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PubMed2000

MRI assessment of children with obsessive-compulsive disorder or tics associated with streptococcal infection.

OBJECTIVE: The authors assessed selective basal ganglia involvement in a subgroup of children with obsessive-compulsive disorder (OCD) and/or tics believed to be associated with streptococcal infection. METHOD: Using computer-assisted morphometric techniques, they analyzed the cerebral magnetic resonance images of 34 children with presumed streptococcus-associated OCD and/or tics and 82 healthy comparison children who were matched for age and sex. RESULTS: The average sizes of the caudate, putamen, and globus pallidus, but not of the thalamus or total cerebrum, were significantly greater in the group of children with streptococcus-associated OCD and/or tics than in the healthy children. The differences were similar to those found previously for subjects with Sydenham's chorea compared with normal subjects. CONCLUSIONS: These results support the hypothesis that there is a distinct subgroup of subjects with OCD and/or tics who have enlarged basal ganglia. These findings are consistent with the hypothesis of an autoimmune response to streptococcal infection.

Autoimmune Diseases↗
PubMed1997

Increased prevalence of the seven-repeat variant of the dopamine D4 receptor gene in patients with obsessive-compulsive disorder with tics.

The polymorphism characterized by a varying number of 48 bp repeats (VNTR) in the dopamine D4 receptor (DRD4) gene was examined in 61 obsessive-compulsive disorder (OCD) probands with and without tics. Most of the OCD patients with tics showed at least one copy of the 7-fold variant compared to those affected subjects without tics (91 vs. 48%, respectively, Yates corrected chi2 = 5.54, P = 0.018). Similarly, a higher number of copies of this common variant were detected in the group of probands displaying tics compared to those OCD's without tics (Yates corrected chi2 = 4.66, P = 0.03). Our study suggests that the seven-repeat allele of the DRD4 gene could be a factor in the phenotypic variance of tics among OCD individuals.

Alleles↗
PubMed2001

Obsessive-compulsive disorder and tic syndromes.

The phenomenology of OCD and TS seem to match perfectly with the existing conceptualization of the functional relationship between frontal cortical and subcortical circuits. Failed editing of thoughts and impulses, perseverative patterns, and inhibitory deficits are the most convenient descriptors of the symptoms, and some operationalized measures can capture evidence for such deficits in TS and OCD patients. Beyond these expectations borne from conceptual models and some broad patterns of distributed metabolic disturbances in neuroimaging studies, a specific causal pathology within CSPT circuitry needs to be identified in these disorders. This is not a criticism of the existing studies of TS and OCD; to the contrary, the scarcity of pathologic material, the limits of resolution of existing technologies, and the heterogeneity of the phenotypes make the accomplishments of these studies more impressive. As clinicians strive to integrate clinical and scientific findings into coherent models for the pathophysiology of OCD and TS, it is useful to identify practical and effective strategies for therapeutic interventions.

Behavior Therapy↗
PubMed1998

Clinical features distinguishing patients with Tourette's syndrome and obsessive-compulsive disorder from patients with obsessive-compulsive disorder without tics.

OBJECTIVE: It is not clear whether obsessive-compulsive disorder (OCD) in the context of Tourette's syndrome (TS) is the same as that disorder found in patients with OCD alone. This study evaluated the severity and characteristics of the obsessive-compulsive symptoms in adult patients with OCD and TS compared to adult patients with OCD alone. METHOD: Thirteen subjects with both DSM-III-R TS and OCD and 13 subjects with OCD alone were recruited. Obsessive-compulsive severity was determined by using the Yale-Brown Obsessive Compulsive Scale. The Tourette Syndrome Association Unified Tic Rating Scale was administered to determine tic severity, and the adult version of the Attention Deficit and Hyperactivity Checklist was used to detect a history of childhood attention-deficit hyperactivity disorder (ADHD). RESULTS: Subjects with OCD alone had very few obsessions and compulsions that were not also experienced by subjects with both TS and OCD. In contrast, subjects with TS and OCD were significantly more likely to report obsessions involving nonviolent images, excessive concern with appearance, and need for symmetry. Touching, blinking or staring, and counting compulsions were also significantly more common in this group. Eight subjects with OCD and TS had a childhood history of ADHD, compared to none of the pure OCD subjects. CONCLUSION: There are subtle but definite differences in symptomatology of subjects with pure OCD compared to those with OCD and TS consistent with putative differences in pathophysiology between the 2 groups, i.e., abnormalities in the serotonergic system in OCD patients and serotonergic and dopaminergic abnormalities in those with OCD and TS. These observations may be consistent with genetic heterogeneity within both OCD and TS.

