Tourette's syndrome associated with restless legs syndrome and akathisia in a family

Sleep Disturbance in Tourette's Disorder: Potential Underlying Mechanisms

Purpose of review

Sleep disturbance is common in TD. However, our understanding of the pathophysiological mechanisms involved is preliminary. This review summarizes findings from neuroimaging, genetic, and animal studies to elucidate potential underlying mechanisms of sleep disruption in TD.

Recent findings

Preliminary neuroimaging research indicates increased activity in the premotor cortex, and decreased activity in the prefrontal cortex is associated with NREM sleep in TD. Striatal dopamine exhibits a circadian rhythm; and is influenced by the suprachiasmatic nucleus via multiple molecular mechanisms. Conversely, dopamine receptors regulate circadian function and striatal expression of circadian genes. The association of TD with restless legs syndrome and periodic limb movements indicates shared pathophysiology, including iron deficiency, and variants in the BTDB9 gene. A mutations in the L-Histidine Decarboxylase gene in TD, suggests the involvement of the histaminergic system, implicated in arousal, in TD.

Summary

These biological markers have implications for application of novel, targeted interventions, including noninvasive neuromodulation, iron supplementation, histamine receptor antagonists, and circadian-based therapies for tic symptoms and/or sleep and circadian rhythms in TD.

Sleep Disorders and Sleep Problems in Patients With Tourette Syndrome and Other Tic Disorders: Current Perspectives

Sleep disorders seem to be a frequent complaint of patients diagnosed with Tourette syndrome (TS) or chronic or persistent tic disorders (CTD or PTD). In this review, we expanded a previously used search using 4 well-known databases up to February 15, 2022, looking for the coexistence of global and/or specific sleep disorders and polysomnographic studies performed on patients with TS/CTD/PTD. The references of interest in the topic were selected by hand. Sleep disorders in general, insomnia, different arousal disorders, the persistence of tics during sleep, excessive daytime sleepiness, and periodic limb movements during sleep (PLMS) were very frequent in patients with TS, most of them being more frequent in patients with comorbid Attention Deficit Hyperactivity Disorder. The most frequent results from polysomnographic studies were decreased sleep efficiency and increased sleep onset latency. Many of these findings could be related to medication used for the treatment of tics and comorbid disorders.

Sleep disorders in tourette syndrome

Sleep disorders are very common in patients diagnosed with Tourette syndrome (TS). The present review focuses on sleep disorders and the results of polysomnographic studies performed in patients with TS. We made a search using the PubMed, Embase, MedLine, and Web of Science Databases, from 1966 until November 14, 2019, crossing the search term "Tourette syndrome" with "sleep", "sleep disorders", "sleep disturbances", and "polysomnography", and with each of the specific sleep disorders listed according to the International Classification of the Sleep Disorders-Third Edition. Then we identified the references of interest for the topic. Insomnia, excessive daytime sleepiness, disorders of arousal (sleepwalking, sleeptalking, sleep terrors, and enuresis), the persistence of tics during sleep, and presence of periodic limb movements during sleep (PLMS) were very frequent in patients with TS. These disturbances were more frequent in children and in patients with comorbid Attention Deficit Hyperactivity Disorder. Decreased sleep efficiency, decreased percentage of delta sleep, increased nocturnal awakenings and increased PLMS were the most consistent findings in the polysomnographic studies.

Sleep difficulties in children with Tourette syndrome and chronic tic disorders: a systematic review of characteristics and associated factors

Sleep difficulties are common in children and young people with Tourette syndrome and chronic tic disorders (TS/CTD). However, it is unclear whether sleep problems can be considered typical of the TS/CTD phenotype or whether they reflect concomitant factors such as individual patient characteristics (e.g. medication use), underlying neurodevelopmental disorders and/or co-occurring psychiatric symptoms. To help address this question, this review systematically explored types and frequency of sleep problems in children and young people with TS/CTD, while also examining the heterogeneity and methodological quality of studies. Psycinfo, Ovid Medline, Embase, and Web of Science databases were searched using a range of terms relating to tics, sleep and co-occurring psychopathology. Studies were considered that included a sample of children with TS/CTD (n > 5) for whom sleep difficulties were measured. Eighteen studies met criteria for inclusion in the review. Findings supported the high prevalence of sleep difficulties in children with TS/CTD, though estimates of sleep difficulties ranged from 9.7% to 80.4%. Twelve studies reported on other factors affecting sleep in this patient group including tic severity, comorbid psychopathological or neurodevelopmental disorders and medication use. Studies varied in terms of methodology, sample characteristics and research quality, but most concluded that children with TS/CTD experienced high levels of sleep difficulties with children with co-occurring anxiety most at risk. The current review highlights the need for further empirical investigation of sleep in children with TS/CTS, with a view to informing understanding and clinical management.

