Clinical Aspects of Premonitory Urges in Patients with Tourette's Disorder

Most patients with Tourette's disorder experience an uncomfortable sensory phenomenon called the premonitory urge immediately before experiencing tics. It has been suggested that premonitory urges are associated with comorbidities such as obsessive compulsive disorder, anxiety disorders, and attention-deficit/hyperactivity disorder, although these associations have been inconsistent. Most patients experience tics as a result of the premonitory urges, and after the tics occur, most patients report that the premonitory urges are temporarily relieved. As a consequence, several studies have assessed the premonitory urge and its potential therapeutic utility. Based on the concept that the premonitory urge induces tics, behavioral treatments such as Exposure and Response Prevention and Habit Reversal Therapy have been developed. However, it is still unclear whether habituation, the main mechanism of these therapies, is directly related to their effectiveness. Moreover, the observed effects of pharmacological treatments on premonitory urges have been inconsistent.

Treatment of Children and Adolescents with Attention Deficit Hyperactivity Disorder and/or Tourette's Disorder with Clonidine Extended Release

We aimed to assess the effectiveness and safety of clonidine extended release (ER) treatment in Korean youth with ADHD and/or Tourette's disorder. We retrospectively reviewed the medical records of 29 children and adolescents treated with clonidine ER. The effectiveness were retrospectively measured at baseline and after 4 and 12 weeks based on the Clinical Global Impression-Severity (CGI-S) and Clinical Global Impression-Improvement (CGI-I) scores. Safety was evaluated at each visit based on spontaneous reports from the subjects or from their parents/guardians. Significant decreases in the CGI-S scores for both ADHD (F=23.478, p < 0.001, partial η2=0.540) and tic symptoms (F=15.137, p < 0.001, partial η2=0.443) were noted over 12 weeks. The most common adverse event was somnolence (n=9, 31.0%) and life-threatening adverse effects were not observed. Our results provide preliminary evidence for the effectiveness and safety of clonidine ER.

Kraepelin's views on obsessive neurosis: a comparison with DSM-5 criteria for obsessive-compulsive disorder

Emil Kraepelin (1856-1926) is considered one of the founders of modern psychiatric nosology. However, his conceptualization of obsessive-compulsive phenomena is relatively understudied. In this article, we compare and contrast excerpts from the eighth edition (1909-1915) of Kraepelin's Textbook of Clinical Psychiatry focusing on what Kraepelin called "obsessive neurosis" and related "original pathological conditions" with the current DSM-5 criteria for obsessive-compulsive disorder (OCD). Consistently with DSM-5 OCD, Kraepelin described obsessive neurosis as characterized by obsessive ideas, compulsive acts, or both together. His detailed descriptions of these symptoms are broadly coherent with their characterization in DSM-5, which is also true for the differential diagnoses he provided. He also mentioned cases illustrating decreased insight into symptoms and association with tic disorders. In conclusion, Kraepelin's experience, which reflects decades of consistent clinical work, may help validate current ideas and explain how the current conceptualization has emerged and developed. Even though one can hardly say that the classification laid out in DSM-5 goes back to Kraepelin's views directly, it still is true that Kraepelin played an outstanding role in systematizing psychiatric diagnostic criteria in general, and provided a major contribution to the conceptual history of OCD.

Comparing Intelligence Test Profiles to Assess Tourette's Disorder with Attention-Deficit Hyperactivity Disorder

OBJECTIVES: The study compared the intelligence test profiles of Tourette's Disorder (TD), attention-deficit hyperactivity disorder (ADHD), and TD with ADHD (TD+ADHD) groups. METHODS: The Korean Wechsler Intelligence Scale for Children-third edition (K-WISC-III) and Korean Wechsler Intelligence Scale for Children-fourth edition (K-WISC-IV) were administered to 13 children and adolescents with TD, 17 children and adolescents with ADHD, and 15 children and adolescents with TD+ADHD. Each parameter was compared among the groups using the Kruskal-Wallis test. RESULTS: The mean scores of the freedom from distractibility/working memory index (FD/WMI) and the digit span and arithmetic subtests of the TD+ADHD group were significantly lower than those of the TD group. CONCLUSION: According to the intelligence test results, the comorbid ADHD+TD group showed a significant decrease in working memory compared to the TD group. These findings are similar to those of previous research on cognitive functions and suggest that the TD+ADHD comorbid and TD alone groups exhibit different endophenotypes. The results also imply that WISC-III and WISC-IV, the most commonly used intelligence tests clinically, are effective in evaluating cognitive functions such as attention. Further research is required to confirm these results.

