• Tourette Syndrome
• SAD
• Depression
• Anxiety Disorder

TS is a diagnosis that doctors make after verifying that the patient has had both motor and vocal tics for at least 1 year. The existence of other neurological or psychiatric conditions[1] can also help doctors arrive at a diagnosis. Common tics are not often misdiagnosed by knowledgeable clinicians. But atypical symptoms or atypical presentation (for example, onset of symptoms in adulthood) may require specific specialty expertise for diagnosis. There are no blood or laboratory tests needed for diagnosis, but neuroimaging studies, such as magnetic resonance imaging (MRI), computerized tomography (CT), and electroencephalogram (EEG) scans, or certain blood tests may be used to rule out other conditions that might be confused with TS. It is not uncommon for patients to obtain a formal diagnosis of TS only after symptoms have been present for some time. The reasons for this are many. For families and physicians unfamiliar with TS, mild and even moderate tic symptoms may be considered inconsequential, part of a developmental phase, or the result of another condition. For example, parents may think that eye blinking is related to vision problems or that sniffing is related to seasonal allergies. Many patients are self-diagnosed after they, their parents, other relatives, or friends read or hear about TS from others.

How is TS treated?

Because tic symptoms do not often cause impairment, the majority of people with TS require no medication for tic suppression. However, effective medications are available for those whose symptoms interfere with functioning. Neuroleptics are the most consistently useful medications for tic suppression; a number are available but some are more effective than others (for example, haloperidol and pimozide). Unfortunately, there is no one medication that is helpful to all people with TS, nor does any medication completely eliminate symptoms. In addition, all medications have side effects. Most neuroleptic side effects can be managed by initiating treatment slowly and reducing the dose when side effects occur. The most common side effects of neuroleptics include sedation, weight gain, and cognitive dulling. Neurological side effects such as tremor, dystonic reactions (twisting movements or postures), parkinsonian-like symptoms, and other dyskinetic (involuntary) movements are less common and are readily managed with dose reduction. Discontinuing neuroleptics after long-term use must be done slowly to avoid rebound increases in tics and withdrawal dyskinesias. One form of withdrawal dyskinesia called tardive dyskinesia is a movement disorder distinct from TS that may result from the chronic use of neuroleptics. The risk of this side effect can be reduced by using lower doses of neuroleptics for shorter periods of time.

Other medications may also be useful for reducing tic severity, but most have not been as extensively studied or shown to be as consistently useful as neuroleptics. Additional medications with demonstrated efficacy include alpha-adrenergic agonists such as clonidine and guanfacine. These medications are used primarily for hypertension but are also used in the treatment of tics. The most common side effect from these medications that precludes their use is sedation.

Effective medications are also available to treat some of the associated neurobehavioral disorders that can occur in patients with TS. Recent research shows that stimulant medications such as methylphenidate and dextroamphetamine can lessen ADHD symptoms in people with TS without causing tics to become more severe. However, the product labeling for stimulants currently contraindicates the use of these drugs in children with tics/TS and those with a family history of tics. Scientists hope that future studies will include a thorough discussion of the risks and benefits of stimulants in those with TS or a family history of TS and will clarify this issue. For obsessive-compulsive symptoms that significantly disrupt daily functioning, the serotonin reuptake inhibitors (clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline) have been proven effective in some patients.

Psychotherapy may also be helpful. Although psychological problems do not cause TS, such problems may result from TS. Psychotherapy can help the person with TS better cope with the disorder and deal with the secondary social and emotional problems that sometimes occur. More recently, specific behavioral treatments that include awareness training and competing response training, such as voluntarily moving in response to a premonitory urge, have shown effectiveness in small controlled trials. Larger and more definitive NIH-funded studies are underway.

Is TS inherited?

Evidence from twin and family studies suggests that TS is an inherited disorder. Although early family studies suggested an autosomal dominant mode of inheritance (an autosomal dominant disorder is one in which only one copy of the defective gene, inherited from one parent, is necessary to produce the disorder), more recent studies suggest that the pattern of inheritance is much more complex. Although there may be a few genes with substantial effects, it is also possible that many genes with smaller effects and environmental factors may play a role in the development of TS. Genetic studies also suggest that some forms of ADHD and OCD are genetically related to TS, but there is less evidence for a genetic relationship between TS and other neurobehavioral problems that commonly co-occur with TS. It is important for families to understand that genetic predisposition may not necessarily result in full-blown TS; instead, it may express itself as a milder tic disorder or as obsessive-compulsive behaviors. It is also possible that the gene-carrying offspring will not develop any TS symptoms.

