Understanding and Responding to Sudden Onset Tics in Teens: An overview for individuals, families, schools, and clinicians

The New Jersey Center for Tourette Syndrome and Associated Disorders, its directors and employees, assume no responsibility for the accuracy, completeness, objectivity, or usefulness of the information presented on our site. 1:43 We do not endorse or recommend, or make any, or any opinion, by any member or physician, nor do we advocate for any treatment. 1:54 You are responsible for your own medical decisions. 1:58 So, tonight, we are welcoming back doctor Graham Hartke for his ninth webinars since 2011. 2:06 His webinars have been attended by over 500 participants and downloaded over 1400 times. 2:13 So, we welcome him and we’re excited to have him this evening. 2:18 Doctor Graham Hartke is a New Jersey,and New York licensed psychologist in private practice in Roseland, New Jersey, specializing in cognitive behavioral treatment of anxiety, obsessive compulsive disorder, body focused repetitive behaviors, depression, tics and Tourette Syndrome, ADHD, Oppositional Defiance Disorder, and High Functioning Autism Spectrum Disorders. 2:50 He also specializes in the area of sport and performing arts psychology. 2:57 Doctor Hartke works with children, adolescents and adults providing therapy, behavioral assessment, and psychological evaluations. He graduated summa cum laude from Rutgers College, Rutgers University. He continued his training at the Graduate School of applied and Professional Psychology at Rutgers University where he received his master’s and doctorate in school psychology. 3:20 He completed clinical training at the Tourette Syndrome Program and completed a concentration in sports psychology. 3:28 Doctor Hartke is a New Jersey certified school psychologist, school supervisor, and school principal. He previously served as Clinical director of the Tourette Syndrome Clinic at Rutgers, and has been a frequent outreach presenter for NJCTS. Welcome, doctor Hartke and we look forward to your presentation. 3:49 Thank You, Kelly. 3:50 And thank you, everyone, and NJCTS, for making this happen tonight. And I want to thank everyone for, for joining us. This is obviously a very hot topic at the moment. 4:03 And I’m going to be covering a lot of information. 4:06 So I will try to go through it and leave enough time for questions, OK. 4:14 So tonight’s topic is Understanding Responding to Sudden Onset Tics In Teens. And it’s an overview. 4:21 So we’re not going to get extremely in detail on every area, but it’s meant to be for individuals that have ticks for the families, schools, and clinicians that work with them. 4:33 OK, let me just make sure my screen is Responding, OK, So our agenda for tonight, we’ll talk about, we’re gonna answer three questions. What has been happening? 4:44 Why is this happening? And how do we help these individuals? Right, so we’re just gonna really get an overview of what is going on behind this, this recent rise in sudden onset ticks, and most of these case seventeen’s. Why is this happening? We’re gonna kinda go, Are different factors thought to be involved in this surge, and how do we help these individuals? So, I’m gonna try to dedicate as much time as we can to some strategies to actually address this. I know a lot of webinars and information really just talks about it, but I will also want to talk about what we can do. 5:17 And also, we’re gonna go over some resources, OK? And we’ll have time for questions. So what has been happening OK? 5:25 So since it started pandemics, so let’s say approximately the beginning of March 2020, you know around when it really hit in America and things shut down There has been a sudden rise in a surge almost in cases of teens and young adults with rapid onset tick like behaviors. 5:45 So we’re going to call them functional tick like behaviors for this purposes of this talk, and this phenomenon is occurring around the world, and it’s widespread, Right, and a parallel fashion. So what we were seeing in America has been happening all over America, but also throughout the world on different continents. So it’s not just America. 6:05 Um, this court, there’s been a correlation found between these functional tick like behaviors and social media such as tick tock. 6:14 So other social media also YouTube’s involved but there’s been a correlation that researchers have found here And I want to point out we’re going to tell you this, that it’s been for many but not all cases. So not every single case. 6:26 Has tick tock been the main? You know, been identified, in many cases, though, in some researchers, have found, you know, in their sample sizes, everyone has been, you know, watching tiktok, but not everybody. So I want to point that out. 6:41 And also, sometime around early last spring, last year, no popular media outlets started reporting on. So, you know, you might have had a neighbor or friend, say, Oh, did you see on? there was a, in the Wall Street Journal, or Vice magazine. There’s reporting on this. So it got mainstream popular media attention. 7:02 So what are these functional take? Like behavior cases, there are rapid onset. Often sudden, an overnight. 7:08 So it’s dramatic, usually complex motor and vocal tick like behaviors, so it’s kind of out of nowhere, Someone wakes up. Literally, someone might wake up that morning and have really, really intense and complex text. It’s dramatic an exaggerated, so these are not, you know, simple ticks off. And usually there, we’re gonna go through a list but they’re very pronounced movements. It’s often extremely disruptive for almost every time it’s extremely disruptive for the families individuals involved, destabilizing and potentially traumatizing. A lot of miss school, many hospital or doctor visits. 7:47 No, ER visits are very common. 7:50 And most of these cases have been with females that are teens. I would say the majority are probably between 12 and 16, but it goes all the way up to 25. But most of these cases have been female. You know, we’re talking about biological, biologically, female. 8:07 An adolescent, OK. 8:09 So these behaviors are classified as tick like they’re different from traditional ticks found in Tourette syndrome and other primary tic disorders. 8:17 Um, so we’re gonna you know, we’re considering, you know, there are different than what you find in Tourette’s syndrome or chronic or persistent motor or persistent vocal tic. Disorders are transient tic disorders. We’re going to refer to them as primary or traditional or typical tic disorders. When they talk about those, they’re called functional tickling behaviors, also, sometimes referred to as functional texts or psychogenic ticks. 8:41 They’re consistent with a category of disorders known as functional neurological disorders, Also known, historically known, and still, some people use this term as conversion disorder. 8:52 Um, they have existed before. They are not brand new, but they have been relatively rare. So they would, most clinicians would see a few cases that they worked for many years and clinics, but not not like they were being flooded with these cases. 9:08 Also suspected besides these here is that this is occurring on a wide scale, So something called a Mass psychogenic illnesses, suspected. So this is what a functional neurological disorder occurs on a larger scale. So a group of people are all kind of simultaneously experiencing similar kind of. 9:26 symptoms. 9:28 So, I also want to point out, like many of you are aware and clinicians definitely now in schools are definitely aware of there’s been an increase in all mental health conditions basically across the boards as the pandemic as stress anxiety. 9:45 And, you know, all the factors related to the pandemic have really increased other disorders and conditions, right? So, referrals for primary tic disorders, Tourette central, persistent motor, and vocal take this or provisional tick disorder, which are for the sake of this discussion. I’m not gonna go over the definition of them in more than this but their neurological disorders. So the traditional tic disorders are neurologically base, and they are sudden rapid recurrent, non rhythmic, repetitive motor movements vocalizations. So they’re consisting of ticks. And that’s what ticks are the traditional text. 10:25 So, there’s been an increase in the tick’s severity for individuals that already have many disorders. 10:31 So, people that already had ticks, many people were reporting that the severity of their ticks were going up as a pandemic unfolded and stress levels went up. 10:39 But also, referrals for people experiencing other comorbid disorders, Comorbid disorders, and stressors went up for anxiety, depression, OCD, just feeling isolated, having more family discord, difficulty with school. Basically, everything went up during the pandemic. 10:57 Um. 10:59 So, the increasing number of of these cases, really, of the functional tic disorders cases, or functional tick like behaviors, really, we’re starting to show up and tick specialty clinics. So there are a lot of places around, are not a lot, but there are many places around the country and around the world that have specialty clinics for tic disorders. And these are, these are clinics that are unique in that they really capture what is going on because they get referrals for take cases. So there was a study that recently came out in this fall where they looked at several clinics in Canada, Australia, London, or England in the USA. And basically they saw a huge increase in these functional tick like behaviors since March of 2020. So pre pandemic. They were reported about one to 2% of referrals. And after March, 20, March 2020, the report, and about 20 to 30% of referrals. So there was a major increase. I also witnessed a similar change in a while. 11:58 I was the clinical director at the Rutgers TS Clinic, which is especially clinic in New Jersey for treating Tourette’s syndrome. 