tics disorder.pptx......................

Tic disorder

1. SEMINAR ON TIC DISORDER PRESENTED BY DENDEN DIANA M. SC (N) 2 nd Yr R.I.N.P.S

2. INTRODUCTION Tics are rapid, repeated, involuntary contractions of a group of muscles that either result in a movement (a motor tic) or a sound (a vocal tic). Most tics are mild, infrequent and hardly noticeable, but some can be frequent and severe . Tics begin before 18 years of age (typically between 4 years and 6 years of age); they increase in severity to a peak at about 10 to 12 years of age and decrease during adolescence.

3. DEFINITION Tics are defined as repeated, sudden, rapid, nonrhythmic muscle movements including sounds or vocalizations. Tics are irregular, uncontrollable, unwanted, repetitive movements of muscles that can occur in any part of the body.

4. INCIDENCE Tics vary widely in severity; they occur in about 20% of children .  Chronic tics affects about  1 out of 100 . American Academy of Child and Adolescent Psychiatry states that tics affect up to 10% of children during their early school years . Tourette syndrome, the most severe type, occurs in 3 to 8/1000 children . Male to female ratio is 3:1. Currently, 0.3 percent of children aged 6 to 17 in the United States have been diagnosed with TS.

5. TYPES Tics is classified into two categories: Simple tics Motor tics.

6. a) Simple tics : It involves a single muscle group and is further divided into two - Simple motor tics - It includes head shaking, eye blinking, sniffing, neck jerking, shoulder shrugging and grimacing. Simple vocal tics - It includes coughing, throat clearing and barking.

7. b) Complex tics : It usually involves more than one muscle group and is further divided into two - Complex motor tics - It includes self-hitting or self-biting, jumping and twirling while walking. Complex vocal tics - It includes repeating words or phrases, echoing what someone else said and speaking obscenities.

8. DSM-V-TR CLASSIFICATION OF TICS DISORDER a. Provisional tic disorders (previously known as Transient tic disorders) b. Persistent (also called Chronic) Motor or Vocal tic disorder: c. Tourette's syndrome: Provisional tic disorders occur when a person has a motor tic, a vocal tic or both almost every day for at least four weeks, but not for more than a year. Provisional motor tics, such as blinking or snapping the fingers, usually only affect one muscle group. The onset of the tics must have been before the individual turned 18 years of age. Chronic tic disorder occurs when a person has had either a motor tic or a vocal tic (but not both), regularly or intermittently for more than one year and appears before the age of 18. According to the  Diagnostic and Statistical Manual of Mental Disorders  (DSM-5), Tourette's may be diagnosed when a person exhibits both multiple motor tics and one or more vocal tics over a period of one year. The disorder is named after Dr. Georges Gilles de la Tourette ,

9. ETIOLOGY The exact cause of tic disorders is unknown. Current research points to abnormalities in certain brain regions (including the basal ganglia, frontal lobes and cortex) and shows that gene plays an important role . Genetics: Tics tend to run in families, so there may be a genetic basis to these disorders.

10. CONTD…. Environmental: Stress, anxiety often diagnose from other mental diagnosis like OCD (Obsessive Compulsive Disorder), ADHD (Attention Deficit / Hyperactivity Disorder and learning disorders). Immunological Factors: Autoimmune process that is secondary to streptococcal infections is a potential mechanism for Tourette’s disorder. Gender: Men are more likely to be affected by tic disorders than women.

11. PATHOPHYSIOLOGY Although no pathogenesis of tics and tourette syndrome has been clearly demonstrated. TS is considered to be an inherited disorder. The pattern of transmission or a gene has not been identified. It is a brain based disorder, with the striatum, globus pallidus or caudate nucleus potentially involved as well as a neurotransmitter or receptor-binding abnormality of the ventral striatum. Abnormal metabolism of dopamine and other neurotransmittters (e.g., serotonin) may be involved.

12. SYMPTOMS Motor tics Facial grimacing, Head and shoulder movements, Excessive blinking, twitching, jerking, or shrugging, L icking fingers, or touching things or other people. Vocal tics Coughing , Throat clearing or grunting, R epeating words or phrases. Sniffing Barking Yelling

13. DIAGNOSIS Tic disorders are diagnosed based on signs and symptoms. The child must be under 18 at the onset of symptoms for a tic disorder to be diagnosed. History and physical examination: - A thorough clinical history & physical examination are generally sufficient to screen for evidence of a secondary tic disorder . MRI CT scan Electroencephalogram Blood test - To rule out other conditions that might be confused with TS when the history or clinical examination is atypical.

14. YGTSS (Yale Global Tic Severity Scale) FOR TICS The YGTSS is a commonly used measure to document the severity of motor and phonic tics. It is performed by a clinician interview. The clinician reviews a list of possible tics that may have occurred over the past week, first motor and then vocal tics. The YGTSS also includes an overall impairment scale rated from 0 to 50. A score of 0 would indicate that the presence of Tourette syndrome has no negative impact on a person’s life. By contrast, a score of 50 would indicate marked interference and disability.