The sex of the person also plays an important role in TS gene expression. At-risk males are more likely to have tics and at-risk females are more likely to have obsessive-compulsive symptoms.

People with TS may have genetic risks for other neurobehavioral disorders such as depression or substance abuse. Genetic counseling of individuals with TS should include a full review of all potentially hereditary conditions in the family.

Tourestte Syndrome Fact Sheet, National Institute of Neurological Disorders and Strokehttp://www.ninds.nih.gov/disorders/tourette/detail_tourette.htm#121623231

• Major depression -- five or more symptoms listed above must be present for at least 2 weeks, but major depression tends to continue for at least 6 months. (Depression is classified as minor depression if you have fewer than five depression symptoms for at least 2 weeks. In other words, minor depression is similar to major depression except it only has 2 - 4 symptoms.)
• Dysthymia -- a generally milder form of depression that lasts as long as two years.
• Atypical depression -- depression accompanied by unusual symptoms, such as hallucinations (for example, hearing voices that are not really there) or delusions (irrational thoughts).

Other common forms of depression include:

• Postpartum depression -- many women feel somewhat down after having a baby, but true postpartum depression is rare.
• Premenstrual dysphoric disorder (PMDD) -- depressive symptoms occur one week prior to menstruation and disappear after you menstruate.
• Seasonal affective disorder (SAD) -- occurs during the fall-winter season and disappears during the spring-summer season. Likely to be due to lack of sunlight.

Depression may also occur with mania (known as manic-depression or bipolar disorder). In this condition, moods cycle between mania and depression.

Depression is more common in women than men and is especially common during the teen years. Men seem to seek help for feelings of depression less often than women. Therefore, women may only have more documented cases of depression.

Adolescent depression is a disorder occurring during the teenage years marked by persistent sadness, discouragement, loss of self-worth, and loss of interest in usual activities.

Causes, incidence, and risk factors

Depression can be a temporary response to many situations and stresses. In adolescents, depressed mood is common because of the normal maturation process, the stress associated with it, the influence of sex hormones, and independence conflicts with parents.

It may also be a reaction to a disturbing event, such as the death of a friend or relative, a breakup with a boyfriend or girlfriend, or failure at school. Adolescents, who have low self-esteem, are highly self-critical, and who feel little sense of control over negative events are particularly at risk to become depressed when they experience stressful events. True depression in teens is often difficult to diagnose because normal adolescent behavior is marked by both up and down moods. These moods may alternate over a period of hours or days.

Persistent depressed mood, faltering school performance, failing relations with family and friends, substance abuse, and other negative behaviors may indicate a serious depressive episode. These symptoms may be easy to recognize, but depression in adolescents often starts very differently than these classic symptoms.

Excessive sleeping, change in eating habits, even criminal behavior (like shoplifting) may be signs of depression. Another common symptom of adolescent depression is an obsession with death, which may take the form either of suicidal thoughts or of fears about death and dying.

Adolescent girls are twice as likely as boys to experience depression.

Risk factors include:

• Stressful life events, particularly loss of a parent to death or divorce
• Child abuse - both physical and sexual
• Unstable caregiving, poor social skills
• Chronic illness
• Family history of depression

Symptoms

• Depressed or irritable mood
• Temper (agitation)
• Loss of interest in activities
• Reduced pleasure in daily activities
• Appetite changes (usually a loss of appetite but sometimes an increase)
• Weight change (unintentional weight loss or unintentional weight gain)
• Persistent difficulty falling asleep or staying asleep (insomnia)
• Excessive daytime sleepiness
• Fatigue
• Difficulty concentrating
• Fifficulty making decisions
• Episodes of memory loss
• Preoccupation with self
• Feelings of worthlessness, sadness, or self-hatred
• Excessive or inappropriate feelings of guilt
• Acting-out behavior (missing curfews, unusual defiance)
• Thoughts about suicide or obsessive fears or worries about death
• Plans to commit suicide or actual suicide attempt
• Excessively irresponsible behavior pattern

If these symptoms persist for at least 2 weeks and cause significant distress or difficulty functioning, treatment should be sought.