12:05 And in my prior practice, where I have, you know, one of my specialty areas working with text for Rutgers, we had a 97% increase after March 2020 in monthly referrals for females. So basically doubled. We had a doubling of how many females. And most of the females that we had after March 2020, were 14 years old, about 14, 15 years old. 12:32 We also had an increase of 6% monthly referrals for boys. So for males, there was a 6% increase. And for females, there was a 97% increase in referrals after March 2020. And they weren’t all for functional type behaviors, but just in general, we had a huge increase in female referrals. 12:52 So why is this happening? OK, so why is, has been happening? here? Are some of the factors thought to be involved in this search? 12:58 So, we’re gonna kinda just kind of recap some recent events that, I’m sure is on everyone’s mind, and we’re gonna kinda cover functional neurological disorders and more specifically functional, tick like behaviors. Which is a subset under that umbrella, right? It’s actually a more rare subset, It’s not usually one of the more typical functional neurological disorder, so I’m gonna go over that. 13:21 We’re also going to talk a little about Social Media and psychogenic illness and and the role that plays our thoughts will be playing and I’m going to address questions about pans and pandas because pans and pandas, which we’ll go over which is response to the body has, which can result in OCD or Tickler behaviors to. 13:44 Usually a pathogen, like strep infection or an illness, also results in sudden onset of severe symptoms and a kid. You know, I think that’s on a lot of clinicians mind sometimes. This is, that’s going on as well especially since the pandemic virus was going around. 14:00 And I want to address that, because I know that’s not really being addressed a lot in, some other articles about this, so we’re gonna talk about that as well. 14:09 So why is this happening? 14:11 Well, Obviously coven 19 spread. There was a global pandemic. We had a lockdown, people were not going out, everything shifted and changed to virtual virtual work, virtual school. Socializing, one’s virtual. Increasing stress, anxiety, isolation, sickness, even. For many people who are experiencing death either, personally, you know how to someone, they know that they lost or we’re just watching on TV and hearing about it. 14:39 It was a major disruption to life. Something that we have not seen on a global scale, really, in our lifetimes. Right? So this was, it really kind of affected people’s sense of security and is unparalleled. And I would, I would, you know, put out there is no, could, potentially, be, considered a collective, worldwide traumatic experience. You know, whether, how you wanted to find trauma, but it was a very impactful experience for, and it disrupted almost everyone’s life or most people’s lives in some way. 15:08 Um, so I’m not going to go more into that. There’s lots of information out about that on online, so let’s talk a little about functional neurological disorder. 15:18 So, um, functional aren’t neurological disorder. Is something that is, like I said, is also known as conversion disorder, and functional tick like behaviors are considered a type of it, right there a subtype under that umbrella, on basically it’s neurological symptoms. Motor and sensory, usually that are not explained by identifiable pathology. 15:40 So, it’s not, you know, there’s usually many tests that are run, They can’t find any abnormal, No markers, any pathogens, any lesions, anything that would show that there’s some kind of pathology, or we know, as it is, and other conditions. So it can also present similarly. 16:00 two other neurological illnesses, like Parkinson’s, epilepsy, stroke, and functional illogically disorders occur 2 to 3 times more in females and males. 16:11 So, in general, it’s an, it’s something that we’ve known about for awhile, and it often has more females than males. So that the fact that we’re seeing that with the current spike with females is not odd for function neurological conditions. 16:27 Um, there are actually a common function. Neurological disorders are actually a common reason. People see neurologists, they’re one of the more common reasons people go to a neurologist. 16:35 So, neurologists have a lot more exposure to this, then, than even just psychologists or other, you know, other doctors, And therapists and schools, I mean, it could seem kind of rare, but neurologists often have a lot more exposure to this. They’re difficult to treat, but they are treatable. 16:55 Suddenly, it’s important to point out. It can be very disabling, hevery healthcare use can be involved. There’s often a lot of treatment co-ordination between multiple providers. It’s also hard to get access to good treatment, sometimes, people, sometimes at the travel really far, or go to a certain kind of hospital programs. 17:15 Often, it’s disabled to a point where people can’t work or individuals can’t go to school, can be very disrupting. 17:21 Um, it’s very often associated with trauma, stress, but it can occur without this. So, you know, it doesn’t always have to have some kind of stressful or traumatic event occurring. It could be in the past or present, it could be something that happened a while ago. 17:34 It can be more of a delayed reaction, but it can occur that stress, and it’s often often co occurs with with anxiety and panic. 17:45 Depression or dissociation, um, symptoms, and can be associated with pain, insomnia fatigue, so sometimes people have, you know, a pain condition that’s similar to a functional pain situation where there’s not really can’t really identify a cause, or there’ll be a lot of reports of that. So it can be interwoven with these areas as well. 18:09 Here’s some examples of presentations. 18:11 So abnormal movements, tremor, affecting someone’s gait, dystonic movements posturing, and text, but functional texts are relatively rare. 18:21 They’re not even, you know, I’m a lot of people’s radars with functional disorders as much as these other ones. Paralysis or limb weakness, sometimes people just often, they’ll be able to move a part of their body or, we feel very weak. It can be sensory. So reduce, altered, or absence. Skin sensation, I’m hearing or vision could be affected. People could have double vision loss of vision. 18:47 No loss of hearing psychogenic, not an epileptic seizure. So functional seizures is a common one where people, it’ll look almost exactly like a regular seizure, a typical seizure where you would show up on an EEG that someone’s having a seizure. But when they’re tested, there’s there’s no activity going on that it’s a seizure but it’ll look just like it. And also episodes of unresponsiveness that resemble a coma or fainting or just completely zoning out. Could happen. It could also affect someone’s ability to speak. So their volume articulation kept trouble swallowing, have a lump and their throat. 19:30 And there are some others that are related to that can be also added. But these are some common ones that that might show up, you know, in the neurologist’s office or in a hospital setting. 19:41 So, the cause is unknown, bright, we don’t know the cause, and that’s part of what. 19:47 But one way to kind of describe functional stores, the old, older term conversion, I think, does a good job of describing what we think is gone is that the brain takes a stimulus. You know, so, and the old-fashioned version was, like, it was some, kind of, had to be a trauma or stress. Now, We know, it doesn’t always have to be a way, but It takes that stimulus, and it turns it into a physical symptoms. So, there could be some kind of psychological stress, or, and it converts it into a physical symptom is one way to look at it. It’s, it’s trouble with how the nervous system functions. And it’s more of a software problem, that a hardware problem is another way it’s described. So, it’s not that there’s any physiological. 20:24 Problem. 20:26 But there’s, it’s the brain is not communicating in the way It should Some areas that are impacted. 20:32 So, you know, there’s there’s often thought to be a hyperactive, amygdala which controls our, you know, our fear responses and a less active cortex, which no controls are, it is our kind of control center of our brain. So we have less control over our brain. So it’s kind of 1, 1 model. Another model is looking at, you know, there’s a problem with how the top of our top-down, our top to bottom communication, so our brain is not communicating as well with our body. And for a better explanation of these, you know, the brain areas, and kinda some of the MRI research on this. The Trade Association of America did a webinar about a month ago that’s available on YouTube If you just go to their YouTube channel, and there are some neurologists that talk about and kind of the specific brain areas impacted. But I just wanted to put this up here generally. This is this part, the MRI research in the brain areas is not my specific specialty, but so I defer to that webinar for a better explanation, but this is just some information about what we think is going on and functional disorders. Some predisposing factors, right? 21:40 So, we don’t know the cause, but some predisposing factors are psychos, psychosocial adversity being female, having a physical illness, or kind of being exposed to illness. So oftentimes, people who are around a lot of illness or suffering, you know, if they’re caring for a family member has been really ill or in those situations, it’s almost like your brain starts to mimic those conditions, precipitating factors have kind of the triggers. And that might really set it off. It would be like a physical injury, some conflict, you know, some big, you know, some extreme stressors, mental health symptoms. So, having, like, a panic attack or some other symptoms might be precipitating like a trigger and perpetrating factors. Or factors that help kinda maintain it. So, oftentimes, the avoidance of kind of getting back to regular irregular routines, or some aspect of your, life belief about your illness that you know, it’s not gonna get better, or, you know, expecting that will always be a way or some kind of social isolation. 