Motor tic

Stimulants should be initiated at recommended starting doses and titrated up with a consistent dosing schedule to the appropriate response while minimizing side effects (Table 39-2). Generally, stimulants should not be used in patients who have glaucoma, severe hypertension or cardiovascular disease, hyperthyroidism, severe anxiety, or previous illicit or stimulant drug abuse. Further, stimulants can be used, albeit cautiously, in patients with seizure disorders, Tourette s syndrome, and motor tics.14... 

Motor tics Sudden, involuntary muscle movements (e.g., spasms). 

Tourette s Disorder. The compulsions of OCD in many respects resemble the complex motor tics exhibited by patients with Tourette s disorder. However, although the tics of Tourette s disorder are preceded by an urgency to perform the motor tic, this irresistible urge is distinct from the obsessional fear that drives the compulsive behaviors of OCD. 

One exception is the patient with both ADHD and tic disorders such as Tourette s syndrome. High potency antipsychotics have proved quite effective in treating both vocal and motor tics. 

Haloperidol is indicated for schizophrenia, severe anxiety, motor tics and intractable hiccup. It is not indicated in the treatment of parkinsonism, which may be aggravated through its use, as haloperidol tends to cause extra pyramidal symptoms. 

Patients with marked anxiety, tension, and agitation, because the drug may aggravate these symptoms hypersensitivity to methylphenidate or other components of the product patients with glaucoma, motor tics, or a family history or diagnosis of Tourette s syndrome during treatment with monoamine oxidase inhibitors (MAOIs), and also within a minimum of 14 days following discontinuation of an MAOl (hypertensive crises may result). 

Marked anxiety, tension, and agitation (the drug may aggravate these symptoms) hypersensitivity to methylphenidate or other components of the product glaucoma motor tics or a family history or diagnosis of Tourette syndrome. 

Brett PM, Curtis D, Robertson MM, Curling HM (1995) Exclusion of the 5-HTlA serotonin neuroreceptor and tryptophan oxygenase genes in a large British kindred multiply affected with Tourette s syndrome, chronic motor tics, and obsessive-compulsive behavior. Am J Psychiatry 152 437-440... 

Contraindications Diagnosis orfamily history of Tourette s syndrome glaucoma history of marked agitation, anxiety, or tension motor tics use within 14 days of MAOIs... 

Children with pervasive developmental disorders are also at higher risk for developing TS. In a recent survey of 447 pupils from nine schools for children and adolescents with autism, 19 children were found to have definite TS, yielding a prevalence rate of 4.3% (Baron-Cohen et ah, 1999). However, caution is warranted, as complex motor tics can be difficult to distinguish from motor stereotypies, and differentiation among these behaviors may be especially problematic among retarded individuals with limited verbal skills. 

Tourette s Syndrome is a familial disorder (Pauls et ah, 1991 Walkup et ah, 1996). Twin and family studies provide evidence that genetic factors are involved in the vertical transmission within families of a vulnerability to TS and related disorders. The concordance rate for TS among monozygotic twin pairs is 50% while the concordance of dizygotic twin pairs is about 10% (Price et ah, 1985). If co-twins with chronic motor tic... 

Obsessive-compulsive, tic, and movement disorders in childhood and adolescence are now recognized as relatively common neuropsychiatric disorders, varying in severity, duration of symptom exacerbations, and degree of disability. In some children, the symptoms of these disorders are distinct and easily defined, whereas others display ever-changing combinations of obsessions, compulsions, abnormal motor movements, and tics that may be a mix of transient, chronic, simple, complex, vocal, or motor tics. 

With an estimated 3 million children and adolescents in the United States taking stimulants daily, the management of side effects is a significant clinical issue. Psychostimulant use is associated with several minor negative side effects in 10% to 15% of children treated that respond to adjustments in dose or in time of administration. Delay of sleep onset, reduced appetite, headache, and jitteriness are the most frequently cited stimulant-related side effects that have been identified in placebo-controlled trials Barkley et ah, 1990. No additional delay in sleep onset was seen after adding a third, mid-afternoon dose of MPH to standard bid dosing regimens (Kent et ah, 1995). Some children experience motor tics while on stimulants, but the mecha-... 

Motor restlessness, insomnia, decreased appetite, fatigue, increased motor tics... 

