics after resection of the nondominant temporal lobe.

Efficacy and Safety of Methylphenidate for ADHD with Tics

Neurology| May 01 2002 Efficacy and Safety of Methylphenidate for ADHD with Tics AAP Grand Rounds (2002) 7 (5): 49–50. https://doi.org/10.1542/gr.7-5-49 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Efficacy and Safety of Methylphenidate for ADHD with Tics. AAP Grand Rounds May 2002; 7 (5): 49–50. https://doi.org/10.1542/gr.7-5-49 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: adult attention deficit hyperactivity disorder, attention-deficit/hyperactivity disorder, methylphenidate, tic disorder Source: Kurlan R, The Tourette Syndrome Study Group. Treatment of ADHD in children with tics: a randomized controlled trial. Neurology. 2002;58:527–536. The efficacy of methylphenidate (MPH) and clonidine (CLON), alone and in combination, in 136 children with attention deficit hyperactivity disorder (ADHD) and chronic tic disorder was evaluated in a multicenter, randomized, double-blind clinical trial and reported by the Tourette Syndrome Study Group from the University of Rochester, Rochester, New York. Patients aged 7–14 years were assigned to 1 of 4 groups receiving MPH alone (average dose, 27.5 mg/d, 37 children), CLON alone (.25 mg/d, 34), CLON plus MPH combined (.28 mg/d + 26.1 mg/d, 33), or placebo (32). The 16-week trial consisted of CLON/placebo dose titration (weeks 1–4), MPH/placebo dose titration (weeks 5–8), and maintenance therapy (weeks 9–16). Several rating scales were employed at baseline, including Parent and Teacher Conners Questionnaires for ADHD, and site investigator, teacher, and parent scales for tic severity and frequency. Using the Conners Abbreviated Symptom Questionnaire (Teacher) as the ADHD primary outcome measure, compared to placebo, 60% and 80% of the CLON- and MPH-treated patients, respectively, were improved (P<.002 and P<.003). The greatest improvement (85%) occurred in the combined CLON plus MPH-treated patients (P<.0001). Impulsivity and hyperactivity were controlled most effectively by CLON, and inattention responded best to MPH. Tic disorder, assessed by the parent/teacher Global Tic Rating and Self Report Scales, worsened in 20% of MPH-treated subjects (either MPH alone or in combination with CLON, limiting dosage increase in 35% for MPH alone); 26% of those receiving CLON alone; and 22% of the placebo group. A lessening of tic severity, as measured by the investigator-completed Yale Global Scale, occurred in all active treatment groups (CLON plus MPH, CLON alone, MPH alone, in that order), when compared with placebo. Sedation was reported in 48% (moderate-severe in 28%) of CLON-treated patients, both alone and in combination with MPH, compared with 14% for MPH alone and 6% for placebo. Cardiac toxicity, necessitating withdrawal from the study, was observed in 1 subject who developed ECG evidence of isorhythmic dissociation while receiving CLON alone. Patients receiving MPH alone had the lowest rate of side effects. ADHD is frequently associated with tics/Tourette syndrome (TS), occurring in 50% of TS patients, and often causing more disability than the tics.1 Neurobiologically, the 2 disorders appear to be independent,2 but etiologically, the precipitation or exacerbation of tics in patients with ADHD is often attributed to treatment with central nervous system stimulants.3,4 Tics seen during MPH treatment are dose-related, occurring mainly with larger doses. Despite the evidence linking TS to MPH, recent studies have tended to minimize the risk and causal relationship.5 In the present placebo-controlled study and report, the authors conclude that their findings fail to support recommendations to avoid MPH in children with ADHD and co-morbid tic disorder. Symptoms of ADHD are benefited by MPH to the same degree as that generally observed in subjects... You do not currently have access to this content.

Tourette syndrome: clinical characteristics and current management strategies.

Tourette Syndrome (TS) is a disorder comprised of involuntary motor and phonic tics often associated with psychiatric conditions. The etiology for TS is unclear, with both genetic and immunological theories being studied to date. When pharmacotherapy is considered by the patient and physician to be required, owing to either functional impairment from tics or comorbid psychiatric illness, dopamine receptor antagonists are commonly used. Our first-line agents for tic suppression include clonidine, guanfacine, clonazepam and baclofen. Should these agents be ineffective, we would recommend pimozide, fluphenazine, risperidone or haloperidol. The potential benefit of other agents, such as olanzapine, ziprasidone, pergolide and botulinum toxin, is encouraging. Despite many years of concern, we have found little exacerbation of tics with stimulant medications for attention deficit hyperactivity disorder, but clearly clonidine and guanfacine can ameliorate both comorbid conditions. Obsessive compulsive disorder, when associated with TS, may be treated with either a selective serotonin reuptake inhibitor in association with a dopamine receptor antagonist or risperidone alone. New therapies for all aspects of TS and its comorbid conditions are in active clinical trials.

