Tics and Tourette Syndrome

Overview

Definition

Tics are repeated, nonrhythmic movements or vocalizations. 

Tourette syndrome is a disorder characterized by at least 1 motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology and 1 vocal tic (may not occur at the same time) not caused by medication or other physiological processes, with an age of onset before 18, and lasting for more than 1 year.

Classification

• Tourette syndrome: motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology and vocal tics for 1+ year 
• Provisional tic disorder: lasting < 1 year, diagnosed in retrospect
• Chronic motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology tics: presence of motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology tics (no vocal tics) for 1+ year 
• Chronic vocal tics: presence of vocal tics (no motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology tics) for 1+ year

Epidemiology

• Tics affect 20% of children worldwide; the severe form (Tourette syndrome) affects 3–8 per 1,000 children.
• Boy:girl prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: 3:1
• Mainly affects children aged 4–9 years
• Often improves as patient grows older, and disappears in adulthood 
• Prenatal maternal smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases thought to be a risk factor
• Comorbid conditions:
  • OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD)
  • Depression
  • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder
  • ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder
  • Self-injurious behavior

Pathophysiology

Causative pathway remains largely unknown, although several theories exist.

• Genetic influence theory:
  • Genetic mutation Mutation Genetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations in developmental period
  • HDC gene Gene A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. Basic Terms of Genetics on chromosome Chromosome In a prokaryotic cell or in the nucleus of a eukaryotic cell, a structure consisting of or containing DNA which carries the genetic information essential to the cell. Basic Terms of Genetics 15q21-q22, inherited in autosomal dominant Autosomal dominant Autosomal inheritance, both dominant and recessive, refers to the transmission of genes from the 22 autosomal chromosomes. Autosomal dominant diseases are expressed when only 1 copy of the dominant allele is inherited. Autosomal Recessive and Autosomal Dominant Inheritance pattern with incomplete penetrance Penetrance The percent frequency with which a dominant or homozygous recessive gene or gene combination manifests itself in the phenotype of the carriers. Familial Juvenile Polyposis  
  • SLITRK1 gene Gene A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. Basic Terms of Genetics on chromosome Chromosome In a prokaryotic cell or in the nucleus of a eukaryotic cell, a structure consisting of or containing DNA which carries the genetic information essential to the cell. Basic Terms of Genetics 13q31.1 are thought to be involved in Tourette syndrome, expressed in:
    • Thalamic nuclei Thalamic nuclei Several groups of nuclei in the thalamus that serve as the major relay centers for sensory impulses in the brain. Thalamus: Anatomy
    • Subthalamic nuclei
    • Globus pallidus Globus pallidus The representation of the phylogenetically oldest part of the corpus striatum called the paleostriatum. It forms the smaller, more medial part of the lentiform nucleus. Basal Ganglia: Anatomy nuclei
    • Striatum Striatum Striped gray matter and white matter consisting of the neostriatum and paleostriatum (globus pallidus). It is located in front of and lateral to the thalamus in each cerebral hemisphere. The gray substance is made up of the caudate nucleus and the lentiform nucleus (the latter consisting of the globus pallidus and putamen). The white matter is the internal capsule. Basal Ganglia: Anatomy
    • Cortex
    • Hippocampus
    • Cerebellum Cerebellum The cerebellum, Latin for “little brain,” is located in the posterior cranial fossa, dorsal to the pons and midbrain, and its principal role is in the coordination of movements. The cerebellum consists of 3 lobes on either side of its 2 hemispheres and is connected in the middle by the vermis. Cerebellum: Anatomy
  • Offspring of parents with tics have a 45% chance of presenting any variant of tics and a 15% chance of developing Tourette syndrome.
• Autoimmune theory:
  • Preceding infection with group A β-hemolytic streptococci → antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions to basal ganglia Basal Ganglia Basal ganglia are a group of subcortical nuclear agglomerations involved in movement, and are located deep to the cerebral hemispheres. Basal ganglia include the striatum (caudate nucleus and putamen), globus pallidus, substantia nigra, and subthalamic nucleus. Basal Ganglia: Anatomy → pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS)
  • Other associated infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease:
    • Herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology infection
    • HIV HIV Anti-HIV Drugs
    • Mycoplasma Mycoplasma Mycoplasma is a species of pleomorphic bacteria that lack a cell wall, which makes them difficult to target with conventional antibiotics and causes them to not gram stain well. Mycoplasma bacteria commonly target the respiratory and urogenital epithelium. Mycoplasma pneumoniae (M. pneumoniae), the causative agent of atypical or “walking” pneumonia. Mycoplasma pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
    • Varicella zoster virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology (VZV)
• Neurobiological theory: 
  • Disorder of fibers of cortico-striatal-thalamic-cortical (CSTC) pathway
  • Dopamine Dopamine One of the catecholamine neurotransmitters in the brain. It is derived from tyrosine and is the precursor to norepinephrine and epinephrine. Dopamine is a major transmitter in the extrapyramidal system of the brain, and important in regulating movement. Receptors and Neurotransmitters of the CNS linked to improvement