Adult↗
PubMed2003

The identification of OCD-related subgroups based on comorbidity.

BACKGROUND: Individuals with obsessive-compulsive disorder (OCD) frequently have other psychiatric disorders. This study employed latent class analysis (LCA) to explore whether there are underlying clinical constructs that distinguish "OCD-related" subgroups. METHODS: The study included 450 subjects, case and control probands and their first-degree relatives, and LCA was used to derive empirically based subgroups of 10 disorders: OCD, obsessive-compulsive personality disorder (OCPD), recurrent major depressive disorder (RMDD), separation anxiety disorder, panic disorder or agoraphobia (PD/AG), tic disorders (TD), generalized anxiety disorder (GAD), somatoform disorders (hypochondriasis or body dysmorphic disorder), pathologic skin picking or nail biting (PSP/NB), and eating disorders (EDs). The derived classes were compared on several clinical variables. RESULTS: The best fitting model is a four-class structure: minimal disorder, predominant RMDD and GAD, "highly comorbid," and PD/AG and TD. The nature and number of disorders represented suggests that the first classes are distributed ordinarily on a dimension of severity, and the fourth class is qualitatively distinct. Support for this structure is based on the number of disorders, age at onset of OCD, neuroticism, and extraversion. CONCLUSIONS: In this OCD enriched sample, LCA identified four classes of disorder. These classes appear to conform to two subgroups that may prove useful in investigating the etiology of OCD.

Age of Onset↗
PubMed2003

Psychiatric comorbidities in children with attention deficit hyperactivity disorder: implications for management.

Attention deficit hyperactivity disorder (ADHD) is frequently comorbid with a variety of psychiatric disorders. These include oppositional defiant disorder and conduct disorder (CD), as well as affective, anxiety, and tic disorders. ADHD and ADHD with comorbid CD appear to be distinct subtypes; children with ADHD/CD are at higher risk of antisocial personality and substance abuse as adults. Stimulants are often effective treatments for aggressive or antisocial behavior in patients with ADHD, but mood stabilizers or atypical antipsychotics may be used to treat explosive aggressive outbursts. Response to stimulants is not affected by comorbid anxiety, but children with ADHD/anxiety disorder may show greater benefit from psychosocial interventions than those with ADHD alone. The degree of prevalence of major depressive disorder (MDD) and bipolar disorder among children with ADHD is controversial, but a subgroup of severely emotionally labile ADHD children who present serious management issues for the clinician clearly exists. Antidepressants may be used in conjunction with stimulants to treat MDD, while mood stabilizers and atypical antipsychotics are often required to treat manic symptoms or aggression. After resolution of the manic episode, stimulant treatment of the comorbid ADHD may be safely undertaken. Recent research suggests that stimulants can be safely used in children with comorbid ADHD and tic disorders, but the addition of anti-tic agents to stimulants is often necessary. Clinicians who work with patients with ADHD should be prepared to deal with a wide range of emotional and behavioral problems beyond the core symptoms of inattention and impulsivity/hyperactivity.

Attention Deficit Disorder with Hyperactivity↗
PubMed2003

Children at familial risk for Tourette's disorder: Child and parent diagnoses.

