Tourette Syndrome. Biological Basis, Clinical Symptoms, Treatment. Drake D. Duane, MS, MD

Transcription

1 Tourette Syndrome Biological Basis, Clinical Symptoms, Treatment Drake D. Duane, MS, MD Director, Institute for Developmental Behavioral Neurology Adjunct Professor, Arizona State University Scottsdale/Tempe, Arizona, USA

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3 Tourette s Disorder Proposed DSM-5: Tourette s Disorder The work group is recommending that this disorder remain in Childhood Disorders, if that section is retained, but if that section is not retained then move to Anxiety and Obsessive-Compulsive Disorders. A. Both mutliple motor tics 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 motor movement or vocalization.) B. The tics may wax and wane in frequency but have persisted for more than one year since first tic onset. C. The onset is before age 18 years. D. The disturbance is not due to the direct physiological effects of a substance (e.g. cocaine, methamphetamine or a general medical condition (e.g. stroke, Huntington s disease, postviral encephalitis).

4 Tourette Syndrome Tics + OCD + ADHD Anatomy - Gross? - Microscopic - N = 5, striatopallidal direct output pathway, lenticular glutamate - In vivo MRI - enlarged corpus callosum, R/L caudate asymmetry and caudate volume Physiology - N-100/P latency prolongation, often - VEP frontal activation (OCD) - FFT - (anxiety) Functional Anatomy rcbf - caudate, anterior cingulate and temporal SPECT - caudate D2 receptor binding fmri - R caudate with tic suppression and bilateral putamen, PET globus pallidus and thalamus - separate functional pathways for TS and OCD in TS - +/- abnormal DA receptors, release and transport

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8 Tourette Syndrome Tics + OCD + ADHD Genetics - Twins - 90% concordance - Bilineal transmission -? assortive mating - Chromosomal sites - 4q and 8p Psychiatric Comorbidity - OCD, anxiety, depression Immune Mechanisms -? PANDAS - GABHStrep infection Pharmacotherapy tics - atypical neuroleptics, 2-adrenergic agonists, pimozide, clonazepam, mecamylamine, botulinum toxin, xenazine ADHD - as above, but observe for tics with stimulants OCD - SSRI's, atypical neuroleptics

9 Frequency of Elevated ASO Titer in Children and Adolescents at Onset or Exacerbation of Tic, OCD or Aggression; Effect of Antibiotic Rx 1 BM Divito, KD Ellis, DD Duane Institute for Developmental Behavioral Neurology / Arizona State University Scottsdale / Tempe, Arizona, USA 1 Poster Presentation, American Neurological Association, October 9, 2012

10 Frequency of Elevated ASO Titer in Children and Adolescents at Onset or Exacerbation of Tic, OCD or Aggression; Effect of Antibiotic Rx 1 (cont d) N = 45 34M / 11F Mean Age 13 +/- 4.5 years Diagnosis: Tourette 10 OCD 24 AD(H)D 11 Increased ASO = 16 (36%) 13M 1 Poster Presentation, American Neurological Association, October 9, 2012

11 Frequency of Elevated ASO Titer in Children and Adolescents at Onset or Exacerbation of Tic, OCD or Aggression; Effect of Antibiotic Rx 1 Antibiotic Rx = 10 Symptom Improved/Total Tic* 6/7 (86%) OCD** 5/7 (71%) Aggression** 3/3 (100%) No Antibiotic Rx 3 no change, 3 unknown * Yale Tic Rating Scale >50% decrease ** Achenbach CBCL T- score <65 1 Poster Presentation, American Neurological Association, October 9, 2012 (cont d)

12 Tic Medications Atypical Neuroleptics (anti-anxiety, anti-aggression) Risperdal, Seroquel, Zyprexa, Geodon, Abilify, Saphris Orap (old neuroleptic) Klonopin (AED, anti-anxiety, anti-obsessive, benzodiazepine) Tetrabenazine (xenazine) Inversine (for increased blood pressure) Lioresal (anti-spasticity) Clonidine/Catapres (alpha blocker for increased blood pressure) Tenex (alpha blocker for increased blood pressure) Topamax or Keppra (AED) Botox injection Rarely old neuroleptic like Haldol or Mellaril

13 Effect on OCD/Attention When Treating Tics in Tourette Syndrome SA Leblang*, DD Duane Institute for Developmental Behavioral Neurology / Arizona State University Scottsdale/ Tempe, Arizona, USA N = 38 29M / 9F Mean Age 10 9 / ( / / 12 ) Instruments: OCD Achenbach CBCL Attention DSM IV, LCT, CPT, Tova Tics Yale TRS What effect on OCD, Attention if: + effect on tics - effect on tics What Rx class in use in each case * Barrett College thesis, Arizona State University

14 Effect on OCD/Attention When Treating Tics in Tourette Syndrome (cont d) + effect on tics N = 26 19M / 7F Mean Age 11 1 / 2 OCD = 2? Incomplete data 8 Attention = 1 Rx 23/26 Atypical Neuroleptic 2/26 Orap 1/26 Antiepileptic

15 Effect on OCD/Attention When Treating Tics in Tourette Syndrome (cont d) - effect on tics N = 12 10M / 2F Mean Age 10 1 / 12 OCD = 7? Incomplete data 3 Attention = 0 Rx 10/12 Atypical Neuroleptic 2/12 agonist

