Thursday, April 30, 2015

My tics and Tourette's modus operandi

When I see a new patient for chronic tics and vocalizations (Tourette syndrome, if you will) the most likely outcome is a single visit wherein the character and natural history of chronic tics and vocalizations in childhood are reviewed. Typically, the tics and vocalizations do not distress the patient nor are they a source of social handicap or stigmatization. I then wish the family a good life, with a request that I be contacted if the tics and vocalizations later cause personal distress or social handicap or if there are ongoing or new concerns. One disclosure: I strive mightily to distance myself from attention issues, leaving those to the primary care physician or some other specialist. The same would be true of obsessive/compulsive behavior, which is less frequently a comorbidity.

A colleague said in response to this:  "At the very least, a diagnostic visit should include asking questions that would help determine whether any of  these coexisting diagnoses exist."

I responded:   I certainly agree and I strive to accomplish this at the typical new patient's one and only scheduled visit. Appropriate referral is suggested if these comorbidities are present.

Another colleague said: "Your approach is pretty much exactly what I do. We do not prescribe stimulants in our clinic, although many of our patients are on them from either Mental Health Clinic, behavioral ped or their pediatricians. We explain why some people choose meds for tics, and why we try not to use them, but if the CHILD is troubled by the tics and wants meds, usually offer guanfacine or clonidine patch. We avoid them if only the parents are bothered by the tics, and child denies social issues or discomfort with the ticing. Only about 5% want meds. There is a local OT group doing tic behavioral therapy nearby, and we tell everyone it is worth a try if they are motivated. Most insurers cover it because it is done by OTs at a community hospital, not psychologists."

My response: "My submission was inspired by seeing two new patients of exactly the sort I describe one day before. At our institution, there has been talk of starting a Tourette syndrome clinic replete with a psychologist doing habit reversal training. When I look at my clientele, I am impressed by how few would benefit from a more intensive approach to their tics and vocalizations. I certainly do have patients on tic-suppressing medications, many of whom are quite happy with the results. Most of the time, though, my role seems to be mollifying anxious parents, telling them how unlikely it is that their child's life will be taken over by tics and that their child will be standing on the street corner blurting out obscenities."


  1. Communication from a colleague:

    I have a different perspective on patients who come with problems that are not “core” neurology.

    Treating a lot of epilepsy patients made it so I had to treat their co-morbid ADHD, Depression, migraine. Psychiatrists and pediatricians are afraid of or lack the confidence to prescribe stimulants in those cases; I am not. Likewise, treating migraine taught me a lot about treating depression. And treating epilepsy meant recognizing nonepileptic seizures. I did not want to say simply that “this is not a seizure “to say “this is a behavior because… “. I got pretty good early on at recognizing sexual abuse, PTSD, borderline personality disorder…. It seems that I cannot help but see the psychiatric dimensions of people who are before me for the purpose of looking at their brains.

    It is possible walk into a room and recognize that the patient has tics in 1 minute, be fairly confident that they are not a movement disorder or the first true PANDAS case you have ever identified in another couple of minutes, and examine them in 5 minutes. A few minute of canned information to the family.

    The problem is that that does not work. I have seen several hundred children in 20 years who had previously seen a child neurologist, all of them saying “He was in the room for 5 minutes and walked out.” So they never believed what was said by the doctor. A far as I can tell, I never had any evidence that the care offered was substandard; but clearly the perception of it was. I am sure that they charged the same-or more-for a visit as do I.

    What I do not know is what I am going to find in the room before I walk in. They might be scheduled as tics and have seizures, or as seizures or movement disorders and have tics. Or as my favorite, PANDAS. So my patients are scheduled for full visits. And by golly, If I scheduled them for a long time I’m going to spend time figuring out something helpful. I know it is tics in a minute, TS in 2 minutes. My next question is: How is his temper? If the eyes roll “how did you know?” it is almost always OCD. In the next couple of minutes I flesh out that impression and if there, make sure it is not really perhaps Aspergers. And I metastasize, getting often diagnostic level descriptions of OCD in other family members. I’ll learn how they’re doing school whether they might have a learning disorder or an attention deficit problems. I then look for how the whole complex of symptoms impacts their life. Tics are almost never a major issue.

    Part of my lecture is that except for sibs, I almost never hear of teasing in any child less than 8; if they have other personality qualities that are good by the time they are 8 they have friends and end up not getting teased or bullied. But that is one of their worries.

    But OCD changes the mix greatly be cue they tend to make their peers hate them. And it USUALLY respond to meds nicely. Zoloft built up to 0.5 to 1 mg/kg/day over a few weeks and the parents come gushing, describing what in Jewish terms we would call Shalom HaBayit—peace in the home.

    Another group of patients are really bothered by the ADHD Sx, and by now I suspect MPH is the best treatment here, but we often start with an alpha agent.

    A lot of the time, I dig into WHY the parents are as bent out of shape as they are for what are barely problematic tics, and getting to that and laying it open often gets them to deal with a much bigger anxiety disorder or fear that the parents they themselves have. (continued below)

  2. Communication from a colleague, part 2:

    I have seen in 25 years of looking for Pandas a couple of cases where they seem to have an exacerbation with documented strep infections. could be random chance to me.

    In 2003 I got my boards in developmental/behavioral peds just so I would have a leg to stand on when I treated bipolar youth. ˚My law: All adoptees are bipolar till proven otherwise.” It used to be I would see teens for ADHD and recognize that there was a strong fmhx of bipolar disorder and elicited specific symptoms about them, not just the given diagnosis. And the patient would have enough-or close enough characteristics-that the dx was there; or probable; except for age related criteria. And these children, who had been treated by psychiatrist for 2-4 years for ADHD would become dramatically more livable with the drugs I now—CBZ, LTG, VPA. THEN, the patients would want to come back to me. By now, the psychiatrists have learned this trick, so I am less plagued.

    So, yes, I teat ADHD/OCD/TICS and sometimes depression, or bipolar (if they also have a psychiatrist). I suspect that I am good at recognizing, and getting help pulse where for patients who are PTSD/body dysmorphic/eating disorder/bipolar.

    Conceptually this kind of approach is really is not all far from seeing a child for leg dystonia or a movement disorder or a seizure disorder, recognizing instead it is infant masturbation. I tell them that it is common, that their child is not a pervert and has about only as much of a chance of growing up to be a pervert as the next child; that if this is the only problem they do not need psychotherapy, that they should be tight that there are things we do in private like take a poop, and this is another one of those. If you do not do that they will simply get on the trail and see other doctors.

    Even a 15-year-old girl with straightforward migraine is likely to come in also on oral contraceptives and not only do I feel compelled to discuss that issue directly, I want to know why she is on them in the first place and whether that might represent a symptom from some other issue that needs to be addressed.

  3. In the past, I did a fair amount of ADHD work, with this as a primary concern, as well as a co-morbidity. I decided some time ago that enough was enough. It is now quite rarely that I initiate or primarily manage pharmacotherapy for ADHD. Likewise, I dabbled in behavioral/psychiatric therapy for an interval of time. Once again, I decided enough was enough. I have chosen to do what I enjoy doing.