11-17-03

TOURETTE SYNDROME
Presented by:
APS Healthcare
Southwestern Health Care Quality
Unit (HCQU)
Disclaimer
Information or education provided by
the HCQU is not intended to replace
information by the consumers primary
care physician or replace any existing
facility policy.
Certificates for training hours will only be awarded to those who
attend a training in its entirety. Attendees are responsible for
submitting paperwork to their respective agencies."

Objectives
The Participant will:
Be able to define Syndrome
Be able to define a Sign versus a Symptom
Define Tourette Syndrome
List & Define known Causes of Tourettes
Identify Five known Signs of Tourettes
Identify Treatment Strategies


What is a Syndrome?
A set of signs and symptoms which
when studied together lead to the
diagnosis of medical, behavioral or
mental health disease.
Not all Signs & Symptoms when studied
together mean a certain disease is
present.
What is a Sign?
An indication of the existence of
something; any objective evidence of a
disease; such as is observable by those
charged for a Consumers care.
Those observable changes which are
measured through testing, and
quantified through time.
What is a Symptom?
Any sensation of change within ones
own body which is identified by a
Consumer. These are not those items
which are noted by outside observers
but rather only those things which are
identified by the Consumer.
Tourette Syndrome
Gilles de la Tourette
A Syndrome
Facial & Vocal Tics
Onset in Childhood
Progressing to generalized jerking
movements in any part of the body, with
echolalia, coprolalia.
Once thought to be terminal now responds
well to prescribed medications.
DSM IV-TR Criteria 307.23
This neuropsychiatric syndrome of
uncertain cause, develops in latency or
early adolescence with the onset of one
or more poorly controlled symptoms,
including head or extremity tics, eye
blinks, and the spasmodic production of
coughs or grunts which occasionally can
include verbal obscenities (coprolalia).
Often it is severe and life long.
DSMIV-TR Criteria - II
This syndrome occurs with increased
incidence in families, indicating a
possible genetic component, and is
associated with obsessive compulsive
disorder and with hyperactivity and
learning disorders in family members.
Symptoms are worsened by stress.
Diagnostic criteria
Medical Study
Complete Medical & Behavioral History
Age at which first identified
Observation of Tics
Scales are available to rate Tic severity
and frequency
Possible Etiology
Genetic Disorder
Environment
Exposure to Drugs or other Toxins in
early development, often prior to birth
Dopamine, Nor-Epinephrine, and
Serotonin in dysregulation
Definition of a Tic
Involuntary movement of one or more
muscle groups.
Most of the time they are meaningless.
Some think that the complex tics are
purposeful.

Categories of Tics
Simple
Motor
Vocal
Complex
Motor
Vocal

What are Motor Tics?
Eye rolling
Eye blinking
Facial grimacing
Licking
Lip smacking
Nose twitching
Clapping
Foot tapping

Shrugging
Hair tossing
Stomping
Shaking the head
Foot dragging
Facial grimacing
Squinting
Arm squeezing
What are Vocal Tics?
Clearing the throat
Sniffing
Shouting
Belching
Snorting
Sucking
Honking
Gasping
Tongue clicking
Yelping
Moaning
Unusual noises
Hissing
Screaming
Gurgling
Hiccupping


Examples of Complex,Motor
Tics
Hopping
Banging
Jumping
Kicking
Punching
Pinching
Kissing
Copropraxia

Echopraxia
Skipping
Scratching
Toe walking
Throwing things
Tearing things
Smelling things
Shivering


Examples of Complex,Vocal
Tics
Animal sounds
Laughing
Palilalia
Echolalia
Coprolalia
Stuttering
Repeating
Words
Phrases
Parts of words
Spitting
Talking to self


Tremors & Tourettes
Unrelated movements that share one major
characteristic, oscillation of a limb or body
parts.
Physiologic Tremor is normally not
observable. Only with increased stress,
anxiety or stimulants.
Treatment involves removal of medications
which over stimulate, and if needed the
addition of a Beta-Blocker like Propranalol.
Treatment Strategies
Offer testing and other activities in separate
location with no time limits.
Educate other staff and Consumers.
Provide a Safe Area where a Consumer may
go and calm down, release tics or obsessions.
Give the Consumer frequent breaks to release
tics in a less embarrassing environment.
If tics are inappropriate, such as spitting,
swearing touching people, it may be
necessary to brainstorm solutions. E.g.
spitting into a tissue regularly.
Motor/Visual Impairment
Use of a word processor is helpful
Occupational Therapy
Sensory Integration
Shorten required tasks required
Never penalize the Consumer for tic
which impairs ability to complete
assigned tasks.

Obsessive/Compulsive
Symptoms
Obsessions & Compulsions can take so
many forms that it is difficult to give a
few pat answers to the problem.
First assess the nature of the
obsessions and then brainstorm with
the treatment team effective
interventions.
Irritability & Poor Coping
Many Consumers with TS become easily
frustrated, become over stimulated, and feel
over whelming anxiety.
Crowds, Cafeteria, Workshops, Living
Quarters tend to cause increased anxiety.
Lack of Structure leads to increased tics
Poor transitioning ability.
Sensory defensiveness, which leads to quick
over loading and then being easily set-off
How to Help ?
Educate the Staff and Provide Structure for
the Consumer.
Educate the Consumer in ways to remove
her/himself from an escalating and frustrating
situation. Some Examples:
Permit the Consumer to leave the area ahead of
the group to avoid crowds.
Permit the Consumer to eat alone and at a
different time than the rest of the group.
ADHD & Tourettes
Preferential Seating at the Workshop
Provide a quiet place to complete tasks.
Consider a head set with music to block out
distractions.
Permit freedom of movement
Establish communication signs that a
Consumer may utilize and recognize as a sign
of needing to stay on task.
Use color coded cards that identify tasks for
the Consumer.
Lets tie this together
Tourette Syndrome is in fact a group of
neuropsychiatric disorders which
resemble other diseases.
Treatment should encompass all areas
identified by the treatment team.
The Consumer with Tourettes does not
want to be out of control. This is not
bad behavior, it is a disease.
Medications
The treatment of TS is complex.
Pediatricians, Internists, and
Neurologists with Psychiatrist may be
required.
Medications have side effects and staff
and/or care givers require formal
education regarding their use.
Medications - II
Prolixin
Haloperidol
Pimozide
Olanzapine
Some Consumers may be intolerant to
the side effects of these drugs. Acute
Dystonia, Akathisia, daytime sedation
and Task Phobias may occur.
Recent Research
Risperidone may be effective for tics
and has a lower side effect profile.
Clonidine
Clonazepam
Nicotine the patch
These so called a-typical drugs have a
much more tolerable side effect profile.
What to Do?
Observe
Analyze
Medical Analysis & Evaluation
Psychiatric Analysis & Evaluation
Neurologic Analysis & Evaluation
Environmental Accommodations
Comprehensive Treatment Plan
- Must include Medical & Behavioral Facets
REFERENCES
http://samed.com
http://apa.org
Olney RK, Aminoff MJ: Weakness, Abnormal
Movements, and Imbalance, Chap. 21 p. 107
http://www.nimh.gov
http://www.who.org
Harrisons Companion Textbook of Internal
Medicine, Fauci A.S., (et al.). Chap. 1 p. 57
THANK YOU
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any other behavioral or physical health
topic please visit our website @

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