Tourette and tic disorders in ICD-11: standing at the diagnostic crossroads

This article reflects discussion by the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders. After reviewing the historical classification of tic disorders, this article discusses their placement in ICD-11. Existing problems with diagnostic labels and criteria, appropriate placement of the tic disorders category within the ICD-11 system, and pragmatic factors affecting classification are reviewed. The article ends with recommendations to (a) maintain consistency with the DSM-5 diagnostic labels for tic disorders, (b) add a minimum duration guideline for a provisional tic disorder diagnosis, (c) remove the multiple motor tic guideline for the diagnosis of Tourette disorder, and (d) co-parent the tic disorder diagnoses in the disorders of the nervous system and the mental and behavioral disorders categories, with secondary co-parenting in the obsessive-compulsive and related disorders and neurodevelopmental disorders sections.

Non-Psychopharmacologic Therapy of Tic or Tourette's Disorder

Tic disorder is a childhood neuropsychological disorder characterized by abrupt, involuntary, and repetitive stereotyped muscle movement or vocal sound. Tourette's disorder shows a chronic prognosis, and can last for life if no treatment is applied. Although tic disorder has been known for ages, the underlying cause is still not well known. Non-pharmacological treatments have long been used for the tic disorder, but few clinical studies were conducted. However, the European Society for the Study of Tourette's Syndrome recently issued non-pharmacologic guidelines for treatment of tic disorders based on the research findings obtained so far. In addition, guidelines for non-pharmacologic evidence-based treatment were reported in Canada, North America. By synthesizing the newly reported foreign guidelines for treatment and review articles, the aim of this study is to investigate the non-pharmacologic therapies used for treatment of tic disorder or Tourette's disorder.

Psychotrophic Drug Therapy of the Tourette's Disorder / 대한정신약물학회지

Tic disorder is a childhood neuropsychological disorder which has the characteristics of abrupt, involuntary, and repetitive stereotyped muscle movement or voice. Tourette's disorder shows a chronic prognosis, and can last for life if no medical treatment is applied. Though the tic disorder has been known for a long time, the underlying cause is still not well known. Psychotropic drugs have long been used for the tic disorder or Tourette's disorder, but few clinical studies were carried out. However, the European Society for the Study of Tourette's syndrome recently reported the clinical guideline of Tourette's syndrome and other tic disorders based on the research findings obtained so far. Also, the guideline for the evidence-based treatment was reported in Canada, and North America. By synthesizing the newly reported foreign guidelines for treatment and review articles, this study aims to investigate the psychotropic drug therapy used for the tic disorder or Tourette's disorder.

The Association of COMT Gene Polymorphism and Tourette Syndrome: A Family Based and Case Control Study

OBJECTIVES: Tourette disorder is known to be a disease with a strong genetic trait. There has been some recent research on the relationship between the allelic frequency distribution and Tourette disorder. In Korea, the relationship between the genetic type and the alleles for the COMT gene has been studied in Tourette patients. METHODS: Seventy two patients who were diagnosed with Tourette disorder according to the DSM-IV diagnostic criteria were selected for this study. The diagnosis and clinical features were confirmed by the Yale Global Tic Severity Scale. For the control group, the parents of the patients were chosen. Blood samples were taken from the 289 subjects. DNA was extracted from the blood lymphocytes and PCR was performed for assessing COMT gene. RESULTS: On comparing the Tourette disorder transmitted group and the not-transmitted group, no significant difference was seen between the COMT genetic type and the allelic distribution. CONCLUSION: Even though this result is viewed that there is no relationship between Tourette disorder and the COMT gene, it is difficult to firmly accept this negative result. Follow up studies with a larger patient population or pure subgroups are expected in the future.