Clinical Presentation

Tics

Simple tics:

• Brief movement of single muscle or muscle groups or vocalization
• Movement and vocalizations have no social meaning.
• Examples of simple motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology tics:
  • Eye blinking
  • Eye rolling Rolling Movement of tethered, spherical leukocytes along the endothelial surface of the microvasculature. The tethering and rolling involves interaction with selectins and other adhesion molecules in both the endothelium and leukocyte. The rolling leukocyte then becomes activated by chemokines, flattens out, and firmly adheres to the endothelial surface in preparation for transmigration through the interendothelial cell junction. Inflammation
  • Limb and head jerking
  • Grimacing
  • Shoulder shrugging
• Examples of simple sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology tics:
  • Throat Throat The pharynx is a component of the digestive system that lies posterior to the nasal cavity, oral cavity, and larynx. The pharynx can be divided into the oropharynx, nasopharynx, and laryngopharynx. Pharyngeal muscles play an integral role in vital processes such as breathing, swallowing, and speaking. Pharynx: Anatomy clearing
  • Whistling
  • Coughs
  • Grunting Grunting Physical Examination of the Newborn
  • Animal sounds

Complex tics:

• Cluster of simple actions, coordinated movements, or vocalizations that involve repetition of words 
• Often, movements or words have social meaning.
• Examples of complex motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology tics:
  • Jumping
  • Touching objects and other people
  • Copropraxia: making obscene gestures in public or touching genitals
  • Echopraxia: imitating gestures of others
• Examples of complex sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology tics:
  • Coprolalia: use of obscene words in public
  • Echolalia echolalia Involuntary (‘parrot-like’), meaningless repetition of a recently heard word, phrase, or song. This condition may be associated with transcortical aphasia; schizophrenia; or other disorders. Schizophrenia: repetition of words said by others
  • Palilalia: repetition of one’s own words

Other tic characteristics:

• Fluctuating course:
  • Waxing and waning pattern:
    • More prominent during stress or fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia
    • Less prominent when patient is engaged in activity
  • Always absent during sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep
• Most common 1st symptom is facial tic (e.g., eye blink, nose Nose The nose is the human body’s primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Nose Anatomy (External & Internal) twitch Twitch An isolated, rapid contraction followed by rapid relaxation Skeletal Muscle Contraction, or grimace)
• Voluntary suppressibility: often associated with build-up of inner tension that resolves when tic is permitted to occur
• Premonitory sensations:
  • Sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology phenomena that occur before motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology or phonic tic 
  • Take the form of urge, impulse, tension, pressure, itch, or tingle
  • More common in adults

