Anxiety Disorders: Kurlan R

Shprecher D, Kurlan R. · Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY 14620, USA. · Mov Disord. · Pubmed #19170198 links to  free full text

Abstract: A tic is a stereotyped repetitive involuntary movement or sound, frequently preceded by premonitory sensations or urges. Most tic disorders are genetic or idiopathic in nature, possibly due to a developmental failure of inhibitory function within frontal-subcortical circuits modulating volitional movements. Currently available oral medications can reduce the severity of tics, but rarely eliminate them. Botulinum toxin injections can be effective if there are a few particularly disabling motor tics. Deep brain stimulation has been reported to be an effective treatment for the most severe cases, but remains unproven. A comprehensive evaluation accounting for secondary causes, psychosocial factors, and comorbid neuropsychiatric conditions is essential to successful treatment of tic disorders.

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, Anonymous00057. · Yale Child Study Center, 230 South Frontage Road, P.O. Box 207900, New Haven, CT 06520, USA. · NeuroRx. · Pubmed #16554257 No free full text.

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.

Pringsheim T, Lang A, Kurlan R, Pearce M, Sandor P. · Tourette Syndrome Neurodevelopmental Clinic, Department of Psychiatry, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada. · Dev Med Child Neurol. · Pubmed #19018838 No free full text.

Abstract: The aim of this study was to understand how children with Tourette syndrome (TS), with or without attention-deficit-hyperactivity disorder (ADHD) and/or obsessive-compulsive disorder (OCD), experience disability. Children seen at two TS centres were eligible for participation. Clinicians compiled baseline information and symptom severity rating scales. Parents completed the Child Health Questionnaire, a measure of physical and psychosocial health. Seventy-one children (56 males, 15 females); mean age 11y 2mo [SD 3y 1mo], range 7-17y) were analyzed in the subgroups: TS only (n=20), TS+ADHD (n=22), TS+ADHD+OCD (n=18), and TS+OCD (n=11). Almost all psychosocial domain scores were significantly lower than national norms for the TS+ADHD and TS+ADHD+OCD subgroups (p<0.001). For the TS only subgroup, only the family activities domain was significantly affected. Psychosocial summary scores were 53.2 for norms, 54.4 for the TS only subgroup (ns), 41.4 for the TS+ADHD subgroup (p<0.001), 35.3 for the TS+ADHD+OCD subgroup (p<0.001), and 35.5 for the TS+OCD group (p=0.003). A multiple linear regression model including diagnosis, age, sex, and TS, OCD, and ADHD symptom severity found that the most significant predictor of the psychosocial summary score was ADHD symptom severity (R(2)=0.55, p<0.001). Children with TS+ADHD+/-OCD experience impairment in all aspects of psychosocial health. For children with TS only, psychosocial health was not different from that of the normative population in the majority of domains tested. This suggests treatment of ADHD and OCD should be the priority in children with multiple diagnoses.

Kurlan R, Johnson D, Kaplan EL, Anonymous00032. · University of Rochester School of Medicine, Mt Hope Professional Building, 1351 Mt Hope Ave, Suite 100, Rochester, NY 14620, USA. · Pediatrics. · Pubmed #18519489 links to  free full text

Abstract: OBJECTIVE: If pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections is a unique clinical entity, we hypothesized that children meeting diagnostic criteria would have more clinical exacerbations temporally linked to bona fide group A beta-hemolytic streptococcus infection than matched control subjects (chronic tic and/or obsessive-compulsive disorder with no known temporal relationship to group A beta-hemolytic streptococcus infection). PATIENTS AND METHODS: Subjects included 40 matched pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections case-control pairs who were prospectively evaluated with intensive laboratory testing for group A beta-hemolytic streptococcus and clinical measures for an average of 2 years. Additional testing occurred at the time of any clinical exacerbations or illness. Laboratory personnel were blinded to case or control status and clinical (exacerbation or not) condition. Clinical raters were blinded to the results of laboratory tests. RESULTS: The cases had a higher clinical exacerbation rate and a higher bona fide group A beta-hemolytic streptococcus infection rate than the control group. Only 5 of 64 exacerbations were temporally associated (within 4 weeks) with a group A beta-hemolytic streptococcus infection, and all occurred in cases. The number (5.0) was significantly higher than the number that would be expected by chance alone (1.6). Yet, >/=75% of the clinical exacerbations in cases had no observable temporal relationship to group A beta-hemolytic streptococcus infection. CONCLUSIONS: Patients who fit published criteria for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections seem to represent a subgroup of those with chronic tic disorders and obsessive-compulsive disorder who may be vulnerable to group A beta-hemolytic streptococcus infection as a precipitant of neuropsychiatric symptom exacerbations. Group A beta-hemolytic streptococcus infection is not the only or even the most common antecedent event associated with exacerbations for these patients. Additional intensive studies are needed to determine whether there is clinical or scientific evidence to support separating out subgroups of tic disorder and/or obsessive-compulsive disorder patients based on specific symptom precipitants.