22:43 These are, kind of, you, know, considered to be factors that help maintain this once it starts. 22:50 So before …, the, the functional tick like be here. 22:54 So now we’re done with a subset of function are larger stores. I kinda show you the bigger picture or zooming in a little more to the functional tick like behaviors. 23:01 They were observed in study, right? 23:04 So, you know, there are a bunch of studies have been put out in 20 19 that were really, you know, looked at this or weren’t there’s not a lot of research on it but there were about a year for the pandemic. You know. It’s, it was taught, these are documented cases. 23:17 I as a clinician have had experience with working with these functional tik cases even from my early training when I was at Rutgers many years ago. So, you know, it just happened to come up on my, my case. 23:31 Load through the years and and it but it wasn’t it wasn’t extremely frequent, Alright, So, we knew about this before the pandemic. 23:38 Um, So, it’s new. What’s new now, though? It’s not that these exist is that it’s been widespread and there’s been a surge. So, it’s never been the case that we’ve had you know, 20 to 30% increase in referrals for functional tic disorders and females in like the span of a few months, right? That is not, that is not new before that. 23:58 It was about 1% and anytime What They are difficult to diagnose, and we will talk about that so it can be difficult to distinguish between a functional tick and a primary or a traditional tick. 24:13 And it can be, you know, tough to diagnose when there’s also a lot of other symptoms going on at once, because you want to rule out, you know, what’s going on here. We’ll talk about that too, with pins. 24:25 So, I want to point out here some information, because I think what I’ve seen in other articles and presentation about this, I want to be clear about this, too, Functional take like, here’s may occur on its own. So, someone might wake up one day, and all sudden have functional text or haptics without a history of primary, takes order, you know, and an older age, But it’s also possible, and does they do, co, occur together, Right? 24:49 And there’s the studies that were done before the pandemic. And we know this happens. 24:55 So, there are people that have had that have both primary like regular traditional ticks. And they have functional ticks and sometimes they can be we don’t know if it’s always functional or even a traditional tech for the same movement. So, that can be the case. 25:12 We call it a functional overlay, or it could be, you know, one tick, it seems more functional, or one behavior sees more of a functional air, and other ones seem, it’s primary objects. So this is why the diagnostic picture gets more complex. 25:24 And this is why sometimes, I think, the cases that I actually see come, you know, when I, as a supervisor, and I’ve worked with, and I talk to others about, often seem more complex, and some of the ones that have been reported in the, in some of the articles. And that’s sometimes people, it’s not always clear if they’d had ticks before, or there’s a combination. So it’s not like you have only one or the other, you could have a mix. Some of the research that was done has shown that. it was not always a mix, but theirs. 25:53 But it definitely occurs, where there can be a mix. 25:57 So here’s some examples of these functional tick like behaviors. 25:59 Remember, they’re sudden abrupt and dramatic onset. 26:03 You know, life changing, like all of a sudden, you’re doing something you’ve never done before, and it’s scary, most of these movements that are the functional take away behaviors that come on suddenly involve the someone’s, you, know, corps, their trunk, and their lens right in their arms or legs. 26:19 But often, their arms and their complex movements or vocalizations often things like immediately go into hitting herself, hitting others, hitting objects, right? So wide swing arms as far as vocal tics, kind of immediately go into the more complex and less comment. 26:35 Carpool Layer, Echolalia, repeating yourself using profanity and oftentimes, saying, changing the words you say, you know, can be 20, 30 different words, and, like, the span of a week, it might not be kind of like, a traditional tick. If cop really happens, is not as often. Usually, it’s kind of a similar few words, but it could be just changing like a kaleidoscope of different words happening. 26:59 You can also be speaking with accents. Whistling, and whooping is a common that was reported, complex leg and arm movements. 27:06 And other functional type symptoms. I’ve observed this, I haven’t seen this as much in, the, some of the articles written about it. But I also have noticed that people have other. They have ticks and they seem functional, but then they also have some other functional moves that might not be exactly functional ticks and would be functional. Some other type of functional but kind of loss of functioning. 27:26 Like someone can’t speak for awhile but it’s not know, the usual. If it’s a tick, it’s kinda temporary blocking, it’s like I can’t speak for an hour and a half. Or, All of a sudden I just my legs give out and I fall? And I and, and or, I can’t move a body part. Sometimes it can be tough to figure out if traditional. But often, these are more of a functional type symptoms. 27:48 So, a recent, the recent study I mentioned before, which is one of the bigger ones because remember, research you have not had a lot of time to get together because the pandemic swimming around for two years to get all these. You know, cases. 28:01 Is, um, you know, in this, this study, from the fall, from … time. 28:07 Anxiety and depression are really common. So, in the functional take like behaviors will show the difference between functional layers and tick the, here’s the next slide. This is something that’s really common in. 28:17 A lot of people have the functional tick like behaviors had anxiety or depression and or going on, either before the ticks or along with the text, but often kind of happening before. Most in this study, this was about 20 people that they identified in this clinic, say, so it wasn’t a huge sample, Had no history of previous six, of those, had a history of checks. I think it was three out of twenty, had a previous history of ticks in this study on the ticks were mild. 28:45 Some similarities to primary … 28:46 disorders that they observe, Some of the people that had these functional text change did identify an urge right before the tick happens, which is important for working with, you know, traditional text, identifying the pre monetary urge. 29:02 And functional tick behaviors seem to be susceptible, similar to project source, to distractibility, and suggestibility. 29:08 So if you start telling someone who has functional ticks, oh, what if you, you know, move your arm this way, They’ll say, Why did you give me an idea? And they might start moving their arm that way. 29:20 I’m also everyone in this study of 20 individuals, reported that they had exposure to tiktok videos and tick tock influencers that were people that had text talking about text and showing their texts. 29:36 Also the people in this study, they found no association between acute infections such as what they have in panzer pandas. So this is a recent study. 29:46 Kind of, I would say, the most comprehensive to this point, because it hasn’t been too long. 29:53 So, let’s look at the difference between traditional texts and functional tickly behaviors. 29:57 OK, so, there is, when you look at this chart kind of puts, you kinda see that there are some overlaps, but on the top I wanna point out here, for onset and course, traditional ticks. Normally start between ages 4 and 10 years old, right? 30:14 The functional ticks are almost exclusively happens suddenly when someone is an adolescent, right? It can happen no on either end or later or earlier. I mean, there are people that have traditional text that develop them later, but on average, it’s not. 30:30 It’s not the, the most common that someone would develop traditional ticks later. So, usually, between the ages of 4 and 10, I mean, it’s usually a gradual onset, usually, The most common ticks for traditional ticks are eye blinking throat, clearing head jerking. Takes us start in the header area, and then as someone ages will move to the rest of their body, right, So from a head to tail kind of direction. 30:52 And then, in contrast, that, the most common ticks are functional tests are immediately complex texts. And usually don’t don’t start in the head, or more of the whole body, and moving your arms. So that’s, that’s different. 31:05 The clear, one of the clear differences as is traditional text happened almost 401 more males than females. Functional texts are mostly female. There are some males that have these, and I’ll say it’s only female, but mostly female. 31:21 As far as the urge, you know, there is most people to have traditional ticks report an urge for. The tick happens usually it’s something like an itch or feels like before you’re going to sneeze. Or some kind of pressure, or an uncomfortable. That’s in the area of the tick, Most. People don’t report a pre monetary urge for functional texts, but some do and when they do, it’s often different. It’s usually like a whole body kind of sensation. Like a pulse of energy suppress. Ability means how much you could hold back your text. 31:52 Often, people with social decks can suppress their ticks temporarily like holding back assays, but people with functional tics often report that they can’t really suppress it all. Or if they do they feel symptoms that don’t normally get. Describe that people hold … of just kind of malaise or dizziness, or even pain or nausea. 