Tourette-Syndrom und Antidepressiva-Therapie: Exazerbation einer Ticstörung unter Paroxetin

One possible side effect of selective serotonin re-uptake inhibitors (SSRI) is the exacerbation of nervous tics in a 12-year-old boy treated with tiapride following prescription of paroxetine for a depressive syndrome. Potential causal factors include residual cholinergic activity of paroxetine, the observably increased drive under paroxetine, metabolic properties, and protein binding. The problem of side effects under selective serotonin re-uptake inhibitors, as well as the issues of co-morbidity and co-medication in the treatment of nervous tics and Tourette's Syndrome are discussed.

Methyiphenidate vs. amphetamine: Comparative review

This article compares the two most common medications for Attention-Deficit/Hyperactivity Disorder (ADHD), using data from controlled studies. Medline and Psychinfo searches were done for 1984-1996 with the key words methylphenidate (MPH) and amphetamine (AMP); these were supplemented with known prior and recent literature. Of 92 animal studies found, 15 showed clear differences between the two drugs. Ten reports of controlled crossover ADHD clinical trials (three in the same sample) and a dozen other articles comparing the two drugs in humans were found. MPH is a pure re-uptake inhibitor of catecholamines, especially dopamine; AMP also releases catecholamines. Lab animals showed differential interactions with other drugs and with behavioral paradigms. Human response profiles are noncongruent. An ADHD patient who fails on one stimulant should try the other. Of 174 patients in the 6 clearest crossover studies, 48 responded better to AMP, 27 to MPH, and at least 72 to both, which is an 87+% overall response rate if both are tried. All crossovers, except the one with comorbid Tourette's, showed a nonsignificant tendency for AMP superiority in response rate. Summed data suggest suspected differences in side effects (AMP more sleep and appetite loss and exacerbation of tics in comorbid Tourette's, MPH possibly more depression/apathy and stomachaches) and effects on comorbid disorders (AMP better for conduct/oppositional symptoms, MPH for Tourette's and possibly learning disorder (LD). Most of the clinical differences are tendencies rather than statistically significant.

Identification of children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections by a marker associated with rheumatic fever.

The authors' goal was to determine whether a trait marker of rheumatic fever susceptibility (labeled D8/17) could identify children with pediatric autoimmune neuropsychiatric disorders (obsessive-compulsive disorder and tic disorders) associated with streptococcal infections (PANDAS). Blood samples obtained from 27 children with PANDAS, nine children with Sydenham's chorea, and 24 healthy children were evaluated for D8/17 reactivity. Individuals were defined as D8/17 positive if they had 12% or more D8/17+ cells. The frequency of D8/17-positive individuals was significantly higher in both patient groups than it was among the healthy volunteers: 85% of the children with PANDAS and 89% of the children with Sydenham's chorea, compared with 17% of the healthy children, were D8/17 positive. Further, the mean number of D8/17+ cells was similar in the two patient groups and was significantly higher in these groups than in the group of healthy children. These results suggest that there may be a subgroup of D8/17-positive children who present with clinical symptoms of obsessive-compulsive disorder and Tourette's syndrome, rather than Sydenham's chorea, but who have similar poststreptococcal autoimmunity.

Acute Basal Ganglia Enlargement with Obsessive-Compulsive Disorder, Tics, and Strep Infection

A 12-year-old boy with an acute exacerbation of obsessive-compulsive disorder (OCD) symptoms and tics following a Group A B-hemolytic streptococcal (GABHS) throat infection is reported from the National Institute of Mental Health, Bethesda, MD.

Sertraline‐induced exacerbation of Tics in Tourette's syndrome

Sertraline‐induced exacerbation of Tics in Tourette's syndrome

Movement Disorders

This article focuses on the current knowledge about movement disorders associated with alcohol and drug abuse. Chronic alcohol use can produce a wide spectrum of movement disorders including tremor, withdrawal parkinsonism and dyskinesias, cerebellar ataxia, and asterixis. MPTP, a neurotoxin first reported to cause parkinsonism in a group of drug abusers, has provided important insights into the pathogenesis of Parkinson‘s disease. There is a growing body of literature providing evidence that dyskinesias such as tics and dystonia may be precipitated or exacerbated by cocaine. Amphetamines have been implicated in the production of stereotypies and exacerbation of tics.