Repeated Transcranial Magnetic Stimulation in Tourette's Disorder: Case Report / 대한정신약물학회지

Tourette's disorder is a chronic refractory neuro-behavioral disease. New treatment strategies, such as repeated transcranial magnetic stimulation (rTMS), have been introduced recently. We report the effect of rTMS in a case with Tourette's disorder and attention deficit hyperactivity disorder (ADHD), a common combination in the clinical setting. This was a treatment-refractory patient, who had undergone 2 years of drug treatment and psychiatric consultation. We administered 10 sessions of rTMS for 10 days, resulting in a clear improvement in symptoms not only of Tourette's disorder but also of ADHD. Our observations indicate that rTMS may be effective in the treatment of Tourette's disorder with ADHD.

A Case of Acute Dystonia Induced by Aripiprazole in a Patient with Tic Disorder / 대한정신약물학회지

An 8-year-old female with Tourette Disorder (TD) was treated with a daily oral dosage of 5 mg of aripiprazole, which did not significantly improve her symptoms. After treatment with 10 mg daily for 3 days, she experienced an acute episode of dystonia with facial muscle spasms, opisthotonus, and torticolis. All symptoms resolved after ingestion of a total of 2 mg of benztropine over 2 days. Previously, aripiprazole was considered to cause few anticholinrgic, antiadrenaline, or antihistamine effects or extrapyramidal symptoms. However, extrapyramidal symptoms have now been reported in patients with TD and in adolescent patients with other psychiatric disorders. We reviewed the literature, and to the best of our knowledge, this is the first report of a child TD patient with acute dystonia. Although the recommended treatment largely precludes acute dystonic reaction, aripiprazole has produced this reaction.

The Volumetric MRI Analysis of the Basal Ganglia in Boys with Tourette's Disorder / 신경정신의학

OBJECTIVES: The purpose of this study was to investigate the regional differences of the basal ganglia volume between the boy subjects who have Tourette's disorder and the control group who don't have this disorder by using Brain MRI. METHODS: Sixteen subjects who were diagnosed as Tourette's disorder using DSM-IV criteria, and sixteen healthy subjects were selected. For analysis the coronal slice images of the basal ganglia were collected and collected MR images were analyzed with NIH Image (version 6.1 ppc). RESULTS: The total brain volume in the subjects with Tourette's disorder were smaller than control group by 6.2% (F=6.2, d.f.=1, p=0.019). The right putamen volume in boys with Tourette's disorder were significant smaller than control group statistically (F=3.2, d.f.=3, p=0.040). The asymmetry (left>right) in the globus pallidus decreased significantly in the boys with Tourette's disorder (p=0.06) were found from this experiment. CONCLUSION: These findings suggest that boys with Tourette's disorder may have neuropathological abnormalities in the basal ganglia. Moreover, the present findings point out the important role of basal ganglia, especially putamen, in pathophysiology of Tourette's disorder. More studies about the structural and functional analysis of the basal ganglia in Tourette's disorder are highly required.

Cortical Information Transmission during Tic Suppression in Boys with Tourette's Disorder / 신경정신의학

OBJECTIVES: Tourette's Disorder (TD) is a chronic neuropsychiatric disorder characterized by multiple motor and vocal tics with onset in childhood. The aim of this study was to ascertain the increased cortical information transmission in frontal area during tic suppression in drug naive boys with TD using new nonlinear analysis of EEGs, be called Transfer Entropy (TE) which can detect the directed exchange of information between two systems. METHODS: Subjects were 11 drug naive boys with DSM-IV diagnosis of TD and 10 control boys. Clinical assessments were performed, and EEGs were recorded from 19 scalp loci of the international 10-20 systems. TE was estimated by EEG timeseries data after noise reduction. TE difference between TD and control during resting state and between tic suppression and resting state in TD were investigated. RESULTS: Elevated TE was found in extensive channels, including frontal, central and temporal channels (F7, Fz, F8,Cz, C3, P3, T3, and T4) in resting state of Tourette's disorder compared to normal controls. During tic suppression elevated TE was found in more extensive and asymmetrical channels especially prefrontal area (Fp1, Fp2, F3, Fz, F7, F8, Cz, C4, C5, T3, and T4). CONCLUSION: These findings suggest that pathogenesis of Tourette's disorder involve impaired cortical neuronal modulation in subcortical neural circuits. EEG analysis of TE may be a useful tool to investigation of cortical mechanism of psychiatric illness.

