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Baizabal-Carvallo JF, Cavanna AE, Jankovic J. Tics emergencies and malignant tourette syndrome: Assessment and management. Neurosci Biobehav Rev 2024; 159:105609. [PMID: 38447821 DOI: 10.1016/j.neubiorev.2024.105609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/29/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
Tourette syndrome (TS) is a complex neurodevelopmental disorder characterized by the presence of tics, frequently accompanied by a variety of neuropsychiatric comorbidities. A subset of patients with TS present with severe and disabling symptoms, requiring prompt therapeutic intervention. Some of these manifestations may result in medical emergencies when severe motor or phonic tics lead to damage of anatomical structures closely related to the tic. Examples include myelopathy or radiculopathy following severe neck ("whiplash") jerks or a variety of self-inflicted injuries. In addition to self-aggression or, less commonly, allo-aggression, some patients exhibit highly inappropriate behavior, suicidal tendencies, and rage attacks which increase the burden of the disease and are important components of "malignant TS". This subset of TS is frequently associated with comorbid obsessive-compulsive disorder. Therapeutic measures include intensive behavioral therapy, optimization of oral pharmacotherapy, botulinum toxin injections, and deep brain stimulation.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA; Department of Sciences and Engineering, University of Guanajuato, León, Mexico.
| | - Andrea E Cavanna
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom; Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and University College London, London, United Kingdom; School of Health and Life Sciences, Aston Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom; School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
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Ashurova M, Budman C, Coffey BJ. Ticked Off: Anger Outbursts and Aggressive Symptoms in Tourette Disorder. Child Adolesc Psychiatr Clin N Am 2021; 30:361-373. [PMID: 33743944 DOI: 10.1016/j.chc.2020.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Tourette disorder is a complex neuropsychiatric syndrome of childhood onset characterized by multiple motor and phonic tics and is associated with high rates of psychiatric comorbidity. Symptoms of impulsive aggression (explosive outbursts or "rage") are commonly encountered in the clinical setting, cause significant morbidity, and pose diagnostic and treatment challenges. These symptoms may be multifactorial in etiology and result from a complex interplay of illness severity and psychosocial factors. Treatment strategies require careful differential diagnostic evaluation and include both behavioral and pharmacologic interventions.
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Affiliation(s)
- Marianna Ashurova
- Zucker Hillside Hospital, ACP Building Basement, 75-59 263rd Street, Glen Oaks, NY 11004, USA; Child & Adolescent Psychiatry Consultation Liaison Service, Cohens Children's Medical Center, 268-01 76th Avenue, New Hyde Park, NY 11040, USA.
| | - Cathy Budman
- Long Island Center for Tourette, 1615 Northern Boulevard, Suite #306, Manhasset, NY 11030, USA; Zucker School of Medicine, 500 Hofstra Boulevard, Hempstead, NY 11549, USA
| | - Barbara J Coffey
- Department of Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Tourette Association Center of Excellence, University of Miami Miller School of Medicine, 1120 Northwest Fourteenth Street, Suite 1442, Miami, FL 33136, USA
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Kamijima K, Aoki M. Effectiveness of paroxetine in the treatment of obsessive–compulsive disorders. Expert Rev Neurother 2014; 6:945-56. [PMID: 16831110 DOI: 10.1586/14737175.6.7.945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Clomipramine ushered in a new age of pharmacotherapy for obsessive-compulsive disorders, and it also facilitated our understanding of the biological aspects of obsessive-compulsive disorder, focusing on the serotonergic systems. The introduction of selective serotonin reuptake inhibitors has led to great progress in the pharmacological study of obsessive-compulsive disorder based on the serotonin hypothesis. Currently, selective serotonin reuptake inhibitors are positioned as a first-line drug of obsessive-compulsive disorder pharmacotherapy in the various guidelines and algorithms. Among six different selective serotonin reuptake inhibitors (paroxetine, sertraline, fluoxetine, fluvoxamine, citalopram, escitalopram) that are available worldwide, paroxetine has the broadest treatment spectrum and promises great benefits not only for obsessive-compulsive disorder patients, but also for those with comorbid depression and/or various kinds of anxiety disorders. This paper presents several clinical trials of paroxetine carried out, and discusses and reviews the therapeutic strategies for obsessive-compulsive disorder.
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Affiliation(s)
- Kunitoshi Kamijima
- International University of Health and Welfare, Department of Health and Social Service, 2600-1, Kitakanemaru, Otawara-city, Tochigi, 324-8501, Japan.
