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Sanderson C, Verdellen C, Debes N, Tárnok Z, van de Griendt J, Zimmerman-Brenner S, Murphy T. Addressing co-occurring conditions in behavioural therapy for tic disorders: a review and guideline. Eur Child Adolesc Psychiatry 2024; 33:2111-2127. [PMID: 36283996 DOI: 10.1007/s00787-022-02097-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 09/27/2022] [Indexed: 11/03/2022]
Abstract
Co-occurring psychiatric conditions are very common in tic disorders and Tourette syndrome. These additional symptoms are often detrimental to quality of life and may impact upon the implementation and efficacy of evidence-based behavioural therapies (BT) for tics. Combining a review of the available literature, relevant theory, and expert clinical practice, we present a guideline for implementing behavioural and psychosocial interventions when common comorbidities are present. These include attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, disruptive behaviour, autism spectrum disorder (ASD) and depression. Practical recommendations are provided for assessment, formulation and management of specific and multiple comorbidities in BT for both children and adults. Despite comorbidities being common in tic disorders, few studies have comprehensively addressed how they may influence the efficacy or implementation of existing therapies or how such treatments may need to be modified or sequenced. We outline recommendations for future research, including randomised control trials of BT for those with specific or multiple comorbidities, as well as adequately powered sub-group analyses within larger scale trials or naturalistic study designs. Transdiagnostic models of psychiatric disorders and treatment, including modular cross-diagnostic therapies, which recognise the dimensionality of psychiatric disorders are also highlighted as an important focus in treatment development in tic disorders.
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Affiliation(s)
- Charlotte Sanderson
- UCL Great Ormond Street Institute of Child Health (ICH), 30 Guilford Street, London, WC1N 1EH, UK.
- Psychological and Mental Health Services, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK.
| | - Cara Verdellen
- PsyQ Nijmegen, Parnassia Group, Sint Annastraat 263, 6525 GR, Nijmegen, The Netherlands
- TicXperts, Julianaweg 7, 6666 CT, Heteren, The Netherlands
| | - Nanette Debes
- Department of Paediatrics, Herlev University Hospital, Borgmester Ib Juuls Vej 25C, 3rd floor, 2730, Herlev, Denmark
| | - Zsanett Tárnok
- VADASKERT Child and Adolescent Psychiatry Hospital and Outpatient Clinic, Lipotmezei str 5, Budapest, 1021, Hungary
| | | | - Sharon Zimmerman-Brenner
- School of Psychology, Reichman University (IDC Herzliya), P.O. Box 167, 4610101, Herzliya, Israel
| | - Tara Murphy
- UCL Great Ormond Street Institute of Child Health (ICH), 30 Guilford Street, London, WC1N 1EH, UK
- Psychological and Mental Health Services, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK
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Sapozhnikov Y, Vermilion J. Co-Occurring Anxiety in Youth with Tic Disorders: A Review. J Child Adolesc Psychopharmacol 2023; 33:402-408. [PMID: 37870770 DOI: 10.1089/cap.2022.0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Objective: To review the current state of the literature regarding anxiety symptoms and anxiety disorders in chronic tic disorder (CTD). Results: We conducted a literature search on anxiety and tic disorders. Anxiety symptoms and anxiety disorders are common in youth with CTD, with ∼30%-50% of youth with CTD having at least one co-occurring anxiety disorder. Tics often improve by young adulthood but anxiety symptoms tend to persist, or worsen, over time. Anxiety and tics are closely related, but the exact nature of their relationship is poorly understood. We discuss some potential ways in which anxiety and tics are linked with an emphasis on the underlying brain circuitry involved. The relationship between anxiety and tics may be related to the premonitory urge. In addition, stress hormones may link anxiety and tics. Individuals with CTD have greater activation of their hypothalamic-pituitary-adrenal system in response to acute stress. We also review the impact of anxiety on youth with CTD and approaches to management of anxiety in youth. Conclusions: Anxiety is common in youth with CTD, is associated with more severe CTD, and can adversely affect a child's function. Thus, it is important to identify anxiety disorders in CTD and manage them appropriately.
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Affiliation(s)
- Yelizaveta Sapozhnikov
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Jennifer Vermilion
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
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Pacheco-Carroza EA. Visceral pain, mechanisms, and implications in musculoskeletal clinical practice. Med Hypotheses 2021; 153:110624. [PMID: 34126503 DOI: 10.1016/j.mehy.2021.110624] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/25/2021] [Accepted: 06/03/2021] [Indexed: 02/07/2023]
Abstract
The global impact of visceral pain is extremely high, representing a significant portion of all forms of chronic pain. In musculoskeletal practice, at least one-third of people with persistent noncancerous pain report recurrent abdominal, pelvic, or chest pain symptoms. Visceral pain can be felt in several different areas of the body and can migrate throughout a region, even though the site of origin does not appear to change. Traditionally, clinicians have examined musculoskeletal pain through a reductionist lens that ignores the influence of the visceral system on musculoskeletal pain. The hypothesis presented is that visceral pain has an important influence on developing and maintaining different types of musculoskeletal pain through processes within the peripheral or central nervous systems, as a result of a visceral nociceptive stimulus generated by pathoanatomical or functional alterations. The hypothesis predicts that a consideration of the function of the visceral system in musculoskeletal pain conditions will improve clinical outcomes, moving beyond a linear model and adopting a more holistic approach, especially in the more complex groups of patients.
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Affiliation(s)
- E A Pacheco-Carroza
- Health Sciences Faculty, Universidad San Sebastián, General Lagos 1022 Valdivia, 56 2632500, Chile.
