| BACKGROUND: tic disorders presenting during adulthood have infrequently been described in the medical literature. Most reports depict adult onset secondary tic disorders caused by trauma, encephalitis, and other acquired conditions. Only rare reports describe idiopathic adult onset tic disorders, and most of these cases represent recurrent childhood tic disorders. OBJECTIVE: To describe a large series of patients with tic disorders presenting during adulthood, to compare clinical characteristics between groups of patients, and to call attention to this potentially disabling and underrecognised neurological disorder. methods: Using a computerised database, all patients with tic disorders who presented between 1988 and 1998 to the movement disorders clinic at Columbia-Presbyterian Medical Center after the age of 21 were identified. patients' charts were retrospectively reviewed for demographic information, age of onset of tics, tic phenomenology, distribution, the presence of premonitory sensory symptoms and tic suppressibility, family history, and associated psychiatric features. These patients' videotapes were reviewed for diagnostic confirmation and information was obtained about disability, course, and response to treatment in a structured follow up interview. RESULTS: Of 411 patients with tic disorders in the database, 22 patients presented for the first time with tic disorders after the age of 21. In nine patients, detailed questioning disclosed a history of previous childhood transient tic disorder, but in 13 patients, the adult onset tic disorder was new. Among the new onset cases, six patients developed tics in relation to an external trigger, and could be considered to have secondary tic disorders. The remaining patients had idiopathic tic disorders. Comparing adult patients with recurrent childhood tics and those with new onset adult tics, the appearance of the tic disorder, the course and prognosis, the family history of tic disorder, and the prevalence of obsessive-compulsive disorder were found to be similar. Adults with new onset tics were more likely to have a symptomatic or secondary tic disorder, which in this series was caused by infection, trauma, cocaine use, and neuroleptic exposure. CONCLUSIONS: adult onset tic disorders represent an underrecognised condition that is more common than generally appreciated or reported. The clinical characteristics of adults newly presenting to a movement disorder clinic with tic disorders are reviewed, analysed, and discussed in detail. Clinical evidence supports the concept that tic disorders in adults are part of a range that includes childhood onset tic disorders and Tourette's syndrome. ( info) |
2/95. Patterns of response to acute naloxone infusion in Tourette's syndrome. The purpose of this study was to replicate findings from an earlier pilot study in which we found a dose-related effect of the opioid antagonist naloxone on tic behavior in patients with Tourette's syndrome (TS). Fifteen subjects with TS were challenged with randomized doses (30 and 300 microg/kg) of naloxone at 3-day intervals. Videotaped recordings of tic behavior were counted in a "blind" fashion. We found that naloxone had opposite effects on tics at different dosages. The low dose caused a significant decrease in tics, whereas the high dose caused a significant increase in tics. Therefore, activity at opioid receptors appears to influence the expression of TS, and the difference in response to naloxone in TS subjects may be based on a dose-response effect. ( info) |
3/95. New-onset tic disorder following acute hemorrhage of an arteriovenous malformation. The etiology of tic disorder includes idiopathic, postencephalitic, head injury, carbon monoxide poisoning, stroke, and developmental syndromes. We report a case of new-onset complex motor and vocal tics that began after hemorrhage of an arteriovenous malformation located in the left frontal lobe. We have found no reported cases of new-onset tics related to arteriovenous malformations or hemorrhage into the frontal lobes. The patient is a 16-year-old right-hand-dominant boy who presented with generalized tonic-clonic seizures. Evaluation, including magnetic resonance imaging, revealed a left frontal arteriovenous malformation, confirmed by angiogram. Following resection, there was an intraparenchymal hemorrhage of the left frontal lobe with intraventricular hemorrhage, noted most prominently in the left lateral and IIIrd ventricles, and a subdural hematoma caudal to the craniotomy. The postoperative course was complicated by hemiparesis and global aphasia. During recovery, the patient developed what was thought to be a complex partial seizure evidenced by head turning to the right with vocalization and left upper extremity clonic jerks. These were brief and occurred multiple times per day. A trial of carbamazepine was given with no improvement. It was noted that the spells occurred more frequently under stress, as when the patient was frustrated with communication. The diagnosis was changed to complex motor tics and the therapy changed to clonidine. The tics subsequently improved by 80%, although they were still present. We believe the development of complex motor tics due to frontal hemorrhage represents a unique etiology and could complicate postsurgical recovery in similar cases. ( info) |
4/95. Distinguishing the drama from the histrionics in a case of hysteria with multiple tics. The author describes a clinical experience with a hysterical patient with multiple tics, an upper-middle class, married woman, who when she started analysis at the age of 30 was in a state of profound tension and anxiety. The first eight years of this analysis are presented in order to describe how the analyst came to identify the dynamics of unconscious phantasies in a situation where analyst and patient found themselves involved in several roles of a drama dominated by theatrics. The insights and therapeutic benefits suggested that this patient unconsciously experienced her oral needs as intensely destructive and cruel, an experience she felt to have been exacerbated by her mother's lack of response to her emotional needs. This primitive cruel orality was accompanied by a split-off experience of a secret, mystical union with the primitive idealised mother. The author considers that this split experience of cruel and idealised orality suffused the patient's genital sexuality, hindering the evolution and realisation of her adult sexuality, giving her a distorted view of the primal scene as an impenetrable fused amalgam acting as an omnipotent, self-sufficient, excluding phallus. Gradually analysis enabled the patient to transform her bodily theatrics into thoughts and to broach the difficult task of relating to others instead of being either fused with them or totally excluded by them. ( info) |