Signs and tests

The doctor will perform a physical examination and order blood tests to rule out medical causes for the symptoms.

The doctor will evaluate the teen for signs of substance abuse. Heavy drinking, frequent marijuana (pot) smoking, and other drug use can be caused by or occur because of depression.

A psychiatric evaluation will also be done to document the teen's history of sadness, irritability, and loss of interest and pleasure in normal activities. The doctor will look for signs of potentially co-existing psychiatric disorders such as anxiety, mania, or schizophrenia. A careful assessment of the teenager will help determine suicidal/homicidal risks -- that is, if the teen is a danger to him or herself or others.

Information from family members or school personnel can often help identify depression in teenagers.

Treatment

Treatment options for adolescents with depression are similar to those for used to treat depression in adults. Treatments may include psychotherapy and antidepressant medications.

MEDICATION

The first medication considered is usually a type of antidepressant called a selective serotonin reuptake inhibitors (SSRI). Prozac is most often the first choice. NOTE: SSRI's carry a warning that they may increase the risk of suicidal thoughts and actions in children and adolescents. Teens and families should be alert for sudden changes or increased suicidal thoughts. Talk to your doctor about the benefits and risks of such medicine.

Not all antidepressants are approved for use in children and teens. For example, tricyclics are not approved for use in teens.

THERAPY

Family therapy may be helpful if family conflict is contributing to the depression. Support from family or teachers to help with school problems may also be needed. Occasionally, hospitalization in a psychiatric unit may be required for individuals with severe depression, or if they are at risk of suicide.

Because of the behavior problems that often co-exist with adolescent depression, many parents are tempted to send their child to a "boot camp", "wilderness program", or "emotional growth school."

These programs often use non-medical staff, confrontational therapies, and harsh punishments. There is no scientific evidence to support such programs. In fact, there is a growing body of research which suggests that they can actually harm sensitive teens with depression.

Depressed teens who act out may also become involved with the criminal justice system. Parents are often advised not to intervene, but to "let them experience consequences."

Unfortunately, this can also harm teens through exposure to more deviant peers and reduction in educational opportunities. A better solution is to get the best possible legal advice and search for treatment on your own, which gives parents more control over techniques used and options.

Though a large percentage of teens in the criminal justice system have mental disorders like depression, few juvenile prisons, "boot camps" or other "alternative to prison" programs provide adequate treatment.

Expectations (prognosis)

Depressive episodes usually respond to treatment, and early and comprehensive treatment of depression in adolescence may prevent further episodes. However, about half of seriously depressed teens are likely to have continued problems with depression as adults.

Complications

Teenage suicide is associated with depression as well as many other factors. Depression frequently interferes with school performance and interpersonal relationships. Teens with depression often have other psychiatric problems, such as anxiety disorders.

Depression is also commonly associated with violence and reckless behavior. Drug, alcohol, and tobacco abuse frequently coexist with depression. Adolescents with additional psychiatric problems usually require longer and more intensive treatment.

Calling your health care provider

Call your health care provider if one or more warning signs of potential suicide are present.

Be alert to the following signs:

• Withdrawal, with urge to be alone, isolation
• Moodiness
• Personality change
• Threat of suicide
• Giving most cherished possessions to others

NEVER IGNORE A SUICIDE THREAT OR ATTEMPT!

Prevention

Periods of depressed mood are common in most adolescents. However, supportive interpersonal relationships and healthy coping skills can help prevent such periods from leading to more severe depressive symptoms. Open communication with your teen can help identify depression earlier.

Counseling may help teens deal with periods of low mood. Cognitive behavioral therapy, which teaches depressed people ways of fighting negative thoughts and recognizing them as symptoms, not the truth about their world, is the most effective non-medication treatment for depression. Ensure that counselors or psychologists sought are trained in this method.

For adolescents with a strong family history of depression, or with multiple risk factors, episodes of depression may not be preventable. For these teens, early identification and prompt and comprehensive treatment of depression may prevent or postpone further episodes.