PANDAS: un modelo autoinmune de trastorno cerebral / PANDAS: an autoimmune model of mental disorder

En 1998, el Instituto Nacional de Salud Mental de los Estados Unidos definió los criterios de diagnóstico para los trastornos neuropsiquiá-tricos asociados a infección por estreptococo beta hemolítico del grupo A (PANDAS). Desde entonces se ha investigado la génesis de la autoinmunidad mediada por este microorganismo y sus impli-caciones clínicas, ya que se ha asociado con el trastorno obsesivo compulsivo, trastorno de la Tourette, corea de Sydenham y con menor evidencia con el trastorno de hiperactividad con déficit de atención, trastorno autista y anorexia nerviosa. La presente es una revisión sobre los aspectos más importantes que se han definido hasta el momento con respecto a la fisiopatología, presentación clínica y manejo de los pacientes del espectro PANDAS, pues son un grupo en el que se podrá cambiar el paradigma de tratamiento en psiquiatría de sintomático a etiológico. [Cadena LP, Toloza CR, Rueda GE. PANDAS: un modelo autoinmune de trastorno cerebral. MedUNAB 2004; 7:106-14]

PANDAS: an autoimmune model of mental disorder. In 1998, the National Institute of Mental Health defined the criteria of diagnosis for the pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). Since then there has been investigating the genesis of the autoimmunity caused by this micro-organism and its clinical implications, since it has been associated with the obsessive-compulsive disorder, Tourette's disorder and Sydenham's chorea and with minor evidence it has been related to of hyperactivity disorder with lack of attention, autistic disorder and anorexia nervosa. The present article is a review on the most important aspects that have been defined up to now in regards to the physiopatlogy, clinical presentation and management of the patients with PANDAS spectrum, since they are a group of diseases in which it will be possible to change the paradigm of treatment in Psychiatry, from being a symptomatic disease to an etiological one

Trastorno de la Tourette / De la Tourette´s disorder

El trastorno de la Tourette (TT) es un complejo síndrome neuropsiquiátrico que se caracteriza por la presencia de tics motores y vocales, síntomas que inician antes de los 18 años de edad. Este trastorno provoca un deterioro significativo en importantes áreas del funcionamiento del individuo, y tiene un patrón de cronicidad bien establecido, alternándose periodos de remisión y exacerbación de los síntomas. El TT presenta una importante comorbilidad con otros trastornos del eje I, como el trastorno obsesivo-compulsivo, trastornos por déficit de atención con hiperactividad y trastornos del aprendizaje. El presente artículo pretende revisar los aspectos epidemiológicos, etiológicos y fenomenológicos de la enfermedad así como las perspectivas terapéuticas. [Oviedo GF. Trastorno de la Tourette. MedUNAB 2004; 7:125-29]

De la Tourette ́s disorder. Tourette Syndrome (TS) is a complex neuropsychiatric disorder in which tic symptoms emerge prior to age of 18 and have, at least, a minimum duration of 12 months. This disorder produces distress and impairs normal functioning; it has a well-known chronic-waxing and waning course. TS has several comorbid conditions like obsessive-compulsive disorder, attention deficit-hyperactivity disorder, and learning disorders, among others. This article will review the epidemiologic, etiologic and phenomeno-logical concepts of the disease and its therapeutic perspectives

Dopamine Transporter Density Assessed with 123IIPT SPECT Before and After Risperidone Treatment in Children with Tourette's Disorder / 대한핵의학회잡지

