What are the pertinent negatives to assess when evaluating tics?

From the Guidelines

When evaluating tics, it is crucial to assess for the absence of underlying conditions that may mimic or exacerbate tic-like symptoms, such as medication or substance use, head trauma, neurological disorders, seizure activity, and functional neurological disorders, as these can significantly impact morbidity, mortality, and quality of life.

Key Considerations

• The absence of compulsions driven by anxiety, which would suggest OCD rather than a tic disorder, is essential to note, as the treatment approaches for these conditions differ significantly 1.
• Lack of choreiform movements, which might indicate Huntington's or Sydenham's chorea, and absence of dystonic posturing are also critical to assess, as these conditions have distinct management strategies 1.
• Assessing for no family history of tic disorders or Tourette syndrome, no recent streptococcal infection (which could suggest PANDAS/PANS), and no developmental regression is vital, as these factors can influence the diagnosis and treatment plan 1.
• The absence of premonitory urges (sensory phenomena preceding tics) and lack of temporary tic suppression ability may also be relevant, as these features are often present in primary tic disorders, and understanding these can help in differentiating between various tic disorders 1.

Diagnostic Approach

• A comprehensive diagnostic approach should include a thorough clinical history, physical examination, and when necessary, additional tests to rule out other conditions that may present with similar symptoms 1.
• It is also important to consider the potential impact of medications, such as stimulants, which may be used in the treatment of ADHD but can have effects on tic severity, although recent studies suggest that they may not worsen motor tics in Tourette’s syndrome 1.

Treatment Implications

• Accurate diagnosis and identification of pertinent negatives are crucial for appropriate treatment planning, as the management of tic disorders can vary significantly depending on the underlying cause and associated conditions 1.
• Careful documentation of these negative findings is essential for developing an effective treatment strategy that addresses the patient's specific needs and minimizes the risk of adverse outcomes.

From the FDA Drug Label

5.6 Increased Risk of Clinically Significant Effects with Pre-Existing Neuromuscular Disorders 5.7 Dysphagia and Breathing Difficulties 5.8 Pre-existing Conditions at the Injection Site

When assessing tics, the pertinent negatives to evaluate include:

• Pre-existing neuromuscular disorders that may increase the risk of clinically significant effects 2
• Dysphagia and breathing difficulties that may be exacerbated by the treatment
• Pre-existing conditions at the injection site that may affect the safety and efficacy of the treatment It is essential to carefully evaluate these factors to ensure safe and effective treatment.

From the Research

Pertinent Negatives to Assess When Evaluating Tics

When assessing tics, several pertinent negatives should be considered to ensure a comprehensive evaluation. These include:

• The absence of other movement disorders, such as akathisia, myoclonus, and stereotypies, which can be differentiated from tics through a thorough clinical evaluation 3
• The lack of response to treatment, which can indicate the need for alternative therapeutic approaches, such as cognitive-behavioral therapy or deep brain stimulation surgery 4, 5
• The presence of comorbid neuropsychiatric symptoms, which can be more problematic than tic symptoms and require separate treatment strategies 6
• The absence of a clear diagnosis, which can lead to misunderstandings and misconceptions about tic disorders and their treatment 6

Important Considerations

Other important considerations when evaluating tics include:

• The age at onset and body distribution of the movement disorder, which can help determine the underlying cause of the tics 7
• The presence of accompanying neurological motor and non-motor features, which can indicate the presence of a underlying neurodegenerative condition 7
• The potential for tics to be induced by psychoactive substances, which can inform treatment decisions and lifestyle recommendations 7

Treatment-Related Negatives

When considering treatment options, it is also important to assess the potential negatives, including:

• The risk of adverse effects associated with pharmacological treatments, such as weight gain, drug-induced movement disorders, and elevated prolactin levels 4
• The potential for cognitive-behavioral therapy to be ineffective or insufficient for some patients, which can inform the need for alternative or adjunctive treatments 4, 5