Tourette's disorder (TD) is a neuropsychiatric disorder that onsets in childhood and appears to result from an interaction of genetic and environmental factors. The goal of the current prospective longitudinal study is to examine the onset of TD in offspring of parents with TD. At-risk children and control children were enrolled between the ages of 3 and 6 years and prospectively studied with yearly structured assessments over intervals of 2-5 years. Of 34 at-risk children free of tics at baseline, 10 (29%) subsequently developed a tic disorder, including 3 with TD. None of the 13 control children developed a tic disorder (P = 0.045). OCD or subclinical OCD emerged in 11 cases but no controls (P = 0.021). Finally, ADHD occurred in 14 at-risk children but no controls (P = 0.005). When at-risk families were dichotomized into bilineal or unilineal categories, rates of TD in children with two affected parents were three times the rate observed for children with one affected parent. These findings support the hypothesis that at least some cases of TD result from a complex genetic etiology. TD, OCD, and ADHD are significantly increased in children with TD parents. Furthermore, the risk is even greater when both parents are affected. Finally, our diagnosis of tic disorders in 21% of subjects initially reported by parents to be unaffected affirms the value of structured clinical assessments.

Adolescent↗
PubMedDate not supplied

Differential responsiveness to lithium in patients with Tourette disorder.

The current status of the use of lithium in the treatment of tic disorders is reviewed. Areas of pathophysiologic overlap between bipolar and tic symptomatology are explored from the standpoint of shared etiology versus co-morbidity. Data from ten cases of children and adolescents with tic disorders treated with lithium are presented. Five exhibited a positive response to tic and associated symptoms, while five did not. Treatment responders versus nonresponders were compared along a number of parameters including co-morbidity with other syndromes, family history, prior medication history, medication used concurrently with lithium, and medication used subsequent to treatment with lithium. Differences between the two groups are explored.

Child↗
PubMed2000

Complex segregation analysis of families ascertained through Gilles de la Tourette syndrome.

Although family and twin studies suggest that genetic factors are involved in the etiology of Tourette syndrome and other related tic disorders, further evidence is needed to demonstrate that the familial transmission is consistent with known genetic factors. We performed a complex segregation analysis that allowed for a variable age of onset of Gilles de la Tourette, other tic disorders and obsessive compulsive phenotype information on 108 extended families, each ascertained through one Tourette proband by using regressive models that are able to incorporate additional explanatory variables and major gene effects. A special version of the S.A.G.E. program, REGTLhunt, was used to explore the likelihood surface of all examined models. Results indicated that the pattern of Tourette and other related tic disorders in our data sample is not consistent with Mendelian inheritance even after modelling explanatory variables such as obsessive compulsive symptomatology.

Adolescent↗
PubMed1995

Behavioral problems and severity of tics.

This study examined the incidence of behavioral symptoms in youngsters with tic disorders. A total of 186 patients were studied using the Child Behavior Checklist and a Motor/Vocal Tic Severity Scale. The relationship between tic severity and the frequency of behavioral symptoms was found to be not simply linear, but influenced by the presence of patients without significant behavioral problems in spite of severe tics (resilient patients) and patients with very negative adjustment although their tic disorder was mild (vulnerable patients). Behavioral problems were not related to age. Patients who were receiving medication showed behavioral problems of different severity from those who were not receiving such agents; this result emphasizes the need for future studies to consider carefully the effects of medication.

Adolescent↗
PubMed2005

Obsessive-compulsive symptoms among patients with Sydenham chorea.

BACKGROUND: Among patients with tic disorders, a distinctive clinical profile of obsessive-compulsive symptomatology has been described. The present investigation was designed to document the phenomenology of obsessive-compulsive symptoms (OCS) among patients with Sydenham chorea (SC), the neurologic variant of rheumatic fever. We hypothesized that OCS occurring in association with SC would be similar to those among patients with tic disorders. METHODS: The authors studied the presence of OCS in 73 patients with SC by using the Yale-Brown Obsessive-Compulsive Scale at the Pediatric Clinics of the University of Sao Paulo Medical Center in Sao Paulo, Brazil (n = 45) and at the National Institute of Mental Health in Bethesda, Maryland (n = 28). RESULTS: The most frequent symptoms observed among subjects with comorbid SC and OCS were aggressive, contamination, and somatic obsessions and checking, cleaning, and repeating compulsions. A principal component factor analysis yielded a five-factor solution (accounting for 64.5% of the total variance), with contamination and symmetry obsessions and cleaning compulsions loading highly. CONCLUSIONS: The symptoms observed among the SC patients were different from those reported by patients with tic disorders but were similar to those previously noted among samples of pediatric patients with primary obsessive-compulsive disorder.