Genetics of restless legs syndrome (RLS): State-of-the-art and future directions

Several studies demonstrated that 60% of restless legs syndrome (RLS) patients have a positive family history and it has been suggested that RLS is a highly hereditary trait. To date, several loci have been mapped but no gene has been identified yet. Phenocopies and possible nonpenetrants made it difficult to detect a common segregating haplotype within the families. Defining the exact candidate region is hampered by possible intrafamilial, allelic, and nonallelic heterogeneity. One important prerequisite for future successful genetic studies in RLS is the availability of large and thoroughly phenotyped patients and family samples for linkage as well as association studies.

Schlafverhalten bei Kindern mit Tic-Störungen - eine polysomnographische Studie

Zusammenfassung: Fragestellung: Charakterisierung des Schlafmusters einer größeren Gruppe Kinder mit Tic-Störung sowie Untersuchung ob und wie Veränderungen des Schlafs mit der Schwere der Tic-Störung assoziiert sind. Methodik: Das Schlafverhalten von 25, zum Untersuchungszeitpunkt unmedizierten Kinder mit chronischer Tic-Störung wurde polysomnographisch untersucht und mit den Befunden von 22 gesunden Kontrollen verglichen. Zwischen beiden Gruppen bestanden keine Unterschiede hinsichtlich Alter, Geschlechtsverhältnis und Intelligenz. Ergebnisse: Kinder mit einer Tic-Störung zeigten eine reduzierte Schlafqualität sowie vermehrtes, bewegungsbezogenes Arousal im Vergleich zu gesunden Kontrollen. Hinsichtlich des Schlafs ging bei Kindern mit Tic-Störung eine schwerere Ausprägung der Tics mit häufigeren bewegungsbezogenen Arousals einher. Die Anzahl der kurzen, mit motorischen Phänomenen assoziierten Arousals korrelierte mit geringerer Schlafeffizienz, verzögertem Schlafbeginn und verlängerter Tiefschlaflatenz. Des weiteren bestimmten geringere Schlafeffizienz und verlängerte Tiefschlaflatenz bei Kindern mit Tic-Störung die Schwere der Tics am Tag. Schlussfolgerungen: Bei Kindern mit Tic-Störung scheint ein Zusammenhang zwischen den bewegungsbezogenen Arousals im Schlaf und der Ausprägung der Tics am Tag zu bestehen. Beeinträchtigungen des Schlafs bei Tic-Störungen könnten die Tic-Symptomatik am Tag verschlechtern.

Restless legs in Tourette syndrome

Restless legs syndrome (RLS) and Tourette's syndrome (TS) share some common features, including the phenomenology of sensations relieved by movements, but few studies have examined the links between RLS and TS. We examined RLS and other TS comorbidities in 144 probands with TS or chronic tics and their parents. RLS was present in 10% of probands and 23% of parents with no gender differences. RLS in probands was linked significantly to maternal RLS but not paternal RLS, suggesting that a maternal RLS factor may contribute to the variable expression of TS.

Disturbed sleep in children with Tourette syndrome: a polysomnographic study

OBJECTIVE

To evaluate objective data on sleep quantity/quality and motor activity during night sleep in children with Tourette syndrome (TS).

METHOD

Polysomnography of 17 unmedicated TS children (ages: 7;11-15;5, mean: 11;10 years) without comorbid attention-deficit hyperactivity disorder (ADHD) was compared with 16 age-, sex- and IQ-matched healthy controls. Sleep analyses according to the procedure of Rechtschaffen and Kales were supplemented by counting epochs with short arousal-related movements (<or=15 s), thus allowing to calculate correlations between motor activity and sleep parameters.

RESULTS

Children with TS demonstrated changes in sleep parameters, including longer sleep period time, longer sleep latency, reduced sleep efficiency, and prolonged wakefulness after sleep onset. Their sleep profiles showed significantly more time awake and less sleep stage II. However, REM sleep variables, slow-wave sleep, and number of sleep stage changes were unaffected. Movement time was similar in both groups, but epochs with short arousal-related movements were increased in TS. Further analyses showed no significant correlations between sleep parameters and nighttime nontic movements, level of psychopathology or tic severity during daytime. Periodic limb movements during sleep (PLMS) were only seen in one TS patient (low PLMS index of 7.8/h).

