Week 8: Assignment

Tic Disorder Study Guide

Amber Lalani

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Walden University

Due: April 20, 2021

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1. Signs & symptoms

a. Sudden uncontrollable repetitive movements that occur without warning without a

purpose

b. Vocal outbursts (often unrelated to any topic/situation)

c. Excessive blinking

d. Facial grimacing and expressions

e. Rapid movements of the extremities and/or head

f. Sounds such as grunting or snorting

g. Often exacerbated with increased emotion (stress or excitement)

h. DSM-5 criteria (APA, 2013):

i. Either motor or vocal tics, but not both

ii. Either occur multiple times throughout the day almost every day or

intermittently for at least 1 year.

iii. Tics must begin prior to the age of 18

iv. Other causes such as medication, other diseases, or drugs must be ruled

out

v. Cannot be diagnosed with Tourette Syndrome

2. Differential Diagnoses

a. Tourette Syndrome

i. Tics must be both motor and vocal, but can occur at different times (CDC,

2021)

b. Seizures (Mount Sinai, 2021)

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i. May be similar to tics:

1. Involuntary convulsions, rapid repetitive movements, jerking

extremities, grunting or snorting

ii. Dissimilar to tics:

1. Loss of bladder or bowel control, tightening teeth, salivating, rapid

eye movements

2. Muscle spasms, blackout, may have aura

3. Incidence

a. An average of 2-3% incidence for children (Black, et. al., 2020)

b. From 1999 to 2000, among 553 children (Sinder, et. al., 2002)

i. Monthly prevalence range: 3.2-9.6

ii. Frequency over the month: 25.7%

4. Development and course (Black, et. al., 2020)

a. Polygenetic (Efron & Dale, 2018)

b. Usually develop between ages of 3-10

c. Often most severe from ages 9-11

d. Onset is often sudden and symptoms are less frequent during moments of

focusing

e. Can become triggered by intense emotions including stress, anger, fatigue, &

excitement

5. Prognosis

a. Chronic tic emerges between ages 6-8 often recover within less than 10 years

(Mount Sinai, 2021)

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i. When diagnosed at an older age, often lasts a lifetime (Mount Sinai, 2021)

b. Transient tics present in about 25% of children (

c. No side effects or harmful effects, aside from anything that may occur during the

physical tic

6. Considerations related to culture, gender, age

a. Children between 3-10 years of age (Black, et. al., 2020)

7. Pharmacological treatments, including any side effects (Efron & Dale, 2018; Pringsheim,

et. al., 2019)

a. Uncommon (Pringsheim, et. al., 2019)

b. Placebos

c. Anti tic medications

i. Cannibus based medication [Drobinol, tetrahydrocannabinol (THC)]

ii. First line: alpha 2 adrenergic agonists

1. Most effective

2. Clonidine, guanfacine

iii. Second line: second generation antipsychotics (SGA)

1. risperdone, aripiprazole

2. First generation Haldol can also be utilized but comes with a risk

of extrapyramidal side effects, often making the risk higher than

the benefit.

iv. Third line: dopamine depleters (Pringsheim, et. al., 2019)

1. topiramate, baclofen

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v. Botulinum toxin injection for severe cases (Efron & Dale, 2018)

8. Nonpharmacological treatments

a. Cognitive behavioral Intervention for tics (CBIT) (Efron & Dale, 2018; Mount

Sinai, 2021)

i. To help suppress/control outburst or tics

ii. Habit reversal training (Pringsheim, et. al., 2019)

b. Deep brain stimulation (Pringsheim, et. al., 2019)

9. Diagnostics and labs (Black, et. al., 2020)

a. Diagnosed via symptoms and keeping track of occurences and types of

occurences

b. Describing the occurrence to rule out seizures

c. MRI to visualize blood flow may reveal decreased blood flow to prefrontal cortex

and left caudate. (Black, et. al., 2020)

i. Thinning of cortices & white matter changes (Efron & Dale, 2018)

10. Comorbidities (Pringsheim, et. al., 2019)

a. ADHD

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b. OCD

c. Disruptive mood behaviors

11. Legal and ethical considerations

a. Ensure that the child’s preferences are highly considered, even with a guardian

present

b. Consider justice with treatment – provide all options and recommendations,

information, informed consent and allow the patient to make an informed decision

c.

12. Pertinent patient education considerations

a. Managements of tics

i. Educate on suppression and therapy

ii. Ensure safety during tics

iii. When to anticipate during high emotion

b. Support groups

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA: Author.

Black, K. J., Kim, S., Schlaggar, B. L., & Greene, D. J. (2020). The New Tics study: A novel

approach to pathophysiology and cause of tic disorders. Journal of psychiatry and brain

science, 5.

Centers for Disease Control and Prevention (CDC). (2021). Persistent motor or vocal tic

disorder. Retrieved from https://www.cdc.gov/ncbddd/tourette/diagnosis.html

Efron, D. & Dale, R. (2018). Tics and tourette syndrome. Journal of Pediatrics and Child

Health, 54, 1148-1153. doi:10.1111/jpc.14165

Mount Sinai. (2021). Chronic motor tic disorder. Retrieved from

https://www.mountsinai.org/health-library/diseases-conditions/chronic-motor-tic-disorder

Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., … &

Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in

people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896-906.

Scharf, J., Miller, L., Mathews, C., & BenShlomo, Y. (2011). Prevalence of tourette syndrome

and chronic tics in the population based avon longitudinal study of parents and children.

https://doi.org/10.1016/j.jaac.2011.11.004

Snider, L., Seligman, L., Ketchen, B., Levitt, S., Bates, L., Garvey, M, & Swedo, S. (2002). Tics

and problem behaviors in schoolchildren: Prevalence, characterization, and associations.

American Academy of Pediatrics, 110 (2) 331-336; DOI:

https://doi.org/10.1542/peds.110.2.331

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