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------=_NextPart_01C5B54E.A6A0A6B0 Content-Location: file:///C:/011E4E74/NeuroGR2005_09_09ppt_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C5B54E.A6A0A6B0 Content-Location: file:///C:/011E4E74/NeuroGR2005_09_09ppt_files/slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Tourette Syndrome - An Integrative Primary Care Perspective
09
September 9, 2005
University of Arizona
Evan S. Trost, M.D.
Troon Family and Preventative Care, PLLC
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Learning Objectives
R= 26;Recognize the signs and symptoms of Tourette Syndrome including identification of the common co-morbid conditions
R= 26;Learn the complexities of treating a patient with Tourette Syndrome
̶= 6;Learn an integrative approach to the care of patients and families with Tourette Syndrome
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Case Presentation
•ID –= ; 8 year old male
•HPI – Abnormal movements over the past two years.  Eye blinking, nasal flaring, jaw = gyrating.  Initial evaluation and treatment = by psychologist (6 months duration).  <= /span>Decrease in movements after 3 months of counseling.
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Case Presenation
•HPI (cont) – 2 months after counseling ceased, movements returned.  Additionally phonic tics (throat clearing and huffing noises).  Movements waxed and waned in character, severity, and frequency.  Mos= t evident at the end of the day.  Over = past few months patient upset because children at school are making fun of him.  Some = of the movements are tiring him out.
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Case Presentation
•PMH – No childhood illnesses; No surgeries; = Broken Leg; No Meds; Immunizations UTD.  Developmental milestones achieved within normal limits. •SH – Lives with parents and sister.  Mother a teacher, father a lawyer, sister 2 years younger a= nd in good health.&n= bsp; 3rd grade student with good grades, no behavioral complaints.  Restless in school.
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Case Presentation
•FH – Grandfath= er with abnormal movements that sound like tics.  Grandmother with Bipolar Disorder.
•ROS ̵= 1; Headaches.  No sleep difficulties.
•PE –= ; WNL except occasional mild simple motor tic observed during times of rest.
•EEG - WNL=
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Criteria For Diagnosis – DSM = IV
•Both multiple motor and one or more vocal tics have been present at some time during the illness,= = although not necessarily concurrently. = •The tics occur many times a day nearly every day <= /span>or intermittently throughout a  period of more than 1 year, and during this period there was never a <= /span>tic-free period of more than 3 consecutive months.=
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Criteria For Diagnosis – DSM = IV
•The onset= is before age 18 years.
•The disturbance is not due to the direct physiological effects of= a substance or a general medical condition.
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Other Possible Diagnoses
•Chronic M= otor Or Vocal Tic Disorder
•Transient= Tic Disorder
•Tic Disor= der NOS
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Differential Diagnosis
•Are the above diagno= ses separate entities or are they merely a continuum or spec= trum of one broad disorder?
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Differential Diagnosis
Other Things To Consider
•Epilepsy&= #13;
•Asthma= 3;
•Allergies=
•Dermatolo= gical Conditions
<= span class=3DBB style=3D'position:absolute;left:-3.94%'>•Other Mov= ement Or Neurological Disorders
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Hallmark Of Diagnosis
•THE TIC
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DEMONSTRATION
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Tics
•Involunta= ry
•Sudden= 3;
•Rapid = ;
•Brief = ;
•Repetitiv= e
•Stereotyp= ed
•Movements= Or Vocalizations
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Motor Tics
•Simple= 3;
•Complex
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Vocal Tics
•Simple noises
•Syllables,= Words, Phrases, Sentences
•Corprolal= ia
•Echolalia=
•Palilalia=
•Corpropra= xia
•Echopraxi= a
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Associated Conditions
•ADHD =
•OCD
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Associated Conditions
•Learning Difficulties
•Obsessive Compulsive Behavior
•Aggressiv= eness
•Rage Atta= cks
•Hyperacti= vity
•Immaturit= y
•Advanced = Maturity
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Associated Conditions
•Social Withdrawal
•Somatic Complaints
•Conduct Disorder
•Oppositio= nal Behavior
•Depressio= n
•Discipline Problems
•Dyslexia<= /span>
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Associated Conditions
•Mania = ;
•Panic Attacks
•Phobias&#= 13;
•Stutterin= g
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Associated Conditions
•Neurosis&= #13;
•Hostility=
•Inappropr= iate Sexual Thoughts Or Behaviors
•Self Inju= rious Behavior
•Sleep Disturbances
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The Diagnosis
•Get an id= ea of what is going on
•Rule out = other possibilities
•Make a te= ntative diagnosis
•Provide information to the patient and family •Reevaluat= e in 2 to 4 weeks (or sooner if necessary)
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The Diagnosis
•Usually w= ill be apparent at the return visit
<= span class=3DBB style=3D'position:absolute;left:-4.11%'>•Patient&#= 8217;s and family’s descriptions are key
•Remember patient may conceal tics while in your presence
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The Diagnosis
•History, = History, History
•Physical Exam
<= span class=3DBB style=3D'position:absolute;left:-4.64%'>•Laborator= y, Imaging, and Other Tests
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History
•Identific= ation
•Current H= ealth History
•Past Medi= cal History
•Social History
•Family History
•Review Of= Systems
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Physical Exam
•General P= hysical Exam
•Neurologi= cal Exam
•Psychiatr= ic Exam
•Observati= on
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Further Studies
•Laboratory Tests
•EEG <= /span>
•MRI <= /span>
•CT
•PET <= /span>
•Psycholog= ical Testing
•Education= al Studies
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Treatment – General Principle= s
R= 26;Symptomatic, Not Curative – Improve patients level of function
R= 26;Comprehensive
•Involves the entire family and social unit
R= 26;Multiple Healthcare Providers
R= 26;Target co-morbid disorders
R= 26;Nonpharmacological, Pharmacological, Behavioral, Alternative Treatments
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Treatment
Involving The Entire Family And Social Unit
<= span class=3DBB style=3D'position:absolute;left:-4.31%'>•What are = the patient’s biggest concerns?
