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ChronicTicDisorders

WhatisaTic?

Motor

Simple Complex

Phonic

Simple Complex

MotorCcs

Simple-suddenbrief,meaninglessmovements–  Eyeblinking,eyemovements,grimace,mouthmovements,headjerks,shouldershrugs

Complex-slower,longer,more“purposeful”– MulCplesimpleCcsoccurringinanorchestratedpaKern,facialgestures,touchingobjectsorself,handgestures,gyraCngorbending,dystonicpostures,copropraxia(obscenegestures)

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PhonicTics

Simple-suddenmeaninglesssoundsornoises–  Throatclearing,coughing,sniffing,spiPng,animalnoises,grunCng,hissing,sucking,othersimplesounds

Complex-sudden,more“meaningful”u;erances–  Syllables,words,phrases(“shutup”,“stopthat”)–  Coprolalia(obscene,aggressivewords)–  Palilalia(echoself)–  Echolalia(echoothers)

OperaConalDefiniCon

•  ToureKe’sDisorderA.  BothmulCplemotorandoneormorevocalCcs

thathavebeenpresentatsomeCmeduringtheillness,althoughnotnecessarilyconcurrently

B.  TheCcsmaywaxandwaneinfrequencybuthavepersistedformorethan1yearsincefirstCconset

C.  Onsetisbeforeage18yearsD.  ThedisturbanceisnotaKributabletoa

substanceorothermedicalcondiCon

OperaConalDefiniCon

•  Persistent(Chronic)MotororVocalTicDisorderA.  SingleormulCplemotororvocalCcsthathave

beenpresentatsomeCmeduringtheillness,butnotbothmotorandvocal

B.  TheCcsmaywaxandwaneinfrequencybuthavepersistedformorethan1yearsincefirstCconset

C.  Onsetisbeforeage18yearsD.  ThedisturbanceisnotaKributabletoasubstance

orothermedicalcondiConE.  CriteriahaveneverbeenmetforToureKe’s

disorder

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Prevalence

•  ToureKe’sisaround0.77%ofchildren,0.05%ofadults

•  LessseverePersistentTicDisordermaybeupto2-3%forchildren

•  Manymoremalesthanfemalesdiagnosed– 2-5:1raCoseen

ToureKe’sDisorder

•  Typicalageofonsetis5-6yearsold– OaenstartswithsimplefacialCcs,thenprogressestomorecomplexandmotorCcs

•  Associatedwithveryhighlevelsofcomorbiddisordersandsymptoms

TicFrequency

•  97.7%SimplemotorCcs– 43.2%Eyes– 43.2%Mouth– 34.1%Facial

•  75.0%SimplevocalCcs

•  13.6%Coprolalia

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ToureKe’s&Comorbidity

•  Obsessionsandcompulsions–50%

•  Depression–41%

•  AKenConalproblems,hyperacCvity–50-75%

•  LearningdisabiliCes–51%

•  PanicaKacks–13%

WhatCausesTics?

•  AppearstobeanirregularityoftheneurotransmiKersdopamineandserotonin

•  Thereisno“cure,”butsymptomstendtodecreaseaaeradolescenceinmostpeople

•  TreatmentopConsincludedrugsandtherapy– AnCconvulsantsandneurolepCcsareusefulforsome,buthaveverynegaCvesideeffects

Can’tTheyControlIt?