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Practice parameter for the assessment and treatment of children and adolescents with tic disorders. J Am Acad Child Adolesc Psychiatry 2013; 52:1341-59. [PMID: 24290467 DOI: 10.1016/j.jaac.2013.09.015] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 09/03/2013] [Indexed: 02/07/2023]
Abstract
Tic disorders, including Tourette's disorder, present with a wide range of symptom severity and associated comorbidity. This Practice Parameter reviews the evidence from research and clinical experience in the evaluation and treatment of pediatric tic disorders. Recommendations are provided for a comprehensive evaluation to include common comorbid disorders and for a hierarchical approach to multimodal interventions.
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Nondopaminergic Neurotransmission in the Pathophysiology of Tourette Syndrome. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2013; 112:95-130. [DOI: 10.1016/b978-0-12-411546-0.00004-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Randomized trial of anger control training for adolescents with Tourette's syndrome and disruptive behavior. J Am Acad Child Adolesc Psychiatry 2009; 48:413-421. [PMID: 19242384 DOI: 10.1097/chi.0b013e3181985050] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the efficacy of a 10-session individually administered anger control training (ACT) for adolescents with Tourette's syndrome (TS) and disruptive behavior. METHOD Twenty-six subjects (24 boys and 2 girls; mean age 12.7 years, SD 0.88) with TS and high levels of disruptive behavior were randomly assigned to ACT or treatment-as-usual (TAU). The parent-rated Disruptive Behavior Rating Scale and the Clinical Global Impression-Improvement Scale rated by the independent evaluator were used as primary outcome measures. RESULTS All randomized subjects completed end-point evaluation, and all subjects in the ACT group completed 3-month follow-up evaluation. The Disruptive Behavior Rating Scale score decreased by 52% in the ACT group compared with a decrease of 11% in the TAU control group (p <.001). On the Clinical Global Impression-Improvement Scale, the independent evaluator rated 9 (69%) of 13 subjects in the ACT condition as much improved or very much improved compared with 2 (15%) of 13 in the TAU condition (p <.01). This reduction of disruptive behavior in the ACT group was well maintained at 3-month follow-up. CONCLUSIONS Anger control training seems to reduce disruptive behavior in adolescents with TS. Larger trials are needed to confirm these results.Clinical trial registration information-Anger Control Training for Youth With Tourette's Syndrome. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00486551.
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Budman C, Coffey BJ, Shechter R, Schrock M, Wieland N, Spirgel A, Simon E. Aripiprazole in children and adolescents with Tourette disorder with and without explosive outbursts. J Child Adolesc Psychopharmacol 2008; 18:509-15. [PMID: 18928415 DOI: 10.1089/cap.2007.061] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE We conducted a retrospective, observational study of aripiprazole for the treatment of tics and/or co-morbid explosive outbursts in 37 children and adolescents with Tourette disorder (TD). METHOD Thirty seven children and adolescents with TD, with and without explosive outbursts, and refractory to previous treatment were treated at one of two university affiliated specialty clinics. All diagnoses were made using Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) criteria. Tic severity was rated using the Clinical Global Impressions Scale for tics (CGI-Tics) and frequency of explosive outbursts was assessed using the CGI-Rage; both measures were obtained at pretreatment baseline and at posttreatment follow up. RESULTS High rates of psychiatric co-morbidity were observed in these subjects: 31 of 37 (84%) subjects met criteria for obsessive-compulsive disorder (OCD), and 31 of 37 (84%) met criteria for attention-deficit/hyperactivity disorder (ADHD). Twenty nine of 37 (78%) subjects met criteria for intermittent explosive disorder (IED) minus criterion C; the remaining 8 subjects had TD only. Eight subjects (22%) discontinued treatment before 12 weeks due to inability to tolerate the drug. At follow up, tics reduced at a mean daily dose of 12.3 (7.50) mg in 29 of 29 (100%) subjects who completed the study, and explosive outbursts improved in 24/25 subjects (96%) who completed the study. Aripiprazole was tolerated reasonably well, although 8/37 (22%) subjects discontinued treatment; most common side effects included weight gain, akathisia, and sedation. CONCLUSION Aripiprazole should be investigated further as a treatment option for TD with and without co-morbid explosive outbursts.