32:15 As far as some similarities, both traditional text and functional text can be impacted by the environment, right? So in certain environments might happen more or less or distraction. 32:27 The most common comorbidities traditional ticks are OCD and ADHD. 32:31 The most common for functional ticks are anxiety, depression and both can be susceptible to suggestion and reinforced by attention from others. 32:39 So this, I think this chart is pretty, kinda, gives you a good picture of the different. So let’s talk real quick about social media and psychogenic, Mass Psychogenic illness. 32:49 So a lot of people have been watching tick tock, tick tock blew up from like a few million views like 50 million views in like 2 or 3 years so like over. 33:00 No. 33:01 I forget the number of billions of views, right? The hashtag Tourette’s has been viewed billions of times, especially in the past year. There are popular influencers, online, people to do things like the … alphabet challenge where you have to know the people will say the alphabet while they’re taking our try to say it without taking. Many people view these videos, you know, obviously billions of viewers have viewed them. But also there’s, there’s many, many people that post about their own ticks on social media, so getting kind of a lot of attention from that as well. 33:34 So some things I want to point out about this are, many people who are experiencing these sudden onset texts were reporting social media and some study. It was as everybody in some studies. 33:44 It was a lot of people, you know, like 70% to 80%. 33:50 So, it’s definitely a correlation there with it, ticks. And functional ticks are susceptible to suggestion. So, I’m watching other people do it. 33:59 You know, is, is, can you influence just anyone who’s been at a tick you know, conference or convention or in a room with a bunch of you? 34:07 Who have ticks knows that you know it could there could be no, it could set off an effect in the room where a contagion effect, where someone might ticket and someone else might copy that. 34:16 Tick An echo it back, and it could set off our room of ticking. 34:21 As far as tips being reinforced by consequences, attention, and support, a sense of belonging, which are all part of the social media are there. 34:28 And that’s all part of it, but I do want to point out, again, not everybody who had the sudden onset of ticks reports watching tiktok. 34:36 So it’s hard to say this is the definite cause for everybody. 34:42 Matt Psychogenic illness I want to point this out. This is a really fascinating area of study of humans. It’s when it’s a rapid spread of functional symptoms among members of our cohesive group. So social contagion, so it’s functional disorder on a group level happening at the same time. 35:00 In history, you know, it’s it’s been there’s documentation of comments of nuns who all start making barking noises, you know, like 400 years ago or the Salem Witch Trials. Recently, about 10 years ago and leroy. In New York, it was all over the media. There was a group of about 19, Mostly females ranging in age from teen to young adult who had a sudden onset of ticks of functional texts, right? 35:27 There was lots of, you know, media coverage and they were looking for contaminants in the environment or cause causes so, It can happen, so, it’s not but, But, it hasn’t really happened on this scale with functional tests, as far as, you know, anything we’ve ever seen. 35:42 So, common characteristics of functional psychogenic illness are a cohesive group, increased anxiety, because he’s, he’s a group in this case could be, you know, that everyone’s on tiktok together. Increase anxiety the pandemic. 35:56 Spread a sentence via sight. Sound communication. Very go. And high female ratio. 36:04 When there’s confusion about the cause when people have this illness, like, so, unlike leroy, New York when it was disagreement, you know, is it talks in the environment? Or, there’s different experts, not agreeing the symptoms tend to be worse, right? So when someone, you know, we don’t know the cause, is it seems to make the symptoms worse. And it’s not as studied as as individual function or a logic disorder, so there isn’t a great deal of research on this. 36:27 Um, so let’s talk about pan’s so pediatric, autoimmune neuropsychiatric disorder or pediatric acute onset neuropsychiatric syndrome, right? 36:38 So panda’s, I think I spelled it wrong here, so I mean, we did. So pandas is with strep infection, is involve and pans is when there is other pathogens or other causes? Pans is now, … is now considered kind of the umbrella term for these both these areas. 36:58 So it’s also a sudden, onset of severe behaviors, Usually, it involves OCD, but also, restricted eating tix, irritability and aggression anxiety. 37:11 Be like moods instability, ADHD symptoms, it’s sudden, and dramatic and scaring. Males tend to have it more than females and median onset is age seven. 37:20 And so right there, you can see is a difference between the functional ticks, It’s triggered by infection and inflammation. And immune response is what is thought. 37:30 So researchers recently, the one I just talked about from 2000, this past fall, did not find a connection. 37:39 And I want to point out that panza Pandas remains controversial in the medical community, OK. 37:45 Um, meaning that some studies have shown connections, others have not to strep infection and ticks. 37:53 But, there, it’s, it’s it’s a: it’s definitely something that’s recognized. 37:58 In a lot of, know, universities, clinics, you know, will and physicians out there do see this and treat this. So, I want to point this out about hands, we know, to kind of look at what’s going on. 38:10 There are some cases Post … that might involve panzer pandas just as it was before. The Cove it happened, right. 38:18 So, but pans is not currently linked to the current surge of cases? Right? That’s, that’s what I think, that’s the best answer I can give about this, is that, yes, there are some cases, the pans out there, but it doesn’t seem to be linked to the current huge surge of cases. Or researchers have not found that link. 38:36 Or most researchers, there hasn’t been, you know, a lot of lot of studies but really nothing that’s, you know, at the forefront of what they’re thinking. 38:44 Stressful events of covert have worsened sentence for people that have, hands already are. 38:49 So it’s possible that you’re seeing more exaggerated just because of all a lot of conditions or worse with the pandemic occurs, in people, Panza curves deal with or without primary texts as people get haptics and also have worsening texts with an infection through like a pan’s like reaction or they can just have it on their own. 39:09 Um, it’s possible to have no, it’s theoretically possible. I have functional ticks and pants as possible have functional text pans and primary texts, you know, as far as, you know, possibility. Yes. 39:21 I mean, these these are some things that I think some clinicians try to consider that it seems like sometimes there’s complex cases where it seems like there might be a bunch of factors going on. A treatment for Pan simply involves medication, CVT and Parent Management training. 39:37 So it’s usually kind of addressing if there is an underlying infection or inflammation. And having Cognitive Therapy is really important to address OCD, and also, and also a lot of parent management training to, you know, work on iOS. The OCD and other behavioral problems that come up with pants. So this is not a discussion on pans out. Like I said, this is a, this is a kind of a quick summary. I know there’s probably a lot of questions about all these areas. I just wanted to kind of cover that. It doesn’t seem to be linked to the meet the big surge. But I want to point out that it’s possible that it could be involved in some of the complex cases we’re seeing. 40:14 So, let’s look at this together of why this is happening. 40:17 There was a shared global stress of the pandemic which led to an increase in mental health problems. Functional ticks have existed before the pandemic. Females have historically had more functional disorders than males. 40:30 Functional ears can coexist, primary tic disorders and social media use have played. A big role in the mass development of functional behaviors explains many, but not all cases. OK. 40:40 So that’s kind of a summary of what I just went through. 40:45 I wanted to talk a little bit just quickly about my clinical experiences as from supervising many cases And during the pandemic at the Rutgers Clinic but also my own work, psychologists, I’ve seen a lot of complex presentations, mostly females, that are teens, almost exclusively, females that are teens. 41:05 Most of the cases aren’t going to have a mixed symptoms which seems you know, often traditional ticks. Some possible functional tax … and there are some times and also some cases been possible pans. Either it seems like there’s some kind of potential hands going on in that, you know, they were getting treatment for that. 41:25 There’s been some acknowledgement of tick tock. 41:27 It tells me, but I was saying like, My experiences through cases I worked with and um, even supervising at Rutgers the students in many cases there, it’s really I would say it’s not. 41:40 It’s maybe 60% to 50%. 41:42 Sometimes less, you know, knowledge and a social tick tock. 41:46 So my professional experience has spent a lot less acknowledgment of tick tock social media whether they were being honest or not or But I take their word for it. 41:55 And often people have a history of at least mild tics, anxiety and depression. So obviously there’s just a sample I do want to talk about this one phenomenon that is kind of not talked about it anymore and it’s like almost written out of the books. But for many years, for like 100 years, this phenomenon called love ballad difference. It’s terrible pronunciation. It’s a French term. It means a beautiful ignorance. It’s basically a situation where there’s like a paradoxical absence of psychological distress when someone has a serious medical illness or symptoms, right? So, kind of where someone has really, overnight, you know, just cannot, often cannot do something. It’s a huge illness or something going on, and they almost seem like they’re not really that concerned about it or the level of concern. 