PURPOSE: Tourette's disorder (TD), which is characterized by multiple waxing and waning motor tics and one or more vocal tics, is known to be associated with abnormalities in the dopaminergic system. To testify our hypothesis that risperidone would improve tic symptoms of TD patients through the change of the dopaminergic system, we measured the dopamine transporter (DAT) densities between drug-naive children with TD and normal children, and investigated the DAT density before and after treatment with risperidone in drug-naive children with TD, using iodine-123 labelled N- (3-iodopropen-2-yl) -2beta-carbomethoxy -3beta- (4-chlorophenyl) tropane ([123I]IPT) single photon emission computed tomography (SPECT). MATERIALS AND METHODS: [123I]IPT SPECT imaging and Yale Global Tic Severity Scale-Korean version (YGTSS-K) for assessing the tic symptom severity were carried out before and after treatment with risperidone for 8 weeks in nine drug-naive children with TD. Eleven normal children also underwent SPECT imaging 2 hours after an intravenous administration of [123I]IPT. RESULTS: Drug-naive children with TD had a significantly greater increase in the specific/nonspecific DAT binding ratio of both basal ganglia compared with the normal children. However, no significant difference in the specific/nonspecific DAT binding ratio of the basal ganglia before and after treatment with risperidone in children with TD was found, although tic symptoms were significantly improved with risperidone. CONCLUSION: These findings suggest that DAT densities are directly associated with the pathophysiology of TD, however, that the effect of risperidone on tic symptoms in children with TD is not attributed to the change of dopaminergic system.

The Regional Volumes of the Cerebrum and Cerebellum in Boys with Tourette's Disorder / 신경정신의학

OBJECTIVE: The aim of this study is to porve the hypothesis that the etiological neuropathological defects of the Tourette's Disorder (TD) lie in a network linking the basal ganglia and the cerebrum, not at a particular single brain region. In this study, the volumes of 10 cerebral and cerebellar regions and their symmetries were measured in normal boys and TD boys by brain magnetic resonance imaging. METHODS: Brain magnetic resonance images were obtained prospectively, controlled for confounding variables(handedness, drug-effect, effect of comorbid psychiatric disorders), in 19 boys with TD and 17 age-matched normal control boys. The frontal, parietal, temporal, and the occipital lobes and the cerebellum were defined using the semi-automated Talairach atlas-based parcellation method. RESULTS: Although the smaller brain volume was taken into account, boys with TD had larger frontal lobes and reduced normal asymmetry (right>left). There were no significant differences in the regions of interest of the parietal, temporal, or the occipital lobes or the cerebellum. CONCLUSION: These findings suggest that boys with TD may have neuropathological involvement in the frontal lobe. And this findings also support the hypothesis of abnormality in Cortical-Striatal-Thalamo-Cortical (CSTC) circuitry as an etiological factors of the Tourette's Disorder.

Dopamine Transporter Density of the Basal Ganglia Assessed with 123IIPT SPECT in Drug-Naive Children with Tourette's Disorder / 신경정신의학

OBJECTIVES: Previous studies in patients with Tourette's disorder suggested presynaptic dopaminergic dysfunction, demonstrating increased dopamine densities. In present study, we investigated dopamine transporter densities using I-123N-(3-iodopropen-2-yl)-2beta-carbomethoxy-3beta-(4-chlorophenyl)tropane(I-123-IPT)-SPECT in drug-naive children with Tourette's disorder and postulated that dopamine transporter density reflected dopamine concentrations. METHODS: Eight drug-naive children with Tourette's disorder and six normal children were included in the with the brain SPECT 2 hours after an intravenous administration of I-123-IPT. Obtained SPECT data were reconstructed for the assessment of specific/nonspecific dopamine transporter binding ratio of basal ganglia and were evaluated both quantitatively and qualitatively. We investigated correlation between total tic severity of children with Tourette's disorder assessed with YGTSS and specific/nonspecific binding ratio of basal ganglia. RESULTS: Drug-naive children with Tourette's disorder had a significantly greater increase of speciffic/nonspecific dopamine transporter binding ratio of left basal ganglia than normal children. However, no significant differences in specific/nonspecific dopamine transporter binding ratio of right basal ganglia were found between children with Tourette's disorder and normal children. Also, we found no significant correlation between total tic severity of children with Tourette's disorder and specific/ nonspecific binding ratio of basal ganglia. CONCLUSION: These findings support the hypothesis of dopamine dysregulation in presynaptic dopamine function of the basal ganglia in the pathophysiology of Tourette's disorder.

