TOURETTE SYNDROME

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TOURETTE SYNDROME

• Presented by
• APS Healthcare
• Southwestern Health Care Quality Unit (HCQU)

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Disclaimer

• Information or education provided by the HCQU is
  not intended to replace information by the
  consumers primary care physician or replace any
  existing facility policy.
• Certificates for training hours will only be
  awarded to those who attend a training in its
  entirety. Attendees are responsible for
  submitting paperwork to their respective
  agencies."

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Objectives

• The Participant will
• Be able to define Syndrome
• Be able to define a Sign versus a Symptom
• Define Tourette Syndrome
• List Define known Causes of Tourettes
• Identify Five known Signs of Tourettes
• Identify Treatment Strategies

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What is a Syndrome?

• A set of signs and symptoms which when studied
  together lead to the diagnosis of medical,
  behavioral or mental health disease.
• Not all Signs Symptoms when studied together
  mean a certain disease is present.

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What is a Sign?

• An indication of the existence of something any
  objective evidence of a disease such as is
  observable by those charged for a Consumers
  care.
• Those observable changes which are measured
  through testing, and quantified through time.

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What is a Symptom?

• Any sensation of change within ones own body
  which is identified by a Consumer. These are not
  those items which are noted by outside observers
  but rather only those things which are identified
  by the Consumer.

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Tourette SyndromeGilles de la Tourette

• A Syndrome
• Facial Vocal Tics
• Onset in Childhood
• Progressing to generalized jerking movements in
  any part of the body, with echolalia, coprolalia.
• Once thought to be terminal now responds well to
  prescribed medications.

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DSM IV-TR Criteria 307.23

• This neuropsychiatric syndrome of uncertain
  cause, develops in latency or early adolescence
  with the onset of one or more poorly controlled
  symptoms, including head or extremity tics, eye
  blinks, and the spasmodic production of coughs or
  grunts which occasionally can include verbal
  obscenities (coprolalia). Often it is severe and
  life long.

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DSMIV-TR Criteria - II

• This syndrome occurs with increased incidence in
  families, indicating a possible genetic
  component, and is associated with obsessive
  compulsive disorder and with hyperactivity and
  learning disorders in family members.
• Symptoms are worsened by stress.

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Diagnostic criteria

• Medical Study
• Complete Medical Behavioral History
• Age at which first identified
• Observation of Tics
• Scales are available to rate Tic severity and
  frequency

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Possible Etiology

• Genetic Disorder
• Environment
• Exposure to Drugs or other Toxins in early
  development, often prior to birth
• Dopamine, Nor-Epinephrine, and Serotonin in
  dysregulation

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Definition of a Tic

• Involuntary movement of one or more muscle
  groups.
• Most of the time they are meaningless.
• Some think that the complex tics are purposeful.

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Categories of Tics

• Simple
• Motor
• Vocal
• Complex
• Motor
• Vocal

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What are Motor Tics?

• Eye rolling
• Eye blinking
• Facial grimacing
• Licking
• Lip smacking
• Nose twitching
• Clapping
• Foot tapping

• Shrugging
• Hair tossing
• Stomping
• Shaking the head
• Foot dragging
• Facial grimacing
• Squinting
• Arm squeezing

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What are Vocal Tics?

• Clearing the throat
• Sniffing
• Shouting
• Belching
• Snorting
• Sucking
• Honking
• Gasping

• Tongue clicking
• Yelping
• Moaning
• Unusual noises
• Hissing
• Screaming
• Gurgling
• Hiccupping

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Examples of Complex,Motor Tics

• Hopping
• Banging
• Jumping
• Kicking
• Punching
• Pinching
• Kissing
• Copropraxia

• Echopraxia
• Skipping
• Scratching
• Toe walking
• Throwing things
• Tearing things
• Smelling things
• Shivering

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Examples of Complex,Vocal Tics

• Animal sounds
• Laughing
• Palilalia
• Echolalia
• Coprolalia
• Stuttering

• Repeating
• Words
• Phrases
• Parts of words
• Spitting
• Talking to self

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Tremors Tourettes

• Unrelated movements that share one major
  characteristic, oscillation of a limb or body
  parts.
• Physiologic Tremor is normally not observable.
  Only with increased stress, anxiety or
  stimulants.
• Treatment involves removal of medications which
  over stimulate, and if needed the addition of a
  Beta-Blocker like Propranalol.