5/95. Pediatric autoimmune neuropsychiatric disorders and streptococcal infections: role of otolaryngologist. OBJECTIVE: To increase awareness and understanding of the putative role of streptococcal infection in the development of neuropsychiatric disorders in children and to discuss therapeutic options in this group of patients. methods: Case illustration and literature review. RESULTS: Two siblings, one with obsessive-compulsive disorder (OCD) and one with a tic disorder, had tonsillectomy for recurrent streptococcal pharyngitis. At the latest follow-up visit (11 mo postoperatively), both patients exhibited significant improvement in their psychiatric illnesses. We discuss these cases as well as the diagnosis, pathophysiology, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). CONCLUSION: PANDAS is an active area of research investigating the relationship between streptococcal infections and the development of obsessive-compulsive disorder or tic disorders (or both) in children. The etiopathogenesis of PANDAS is thought to reflect autoimmune mechanisms and involvement of the basal ganglia of susceptible hosts. Because otolaryngologists evaluate a large portion of pediatric patients with recurrent streptococcal pharyngitis, it is important to be aware of this association and to manage these patients appropriately. ( info) |
6/95. Quetiapine for tic disorder: a case report. tic disorders happen in nearly 20 per cent of children. There is no "best drug" to treat this illness. Potent antipsychotics e.g. haloperidol and pimozide, are the most effective drugs but their limitations are their extrapyramidal side effects (EPS). risperidone has been proved on efficacy for tic disorders but EPS still remain, even though it was claimed to be less. Thus, quetiapine, a newer atypical neuroleptic with the same action as risperidone and produces fewer EPS, was included in this study. OBJECTIVE: To study the efficacy and side effects of quetiapine in tic disorders. METHOD: A case report of a 19-year-old female patient with tic disorder who had taken haloperidol 2 mg/d with benzhexol HCl 2-4 mg/d, then switched to risperidone 1.5 mg/d with benzhexol HCl 4 mg/d because of acute dystonia and oculogyric. She was then prescribed quetiapine, 50 mg/d as a starting dose without benzhexol HCI, because of the remaining symptoms and EPS. The severity of the symptoms was assessed monthly using the behavior Rating Scale. The dose was increased by 50 mg/d weekly for a better outcome. RESULTS: The tic was improved after the first week and disappeared for three weeks with 150 mg/d of quetiapine. However, the tic returned again, but less frequently (20%). Thus, the dose was stepped up to 200 mg/d. One week later, the patient reported that the tic has disappeared. CONCLUSION: Quetiapine showed the efficacy and fewest EPS in this patient. However, a further clinically controlled trial must be carried out before quetiapine can become the first-line treatment for tic disorders. ( info) |
| We report on 8 patients with adult-onset motor tics and vocalisations. Three had compulsive tendencies in childhood and 3 had a family history of tics or obsessive-compulsive behaviour. In comparison with DSM-classified, younger-onset Gilles de la tourette syndrome, adult-onset tic disorders are more often associated with severe symptoms, greater social morbidity, a potential trigger event, increased sensitivity, and poorer response to neuroleptic medication. ( info) |
8/95. Beneficial effects of botulinum toxin type a for patients with painful tic convulsif. Botulinum toxin is a well-known therapy for patients with diverse movement disorders. Its application has been extended to other disorders. Here, we document the case of a 70-year-old man with hemifacial spasm associated to trigeminal neuralgia secondary to an ectatic basilar artery. He was treated with botulinum toxin type A, 2.5 mouse units over five sites at the orbicularis oculi and one over the buccinator muscle. After botulinum toxin injections, relief was gained not only from twitching but also from pain. When the effects of the toxin vanished, spasms and pain recurred. Further infiltrations were given every 12 weeks following the same response pattern. This observation further validates the increasing role of botulinum toxin in pain management. ( info) |
| PURPOSE: To describe the circumstances associated with eye injury from an ocular examination of two patients with tourette syndrome. DESIGN: case reports. methods: A 21-year-old man and a 24-year-old man had sudden and unpredictable movement during an eye examination, causing conjunctival laceration and hemorrhage abrasion in the first patient and a corneal abrasion in the second patient. RESULTS: With topical antibiotics for both patients and patching of the eye for the 24-year-old patient, healing was uncomplicated. CONCLUSIONS: patients with tourette syndrome are at risk of eye injury when an unanticipated tic movement occurs during eye examination. Physician precautions, particularly mental preparedness for sudden jerking movement, should be taken when examining patients with tourette syndrome. ( info) |
| A 6-week-old infant had recurrent contractions of the facial musculature on the left side, which continued throughout early childhood. Surgical exploration at 5 1/2 years of age revealed a ganglioneuroma of the fourth ventricle. hemifacial spasm (HFS) in infancy and childhood suggests the possibility of serious intracranial pathologic findings. ( info) |