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Affiliation(s)
- Cathy Budman
- North Shore University Hospital-Long Island Jewish Hospital System, Manhasset, New York
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Anger symptoms and "delinquent" behavior in Tourette syndrome with and without attention deficit hyperactivity disorder. Brain Dev 2008; 30:308. [PMID: 17920219 DOI: 10.1016/j.braindev.2007.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 08/23/2007] [Indexed: 11/21/2022]
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Rizzo R, Curatolo P, Gulisano M, Virzì M, Arpino C, Robertson MM. Disentangling the effects of Tourette syndrome and attention deficit hyperactivity disorder on cognitive and behavioral phenotypes. Brain Dev 2007; 29:413-20. [PMID: 17280810 DOI: 10.1016/j.braindev.2006.12.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 11/17/2006] [Accepted: 12/14/2006] [Indexed: 11/16/2022]
Abstract
Eighty participants (62 males; 18 females; age range: 6-16 years) took part in the study, comprising four groups of 20 subjects each: TS-only, ADHD-only, TS+ADHD, controls. The age distributions, did not differ significantly among the four groups. The severity of symptoms, assessed by the TSGS, did not differ significantly between the two TS groups. Standardised measures were used throughout. The "cases" (i.e. TS-only, TS+ADHD, ADHD-only) were significantly different from controls on most measures of behavior. There were also differences amongst the various clinical subgroups, with, in general, TS-only participants being similar to controls with regards to both "total behavior" ratings and cognitive testing results. A diagnosis of ADHD, either or its own or in association with TS, was associated with greater maladaptive behavior and worse cognitive functioning. With regards to affective symptoms and anxiety, the three clinical groups did not differ from each other, but each of them was more affected than the control group. One finding in our study which differed from previous literature was that TS-only patients were rated as more "delinquent" than controls by their parents: possible reasons for this are discussed. Oppositional defiant disorder (ODD) was seen in a few (2,3,3 ODD patients in each clinical group), but as numbers were small no statistics were undertaken. Family histories were in accord with both TS and ADHD being genetic disorders, but sharing an overlap in only some cases. The "additive effect" hypothesis is discussed in detail in the light of our results and recent literature.
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Affiliation(s)
- Renata Rizzo
- Section of Child Neuropsychiatry, Department of Pediatrics, University of Catania, Italy.
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Scahill L, Sukhodolsky DG, Bearss K, Findley D, Hamrin V, Carroll DH, Rains AL. Randomized trial of parent management training in children with tic disorders and disruptive behavior. J Child Neurol 2006; 21:650-6. [PMID: 16970865 DOI: 10.1177/08830738060210080201] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Oppositional, defiant, and disruptive behaviors are common in clinical samples of children with tic disorders. In this study, we sought to evaluate the short-term efficacy of a structured parent training program in children with tic disorders accompanied by disruptive behavior. Children with tic disorders and at least a moderate level of disruptive behavior were randomly assigned to a 10-session structured parent management training program or to continue treatment as usual. Twenty-four children (18 boys and 6 girls) between the ages of 6 and 12 years (mean 8.9 +/- 2.0 years) were enrolled; 23 subjects completed the study. At baseline, subjects showed moderate to severe levels of oppositional and defiant behavior. Twenty subjects (83%) were on stable medication. The parent-rated Disruptive Behavior Rating Scale score decreased by 51% in the parent management training group compared with a decrease of 19% in the treatment as usual group (P < .05). On the Improvement scale of the Clinical Global Impression, a rater masked to treatment assignment classified 7 of 11 subjects who completed parent management training as much improved or very much improved compared with 2 of 12 subjects in the treatment as usual group (Fisher exact test, P < .05). These results suggest that parent management training is helpful for short-term improvement in disruptive behavior problems in children with tic disorders. Larger randomized clinical trials are needed.
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Scahill L, Erenberg G, Berlin CM, Budman C, Coffey BJ, Jankovic J, Kiessling L, King RA, Kurlan R, Lang A, Mink J, Murphy T, Zinner S, Walkup J. Contemporary assessment and pharmacotherapy of Tourette syndrome. NeuroRx 2006; 3:192-206. [PMID: 16554257 PMCID: PMC3593444 DOI: 10.1016/j.nurx.2006.01.009] [Citation(s) in RCA: 151] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To develop a guide to clinical assessment and pharmacotherapy for children and adults with Tourette syndrome (TS), we reviewed published literature over the past 25 years to identify original articles and reviews on the assessment and pharmacological treatment of Tourette syndrome, attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). The literature search also included a survey of reviews published in book chapters. The assessment section was compiled from several reviews. Pharmacological treatments were classified into those with strong empirical support (as evidenced by two positive placebo-controlled studies for tics, OCD, or ADHD in TS samples); modest empirical support (one positive placebo-controlled study), or minimal support (open-label data only). We conclude that accurate diagnosis, including identification of comorbid conditions, is an essential step toward appropriate treatment for patients with TS. In many patients with TS, symptom management requires pharmacotherapy for tics or coexisting conditions. The evidence supporting efficacy and safety for medications used in patients with TS varies. But this evidence offers the best guide to clinical practice.
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Affiliation(s)
- Lawrence Scahill
- Yale Child Study Center, 230 South Frontage Road, P.O. Box 207900, New Haven, CT 06520, USA.