•  Shortanswer:No

•  Controlandseveritywaxesandwanesovertheday

•  Bestanalogyformostpeopleisasneeze– Youcanfeelitcomingon,canholditoffforaliKlewhile,butulCmatelyyouhavetoletitout

– Thelongermostpeopleholditin,thegreatertheseveritywhenitisletout

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HowaTicHappens

Sensory event or premonitory urge

State of inner conflict over if and when to yield to urge

Motor or Phonic Production

Transient relief sensation

ToureKe’sRelatedProblems

•  Loweredoverallqualityoflife

•  Academicproblems

•  ImpairedsocialinteracCons

•  Numberofhome-lifeimpairments–  IncreasedmaritaldifficulCes,substanceabuse,familyconflict,andparenCngfrustraCon

ToureKe’sRelatedProblems

•  88%ofthosewithCcsreportanegaCveimpactontheirdailyfuncConing

•  Higherunemploymentratesandloweredincomeasadults

•  Self-esteemandsocialanxiety

•  Physicaldamage

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CommonTriggersforTics

•  Beingupsetoranxious•  WatchingTV•  Beingalone•  Socialgatherings•  Stressfullifeevents•  Hearingotherscough•  TalkingaboutCcs

PharmacologyforTics

•  Pharmacologyisveryfrequentlyused,asfewpeoplearetrainedinbehavioraltreatments

•  AnCpsychoCcsareoaenthefirstline,butusuallyfailtoeliminatetheCcsandcancause– SedaCon– Weightgain– CogniCvedulling– Tardivedyskinesiaorparkinsonism

PharmacologyforTics

•  SurprisinglyfewRCTsonvariousanCpsychoCcsforCccontrol

•  Clonidine(anα2adrenergicagonistandimidazolinereceptoragonist)isalsofrequentlyused,primarilyinADHD/TS

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TherapyforTics

•  Gold-standardtreatmentisCogniCve-BehavioralIntervenConforTics

•  Effectsizesof.7-.8foundinmeta-analyses

•  Long-lasCngeffects,lowdrop-outrates,nonegaCvesideeffects

CBITOutline

•  PsychoeducaCon•  HabitReversalTraining•  FuncConalIntervenCon•  RewardSystem•  RelaxaConTraining

CBITPsychoeducaCon

•  PhenomenologyofCcs•  PrevalenceofCcs•  NaturalhistoryofCcs•  Commoncomorbids•  CausesofCcs•  Psychosocialimpairments

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HabitReversalTraining

•  Mostwell-researchedmethodtodate

•  ThreecriCcalcomponents– Awarenesstraining– CompeCngresponsetraining– Socialsupport

AwarenessTraining

•  InvolvesmakingclientsmoreawareofwhenandwheretheCcismostlikelytooccur

•  FirststepisacompleteoperaConaldefiniConoftheCc(s)– Describewhereitoccurs,whatitlookslike,typicallocaCon(s),typicalmoodstate(s)

AwarenessTraining

•  Then,anyenvironmentalfuncConsofthebehaviorneedtobeidenCfied– SociallymediatedposiCvereinforcement

•  GainingaKenCon– SociallymediatednegaCvereinforcement

•  EscapingfromunwantedsituaCons/acCons

– AutomaCcreinforcement•  Physical/emoConalchangesthathappenfrombehavior

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AwarenessTraining

•  Forhomework,clientsaretokeepanongoinglogofallCcs

•  Typicallyincludesseverity,duraCon,triggers,emoCons,sensaCons,thoughts,locaCon

CompeCngResponseTraining

•  Inthisphase,youteachandpracCcedoingbehaviorsthatarephysicallyincompaCblewiththeCc

•  UlCmategoalistodesensiCzeclienttothe“urges”thatoaenoccur,aswellasconCnuetoraiseawareness

CompeCngResponseTraining

•  CRTisverysimilartodoingEX/RPforOCD–it’sallaboutprevenConoftypicalresponsesandlePngdiscomfortnaturallydissipate

•  MayneedtogethighlycreaCvetodevelopappropriatecompeCngresponses

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CompeCngResponseTraining

•  Typicallybeginsbydoing“pracCce”phasewherespend30minutesadaypracCcingCcanddoingCRs