Adolescent↗
PubMed2003

Risperidone-induced obsessive-compulsive symptoms in two children.

OBJECTIVE: To present two cases of rapid-onset obsessive-compulsive symptoms in children treated with risperidone. CASES: "A" was an 8-year-old boy with attention deficit and chronic tic disorder who developed obsessive-compulsive symptoms within 2 weeks of starting risperidone. When the dose of 0.5 mg tid was discontinued, the obsessive-compulsive symptoms resolved with no return over 8 months of follow-up. "B" was an 11-year-old girl with mild mental retardation and aggression who was treated with risperidone 1 mg per day. Obsessive-compulsive symptoms suddenly emerged 10 days after starting risperidone and resolved within 3 days of discontinuation. In both cases, streptococcal pharyngitis was ruled out. CONCLUSION: Although the mechanism is not clear, these cases add to several other reports concerning the sudden emergence of obsessive-compulsive symptoms and anxiety symptoms in children treated with atypical antipsychotics. Clinicians should be alert to the possibility of these adverse effects in children treated with these drugs.

Adult↗
PubMed1994

Behavioral and pharmacological treatments for tic and habit disorders: a review.

Children with tic and habit disorders are often seen by pediatricians, psychologists, or psychiatrists for evaluation and treatment. Current knowledge of the treatment-outcome research in these areas can serve as an important guide in the evaluation and treatment planning process. This article reviews the behavior therapy and pharmacological treatment of motor and vocal tic disorders, self-destructive oral habits, trichotillomania (hair pulling), onychophagia (nail biting), and thumb sucking. The research evidence indicates that all of these disorders can be effectively treated with behavioral or pharmacological approaches.

Behavior Therapy↗
PubMed1998

[Exacerbation of tics by prednisolone].

Tics-disorders are hyperkinetic movement disorders which manifest in childhood or early adolescence and ameliorate in later adulthood. We report on two patients with a basically subclinical tic-disorder (age of 53 and 68 years). During the therapy of polymyalgia rheumatica and endocrine orbitopathy in Graves disease with prednisolone the tics exacerbated and were therefore diagnosed and treated for the first time. Possible causes for the exacerbation of the tics during the therapy with glucocorticosteroids are discussed in the context of the dopamine hypothesis of tics.

Aged↗
PubMed2005

Effectiveness and safety of risperidone for children and adolescents with chronic tic or tourette disorders in Korea.