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Abstract
OBJECTIVE The purpose of this study was to investigate the short-term safety and effectiveness of quetiapine in the treatment of children and adolescents with Tourette's disorder. METHODS This was an 8-week, open-label trial that included 12 subjects with a mean age of 11.4 +/- 2.4 years. The subjects were seen every week throughout the study. RESULTS Clinical responses, as measured by the Turkish version of the Yale Global Tic Severity Scale, revealed a statistically significant reduction in tic scores ranging from 30-100%. Mean dose of quetiapine at the end of the study was 72.9 +/- 22.5 mg/day. Three subjects complained of sedation in the first week of treatment. CONCLUSIONS The favorable results of this open-label study should be interpreted with caution due to the uncontrolled nature of the study. Spontaneous waxing and waning of symptoms should also be considered. Further controlled studies are required.
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Affiliation(s)
- Nahit Motavali Mukaddes
- Istanbul University, Child and Adolescent Psychiatry Department, Medical Faculty of Istanbul, Istanbul, Turkey.
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Simpson BS, Papich MG. Pharmacologic management in veterinary behavioral medicine. Vet Clin North Am Small Anim Pract 2003; 33:365-404, vii. [PMID: 12701517 DOI: 10.1016/s0195-5616(02)00130-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
As our knowledge expands, behavioral pharmacology plays an increasingly important role in behavioral medicine. Drugs traditionally categorized as anxiolytics, antidepressants, anticonvulsants, and hormones may be used to help manage a range of animal behavioral problems. Knowledge of how these agents act in the body and interact with other agents is imperative for safe and efficacious use.
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Grimaldi BL. 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. Med Hypotheses 2002; 58:47-60. [PMID: 11863398 DOI: 10.1054/mehy.2001.1447] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Budman CL, Feirman L. The Relationship of Tourette's Syndrome With Its Psychiatric Comorbidities: Is There an Overlap? Psychiatr Ann 2001. [DOI: 10.3928/0048-5713-20010901-06] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
The phenomenology of OCD and TS seem to match perfectly with the existing conceptualization of the functional relationship between frontal cortical and subcortical circuits. Failed editing of thoughts and impulses, perseverative patterns, and inhibitory deficits are the most convenient descriptors of the symptoms, and some operationalized measures can capture evidence for such deficits in TS and OCD patients. Beyond these expectations borne from conceptual models and some broad patterns of distributed metabolic disturbances in neuroimaging studies, a specific causal pathology within CSPT circuitry needs to be identified in these disorders. This is not a criticism of the existing studies of TS and OCD; to the contrary, the scarcity of pathologic material, the limits of resolution of existing technologies, and the heterogeneity of the phenotypes make the accomplishments of these studies more impressive. As clinicians strive to integrate clinical and scientific findings into coherent models for the pathophysiology of OCD and TS, it is useful to identify practical and effective strategies for therapeutic interventions.
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Affiliation(s)
- N R Swerdlow
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA.
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Budman CL, Bruun RD, Park KS, Lesser M, Olson M. Explosive outbursts in children with Tourette's disorder. J Am Acad Child Adolesc Psychiatry 2000; 39:1270-6. [PMID: 11026181 DOI: 10.1097/00004583-200010000-00014] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Sudden, explosive outbursts of behavior occur in some children with Tourette's disorder (TD). The etiology of these symptoms is unknown. This study investigated the relationship between explosive outbursts, TD, and its comorbid disorders. METHOD Tic type and severity and the presence of specific comorbid disorders were compared in 37 children with TD and explosive outbursts and 31 children with TD who did not have such symptoms. RESULTS Children with TD and explosive outbursts were more likely to demonstrate significant comorbid conditions, particularly attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, and oppositional defiant disorder. Tic type and severity did not appear related to the presence of explosive outbursts. A highly significant relationship was demonstrated between the number of comorbid psychiatric diagnoses and explosive outbursts. CONCLUSIONS Explosive outbursts in children with TD resemble intermittent explosive disorder and may reflect dysregulation of diverse domains of brain function. The presence of such symptoms should alert the clinician to underlying comorbid conditions.
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Affiliation(s)
- C L Budman
- Department of Neurology and Psychiatry, New York University School of Medicine, New York, USA
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Abstract
Obsessive-compulsive behavior (OCB) or full-blown obsessive-compulsive disorder (OCD) afflict more than 50% of patients with Tourette's syndrome (TS) and often are more debilitating than the tic disorder itself. Medications for OCD, including selective serotonin reuptake inhibitors (SSRIs), help patients with TS and OCD, particularly in combination with low-dose antipsychotic drugs, but seldom eliminate OCD entirely. Behavioral therapies are more effective as medications for the treatment of OCD. A combination of cognitive behavioral therapy and medication is the treatment of choice for most patients with TS and OCD.
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