References

MacKenzie DL, Gover AR, Armstrong GS, Mitchell O. A National Study Comparing the Environments of Boot Camps With Traditional Facilities for Juvenile Offenders. Washington, DC. National Institute of Justice, US Dept. of Justice; 2001.

Borque B, Han M, Hill S. A National Survey of Aftercare Provisions for Boot Camp Graduates. Washington, DC. National Institute of Justice, US Dept. of Justice; 1996.

Bottcher J, Isorena T. First-year evaluation of the California Youth Authority Boot Camp. In: D MacKenzie, E Herbert, eds. Correctional Boot Camps: A Tough Intermediate Sanction. Washington, DC: National Institute of Justice, US Dept of Justice; 1995.

MacKenzie D, Souryal C. Multi-site Evaluation of Shock Incarceration. Washington, DC: National Institute of Justice, US Dept of Justice; 1994.

Peters M, Thomas D, Zamberlan C. Boot Camps for Juvenile Offenders Program Summary. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, US Dept of Justice; 1997.

Health Professor Web Site: http://www.healthprofessor.com

Generalized anxiety disorder (GAD) is behavior marked by a pattern of frequent, persistent worry and anxiety over many different activities and events.

Alternative Names

GAD; Anxiety disorder

Causes, incidence, and risk factors

Generalized anxiety disorder (GAD) is a common condition. It is characterized by excessive anxiety and worry, which is out of proportion to the impact of the event or circumstance that is the focus of the worry.

For example, while college students often worry about tests, a student who constantly worries about failure -- despite getting consistently good grades -- has the pattern of worry typical of this disorder.

The person finds it difficult to control the worry. The cause of GAD is not known, but biological and psychological factors play a role. Stressful life situations or maladaptive behavior, acquired through learning, may also contribute to GAD.

The disorder may start at any time in life, including childhood. Most patients with the disorder report that they have been anxious for as long as they can remember. GAD occurs somewhat more often in women than in men.

Symptoms

Anxiety and worry are often associated with the following symptoms:

• Restlessness or feeling keyed up or "on the edge"
• Being easily fatigued
• Difficulty concentrating
• Irritability
• Muscle tension -- shakiness, headaches
• Sleep disturbance (difficulty falling or staying asleep; or restless, unsatisfying sleep)
• Excessive sweating, palpitations, shortness of breath, and various gastrointestinal symptoms

Signs and tests

A physical examination and a psychological evaluation should be completed in order to rule out other causes of anxiety. Physical disorders that may mimic an anxiety state should be ruled out, as well as drug-induced symptoms. Various diagnostic tests may be done in this process.

Treatment

Treatment may involve specific medications that provide a sedative (sleep-inducing) or calming effect. Several antidepressant medicines are approved for generalized anxiety disorder.

Other drugs such as antihistamines, which have the favorable side effect of reducing anxiety, may be used. Benzodiazepines, a common class of anti-anxiety medications, are used with caution because they can cause judgment problems and can be addictive.

Two types of therapy are used to treat GAD:

• Relaxation training -- a systematic relaxation of the major muscle groups in the body
• Cognitive behavioral therapy -- helps patients identify thoughts that contribute to anxiety

Support Groups

Patient support groups may be helpful for some patients suffering from GAD. Patients have the opportunity to learn that they are not unique in experiencing excessive worry and anxiety.

Support groups are not a substitute for effective treatment, but can be a helpful addition to it.

The disorder may be long-standing and difficult to treat, but the majority of patients can expect substantial improvement with medications and/or behavioral therapy.

Complications

People with GAD may eventually develop other psychiatric disorders, such as panic disorder or clinical depression. In addition, substance abuse or dependence may become a problem, usually because the person tries to self-medicate with drugs or alcohol to alleviate their anxiety.

Calling your health care provider

Call your health-care provider if you are experiencing the signs and symptoms of generalized anxiety disorder, especially if this has been going on for a period of 6 months or longer, or it interferes with your daily functioning.

References

Moore DP, Jefferson JW. Handbook of Medical Psychiatry. 2nd ed. St. Louis, Mo: Mosby; 2004: 174-175.

Noble J. Textbook of Primary Care Medicine. 3rd ed. St. Louis, Mo: Mosby; 2001:416.

Health Professor Web Site: http://www.healthprofessor.com

Please note that you should always check with your doctor before undertaking any type of treatment.