A randomized, double-blind, placebo-controlled crossover trial of botulinum toxin for the treatment of simple motor tics was conducted in 20 patients, ages 15-55, 18 of whom completed the study (Marras et al., 2001) (Table 40.2). As rated blindly on a 12-minute videotape sample, the proportional change in treated tics per minute was —39% during the botulinum toxin phase in contrast to an increase of +5.8% during the placebo phase. Half of the patients noted weakness of the injected muscles that was not functionally disabling. Two patients reported inner restlessness, accompanied by an increased urge to perform the treated tic. Two others felt that the decrease in the treated tic prompted a new replacement tic. Despite improvement in the treated tic, there was no significant evidence of overall improvement. 

Marras, C., Andrews, D., Sime, E., and Lang, A.E. (2001) Botulinum toxin for simple motor tics a randomized, double-blind, controlled clinical trial. Neurology 56 605-610. 

Tourette s syndrome (TS) is a chronic neurological disorder characterized by motor tics, involuntary verbalizations, and obsessive-compulsive behaviors. The current treatment lends itself to the use of antipsychotic agents. However, these treatments are only effective in about 70% of the treated population.84-85 Nicotine potentiates the behavioral effects of antipsychotics in a number of animal models.86 Clinical trials are under way involving patients receiving both nicotine and antipsychotic agents and appear to be promising.87 To date, there have been no studies mentioning the use of lobeline in TS. 

Neuroleptics are the drugs of choice in the treatment of tic disorders but they should only be considered in situations where the life of the child is seriously affected and when behavioural treatments have failed. Of the classical neuroleptics which have been used, haloperidol and pimozide have shown success but so far there have been no adequately controlled trials of any neuroleptic to objectively validate their efficacy. It would appear that only low doses of haloperidol are necessary (2-3mg/day) to obtain a significant reduction in tic frequency. It would seem reasonable to consider the use of the atypical antipsychotics for these disorders but, to date, there is no evidence of their efficacy in children. Recently there have been studies in which clonidine was used in the effective treatment of motor tics. The side effects are similar to those seen in the adult and include sedation, headache, irritability and sinus bradycardia. 

A 37-year-old woman developed Tourette s syndrome at 9 years of age, with motor and phonic tics. At 25 she began to smoke heroin weekly. After 3 months, her motor tics became uncontrollable and she began to have coprolalia for the first time at a rate of about 10 words per minute. Heroin was withdrawn over 6 months but her motor tics and coprolalia did not improve, despite various drug treatments. Six months later she smoked heroin again and was readmitted with violent motor tics and constant coprolalia. She was sedated and her condition improved slightly, after which she was given sulpiride 600 mg/day and clonazepam 4 mg/day. She made a partial recovery with inadequate control of motor tics. 

If patient has motor tics or Tourette s sydrome or if there is a family history of Tourette s, unless administered by an expert in cases when the potential benefits for ADHD outweigh the risks of worsening tics... 

Vocal and motor tics in patients who fail to respond to treatment with other antipsychotics... 

Asterixis, dystonias, and dyskinesias (including motor tics, orofacial and lingual dyskinesias, and oculogyric crises) are uncommon, as are auditory disturbances (SED-13,146) (13-15), (SEDA-20,60) (SEDA-21,69). 

Combined phonic and motor tics occurred in a 7-year-old boy with Down s syndrome when he took carbamazepine 19 mg/kg for suspected focal epilepsy (19). Carbamazepine concentrations were within the usual target range. The symptoms resolved completely after withdrawal. 

Holtmann M, Kom-Merker E, Boenigk HE. Carbamazepine-induced combined phonic and motor tic in a boy with Down s syndrome. Epileptic Disord 20002(1) 39-40. 

A retrospective survey yielded five cases of tics in three men and two women aged 2.5-12 years) within the first 10 months of therapy (4-17 mg/kg/day) (32). Four had simple motor tics and one had mostly vocal tics (gasping sounds) with normal laryngoscopic evaluation. In three cases the tics resolved completely within 1 month of drug withdrawal and recurred in two after reintroduc-tion. A fourth had gradual improvement over 4 months after withdrawal in the fifth, simple motor tics improved spontaneously with a reduction in dose. 

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