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Vermilion J, Pedraza C, Augustine EF, Adams HR, Vierhile A, Lewin AB, Collins AT, McDermott MP, O'Connor T, Kurlan R, van Wijngaarden E, Murphy TK, Mink JW. Anxiety Symptoms Differ in Youth With and Without Tic Disorders. Child Psychiatry Hum Dev 2021; 52:301-310. [PMID: 32519083 DOI: 10.1007/s10578-020-01012-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We compared anxiety symptoms in youth with and without tic disorders by comparing scores on the Multidimensional Anxiety Scale for Children (MASC) in youth with tic disorders to those in a concurrent community control group and in a group of treatment-seeking anxious youth from the Child/Adolescent Anxiety Multimodal Study (CAMS). Data from 176 youth with tic disorders, 93 control subjects, and 488 CAMS participants were included. Compared to youth with tic disorders, controls had lower total MASC scores (p < 0.0001) and CAMS participants had similar total MASC scores (p = 0.13). Separation Anxiety (p = 0.0003) and Physical Symptom (p < 0.0001) subscale scores were higher in youth with tic disorders than in CAMS participants. We conclude that the anxiety symptom profile differs in youth with and without tic disorders, which may have important implications for targeting treatment of anxiety in youth with tic disorders.
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Affiliation(s)
- Jennifer Vermilion
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA. .,Division of Child Neurology, Department of Neurology, Box 631, 601 Elmwood Ave, Rochester, NY, 14642, USA.
| | | | - Erika F Augustine
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Heather R Adams
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Amy Vierhile
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Adam B Lewin
- Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Alyssa T Collins
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, USA
| | - Thomas O'Connor
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Roger Kurlan
- Center for Neurological and Neurodevelopmental Health, Voorhees, NJ, USA
| | - Edwin van Wijngaarden
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Tanya K Murphy
- Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Jonathan W Mink
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
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Gut-Brain Axis Exploration: Stabilometric Platform Performances in Children Affected by Functional Gastrointestinal Disorders. J Pediatr Gastroenterol Nutr 2021; 72:347-353. [PMID: 33075011 DOI: 10.1097/mpg.0000000000002968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The pathophysiology of functional gastrointestinal disorders (FGIDs) is associated with dysfunction at various levels of the gut-brain axis. Hypervigilance can result in an increased tendency to report pain. In the present study, we aimed to explore whether hypervigilance can influence attentional processing in postural control in children with FGIDs. PATIENTS AND METHODS Fifty-nine participants classified into healthy subjects, those with FGIDs, and those with organic diseases (Org) based on Rome IV criteria were enrolled. Postural control under 6 sensory conditions was evaluated using a stabilometric platform. The mean velocity of the center of pressure (CoP) displacement in the anteroposterior direction and the mediolateral direction, the length of the CoP trajectory, and the sway area were also measured. RESULTS With visual and somatosensorial normal inputs, participants with FGIDs showed a higher number of anteroposterior (FGIDs: 4[interquartile range [IQR] 3-7], control [Cntl] 3 [IQR 3-4], P < 0.05) latero-lateral oscillations (FGIDs: 3 [IQR 3-6], Cntl 3 [IQR 2-3], P < 0.05) and a higher perimeter value (FGIDs: 148 [IQR 121-240], Cntl 124 [IQR 111-140], P = 0.056) compared to healthy subjects. With normal visual but altered somatosensorial input, subjects with FGIDs showed higher values of all parameters (anteroposterior: FGIDs 6[IQR 5-8], Cntl and Org 5 [IQR 4-6], P < 0.05; latero-lateral FGIDs 6 [IQR 4-8], Cntl 4 [IQR 4-5], Org 4[IQR 3-5], P < 0.05; perimeter FGIDs 253 [IQR 167-305], Cntl 185 [IQR 161-217], Org 176 [IQR 142-219], P < 0.05; area FGIDs 98 [IQR 81-233], Cntl 86 [IQR 59-114], Org 56 [IQR 41-97], P < 0.05). CONCLUSIONS The higher number of oscillations in subjects with FGIDs who had normal visual input could be expression of alteration in attention and therefore hypervigilance as hypothesized in the context of gut-brain axis alterations.
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Yadegar M, Guo S, Ricketts EJ, Zinner SH. Assessment and Management of Tic Disorders in Pediatric Primary Care Settings. CURRENT DEVELOPMENTAL DISORDERS REPORTS 2020; 6:159-172. [PMID: 32467820 DOI: 10.1007/s40474-019-00168-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose of Review Pediatricians and other primary care providers are often the first and sole healthcare clinicians of patients who present with tics. However, limited primary care pediatric training in neuropsychiatric concerns, as well as perceived lack of comfort and preparation, make it challenging for these clinicians to confidently identify and manage tic disorders. Recent Findings Current empirical findings of tic disorder management relevant to pediatric physicians, including assessment, psychoeducation, behavioral interventions, psychotropic medications, and alternative treatments are reviewed. Summary This article discusses neuropsychiatric and medical complexities of tic disorder assessment, with particular emphasis on differential and comorbid diagnoses. Tiered referral recommendations, based on symptom severity, impairment, and consideration of comorbid conditions, are provided. Future directions for tic management, including dissemination of evidence-based treatments of tic disorders and multidisciplinary teams within pediatric primary care settings, are included.
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Affiliation(s)
- Mina Yadegar
- Univeristy of California, Los Angeles.,Boston Child Study Center - Los Angeles.,Behavioral Associates Los Angeles
| | - Sisi Guo
- Univeristy of California, Los Angeles
| | | | - Samuel H Zinner
- University of Washington School of Medicine.,Seattle Children's Hospital
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