Other Specified Tic Disorder DSM-5 307.20 (F95.9)

Other Specified Tic Disorder DSM-5 307.20 (F95.9)

DSM-5 Category: Neurodevelopmental Disorder

Introduction

Other Specified Tic Disorder (OSTD) is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who are experiencing symptoms of Tic Disorder, which cause distress or impairs social, educational/occupational, or other vital areas of functioning. The OSTD diagnosis is used when the symptoms do not meet the complete diagnostic criteria for another type of tic disorder, or when the clinician chooses to specify the reason the diagnostic criteria are unmet. The clinician will record the reason in the diagnostic note (American Psychiatric Association, 2013).

Dysfunction in the basal ganglia is implicated in Tic disorders. It has been found that there are neural signals sent from the basal ganglia to the cerebellum and the motor cortex that produce motor and phonic tics in experimental primates (McCairn, Iriki, and Isoda, 2013). Tic disorders can be disfiguring and produce consequences of social rejection, ridicule and peer abuse, which can affect a child’s self-image and negatively impact self-esteem.

Symptoms of Other Specified Tic Disorder

According to the DSM-5, (American Psychiatric Association, 2013), the symptoms of Tic Disorder include motor movements or vocalizations which reoccur and are non-rhythmic. Tics are classified as either motor or phonic, and further sub-classified as simple or complex. Motor tics involve involuntary movements, while phonic tics involve utterances. Simple tics involve single muscle groups, and complex tics involve more than one muscle group, sequential motor movements, or complete words or sentences (Harris, & Wu, 2010). Motor movements can include but are not limited to blinking, grimacing, and twitching of the facial muscles. The vocalizations can include, but are not limited to sniffing, snorting, grunting, and throat clearing (American Psychiatric Association, 2013).

Tic Disorder can be sub-categorized as Tourette’s disorder, in which there are both multiple motor tics and at least one vocal tic, persisting for at least one year, with age of onset before age 18. The tics occur in the absence of substance use. The other category is Chronic vocal or motor tic disorder, which is similar to the diagnostic features of Tourette’s Disorder, in which there are either motor or vocal tics, but not both. OSTD involves an atypical presentation, with a specific feature of tic disorder is more prominent and the focus of clinical attention. An example would be the rare but documented cases of a tic emerging post TBI (Traumatic Brain Injury). Speculation in this case is that the TBI did not cause the tic, but rather a latent tic disorder was present which was unmasked by the TBI in the case of damage to the neural loop linking the basal ganglia, cerebellum, and thalamus (Ranjan, Nair, Romanoski, Singh, and Ventketswara, 2011).

Risk Factors for Other Specified Tic Disorder

The DSM-5 does not specify risk factors for OSTD (American Psychiatric Association, 2013). Tic disorders are genetically transmitted, so having a first order relative with a tic disorder is a risk factor (Harris, & Wu, 2010).

Onset of Other Specified Tic Disorder

The DSM-5 indicates that the typical onset of TD symptoms is before age 18. Therefore, an example of OSTD could be motor or vocal tics which manifested after age 18 (American Psychiatric Association, 2013).

Comorbidity of Other Specified Tic Disorder

AD/HD and OCD are commonly seen as comorbid conditions with tic disorders (Bronfeld, and Bar-Gad, 2013). The incidence of AD/HD with Tic disorders is ~ 70%, and the incidence of comorbid OCD is over 80%. Anxiety disorders are also seen in 30% of cases (Harris, & Wu, 2010). ODD (Oppositional Defiant Disorder) and CD (Conduct Disorder) are seen with Tic disorders (Lin, Lai, and Gau, 2012). There is a commonality in that all of the disorders are along a spectrum of disinhibited behavior, in which there is neurobiological commonality involving the orbito-frontal cortex cerebellum, and basal ganglia. The orbito-frontal cortex is primarily responsible for executive function and inhibition, while the hindbrain structures of the cerebellum and basal ganglia are involved with fine-tuning motor movement. A dysfunction in this neural loop can account for the symptoms common to AD/HD, OCD, ODD, CD, and Tic Disorders.

Differential Diagnosis in Other Specified Tic Disorder

The DSM-5 lists a number of conditions as diagnostic rule-outs:

  • Stereotypical motor movements: These are repetitive movements that are qualitatively different from tics, in that they tend to be more complex in terms of muscle group involvement, and have a more volitional quality. They are not considered a disorder, but symptomatic of a disorder.
  • Substance induced paroxysmal dyskinesia: Abuse of CNS (central Nervous System) stimulants can produce muscle twitching, flailing, restlessness, as can withdrawal from CNS depressants. CNS Depressant withdrawal can also produce gulping and gasping, which can indicate respiratory distress.
  • Myoclonus: A muscle spasm that can involve the whole body, frequently associated with onset of sleep. It is a sensation of falling and waking with a start that is familiar to many. It should be noted that myoclonic jerks during the onset of Stage one sleep are not a disorder. It is considered a WNL (Within Normal Limits) part of the sleep induction process, albeit an unpleasant one.
  • OCD (Obsessive Compulsive Disorder): Compulsion to perform repetitive movements, such as nail biting, skin picking, and hair pulling. These behaviors involve complex motor movements, fine motor skills; have a tension relieving effect, and a semi-volitional quality (American Psychiatric Association, 2013). However, tics can have an OCD quality, in which the individual will feel a premonitory urge to perform the tic, and a feeling of discomfort that they seek to relieve by performing the tic, and as noted above, it is a common comorbid condition (Bronfeld, and Bar-Gad, 2013).
  • Anxiety: grooming, self-soothing and tension relieving behaviors are another WNL behavior- such as stroking one’s hair, scratching or rubbing of the legs. This is also a behavior that depending on the context is a flirtatious behavior, part of attachment seeking and indicators of attraction toward another. The latter is a normal social behavior, not a disorder, and the former can be a symptom of anxiety, but not necessarily pathological anxiety.

Treatment of Other Specified Tic Disorder

The DSM-5 does not specify treatment options for OSTD (American Psychiatric Association, 2013). To provide the best quality of care, an accurate diagnosis must be established. If the diagnostic picture is ambiguous, the patient should be observed further, or another clinician should be consulted. The severity of the tic must justify the use of pharmacological interventions due to potential side effects. The first –line medication choices for tics are alpha-adrenergic antagonists, such as Clonidine, although small doses of antipsychotic medications are also used (Harris, and Wu, 2014). The discomfort of the tics could actually be outweighed by the discomfort of side effects, especially in the case of D-2 receptor antagonists- e.g., antipsychotics such as Haldol (Haloperidol), (Qasaymeh & Mink, 2006), which can also produce long term, irreversible neurological problems, e.g. - tardive dyskinesia, due to long term indiscriminate blockade of D-2 receptors in the nigrostriatal pathway, and collateral effects on the cholinergic system in the basal ganglia.

There are psychotherapeutic interventions for tic disorders, including OSTD. This includes Behavioral therapy, which is sub-divided into HRT (Habit Reversal Therapy) and CBIT (Cognitive Behavioral Intervention for Tics). HRT involves identifying the tic, and then substituting another voluntary incompatible behavior for the tic. CBIT includes Habit Reversal, psycho-education about tics for child and parents, relaxation techniques, and concrete coping strategies to lessen the social impact of tics (Harris, and Wu, 2010; Harris, and Wu, 2014).

Prognosis of Other Specified Tic Disorder

For most people, tics can resolve spontaneously by early adulthood, but for others, they continue into adulthood (Bronfeld, and Bar-Gad, 2013). The high co-morbidity of AD/HD and OCD must also be considered in the prognostic picture, as these disorders can have an independent course, interfere with or impair social/educational/occupational functioning, and require different treatment methods. It has been found that children with Tic disorders and comorbid AD/HD actually experience less interpersonal/social conflicts and peer rejection than children without Tic disorders. However when the Tic disorder was accompanied by ODD/CD, interpersonal conflicts increased, including maternal relationship problems (Lin, Lai, and Gau, 2012).

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

Bronfeld, M., and Bar-Gad, I. (2013). Tic Disorders: What Happens in the Basal Ganglia? Neuroscientist. 19: 101. DOI: 10.1177/1073858412444466

Harris, E., Wu, S.W. (2010). Children with tic disorders: How to match treatment with symptoms Algorithm helps determine when behavioral therapy, medication is appropriate. Current Psychiatry. 9, (3).

Harris, E., and Wu, S.W. (2014). Tourette Syndrome. Centers for Disease Control and Prevention. Retrieved November 1, 2014, from

Lin, Y. J., Lai, M.C., Gau, S.S. (2012). Youths with ADHD with and without tic disorders: Comorbid psychopathology, executive function and social adjustment. Research in Developmental Disabilities. 33(2012) 951–963.

McCairn, K.W., Iriki, A., Isoda, M. (2013). Global Dysrhythmia of Cerebro-Basal Ganglia–Cerebellar Networks Underlies Motor Tics following Striatal Disinhibition. The Journal of Neuroscience. 33(2): 697-708; doi: 10.1523/JNEUROSCI.4018-12.2013

Qasaymeh M.M., and Mink, J.W. (2006). New treatments for tic disorders. Current Treatment Options in Neurology. [Abstract]. 8(6):465-73. Retrieved October 19, 2014 from http://www.ncbi.nlm.nih.gov/pubmed/17032567

>Ranjan, N., Nair, K.P.S., Romanoski, C., Singh, R., & Ventketswara, G. (2011). Case Study: Tics after traumatic brain injury. Brain Injury. 25(6): 629–633.


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