42:40 Um, just seems really not that high compared to what you think they would be right? 42:45 Like a few offsetting couldn’t, um, no stop moving your arm and flapping it. 42:51 You think the person would be very nervous about it. But oftentimes, there’s kind of a sense of just, kind of, like, oh, it’s going on. Now, this is no longer used to diagnose rule in or out functional disorder, but, because it occurs in other conditions as well. Not just functional. But I found it quite occurring quite often in functional cases. 43:08 Where the parents, or will often be extremely concerned about selling and the individual, kind of, just, kinda just be there and talk about it. 43:16 But not seem as concerned that like all of a sudden, can’t stand anymore, Know, for a few minutes, and then, you know, just, it. Just, there’s just a sense. So, I’m not saying it’s a way of diagnosis, but I definitely think this is phenomena that happens. And I think that clinically, it’s helpful to know about it. Because sometimes it can, you can kind of work with that with someone to kind of work on their motivation, and also have in their understanding what’s going on. 43:44 So, how to help? So let’s go over some treatments and coping strategies that might help. 43:49 So, here’s an overview. 43:51 Now, there is so much here that we can, every one of these could be its own presentation, So, I’m just gonna give a summary. First step is to find professional help and get a diagnosis. 44:02 Second is to get your own personalized education after you get this agnos about what, what is the diagnosis, how does it work, and what’s the plan? 44:10 Comprehensive Behavioral Intervention for ticks. … is still recommended because there’s definitely elements that can be helpful. 44:18 Addressing comorbid anxiety. depression is often an essential component to working with functions. Or sometimes that’s the main thing you’re going to do. 44:26 If you have more functional symptoms that aren’t just ticks, or the ticks are more creating some kind of real difficulty in, like movement or functioning, sometimes, people might need more of what you would have for traditional functional neurologic disorders like a rehabilitation and motor retraining program. So we’ll talk a little bit about that medication. Alternative treatments, I’ll discuss school combinations, and take home strategies. So let’s go through this. 44:53 Um, so first, you want to find professional help, right? The first step is usually see your primary doctor, right? The first F for some people, is go to the emergency room. Honestly, if it’s really sudden and severe, but then you’ll probably follow up with your primary doctor. 45:09 If you already have a neurologist, you know, you might go to a neurologist right away. Obviously, if it’s really a scary onset of symptoms, emergency rooms, probably going to be where you end up. But they usually contact your primary doctor, especially you have good relation with them. 45:25 It’s gonna often involve a multi-disciplinary team to help diagnose or work with this, and really in the medical. You want neurologists usually, You want a movement specialists, neurologists, or Mood Disorder Specialist neurologists that, that most, or all this would be fine to identify it, but a movie specialist might be a little bit more knowledgeable. 45:44 You need often, having a psychologist or other trained therapists who works with ticks involved on, preferably, they have some idea about functional techs. 45:52 It’s not easy to find people that have a lot of experience with that and, and ticks. 45:57 But, there are, there are psychologists and other therapists that they have training in functional disorders. 46:02 School is important for their teens. 46:06 Getting the administration on board to be flexible is probably the first step, right? Like, Hey, my, my kid, all of a sudden, having a sudden severe onset of symptoms. We don’t know what’s going on. Can you give us a break? I mean, that’s kind of the big thing for schools. You know, so while we figure this out, and if needed, like I said, there’s more functional ticks or there’s other functional neurological conditions you might need more of the rehabilitation route, which involves speech, OTI, physical therapy, or combination of those. 46:36 So, and getting the diagnostic picture, what is this is this primary check functional six is this sudden onset pans condition, others are combination. There’s lots of things to figure out. 46:48 So, getting your education, and this is pretty straightforward, you know. 46:51 But it’s very important in functional neurologist’s order. 46:56 Research and literature, you know, and anyone that works as condition, The first part of treatment is almost always giving a diagnosis explaining to a client and their family. What this is right in, this could be a huge thing. Because some people might swear that this is not, this has to have some kind of biological cause there must be a toxin. There must be a reason, and it can be really tough for someone, and they can, you know, feel like you’re not hearing them. If you say this is functional, and we think it’s more, you know, kind of, psychologically base, it’s in. There are largely, you know, it’s, there’s not a physiological cause. 47:33 So, what one way to explain it is to say that it’s an, it’s a known unknown, right? We didn’t know exactly the cause What we know about this. We don’t have specific cause it’s treatable. It’s not your fault. It’s a problem with how your brain works, right, There’s better outcomes when the patient and doctor an agreement. 47:49 Often, people are not an agreement. There could be multiple doctors that don’t agree. 47:54 So, this is, sounds easy, but it’s actually really not easy, and in real life, so often, when people are on the same page, it could be helpful. 48:03 And sometimes, you know, there’s a, there’s a lot to rule out, I think one area of that happens a lot is, people really searching for a possible pan’s diagnosis, I’m looking for some kind of pathogen. And not being fully satisfied that there isn’t something that could be something, when, it seems clearly more functional at time. So, I think that’s something that comes up a lot. 48:27 Treatment involves retraining your brain, Right. And I think that’s analysis explained. We have to retrain your brain to kind of have normal and retrain it to have the normal automatic movements. Again, are voluntary movements, again. 48:39 And you want to review a treatment plan. 48:42 So, as far as … concerns and this, if you’re interested in learning about e-bay or comprehensive behavior intervention for ticks, I have a whole webinar on it. There’s lots of information out on the web about it. Now, it’s, It’s amazing. How in the last, you know, 16, 17 years, it’s become like, you know, normal to talk about this. 48:59 And the top treatment years ago, it was considered, you know, forgotten about and, and you can’t do this with text and now it’s pretty popular. So I’m just gonna give you a quick overview now about this. but save it involves usually a combination of something called habit reversal and functional based strategies, with some relaxation training. 49:19 So the functional strategies can be key for functional ticks. So this is looking at really modifying the environment, looking at what happens before and after, The symptoms occur, the antecedents and consequences. So kind of looking at mitigating potential triggering, exposures, reducing and eliminating social media exposure can be the number one thing you do. Just. Alright, we’re not watching tick tock. Is that people taking anymore right now? 49:43 Like Let’s just stop our YouTube. Reduce attention for it. 49:48 So how parents around react to what is going on, modifying, you know, responses? and Considering it through secondary gain. So this is not what’s this happens. 50:00 In many conditions, not just functional conditions, but sometimes, you know, if someone has something that’s debilitating, they might, you know, not have to do some things for awhile. And it’s not why they’re doing it. It’s just they get these other. And so, considering, you know, all of a sudden, you’ll have to do schoolwork again for two weeks, considering that as part like, well, let’s try to incorporate some schoolwork or some other aspects in. 50:20 Obviously, everyone will have an individualized plan, regular habit reversal, right? This is what works for primary text, So the traditional text, Sometimes you can try this, because we don’t always know if it’s functional or not, and it might work. And, and I’ve found that it often does, Because it’s seen something that might see more functional, Could be more primary, so it’s a way to kind of try it out. So, it involves kind of be more aware of that, that tick urge, before it happens, in describing in detail, so we do awareness training. Once someone’s aware of the tick, we will incorporate an opposite or competing response. 50:55 So, it’s catching the check for it happens or interrupting it as it’s happening engaging an incompatible behavior, um, and holding this for one minute until the urge goes away. The other part is having a support when you’re working on this, right. 