•How is the patient affected by their symptoms?
•What both= ers the patient the most?
•What both= ers the family the most?
•What both= ers you the most?
•What does= the patient want?
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Treatment
Multidisciplinary Approach
•Patient, Parent, Sib= lings, Other Immediate Family Members
•Primary C= are Physician
•Neurologi= st
•Psychiatr= ist
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Treatment
Multidisciplinary Approach
•Social Worker
•Psycholog= ist
•Guidance Counselors
•Behavioral Counselors
•Clergy
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Treatment
Multidisciplinary Approach
•Teachers&= #13;
•Principal=
•School Nu= rse
•Superinte= ndent
•School Bo= ard
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Treatment
Multidisciplinary Approach
•State Legislature
•Patient Advocate
•Tourette = Syndrome Association
•Lawyer
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Treatment Multidisciplinary= Approach – Goal Directed
•What is the patient’s (family’s) short term goal? •What is t= he patient’s (family’s) long term goal?
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Treatment
Comorbid Disorders
•Treating co-morbid disorders many times eliminates the need to treat tics a= nd restores a higher level of function
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Treatment
Tics
•Treat when they are a problem for the patient, not you or the parent
•Reduction= not elimination
•Start low= , go slow, monitor
•Close fol= low-up and frequent re-evaluation
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Treatment
Tics – Nonpharmacologic<= /span>
R= 26;Massed Negative Practice (Voluntary Performance Of A Tic Movement For A= Period Of Time)
R= 26;Contingency Management (Rewards For Not Performing Tics)
R= 26;Relaxation Training (Muscle Relaxing, Deep Breathing, Visual Imagery, Verb= al Imagery)
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Treatment
Tics – Nonpharmacologic<= /span>
•Self R= 11; Monitoring
•Habit Rev= ersal
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Treatment
Tics - Pharmacolgic
•Haldol= 3;
•Orap =
•Atypical Neuroleptics
•Clonidine=
•SSRIs = ;
•Psychosti= mulants
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Living With Tourette Syndrome
•It is not easy, but = with the help of physicians, parents, teachers, and friends, it = can be done!
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Recommended References
•Advances In Neurology
•Volume 85 =
•Tourette Syndrome
•
•Donald Cohen
•Joseph Jankovic
•Christopher Goetz
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Recommended References
•Toure= tte’s Syndrome
•Tics, Obsessions, Compulsions
•Devel= opmental
•Psych= opathology
•And Clinical Care
• =
•James Leckman
•Donald Cohen
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Recommended References
•A Cursing Brain?
•The Histories = Of Tourette Syndrome
•
•Howard Kushner
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Recommended References
•Tourette Syndr= ome And Other Tic Disorders
•Diagnosis, Pathophysiology, And Treatment
•
•Harvey Singer, MD
•John Walkup, MD
•
•Medicine
•Volume 70, Number 1, 1991
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Recommended References
•Tourette Disorder
•
•Samuel Zinner, MD
•
•Pediatrics In Review
•Volume 21, Number 11, November 2000
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Recommended References
•Tourette’= ;s Syndrome
•
•Joseph Jankovic, MD
•
•New England Journal Of Medicine
•Volume 345, Number 16, October 18, 2001
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Recommended References
•Tourette Syndr= ome Association, Inc.
•42-40 Bell Boulevard
•Bayside, New Y= ork 11361-2820
•(718)224-2999&= #13;
•www.tsa-usa.or= g
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