Autoimmune Neuropsychiatric Disorder and Tic Symptom Exacerbation in Tourette's Disorder: Comparision of Treatment Modalities / 신경정신의학

OBJECT: The purpose of this study was to investigate that infection with group A[beta] hemolytic streptococcus may associate the mechanisms that cause or exacerbate some cases of Tourette's disorder and to evaluate the treatment effect of IG therapy, comparing between IG therapy and drug therapy. METHOD: The subjects were divided into three groups composing of the groups with increasing level of ASO titer and the group with normal level of ASO titer, treating with antipsychotics. Children with infection-triggered exacerbation of Tourette's disorder were assigned treatment with IVIG (400mg/kg/daily on 5 consecutive days) or antipsychotic drugs. Symptom severity was rated at baseline, and at 4weeks, at at 8weeks after treatment by use of standard assessment scale of tics. RESULTS: 1) The motor tic score, global severity scores and overall TS impairment rating scores of YGTSS in the group with incresing level of ASO titer were related with ASO titer. 2) Immune therapy was more effective in the group with incresing level of ASO titer than antipsychotic drug therapy. CONCLUSION: These results suggest that increasing level of ASO titer, resulting from group A[beta] hemolytic streptococcal infection has affected worsening the tic symptoms in Touette's disorder and in group with increasing level of ASO titer, IVIG therapy is more effective than drug therapy.

The Comparison of the Executive Functions in Children with Tourette's Disorder with Those with Attention Deficit Hyperactivity Disorder / 신경정신의학

OBJECTIVES: This study was performed to verify and compare deterioration of executive functions in the children with Tourette's disorder (TS) with those with Attention Deficit Hyperactivity Disorder (ADHD) and to understand the differentes. METHOD: We administered Kaufman Assessment Battery for Children (K-ABC), Continuous Performance Test (CPT), Wisconsin Card Sorting Test (WCST) on three groups of 18 children each: tow groups of outpatients, one pure TS and one pure ADHD, diagnosed using DSM-IV criteria, and the third, a control group of normal, healthy children who were selected considering age, sex and academic achievement. The children performed all testings without the use of medications RESULTS: In comparisons of CPT perfotmance, the ADHD group showed poor performance with significant difference in commission error, attentiveness and risk taking (p< .05), and the TS group showed significant difference in attentiveness (p< .05) when compared with the control group. There was significant difference between the ADHD group and the TS group in commission error (p< .05). In comparisons of WCST, the ADHD group and the TS group showed significantly poorer performance than the controls in number of trials administered, total number of errors, conceptual level response, number of categories complete, perseverative response and perseverative error (p< .05), but only the ADHD group showed poor performance in perseverative response and perseverative erro r (p< .05). When the results of CPT were analyzed after adjustment for IQ, the ADHD group showed significantly more errors than the TS disorder group in commission error, and only the ADHD group showed significant difference in attentiveness compared with the normal controls (p< .05). In WCST, while these two groups showed significant difference in number of trials administrated, only the ADHD group showed significantly poor performance compared with the normal children group in the 5 sub-categories such as total number of errors, perseverative response, perseverative error, conceptual level response and number of categories complete (p< .05). CONCLUSION: The abnormalities of executive functions appear in both ADHD and Tourette's disorder, but more apparent abnormalities in executive functions were shown in ADHD than in Tourette's disorder. Also the differences of executive functions suggest that these two diseases may have different psychopathophysiology in these dimensions.

Tourette disorder and HLA typing

HLA A, B, C and DR were typed in 73 Korean patients with Tourette disorder meeting the diagnostic criteria of DSM III-R and compared with 291 normal subjects. Relatively higher frequencies were found in HLA A11 and A26(10) with lower incidences in HLA A24(9) and B13. A family history of tic disorders was associated with a lower frequency of HLA A24(9).