51:09 So having family support you, one thing I’ll say I have a reversal is it’s not an alternative or replace of behavior, we’re not replacing the tick with another behavior that satisfies the urge. 51:21 So we’re gonna if someone moved their neck when a regular ticket, traditional tech because they have an urge in there there the farther back I wouldn’t have them move their neck another way to satisfy that, urge this is a competing behavior. This. This is an opposing response. We don’t want to satisfy the urge. 51:40 Um, so addressing comorbid anxiety depression is often, I would say, that the top three things you should do for most functional conditions. If you reduce the stress level, you often see a decrease in the functional behaviors for, for, especially the functional tests, for many people. 51:57 And in traditional ticks as well, particularly these behaviors, So, Cognitive Behavioral Therapy, suing, you know, restructuring, how you think about situation, relaxation training, Potential exposures to anxiety, situations that are feared or, and behavioral activation for depressive behaviors. So kind of not avoiding and withdrawing, kind of getting back into your life and more active other CBT modalities, like motivational interviewing, DVT, mindfulness act, incorporate a lot of these aspects and can be very helpful for that kind of reduce the anxiety and depression. In general. 52:36 I will say, on here, stress management interventions, problem solving, is sometimes not thought about. You don’t have to sometimes go to some intensive therapy, sometimes. Just think what is causing this individual to be extra stress, right now. Besides these, you know, oftentimes with teen girls, it’s, you know, starting high school, having, you know, sometimes the pressure of the class at the academics. There are a lot of students who feel very pressure after having, you know, virtual learning, getting back into more rigorous academics, or some students simply take AP classes as a freshman, and I’m just, I’m exaggerating and they don’t sleep. And that might be something that you like, maybe we should reduce that now. So, sometimes, the Stress Management, … and problem solving them can be the very first strategy that you don’t need a professional for it. 53:23 You can think about two to help bring the volume down and everything, um, and supportive Talk therapy can be helpful, as well. 53:32 So, rehabilitation motor returning, this is not gonna, by any means, B is just one slide on this. This is the whole topic that I’m do not first, professionally, do too much of. This will happen more in an inpatient, usually, or, or even an outpatient. 53:45 But in a hospital kind of such situation, or but it involves basically retraining the brain too, for functional conditions, oftentimes it’s for, you know, tremors or loss of movement or the psychogenic seizures. Kind of noticing you know the patterns there, but it can be modified for ticks, possibly. There isn’t a lot of research on that. But the idea is that you’re in one thing I’ll highlight here is this is a good I have resource at the end of this. 54:17 Nielsen paper kind of gives a lot of examples of basically retraining and movement. So someone might have trouble with their arm. You might have them focus on their other arm, they have more voluntary control on and divert their attention. And practice moving that arm in a controlled manner to help kind of bring the other arm along. So there’s different ways they use distraction, diverted attention to retrain movement. They will, you know, try to reduce using adaptive equipment. So kind of typical rehabilitation aspects. And there’s a lot of psychological aspects of I of challenging your beliefs. You know, maldef, beliefs and relaxation. 54:54 So let’s talk real quick. 54:56 I’m almost done everybody if you’re, I know I’ve been talking non-stop for awhile. 55:00 But medical, OK, So for the many cases I worked for primary or traditional ticks, like Tourette syndrome ticks, are you? The Antihypertensive the alpha two drugs …? Clonidine, intuitive is the Center Released Club scene, and the neuroleptics atypical, anti-psychotics are, or the traditional psychotic anti-psychotics that works the best for ticks. They usually have little effect on the functional texts, right casually. You will find that placebo effect where somehow miraculously Cup recover better than a one primary text would by giving a, you know, one dose of a medication or something for functional ticks. But often, there’s little effect on what’s most usually A targeted are the comorbid anxiety depression medication to address that like SSRI’s like Prozac is all off. Those are common ones, lexapro. 55:53 So other medical procedures like Botox and deep brain stimulation, which are used for more severe cases of Tourette syndrome or other primary tic disorders. I’m not typically used for functional ticks. Botox would address some pain. Usually it’s for a painful neck. Tick, some docs. I’ll just put this on and it’s not recommended for promotional text. but a lot of people are, you know, we’ll still try to rule out panzer. Pandas are there, particularly because it’s it’s hard to find, sometimes, if something was going on. And so, some people will be taking, you, know, prophylactic antibiotics or probiotics or anti inflammatory medication, it’s not recommended. I’m not recommending I’m just saying that sometimes you’ll find people that are trying to just rule, that out at the same time alternative treatments. 56:41 There’s limited or anecdotal evidence on but some families try THC or CBD supplements are THC CBD or supplements right. 56:51 There was very small study documenting people that have functional tests using THC or CBD Mix. I think there were self medicating. I don’t think it was a controlled study. 57:05 It show that they had some improvement, you know, so I’m not saying it’s, it’s very, I would think there were five people documented, but, but it’s just, you know, it’s in, and for primary and traditional ticks are still is not a lot of research on marijuana, or THC CBD for it. 57:22 So it’s something that is not, it’s still considered alternative, right? And there’s no supplements that are known to cure functional tests. 57:31 Like I said, it’s more of a psychological, um, root cause of a software problem that a hardware problem. Hypnosis: know, in thinking about the suggests ability of functional disorders, there’s some research that shows that it may be helpful. I will be careful just jumping to anyone that doesn’t know this and try to maybe go through a functional center where people focused on functional ticks or functional disorders first. But it possibly can be helpful. 58:01 I don’t know much more about it than that. So, I know there might be questions. But that’s just, you know, there’s been some research showing it’s helpful. I don’t do hypnosis with functional, but I just want to point that out. 58:12 Educational combinations. 58:13 Like I said before, sometimes this needs to be an immediate stopgap because these are a sudden disruption in someone’s life. So, school people, if you’re listening, I obviously I worked, I worked in schools for 13 years as a psychologist and administrator. 58:27 So I, you know, I understand the complexities of this, but sometimes you have family in this situation, if you can just be flexible and beginning. It’ll change maybe in a few weeks, but try to reduce the stress, the load, and modify the work heavy liaison in school. 58:43 And he’s options could be helpful with any tick disorder. Functional or primary, I think, general coping strategies are what most people use to get through their day. So, distractions, fidgets. Gum breaks, having a stress ball, I mean just in the environment to make it more relaxing. Healthful activities like sports, music, yoga, or it shouldn’t be overlooked as as, you know, helping to reduce stress and also improve the quality of life for individuals going through these situations. So, some take home strategies and then we’ll take some questions for addressing functional tips. 59:18 The first thing I would recommend after, you know, going to your doctor, you know, and it’s greatly reduced social media exposure if it’s, you know, at this point we think it’s, it’s linked. So it’s not to punish the individual. 59:29 It’s because, you know, if these ticks really disruptive, let’s try to like, see what happens if we reduce social media. Exposure easier said than done for most. I get it, reduce attention for the functional behavior, so try to increase attention for other behaviors and reduce attention for the functional tests as much as possible. 59:45 Obviously, if there are self injurious behaviors, you can’t just ignore that, obviously, at the tick safety consideration, but to try to not focused on them as much as you can. Reduce general life stress, You know, consider the course load of people in school, activities, exercise. Are they basically busy all the time and not stopping? Maybe we need to like, slow this down a little bit. 60:06 Increased stress, reducing activities, downtime. Exercise. since they enjoy. And try to get back to know more. Teens, a little, you know, as soon as you can, even if you’re gradually getting back into your routine, you know, and trying to think about, you’re trying to get back in, school. More. in person, you can have less time socializing and not just with your caretakers, right? 60:24 Because a lot of times what happens is you will find themselves with their parents all the time now. So you want to kind of try to get back to Margaret, normal routines, reducing doctors appointments, if, if you can write and reduce how much the family and parents are accommodating of behaviors. So there could be oftentimes a relationship between how much attention that kids are getting, and how much they depend on their parents. So trying to, really the theme is trying to get back to normal and reduce stress. 60:52 Roles for different stakeholders, I forgot about this slide, sorry, everybody, real quick? 60:58 Individuals with functional take stay positive, This is treatable. 61:02 Work on your motivation, right? 61:04 Parents, find providers, reduce stress, minimize attention. Stay calm in front of your child. 61:09 Try to, if you try to stay as calm as you can, I know it’s easier said than done. Clinicians communicate with each other. 