16 Effect on OCD/Attention When Treating Tics in Tourette Syndrome (cont d) Conclusions + effect on tics is commonly but not invariably associated with improved OCD + effect on tics is usually associated with improved attention However, even with no effect on tics, the use of atypical neuroleptics is most often associated with improved attention

17 Effect on OCD/Attention When Treating Tics in Tourette Syndrome (cont d) Conclusions Is the effect on attention from decreased interference from tics or some property of atypical neuroleptics not dependent on tic effect? Further analysis is pending

18 Quantitative Neurobehavioral Exam Features of Children and Adults With Tourette Syndrome Drake D. Duane, M.D. and Sarah B. Stuart, B.S. Institute for Developmental Behavioral Neurology Arizona State University Scottsdale / Tempe, Arizona Jacob Venter, M.D. Maricopa Medical Center, Phoenix, Arizona

19 Sudden Disappearance of Tics in Tourette Syndrome Associated with Sudden Onset Mania DD Duane, JL Case, LL LaPointe Arizona Dystonia Institute / Arizona State University Scottsdale / Tempe, Arizona

20 Tourette Syndrome N=47 OCD / ADD / Tics in Children vs. Adults Child (Tanner I-III) Adult p M/F 37/10 N Mn Age, yrs 9 9/12 32 OCD 1 64% 68% N.S. ADD 2 57% 21% 0.1 Mn Tic Score YOBCS, MMPI, Achenbach; 2- Achenbach, DSM IV, Adult Retro, TOVA, CPT 3- Yale Tic Rating Scale

21 Medication Options In Developmental Disorders Atypical Neuroleptics Risperdal -.25,.5, 1, 2, 3, 4 mg tab (risperidone) - liquid;.5, 1, 2 mg M tab Seroquel - 25, 50, 100, 200, 300, 400 mg (quetiapine) - 50, 150, 200, 300, 400 mg XR Zyprexa - 2.5, 5, 10, 15, 20 mg (olanzapine) - 5, 10 mg Disintetab Geodon - 20, 40, 60, 80 mg; liquid (ziprasidone) Abilify - 2, 5, 10, 15, 20, 30 mg (aripiprazole) - liquid 1 mg/ml Saphris - 5, 10 mg; sublingual (asenapine) 1-3d Side Effects: appetite drowsiness nausea restlessness Institute Developmental Behavioral Neurology R 02/11

22 Medication Options In Developmental Disorders Attention = Increase Dopamine 1. Psychostimulants Pemoline: Cylert* Methylphenidate: Ritalin - Focalin - Concerta Methylin - Metadate - Daytrana Amphetamine: Dexedrine - Adderall - Desoxyn - Vyvanse see chart 2. Psychotropics (antidepressants) Wellbutrin Prozac see SSRIs d Zoloft 3. Provigil (modafinil) - 100, 200 mg ½ -2/d Nuvigil (armodafinil) 50, 150, 250 mg 1-2/d 4. Strattera* (atomoxetine) - 10, 18, 25, 40, 60 mg 1/d 7-15 d * May cause liver dysfunction Institute Developmental Behavioral Neurology R 03/10

23 Medication Options In Developmental Disorders Selective Serotonin Reuptake Inhibitors (SSRI) Prozac - 10, 20 mg; liquid 1/d (fluoxetine) - 90 mg 1/w Zoloft - 25, 50, 100 mg; liquid 1/d (sertraline) Luvox - 25, 50, 100 mg 2/d (fluvoxamine) - 100, 150 mg CR 1/d Paxil - 10, 20, 30, 40 mg; liquid 1/d (paroxetine) , 25, 37.5 mg CR 1/d Celexa - 20, 40 mg 1/d (citalopram) Lexapro - 10, 20 mg; liquid 1/d (escitalopram) Anafranil - 25, 50, 75 mg 1 or 2/d (clomipramine) Viibryd - 10, 20, 40 mg 1/d (w/food) (vilazodone HCl) 15-60d Side Effects: GI HA sweats ± weight ± sex Institute Developmental Behavioral Neurology R 11/12

24 Medication Options In Developmental Disorders Selective Noradrenergic Reuptake Inhibitor (SNRI) Effexor , 75, 150 mg XR (venlafaxine) Cymbalta - 20, 30, 60 mg (duloxetine HCl) Pristiq - 50, 100 mg (desvenlafaxine) Side Effects: - nausea - sweating Dopaminergic Antidepressant Wellbutrin [Zyban] - 150, 300 mg XL (bupropion) Side Effects: - agitation - sleep disturbance Institute Developmental Behavioral Neurology R 10/11

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26 Geschwind s Lesson Much of what you have been taught is in error. Your job is to get things right. Personal communication, 1980

27 Brain, Mind & Classroom Summary Biologically engendered developmental variations in brain anatomy, physiology, chemistry generate cognitive patterns (intelligence, memory, attention, alertness, coordination, aptitudes) as well as internally generated moods which together affect adaptability, educability, social competence and emotional stability. These central factors operate within a physical, social, educational environment which will determine the extent to which learning potential will be realized.

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