15. Number (0-5) Frequency (0-5) Intensity (0-5) Complexity (0-5) Interference (0-5) TOTAL (0-25) Motor Tic Severity Vocal Tic Severity Total Tic Severity Score = Motor Tic Severity + Vocal Tic Severity (0-50) Total Yale Global Tic Severity Scale Score (Total Tic Severity Score + Impairment) (0-100)

16. Medical management Treatment depends on the type of tic disorder and its severity. In many cases, tics resolve on their own without treatment. In other cases, doctors may prescribe behavioral therapy, medication, or a combination of the two . Mild case: no treatment required Severe cases: Behavioural therapy and pharmacotherapy

17. Behavioural Therapies for tic disorders: Habit reversal therapy (HRT) Comprehensive Behavioural Intervention for Tics (CBIT) Exposure and response prevention (ERP)

18. 1) Habit reversal therapy (HRT) HRT is based on the presence of a premonitory urge, or sensation occurring before a tic. It is a therapy that can be effective in treating troublesome behaviors caused by a number of conditions.

19. 2) Comprehensive Behavioural Intervention for Tics (CBIT) CBIT is "Do Something Else" therapy, and not "Stop It" therapy The success of CBIT comes from a comprehensive approach that includes : Psychoeducation Self-awareness training, Relaxation training, Establishing a tic hierarchy, selecting a target tic and reverse engineering it, Formulating a competing response to the target tic using habit reversal techniques, Social support

20. a) Psychoeducation It includes examining what situations tend to make tics worse and what situations make tics better. The goal is to use that knowledge to avoid the situations that exacerbate tics or to find ways to lessen their impact; then to encourage situations that lessen tic activity.

21. b) Self-awareness training Tic-awareness training teaches the child how to self-monitor for early signs that a tic is about to occur using recognition of the premonitory urge.

22. c) Relaxation training This would include diaphragmatic (deep) breathing, progressive muscle relaxation and imagery.

23. d) Tic Analysis: The therapist will help the child (person) identify their most bothersome tic but the tic that causes the person with symptoms the most discomfort, distress or difficulty.

24. e) Formulating a competing response to the target tic using habit reversal techniques Once the bothersome tic is identified and analyzed, and some evaluative assessments are made by the therapist, a tic blocker or competing response (CR) is developed so the child (person) can apply the CR when the urge for that tic is experienced.

25. f) Social Support: When the child employs the correct CR, she/he needs to be praised and if she/he happens to miss using the CR and the tic emerges, parents should remind the child about using the CR, not in a punitive tone, but rather in a supportive and encouraging tone.

26. 3) Exposure and response prevention (ERP) The  Exposure  in ERP refers to exposing someone to the thoughts, images, objects and situations that make him/her anxious and /or start obsessions. While the Response Prevention  part of ERP, refers to making a choice not to do a compulsive behavior once the anxiety or obsessions have been “triggered.”

27. PHARMACOTHERAPY Alpha-2 adrenergic agents Atypical antipsychotics Antiepileptics Norepinephrine reuptake inhibitors Selective serotonin (5-hydroxytryptamine) uptake inhibitors

28. CONTD… Alpha-2 adrenergic agents: Clonidine : 0.1-0.3 mg/day Guanfacine : 1-3 mg/day Side-effects : Sedation, dry mouth, nasal mucosa, etc. Atypical antipsychotics: Risperidone  0.25 to 1.5 mg 2 times a day Haloperidol 0.5 to 2 mg 2 or 3 times a day Pimozide  1 to 2 mg 2 times a day Side-effects: dry mouth, blurred vision, constipation, dizziness, etc.

29. CONTD…. Antiepileptics : Topiramate : 100 mg 2 times a day Levetiracetam : Initial dose 250 mg/day for 12 weeks Side-effects: Poor concentration, short term memory, speech problems, etc. Norepinephrine reuptake inhibitors Atomoxetine : 36-100 mg/day Side-effects: Dizziness, nausea, dry mouth, sweating , etc.

30. CONTD… Dopamine agonists: Tetrabenazine: 5mg/kg/day Side effects: Depression, fatique , insomnia, sedation/ somlolence . Selective serotonin (5-hydroxytryptamine) uptake inhibitors Fluoxetine (Prozac): 20 to 80 mg/day Clomipramine ( Anafranil ): 25 to 250 mg/day Side-effects : Nausea, vomiting, dry mouth, drowsiness, dizziness, etc.

31. SURGICAL MANAGEMENT: No surgical procedure is currently recommended for tics or TS in general; however, thalamic deep brain stimulation has been suggested in some cases.

32. CHARACTERISTICS OF A NURSE Caring for people Acceptance and trust Understanding Response Authenticity Ethical behavior

33. ROLE OF A NURSE Identify the child feelings and level of anxiety while they are completing compulsive task. Encourage the patient to talk about why they have to do the behavior and what it means, can also help them to relieve anxiety. Training should be provided to the child how to self-monitor for early signs that a tic is about to occur using recognition of the premonitory urge. The child should teach how to manage the urge to tic like diaphragmatic breathing so they don’t have to tic as often or intensely.

34. CONTD…. Parents should educate to be praised when their child employs the correct competing response, if she/he happens to miss using the competing response. Parents should educate to remind the child about using the competing response, not in a punitive tone, but rather in a supportive and encouraging tone. Training should be given to all people who are in contact with the child in such a way to ensure a consistent approach to child’s behavioral management.

35. COMPLICATIONS Anxiety Attention Deficit/Hyperactivity Disorder Depression Autism spectrum disorder Learning difficulties Obsessive Compulsive Disorder Speech and language difficulties Sleep difficulties

36. SUMMARY

37. CONCLUSION Tic is a neurological disorder characterized by motor and vocal tics. However for many individuals with TS, the tics are neither the most prominent nor distressing part of the disorder. In the majority of children with tics, tic symptoms diminish significantly during adoleslescence . Proper diagnosis & treatment of tic involves appropriate evaluation and recognition.