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Treatment Strategies

• Offer testing and other activities in separate
  location with no time limits.
• Educate other staff and Consumers.
• Provide a Safe Area where a Consumer may go and
  calm down, release tics or obsessions.
• Give the Consumer frequent breaks to release tics
  in a less embarrassing environment.
• If tics are inappropriate, such as spitting,
  swearing touching people, it may be necessary to
  brainstorm solutions. E.g. spitting into a
  tissue regularly.

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Motor/Visual Impairment

• Use of a word processor is helpful
• Occupational Therapy
• Sensory Integration
• Shorten required tasks required
• Never penalize the Consumer for tic which impairs
  ability to complete assigned tasks.

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Obsessive/Compulsive Symptoms

• Obsessions Compulsions can take so many forms
  that it is difficult to give a few pat answers to
  the problem.
• First assess the nature of the obsessions and
  then brainstorm with the treatment team effective
  interventions.

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Irritability Poor Coping

• Many Consumers with TS become easily frustrated,
  become over stimulated, and feel over whelming
  anxiety.
• Crowds, Cafeteria, Workshops, Living Quarters
  tend to cause increased anxiety.
• Lack of Structure leads to increased tics
• Poor transitioning ability.
• Sensory defensiveness, which leads to quick over
  loading and then being easily set-off

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How to Help ?

• Educate the Staff and Provide Structure for the
  Consumer.
• Educate the Consumer in ways to remove
  her/himself from an escalating and frustrating
  situation. Some Examples
• Permit the Consumer to leave the area ahead of
  the group to avoid crowds.
• Permit the Consumer to eat alone and at a
  different time than the rest of the group.

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ADHD Tourettes

• Preferential Seating at the Workshop
• Provide a quiet place to complete tasks. Consider
  a head set with music to block out distractions.
• Permit freedom of movement
• Establish communication signs that a Consumer may
  utilize and recognize as a sign of needing to
  stay on task.
• Use color coded cards that identify tasks for the
  Consumer.

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Lets tie this together

• Tourette Syndrome is in fact a group of
  neuropsychiatric disorders which resemble other
  diseases.
• Treatment should encompass all areas identified
  by the treatment team.
• The Consumer with Tourettes does not want to be
  out of control. This is not bad behavior, it is
  a disease.

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Medications

• The treatment of TS is complex.
• Pediatricians, Internists, and Neurologists with
  Psychiatrist may be required.
• Medications have side effects and staff and/or
  care givers require formal education regarding
  their use.

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Medications - II

• Prolixin
• Haloperidol
• Pimozide
• Olanzapine
• Some Consumers may be intolerant to the side
  effects of these drugs. Acute Dystonia,
  Akathisia, daytime sedation and Task Phobias may
  occur.

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Recent Research

• Risperidone may be effective for tics and has a
  lower side effect profile.
• Clonidine
• Clonazepam
• Nicotine the patch
• These so called a-typical drugs have a much more
  tolerable side effect profile.

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What to Do?

• Observe
• Analyze
• Medical Analysis Evaluation
• Psychiatric Analysis Evaluation
• Neurologic Analysis Evaluation
• Environmental Accommodations
• Comprehensive Treatment Plan
• - Must include Medical Behavioral Facets

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REFERENCES

• http//samed.com
• http//apa.org
• Olney RK, Aminoff MJ Weakness, Abnormal
  Movements, and Imbalance, Chap. 21 p. 107
• http//www.nimh.gov
• http//www.who.org
• Harrisons Companion Textbook of Internal
  Medicine, Fauci A.S., (et al.). Chap. 1 p. 57

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THANK YOU

• For further information regarding this or any
  other behavioral or physical health topic please
  visit our website _at_
• http//hcqu.apshealthcare.com

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