Hess CW, Raymond D, Aguiar Pde C, Frucht S, Shriberg J, Heiman GA, Kurlan R, Klein C, Bressman SB, Ozelius LJ, Saunders-Pullman R. · Department of Neurology, PACC, Beth Israel Medical Center, Suite 5J, 10 Union Square East, New York, NY 10003, USA. · Neurology. · Pubmed #17296918 No free full text.

Abstract: Although myoclonus and dystonia are the hallmarks of myoclonus-dystonia (M-D), psychiatric features, particularly obsessive-compulsive disorder and alcohol dependence, have been reported in three families linked to chromosome 7q21. As the epsilon sarcoglycan (SGCE) gene for M-D was subsequently identified, we evaluated the relationship between psychiatric features and SGCE mutations in these original and two additional families and confirm that OCD and alcohol dependence are associated with manifesting mutated SGCE.

Kurlan R. · University of Rochester School of Medicine and Dentistry, Department of Neurology, Rochester, New York 14620, USA. · Cogn Behav Neurol. · Pubmed #16175021 No free full text.

Abstract: OBJECTIVE: To describe "fear of falling" gait. BACKGROUND: "Fear of falling" gait is a largely psychogenic gait disorder of the elderly that is often unrecognized. METHODS: Report of a representative case and clinical experience. RESULTS: "Fear of falling" gait usually begins after a fall and is characterized by a shuffling or sliding stride and an intense need to hold on for support. It appears to be most common in elderly women, can be reversed by education, suggestion, and physical therapy, and is often mistaken for Parkinson disease. CONCLUSIONS: "Fear of falling" gait is a potentially reversible, largely psychogenic gait disorder that occurs mostly in women and must be distinguished from other gait disorders in the elderly.

Kurlan R. · Department of Neurology, University of Rochester School of Medicine, Rochester, New York 14642-8673, USA. · Mov Disord. · Pubmed #15077241 No free full text.

Abstract: We report on 6 patients with Parkinson's disease who developed severe repetitive behavior, 2 with pathological gambling and 4 with cleaning, rearranging, and ordering rituals. The onset of repetitive behaviors was not associated with changes in antiparkinsonian medications, the behavior did not improve after reductions in dopaminergic therapy, and thus they seem to be part of the underlying illness. The disabling cleaning/rearranging/ordering behaviors had associated features of hypomania, occurred exclusively during motor on periods, and often occurred nocturnally. The repetitive behavior responded poorly to serotonin reuptake inhibitors. Certain atypical antipsychotics may be of benefit.

Kurlan R, Kaplan EL. · Cognitive and Behavioral Neurology Unit, Department of Neurology, University of Rochester School of Medicine, Rochester, New York 14642-8673, USA. · Pediatrics. · Pubmed #15060240 links to  free full text

Abstract: Clinicians have been faced with much publicity and contradictory scientific evidence regarding a recently described condition termed pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). It has been proposed that children with PANDAS experience tics, obsessive-compulsive behavior, and perhaps other neuropsychiatric symptoms as an autoimmune response to streptococcal infection. We review current scientific information and conclude that PANDAS remains a yet-unproven hypothesis. Until more definitive scientific proof is forthcoming, there seems to be insufficient evidence to support 1) routine microbiologic or serologic testing for group A streptococcus in children who present with neuropsychiatric symptoms or 2) the clinical use of antibiotic or immune-modifying therapies in such patients. The optimum diagnostic and therapeutic approach awaits the results of additional research studies.

Kurlan R, Como PG, Miller B, Palumbo D, Deeley C, Andresen EM, Eapen S, McDermott MP. · Department of Neurology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642-8673, USA. · Neurology. · Pubmed #12177376 No free full text.