61:17 There’s often many conditions, and we know we don’t do a great job, always communicate with each other, so let’s try to do a better job, if we can. And schools be flexible, understanding, accommodating. 61:29 OK, so, sorry if that was too long, Kelly, and everybody. 61:33 But, it was, it was, that was a reduced amount of slides compared to an app, before, this is a huge topic with lots of areas. If you’re interested, there’s resource on the slides on referrals …. Who does this webinar is? Basically, your source in New Jersey. If you’re outside New Jersey, the National Trade Association has a listing of trained certified providers, receive it in other areas related to text. 61:57 There’s online cebit training for tick helper dot org. The trade association has a website on their page, a web page about this situation that has a summary, kinda similar or what I went over. 62:11 And they also the webinar, I mentioned that here’s the link to if you go to a website, they do a webinar on this topic as well. If you want websites, there’s a bunch of information for function neurologic disorders. Most of them are in the UK or Australia, or in Europe. But there are a bunch of resources. Stanford has one for, if you have kind of functional neurologic disorders describing it and there’s some of them are for Kids. Neuro Kit is kind of a good one for children. 62:36 Um, OK, here’s my contact info. My prior practices and roles and New Jersey, I do virtual though, licensed in New York New Jersey amps. my PSYPACT, licensed me. 62:47 I can work in, like 36 other states is pending as soon as they approve it, so as to be able to work in other states virtually as well. Tell therapy, Luis …, and the references are all here. 63:02 All right, So, Kelly, there are any questions. 63:04 There are people still on, or they are go to sleep at this point. 63:09 They haven’t been asleep. And yes, they are. 63:13 They are still hanging in here. So. So we’ll start with our first question that came in. 63:20 If a teenage girl had a simple head neck, head neck motor tick From April of 2021 to January of 2022 then began a sudden onset of short vocal, tics, and more impressive head neck and hand and motor cortex. 63:41 Would this be a primary check disorder and a functional tick like behavior or just worsen primary disorder? 63:52 Um OK, so I didn’t I didn’t write everything you down. You sat down. So it started with what Area, Kelly. 64:00 It was I hadn’t motor tech. 64:04 Yeah, I’m head and neck. How old is this person? 64:09 Not listed. 64:11 OK, I mean, it doesn’t sound on. That doesn’t sound like a functional tick to me, but it could. There could be some functional aspects to it. 64:19 I mean, starting with the head movement is not and if it was a, it was a teenager and it was you know, involving other complex movements all overnight and it wasn’t as gradual but traditional tic disorders to come and waves the wax and wane. Right? 64:36 So as part of my cutting this presentation, I didn’t go into all the aspects of traditional tic disorders. There’s a lot of, I have other presentations on that on this website, and there’s other ones. So um, but take disorders, even the primary ones wax and wane. 64:49 And they can start with a few ticks and then it can kind of all of a sudden seemed like a lot are coming on at once. 64:56 But generally, the difference is, they usually have a somewhat gradual start at the beginning, and they could have like, know, they can just jump up at some point, The functional ticks usually just come on like a bang. 65:08 It’s like overnight, they’re all there and complex. So I can’t I am not in a position to diagnose someone. I don’t know. But I would say it sounds more primary to me from what you’re saying. 65:19 But no, I guess you’d have to talk to a professional. 65:24 Like I said, there could be combination. So someone can have a lot of people that have these functional ticks that I worked with seem to have primary ticks as well so we don’t always know what have to be really be rolled out. 65:37 I have a child who’s Tix didn’t develop until they had a Tech Talk account at 16 mm. 65:46 When they check, they mimic the same texts that are on the popular tick tock, OK? 65:53 They look at the parents for a reaction, and they appear excited about their tix, looking to ensure we witnessed them, which I know is not typical of test diagnose children. What’s the best approach in these situations? 66:12 Um, the best approach is, like I said to minimize, minimize attention, right? 66:18 Like tonight, I would say, you know, you can obviously go to it, one approach. I don’t know what approach you exactly mean, but if you mean, you know, how do you can always go to professionals like psychologists, or to just kind of rule out what’s going on, you know, see if they’re more traditional text. And if they are, you can work on them. 66:38 Or even functional tests with some of this, know, the C bits. we talk about or addressing other comorbidities. 66:43 But if you’re talking more about how to respond in the moment, I would say that kind of what I had in the take home slide of, um, minimizing attention. You know, if they’re looking for your attention, it’s fine. I mean, you can avoid a child in front of you doing something. But, and looking at it, but I would just kind of have a minimal response and try to focus on the behaviors you that aren’t the text, you know? And like, oh, are you talking about something else to distract them? 67:09 No, but kinda let it happen, and kind of be minimal. And then later on, putting up the other, you know, I wouldn’t, I wouldn’t give a lot of attention for either anything while it’s going on. 67:20 Would you recommend a, quote, dopamine diet? 67:24 That is a break from social media to weed out the rewards of affirmation for exhibiting certain symptoms versus not having that reward for potentially mimicked behavior. 67:43 Well, like I said, I think, I think it’s a tough thing to tell a kid and take it off their social media account, That’s a huge part of their life. 67:52 But if you’re seeing, if you’re seeing these, if you’re seeing a lot of ticks, I think, um, some parents, even with traditional texts, while sometimes, you know, reduce how much technology that kids have. I don’t like to across the board recommend doing that. 68:05 Because sometimes every situation is different. But I would say if you suspect there’s functional ticks, is something you can consider is taking a break and see how it goes. 68:16 Know, let’s let’s kinda went and I would try to get your, your teen or your child on board. Like, hey, this isn’t really let’s see what it’s like to not do this and maybe replace it with something else, is enjoyable for them, or make it worth their while so they don’t feel like it’s a punishment. 68:35 Um. 68:38 So I have a my next question is really long. 68:43 So I’m going to try and truncate it without losing anything. Recently, research literature literature suggests that the *** ratio of … spectrum disorder is incorrect. 68:58 And that a difference is actually better defined by a variance in system presentations. Is it possible that that is the same occurring with T S and tic disorders. 69:15 I mean, I would say it doesn’t seem like that’s the case, but it could be possible. 69:20 I mean, I don’t the tick, the degenerate. This the *** breakdown for Trad Syndrome has been cut or else it’s been pretty consistent for a long time. 69:31 I think there um, I think tic disorders are potentially in some ways, easier to, know, pick out, then, autism sometimes and that, you know, you visually are looking for, motor ticks are vocal tics, so I, I, I don’t, really I think that there is though something to be said in that question that? 69:55 There isn’t there is research out there and looking into kind of how females experience, you know, biologically females of the experience tix, protect and how that trajectory goes. 70:07 This is traditional text over time, particularly seem to have, um, maybe slightly poorer outcomes as adults, and there could be some differences, Better there, but I don’t think that the ratio is totally off. I mean, it’s, it seems unlikely, but it’s, it’s possible. 70:24 I don’t know if it’s a thousand tough questions Answer, simply, but, no, that’s good point, though, there there are, I think there’s still really trying to figure out if there’s, you know, the gender differences there, and how it’s experienced more, more than the ratio of how many have symptoms. 70:47 The functional, the functional disorders have historically been more female, though. 70:52 And, really, we’re not really sure why. 70:56 It seems like some, kind of, it seems like there must be a, some kind of, genetic or biological link there. 71:03 But, I haven’t, I haven’t, I haven’t really got an answer on that one. 71:11 My daughter has a history of panic attacks, and now has an anxiety disorder diagnosis. 71:17 Both of her brothers have diagnosis of Tourette syndrome, and since cope with 19, she has been worse. She has a neck, chick, and an armed flap. 71:31 Both arms would do something when she had night terrors. 71:36 She also has a past history. 71:39 Scoria Show, I’m wondering, do you think she has Tourette’s? And is it coming out now, or is it just related to the search? 71:48 You’re talking about, she has court. 71:52 It’s, well, I think, I think you really have to goes, get it checked out by a neurologist that Swabbing recommendation. I can’t diagnosis from a question. I think there have to be. 72:05 I think that there’s so many possibilities when I hear about two cases that I think you really have to take each case and, um, talk about it. But I think it’s, I think it’s possible either way it’s possible it’s a manifestation of a traditional tick disorder that just got worse and teen years and may be exacerbated by the stress. 72:24 Other pandemic it could be a combination or, it could be possibly functional tics. 72:30 But I think that you’d have to go to a neurologist I would say a movement specialists, Neurologist too, would be a good start. 