The aim of this 6-week, open-label design study was to determine the short-term effectiveness and safety of risperidone as an alternative for traditional antipsychotic drugs in the treatment of chronic tic disorder or Tourette's Disorder in young children and adolescents. The subjects were 15 young children and adolescents (the ratio of male:female subjects was 13:2 and their mean age was 10 +/- 2.4 years). Seven subjects were diagnosed with Tourette's Disorder and 8 subjects with chronic tic disorder, and all subjects were administered risperidone without hospitalization. Of the 15 subjects, 1 subject had a comorbid disorder (obsessive compulsive disorder), but no subject had a previous history of psychiatric hospitalization. Ten of the 15 subjects were administered risperidone for the first time, and 5 of the 15 subjects had been previously treated with traditional drugs (haloperidol or pimozide). Clinical responses were measured at baseline and after 1, 3, and 6 weeks of drug treatment by using the Korean version of the Yale Global Tic Severity Scale and the Global Assessment of Functioning Scale. Side effects were carefully monitored using adverse event evaluation charts. The mean dosage of risperidone was 0.53 +/- 0.13 mg on the 1st week, 0.90 +/- 0.28 mg on the 3rd week, and 1.23 +/- 0.37 mg on the 6th week. Comparison between periods according to the Korean version of the Yale Global Tic Severity Scale showed significant differences (t = 4.920; df = 14; p < 0.01) during the 1st- to 3rd-week period. After 6 weeks of administration, the tic severity scale showed a 36% reduction in the overall tic symptom scores and 13 of the 15 subjects showed significant improvement, 1 subject showed no difference in symptoms, and, for 1 subject, the symptoms worsened. Also, the mean Global Assessment of Functioning Scale score was 66.8 +/- 10.8 at baseline and improved to a mean of 73.1 +/- 10.1 after 6 weeks of treatment. Regarding side effects, only 1 case reported sedation, but drug administration was continued because the degree was mild. The results of this study show that, risperidone, a potent combined serotonin (5-HT2) and dopamine (D2) receptor antagonist, is both effective and safe for the treatment for Tourette's Disorder and chronic tic disorder in children and adolescents.

Adolescent↗
PubMed2004

Tic reduction with risperidone versus pimozide in a randomized, double-blind, crossover trial.

OBJECTIVE: To compare the tic suppression, electrocardiogram (ECG) changes, weight gain, and side effect profiles of pimozide versus risperidone in children and adolescents with tic disorders. METHOD: This was a randomized, double-blind, crossover (evaluable patient analysis) study. Nineteen children aged 7 to 17 years with Tourette's or chronic motor tic disorder were randomized to 4 weeks of treatment with pimozide or risperidone, followed by the alternate treatment after a 2-week placebo washout. The primary efficacy outcome measure was change in tic severity assessed by the Yale Global Tic Severity Scale (YGTSS). ECG results, weight gain, and side effects were also compared. RESULTS: Compared to pimozide treatment, risperidone treatment was associated with significantly lower tic severity scores (YGTSS: baseline 43.3 +/- 17.5, pimozide 34.2 +/- 14.2, risperidone 25.2 +/- 13.6; p =.05). Weight gain during the 4-week treatment periods was greater for risperidone (mean 1.9 kg) than pimozide (1.0 kg). No patient suffered a serious adverse event, but 6 of 19 subjects failed to complete the protocol. Neither medication was associated with ECG changes. CONCLUSIONS: In this study, risperidone appeared superior to pimozide for tic suppression but was associated with greater weight gain.

Adolescent↗
PubMed1994

Observations and ratings of tics in school settings.

This paper describes the findings of a school-based tic assessment procedure (direct observations, teacher rating scales) for hyperactive children with comorbid tic disorder. Rates of motor tic frequency were found to be moderately stable across both days and school settings. Correlations between direct observations of tics and clinician rating scales were generally in the low to moderate range as were correlations between teacher and clinician rating scales. Overall rates of hyperactive/disruptive behaviors were not associated with rates of motor tic occurrence, and the behavioral symptoms of both disorders were also independent for specific intervals of time.

Attention Deficit Disorder with Hyperactivity↗
PubMed2002

Is Tourette's syndrome an autoimmune disease?

We provide a review of recent research findings which support the involvement of autoimmunity in childhood-onset tic disorders, in particular the presence of antineuronal autoantibodies, D8/17 B lymphocyte overexpression, a marker of chorea associated with streptococcal infection, and possible beneficial effects of immunomodulatory intervention. One of the most controversial areas in this field is the validity of the proposed PANDAS concept. Some researchers have delineated a putatively unique subgroup of patients, from the spectrum of illness encompassing Tourette's syndrome and obsessive-compulsive disorder (OCD), whose tics and obsessive-compulsive symptoms are shown to arise in response to beta-hemolytic streptococcal infections. They designated it by the term pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Herein we additionally present pros and cons concerning the concept of PANDAS. Finally, recommendations for future research directions are given.

Autoantibodies↗