CONCLUSIONS

Children with TS have disturbed sleep quality with increased arousal phenomena, which both may be intrinsic to the disorder and might trigger tics and other behavioral problems during daytime. This indicates the need for sleep evaluation in patients with TS.

[Worsening of autosomal dominant restless legs syndrome after use of mirtazapine: case report]

We report the case of a 78 years old female patient with primary restless legs syndrome (RLS) with an autosomal dominant pattern of inheritance. In addition, the patient also had depression. We emphasize the worsening of symptoms of RLS after the use of a selective serotonin uptake inhibitor (mirtazapine), with improvement after the drug was discontinued, and an excellent recovery with the use of low dose dopaminergic agonist (pramipexol).

The central role of magnesium deficiency in Tourette's syndrome: causal relationships between magnesium deficiency, altered biochemical pathways and symptoms relating to Tourette's syndrome and several reported comorbid conditions

Prior studies have suggested a common etiology involved in Tourette's syndrome and several comorbid conditions and symptomatology. Reportedly, current medications used in Tourette's syndrome have intolerable side-effects or are ineffective for many patients. After thoroughly researching the literature, I hypothesize that magnesium deficiency may be the central precipitating event and common pathway for the subsequent biochemical effects on substance P, kynurenine, NMDA receptors, and vitamin B6 that may result in the symptomatology of Tourette's syndrome and several reported comorbid conditions. These comorbid conditions and symptomatology include allergy, asthma, autism, attention deficit hyperactivity disorder, obsessive compulsive disorder, coprolalia, copropraxia, anxiety, depression, restless leg syndrome, migraine, self-injurious behavior, autoimmunity, rage, bruxism, seizure, heart arrhythmia, heightened sensitivity to sensory stimuli, and an exaggerated startle response. Common possible environmental and genetic factors are discussed, as well as biochemical mechanisms. Clinical studies to determine the medical efficacy for a comprehensive magnesium treatment option for Tourette's syndrome need to be conducted to make this relatively safe, low side-effect treatment option available to doctors and their patients.

Restless legs syndrome in 218 patients: associated disorders

Background: Restless legs syndrome (RLS) is a disorder characterized by disagreeable sensations in the legs that occur at rest and are relieved by movement. These symptoms, which are worse at night, may result in sleep onset or sleep maintenance insomnia. Most patients are found on polysomnography (PSG) to have periodic limb movements in sleep (PLMS). The disorder, idiopathic in most cases, may be sometimes associated with specific disorders.Methods: Using the Province of Manitoba Health database, we compared the diagnoses made in the 5 years prior to sleep laboratory evaluation of 218 patients (103 men and 115 women) with RLS and 872 matched control subjects from the general population.Results: We found that 43.7% of male RLS patients vs. 10.4% of male controls and 46.1% of female RLS patients vs. 22.8% of female controls had been diagnosed as having psychological/psychiatric (most often depression) disorders (P<0.05). Extrapyramidal disease or movement disorders were previously diagnosed in 17.5% of male RLS patients vs. 0.2% of male controls and in 23.5% of female patients vs. 0.2% of female controls (P<0.05). Many patients had been previously diagnosed with disorders of the musculoskeletal system: 35.9% of male patients vs. 22.8% of male controls and 49.6% of female RLS patients vs. 23.3% of female controls had been diagnosed as having diseases of joints (male; P=ns, female; P<0.05). Disorders of the back were also more frequently diagnosed in RLS patients: 21.4% of male patients vs. 13.1% of male controls and 38.3% of female patients vs. 15.0% of female controls (male; P=ns, female; P<0.05).Conclusions: We conclude that RLS patients are much more likely to have previously been diagnosed with extrapyramidal disorders, musculoskeletal disorders, depression, and painful conditions such as joint and back disorders.

Association of dopamine D3-receptor gene variants with neuroleptic induced akathisia in schizophrenic patients: a generalization of Steen's study on DRD3 and tardive dyskinesia

Neuroleptic induced akathisia is a common and distressful extrapyramidal side effect of antipsychotic treatment. A significant proportion of the variability of its development has been left unexplained and has to be attributed to individual susceptibility. Since hereditary factors have been discussed in the etiology of acute akathisia (AA), part of the individual susceptibility might be of genetic origin. Moreover, AA is regarded as a forerunner of tardive dyskinesia, a drug-induced chronic movement disorder, which may be associated with homozygosity for the Ser9Gly variant of the DRD3 gene. Considering expression studies, which demonstrated functional variants of DRD3 polymorphisms, we investigated whether homozygosity for the Ser9Gly variant of the DRD3 gene is associated with AA. Homozygosity for the Ser9Gly variant of the DRD3 gene was connected to an 88% incidence of AA as compared with a considerably lower 46.9% incidence of AA in schizophrenic patients nonhomozygous for the 2-2 allele (exact P = 0.0223). Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:187-191, 2000.