Tourette syndrome

• Symptoms appear before age 18:
  • Typically appear in school-aged children 
  • Generally worst around age 10
  • Adults usually have mild symptoms that may go unnoticed.
• Associated with ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder and OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD) 
• Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology tics normally appear 1st:
  • Upper body tics more common than lower body tics
  • Examples: blinking, grimacing

Diagnosis

• Diagnosis is clinical, involving identification Identification Defense Mechanisms of specific tic phenomenology. 
• History and physical examination:
  • Observe for tics during interview and physical examination.
  • Ask about past medical history Past Medical History Adult Health Maintenance of ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder and OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD).
  • Ask about family history Family History Adult Health Maintenance of tic disorders.
• Diagnosed when patient has both motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology and vocal tics for 1+ year, beginning before age 18
• Imaging and blood testing may rule out other potential etiologies: 
  • Functional MRI: 
    • Used to demonstrate brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification function during occurrence of tics
    • Shows reduced caudate volumes
  • CT: 
    • Employed in investigating associated structural abnormalities 
    • May show reduced caudate volumes
  • EEG EEG Seizures: performed during sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep to ascertain nature of brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification activity during tics and distinguish from other causes of involuntary movement
  • PET PET An imaging technique that combines a positron-emission tomography (PET) scanner and a ct X ray scanner. This establishes a precise anatomic localization in the same session. Nuclear Imaging: shows increased brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification activity during tics in thalamus Thalamus The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. Thalamus: Anatomy and striatum Striatum Striped gray matter and white matter consisting of the neostriatum and paleostriatum (globus pallidus). It is located in front of and lateral to the thalamus in each cerebral hemisphere. The gray substance is made up of the caudate nucleus and the lentiform nucleus (the latter consisting of the globus pallidus and putamen). The white matter is the internal capsule. Basal Ganglia: Anatomy
  • Blood testing: rules out chronic disease
  • Urine testing: drug screening Screening Preoperative Care (e.g., stimulant use) if there is suspicion for intoxication

Management

Treatment is only needed when the disease interferes with a patient’s image, social activity, or education. Most patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship do well with education and CBT, without the need for medication or deep brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification stimulation.