Abstract: BACKGROUND: Tourette syndrome (TS) and related tic disorders are commonly associated with obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD). It has been argued, however, that any observed association between TS and these and other psychopathologies may be due to ascertainment bias in that individuals with multiple problems are more likely to be referred for medical evaluation. METHODS: In order to overcome the potential confounding by ascertainment bias, the authors conducted a community-based study of school children using direct interviews to determine the prevalence of tic disorders and any comorbid psychopathology. A standard psychiatric interview and standardized rating scales were utilized to diagnose childhood behavioral disorders. RESULTS: Of the 1,596 children interviewed, 339 were identified as having tics. The following psychopathologies were found more commonly (p < 0.05) in the children with tics: OCD, ADHD, separation anxiety, overanxious disorder, simple phobia, social phobia, agoraphobia, mania, major depression, and oppositional defiant behavior. CONCLUSION: The behavioral spectrum of tic disorders includes OCD, other anxiety disorders, a mood disorder, and attention-deficit and disruptive behavior disorders.

Saunders-Pullman R, Shriberg J, Heiman G, Raymond D, Wendt K, Kramer P, Schilling K, Kurlan R, Klein C, Ozelius LJ, Risch NJ, Bressman SB. · Department of Neurology, Beth Israel Medical Center, New York, NY 10003, USA. · Neurology. · Pubmed #11805251 No free full text.

Abstract: BACKGROUND: Inherited myoclonus-dystonia (M-D) is a disorder that is characterized primarily by myoclonic jerks and is often accompanied by dystonia. In addition to motor features, psychiatric disease is reported in some families. METHODS: To determine whether the same genetic etiology underlies both neurologic and psychiatric signs, the authors studied psychiatric symptoms in nonmanifesting carriers (NMC), noncarriers (NC), and manifesting carriers (MC) in three families demonstrating linkage of M-D to the 7q21 locus. Interviewers administered the computerized version of the Composite International Diagnostic Interview. Algorithms for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of obsessive-compulsive disorder (OCD), generalized anxiety disorder, major affective disorder, alcohol abuse, alcohol dependence, drug abuse, and drug dependence were used. Rates of disorders among the MC, NMC, and NC were compared. RESULTS: Of 55 participating individuals, 16 were MC, 11 were NMC, and 28 were NC. The rate of OCD was greater in carriers (5/27) compared with NC (0/28) (p = 0.023). It was also greater in the symptomatic gene carriers (4/16) compared with the asymptomatic group (1/11) (p = 0.022). Alcohol dependence was increased in the symptomatic carriers (7/16) (p = 0.027), but not in the carrier group overall (7/27). CONCLUSION: OCD may be associated with the DYT11 M-D gene; however, a larger sample is necessary to confirm this finding. Alcohol dependence is highly associated with expressing symptoms of M-D. This may be explained by self-medication with alcohol to improve motor symptoms of M-D.

Richard IH, Justus AW, Kurlan R. · Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA. · J Neuropsychiatry Clin Neurosci. · Pubmed #11207327 links to  free full text

Abstract: Mood fluctuations have been reported in up to two-thirds of patients with Parkinson's disease who experience motor fluctuations. Most researchers indicate that mood fluctuations tend to be associated with motor fluctuations in that patients experience decreased mood when "off" (immobile) and elevated mood when "on" (mobile). Sixteen patients with Parkinson's disease and motor fluctuations completed hourly diaries for 7 consecutive days documenting their mood, anxiety, and motor states using visual analogue scales. Mood and anxiety fluctuations were frequently documented. Motor and emotional states were not, however, consistently correlated. When they were correlated, the most frequent pattern was the common occurrence of decreased mood, increased anxiety, and reduced motor function.

Richard IH, Szegethy E, Lichter D, Schiffer RB, Kurlan R. · Department of Neurology, University of Rochester School of Medicine and Dentistry, New York 14642, USA. · Clin Neuropharmacol. · Pubmed #10367182 No free full text.

Abstract: In this pilot study, we performed an oral yohimbine challenge in 6 patients with Parkinson's disease (PD) and anxiety or depression, 2 parkinsonian patients without psychiatric illness, and 2 healthy control subjects to determine whether patients with Parkinson's disease and anxiety respond to this adrenergic agent in the same way patients with idiopathic anxiety disorders respond. Given the atypical nature of depression in Parkinson's disease (characterized by prominent anxiety), we also wanted to see if patients with Parkinson's disease and depression (but no history of anxiety) are susceptible to yohimbine-induced panic. Parkinsonian patients with anxiety developed panic attacks at frequencies comparable to primary psychiatric patients with panic disorder. The one patient with PD and a history of major depression alone developed a panic attack. Regardless of their history of anxiety or depression, parkinsonian patients demonstrated a vulnerability to yohimbine-induced somatic symptoms.