•  IdenCfythemostproblemaCcCctotargetfirst

CompeCngResponsePracCce1)  BasedonprioroperaConaldefiniCons,you

begintheCc

2)  StarttheCc,butdonotcompleteit

3)  DoCRimmediately

4)  HoldtheCRfor1minuteorunClurgegoesaway,whicheverislonger

5)  Rinseandrepeat

SocialSupport

•  Involvesbringinglovedonesandfamilymembersintothetherapyprocessto:– ProvideposiCvefeedbackwhentheindividualengagesincompeCngresponses

– Cuethepersontoemploythesestrategies– Provideencouragementandreminderswhentheindividualisina“trigger”situaCon

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SessionBreakdownforHRT

•  Session1-Interview•  Session2-Awarenesstraining•  Session3–CompeCngResponseTraining•  Session4–CRGeneralizaCon

Session1-Interview

•  FuncConalassessmentofCcs

•  Assessmentofcomorbidissues

•  Establishongoingassessmentplan

•  Discusstreatmentoutline

YaleGlobalTicSeverity

Scale

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Session2-Awarenesstraining

•  ProvideraConaleforawarenesstraining

•  GetdetaileddescripConofCcs

•  Discuss“warningsigns”ofCcs,establish1-3

•  TherapistsimulatesCc,clienthastoacknowledgeCc

Session2-Awarenesstraining

•  Repeatprocesswithwarningsigns

•  Homeworkistodoself-monitoringofCcbehaviorforthenextweek

Session3–CompeCngResponseTraining

•  ReviewmonitoringHW

•  ChooseacompeCngresponse

•  ClinicianmodelsCR

•  AddressconcernsaboutCR– SituaConsitwillnotpossible,worriesaboutitfeelinguncomfortable

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Session3–CompeCngResponseTraining

•  TeachclienttheCR

•  Socialsupporttraining–  IdenCfysupportperson– HaveclientdemonstrateCR– Havesupportpersonpraise(basedontherapistmodeling)

•  HomeworkistopracCceCRfor20-30minutesdailyandconCnueself-monitoring

Session4–CRGeneralizaCon

•  ReviewHW,troubleshootasneeded

•  Assessself-monitoringdata

•  ReviewCRtoensureit’sbeingdonecorrectly

•  Asksupportpersonaboutanyproblems

Session4–CRGeneralizaCon•  IntroduceuseofCRoutsideofpracCce

•  Determinehowsupportperson(s)willletclientknowwhentodotheCR(iftheydon’tcatchitthemselves)

•  PracCceinsession

•  Homework–conCnueself-monitoringandpracCce,implementgeneralCRuse

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Sessions5+

•  ReviewandtroubleshootprogressusingCRandpracCcing

•  RepeatawarenessandCRprocessforotherBFRBs

•  Spacesessionsouttoprovidecontactasneeded

CBITFuncCon-BasedIntervenCons

•  AssessmentofantecedentsandconsequencesassociatedwithincreaseinCcs

•  WorktodevelopstrategiestoreduceCcsbasedonassessment

FuncConalStrategies

•  MinimizeoreliminateCcexacerbaCngsituaConswhenpossible

•  RemovepotenCallyreinforcingconsequencestotheCcinCcexacerbaCngsituaCons

•  WhenenteringCc-pronesituaCons,thepaCentshouldberemindedtouseHRTprocedures

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FuncConalStrategies•  ForCc-pronesituaConsthatarenoteasilymodifiable,teachpaCentstrategiestominimizetheimpactofthatsituaCon–  TeachingrelaxaConstrategiesforhighstresssituaCons

–  TeachingcogniCverestructuring–  TeachingscheduledacCvityorbreaks

•  MinimizetheimpactoftheCcsonthechild–  Educatepeers,teachersandrelaCvesaboutthechild’scondiCon

OCRDHomework#4

•  Getintogroupsof3-4

•  Decidehoweachofyouwilldoalow-tomid-levelfearexposureoverthenext3hours

•  BebackattheassignedCme,readytodiscusswhatyoudidandtheresults

MediaCriCque#4