• CBT:
  • Habit reversal therapy:
    • Most effective nonpharmacological treatment
    • Include detailed description of tic to find competing response 
    • Reduces chances of tic occurrence
  • Education about tics: Understanding tics as a neurobehavioral disease helps patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship to cope with the disorder.
  • Social support and reward system: Good support reduces associated psychiatric conditions.
  • Functional intervention: identifies environmental events that worsen tics 
  • Relaxation training: reduces stress that could trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation tics
• Pharmacological therapy/antipsychotics:
  • Alpha-adrenergic agonist (e.g., clonidine Clonidine An imidazoline sympatholytic agent that stimulates alpha-2 adrenergic receptors and central imidazoline receptors. It is commonly used in the management of hypertension. Sympathomimetic Drugs, guanfacine) 
  • 1st-generation antipsychotics (e.g., haloperidol Haloperidol A phenyl-piperidinyl-butyrophenone that is used primarily to treat schizophrenia and other psychoses. It is also used in schizoaffective disorder, delusional disorders, ballism, and tourette syndrome (a drug of choice) and occasionally as adjunctive therapy in intellectual disability and the chorea of huntington disease. It is a potent antiemetic and is used in the treatment of intractable hiccups. First-Generation Antipsychotics)
  • 2nd-generation antipsychotics (e.g., risperidone Risperidone A selective blocker of dopamine D2 receptors and serotonin 5-HT2 receptors that acts as an atypical antipsychotic agent. It has been shown to improve both positive and negative symptoms in the treatment of schizophrenia. Second-Generation Antipsychotics, olanzapine Olanzapine A benzodiazepine derivative that binds serotonin receptors; muscarinic receptors; histamine h1 receptors; adrenergic alpha-1 receptors; and dopamine receptors. It is an antipsychotic agent used in the treatment of schizophrenia; bipolar disorder; and major depressive disorder; it may also reduce nausea and vomiting in patients undergoing chemotherapy. Second-Generation Antipsychotics) 
  • Currently: 2nd-generation antipsychotics are preferred pharmacological treatment due to fewer side effects.
• Deep brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification stimulation:
  • Implantation Implantation Endometrial implantation of embryo, mammalian at the blastocyst stage. Fertilization and First Week of electrodes Electrodes Electric conductors through which electric currents enter or leave a medium, whether it be an electrolytic solution, solid, molten mass, gas, or vacuum. Electrocardiogram (ECG) and passage of stimulatory current to selected areas of brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification in which increased activity is likely to cause tics
  • Includes thalamus Thalamus The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. Thalamus: Anatomy and globus pallidus Globus pallidus The representation of the phylogenetically oldest part of the corpus striatum called the paleostriatum. It forms the smaller, more medial part of the lentiform nucleus. Basal Ganglia: Anatomy
• Treatment of comorbid conditions:
  • ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder: low-dose stimulants Stimulants Stimulants are used by the general public to increase alertness and energy, decrease fatigue, and promote mental focus. Stimulants have medical uses for individuals with ADHD and sleep disorders, and are also used in combination with analgesics in pain management. Stimulants 
  • OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD): antidepressants (e.g., selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors Serotonin Reuptake Inhibitors and Similar Antidepressants ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants) such as fluoxetine Fluoxetine The first highly specific serotonin uptake inhibitor. It is used as an antidepressant and often has a more acceptable side-effects profile than traditional antidepressants. Serotonin Reuptake Inhibitors and Similar Antidepressants and clomipramine Clomipramine A tricyclic antidepressant similar to imipramine that selectively inhibits the uptake of serotonin in the brain. It is readily absorbed from the gastrointestinal tract and demethylated in the liver to form its primary active metabolite, desmethylclomipramine. Tricyclic Antidepressants)
  • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder: CBT and anxiolytics

Differential Diagnosis

• ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder: characterized by limited attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment and hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder for 6+ months in 2 different social environments. Presentation is classified as predominantly inattentive, predominantly hyperactive, or combined. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are diagnosed clinically based upon symptoms lasting more than 6 months, with onset before the age of 12. The disease usually continues into adulthood. Treatment is stimulant medication with other options including non-stimulant medications (e.g., atomoxetine) and behavioral therapy. The disease can cause functional decline.
• OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD): characterized by recurring intrusive thoughts, feelings, or sensations (known as obsessions Obsessions Recurrent thoughts, images, or urges that are intrusive and recognized as unwanted, causing significant anxiety and distress . Obsessive-compulsive Disorder (OCD)) that are time consuming and cause severe distress; relieved partially by performance of repetitive actions (known as compulsions Compulsions Repetitive behaviors or mental acts that the individual is driven to perform in relation to an obsession. Obsessive-compulsive Disorder (OCD)). Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship diagnosed clinically by presence of obsessions Obsessions Recurrent thoughts, images, or urges that are intrusive and recognized as unwanted, causing significant anxiety and distress . Obsessive-compulsive Disorder (OCD) or compulsions Compulsions Repetitive behaviors or mental acts that the individual is driven to perform in relation to an obsession. Obsessive-compulsive Disorder (OCD) that are time consuming and affecting daily life. Treatment includes CBT and medications (e.g., SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants).  
• Oppositional defiant disorder Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Oppositional Defiant Disorder (ODD): continuous pattern of angry/ irritable mood Irritable mood Abnormal or excessive excitability with easily triggered anger, annoyance, or impatience. Oppositional Defiant Disorder, argumentative/ defiant behavior Defiant behavior Oppositional Defiant Disorder, or vindictiveness Vindictiveness Oppositional Defiant Disorder that is present for at least 6 months. This diagnosis is frequently found in those with ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder. Symptoms of ODD are mostly directed toward authoritative figures, such as parents or teachers.