Neuropsychiatric disorders

Neuropsychiatric disorders of childhood include autism spectrum disorders, disorders comprising attention deficits (attention-deficit-hyperactivity disorder and deficits in attention, motor control and perception), tics (motor or vocal, or both), and obsessions and compulsions (obsessive-compulsive disorder). They affect a small proportion of the child population. They can now reliably be diagnosed, and are valid and clinically meaningful conditions. Effective interventions are available for most of these disorders.

Restless legs syndrome--a review

Restless legs syndrome is also known as Ekbom's syndrome, following his description in 1944, although the earliest known description dates from 1685 (Willis). It is a fairly common complaint which is not widely recognised by the medical profession. It gives the sufferer an unpleasant sensation in the legs at rest, causing an irresistible desire to move, which alleviates the discomfort.

Characteristics of obsessive-compulsive symptoms in Tourette's syndrome, obsessive-compulsive disorder, and Parkinson's disease

A high incidence of obsessions and compulsions is documented in basal ganglia disorders, especially in patients with Tourette's syndrome (TS). A comparison of patients with obsessive-compulsive disorder (OCD), TS, and Parkinson's disease (PD) revealed significantly higher total scores in both OCD and TS patients than in a healthy control group on the Maudsley obsessive-compulsive inventory (MOCI) and the Hamburg obsessive-compulsive inventory (HZI-K), two self-report measures of obsessive-compulsive symptoms. On most subscales (especially Checking, Ordering, and Counting/touching), TS patients scored higher than controls. Patients with Parkinson's disease merely scored higher on the subscale 'Ordering' of the HZI-K. Differences between OCD patients and TS patients were evident on the MOCI subscales 'Checking' and 'Slowness/Repetition' as well as on the MOCI total score and on the HZI subscales 'Cleaning' and 'Obsessive Thoughts'. On these scales, TS patients reported fewer symptoms than OCD patients. Stepwise discriminant analysis with preselected single items as variables was used to look for specific symptom patterns of OCD and TS. Seventy-eight percent of the patients could be correctly classified with respect to their diagnoses on the basis of only two items of the HZI-K. One item asks for fearful obsessive thoughts, which was found in 90% of the OCD patients; the second item represented echo phenomena, found in 56% of the TS patients. It is concluded that considering specific patterns of obsessive-compulsive psychopathology may contribute to a more reliable differential diagnosis in OCD and TS and help to avoid misdiagnosis of OCD in TS patients.

Dopamine agonist treatment of Tourette disorder in children: results of an open-label trial of pergolide

This exploratory study was meant to determine the effect of the dopamine (DA) agonist pergolide on Gilles de la Tourette syndrome (GTS) in children and adolescents and to ascertain correlates of pergolide response. Thirty-two outpatients, aged 7-19 years, were systemically assessed in a neuropsychiatric clinic for the presence of GTS and comorbid disorders. After a 6-week open-label, fixed-flexible dosing schedule, response to pergolide on standard GTS severity outcome measures was assessed. Overall, 75% of patients (24/32) had a > 50% drop in their tic severity rating from baseline with a mean treatment dosage of 177 +/- 61 micrograms/day. Highly significant (p = 0.0001) baseline to week 6 differences were demonstrated in all tic symptom measures. The presence of restless legs syndrome (RLS) comorbidity (59%) was highly associated with a positive response. These results suggest DA agonism as a strategy, and pergolide in particular, may be a practical form of therapy for GTS. Response predictors of patient comorbid RLS argue for its further study with regard to GTS.

Quantitative EEG analysis during motor function and music perception in Tourette's syndrome

Gilles de la Tourette's syndrome (TS) is a neurobehavioral disorder of childhood onset that is characterized by motor and vocal tics and associated behavioral disturbances including obsessive-compulsive symptoms. We performed 30 channel quantitative electroencephalograms (EEGs) on 13 Tourette patients and 26 controls and studied both resting and manumotor/music perception activation conditions. Resting EEGs did not show any differences between patients and controls, as known from the literature. However, during simple and complex hand movements, as well as music perception tasks, there were subtle differences predominantly in alpha frequency. They suggested reduced brain activation during motor tasks in frontal and central regions, and on music perception in temporal and parietal regions, respectively. These findings may add evidence to the functional neuroanatomy of Tourette syndrome, affecting more areas than disturbed motor circuits.