72:41 Next question, I think, my daughter has a functional tick like behavior, she ticks. In quotes, sorry. Every box you had mentioned including the sudden onset of complex. Physical and vocal tics, she’s 14 and watching tick tock. Tick tock videos before sudden onset of set of behaviors My husband is still very worried about something physical. Although she had an MRI and EG, a lot of other tests MRI. Wasn’t clear because of. 73:24 Races. 73:27 And our current neurologists and therapists think we should treat this like a functional tick like behavior. I’m worried, I’m worried because it’s. 73:42 Avoid it, yeah, my, my apologies. They’re avoiding additional doctors and testing because it’s making things worse. Is there any advice for our family? 73:59 Well, I wait, um, I mean, if you’re a therapist and the doctors can work with you, and as they’re, if they’re functional, you know, kind of working on some of the functional interventions, like, like that or and save it, you know, trying to modify the environment, reduce stress. I would work on that while, you know, if they’re still looking for some path, a lot, You know, some biological cause of this. You can always do that, while you’re getting the other intervention in place. 74:25 But, remember what I said before, that, oftentimes, is functional conditions. The biggest part is, is having everyone on the same page about the diagnosis. 74:34 Oftentimes, people are worried about, you know, being, Yes, they know the function diagnosis. Often hard for a lot of families to take in that, it just, it seems like there must be some kind of cause. 74:45 So, you can always, you can keep looking or, you know, maybe, you know, go with what they’re saying and work with them on, you know, some strategies for that, you know, as as we outlined here, whatever they’d recommend. 75:00 Do believe there’s any correlation between sudden onset ticks and the and the increased level of rust rough housing socially inappropriate, physical, touch interactions seen from younger children and adolescents. 75:20 I don’t, I don’t think that is linked to this current surge. 75:24 Think this current surge is more linked to people watching the, you know, the I think a lot of the case in the surge were linked to the tick tock videos, right? But I think there’s other other aspects like, primary tic disorders have surged. 75:39 Have gone up the case have gone up for regular tic disorders during the pandemic and I just think that I don’t think that’s the specific type of video, but it’s possible that they’re linked to it. 75:54 It just seems like that is not what we’re seeing. 76:00 The sun at 16, and he wanted to spread awareness of tourettes until he reached high school. Now, he doesn’t want anyone to know that he has that. 76:10 I’m concerned has ticks have started again, and can looking at tech talks and social media make that worse? 76:21 Like I said, I don’t want everyone to come up off this and like immediately take all their kids off social media, because they might not be happy. 76:28 And I don’t wanna get many angry phone calls from like people across the area saying, you know, why, or am I not allowed to be on social media more? 76:36 I would say that ticks wax and wane naturally, right? So if your son has had a son, right? I’m trying to remember, it takes before And that there are coming up against Particularly if you 16 there, could be more stress going on in high school at that age. It’s not abnormal for ticks. Just don’t go away for everybody. When there’s a teen, sometimes they come back. 76:58 With that said, you know, there’s many factors that can cause primary ticks, regular, typical text to, Be exacerbated, right? So sometimes, people in general are six or more exacerbated by stress, or tiredness sometimes excitement. So sometimes, for anyone with ticks watching, social media or entertainment or playing video games could get them the tick more, but that doesn’t necessarily mean it’s a problem, right. 77:22 My, my working model for working on T X is this. There are four reasons to work on tax, right? Otherwise, I generally would say, like, just let it be, though it’s if it’s not cause any problem. 77:33 If it’s causing still in pain, if it’s could cause an injury if it’s really bothering the individual that’s ticking, and they just don’t like it. Or if it’s potentially or is disrupting other people or insulting to other people around that, right? So, so, if, if your son is having more text, but it’s not really causing him distress or bothering, parents sometimes would be concerned that it’s, you know, socially not going to be the appropriate. 78:01 But I think you could work with your, you’re your child. You can say, Let’s try not doing social media for a day or two and see if it helps. Reduce it, if you want to do that or they might say, I don’t want to, I’m 16. I want to be on my social media, I don’t really care. So I think it really depends on the individual and when I work with people in these situations we kinda talk about the pros and cons of both and. 78:20 um, know, I think it takes can actually wax and wane. Yes we think that they can be spurred by suggests ability from the video. So one thing you can say specifically is maybe don’t watch the tick tock videos or the Tiktok video is about ticks. Like that might That might be we think that might have a more specific link to it. 78:40 As, you know, Suggestibility is like you know you’d be on, watch your YouTube videos about Minecraft or or you know Fortnite but you know, maybe not The Tik TOK alphabet challenge, Tourette Alpha Challenge. 78:55 How do we differentiate between tics and repetitive OCB rituals and behaviors? 79:03 For example, knocking on walls hopping over lines. We just noticed noted a sudden onset of vocalizations such as stop it stop it, stop it. 79:19 Also, are Petted as F Bomb techs. 79:23 There was not much use, or even much use of Tiktok or social media with this individual. 79:32 Yeah, I mean, OK, it’s just a bunch of questions, that there’s a bunch of question and statement in there. So I would say so. 79:39 Differentiate between ticks and OCD amidst a whole discussion, but for basically ticks, usually, primary ticks, traditional ticks are usually, it’s more of a physiological urge that you’re responding to. So someone will get an urge in their body, usually, not always, but most of the time, in the area of the tick. 79:57 Feeling like, kinda similar when you have an itch you want to scratch, or when you feel like you’re going to sneeze, or it might feel like a pressure. So when it’s uncomfortable, we call it a pre monetary sensor, yours or a tick urge. And the ticks function is when it tick happens, a temporary reduces that urge, right? So, ticks are most of the time almost always a physiological or sponsor of physiological uncomfortableness. 80:18 OCD is usually it’s, it’s an impulse control and anxiety disorder combined. So basically the O is the obsessive worry thoughts and the compulsion is the ritual virtualize behavior that helps you avoid your worry right? So, it’s basically you have your worry and you have your way of avoiding that worry and it doesn’t always make rational sense. 80:38 So, in OCD usually, the behaviors And oftentimes people with ticks and OCD don’t have as, well, they can have both. 80:47 but often they have unspecific worries like, I just feel like something’s not right. You know, it’s not always, I’m washing my hands, because I feel like I’m gonna get coven a specific worry. 80:58 It could be something like, I just why do you jump over this line? It just doesn’t feel right. But the difference between ticks and OCD is that the obsessive thoughts are more of a mental worry kind of feeling where the ticks it’s, it’s a physical pre monetary urge. So, that’s how we differentiate usually is, Is it more physiological? they? Usually, you feels like in your body or is it more of a worry? This thing just not right or fixing bad’s gonna happen. if you don’t do this behavior. 81:25 We do have tick …, which is when you have combinations of both, and that’s why there’s a whole other discussion. But, it’s not as common and, sometimes people, which means, you have people report a physiological urge but also kind of an OCD type, worry along with, that urge, so, treat that. Well, I’ll usually do like a combination of sea bed with what we do for OCD exposure kind of merge. 81:49 The two have a competing response with, um, kind of paired with some kind of exposure and sometimes when you do that, you find out like if something is more of a ticker OCD but the other part, I don’t, I’m sorry. 82:02 I forgot what the other part of that, but I think you answered the primary part of that question. So, Um. 82:13 The next last question because we are running late. 82:20 Have you seen an overlap with tick disorders and transgenderism specifically female to male? 82:28 Um, honestly, yeah, it was on one of my slides now. I don’t think I actually mentioned. 82:34 And when I was talking about my clinical experience. 82:38 I’ll just go back to my screen. 82:42 Can you see me? 82:45 Am I on still? 82:47 I can still see you, Yes. But what we’re, what we’re viewing as our, our, I’m sorry. It’s something happened. 82:53 Um, Yeah, so, I have not seen anything in the research literature, but I will say, my, if you, in my clinical experience, I’ve seen A, this is actually, I saw this question actually. I think it was on the question. You e-mail me before? 83:06 I’ve seen, I’ve seen a correlation between identity, just gender identity, questioning, which is also increasing in general in the last couple of years. 83:17 Um, but in specifically in these functional cases, a lot of the biologically female, um, individuals that, you know, for it through my clinical supervision experiences, have brought this up, right? So I would say that there is I have not seen a study die, but as far as anecdotal and professional experiences, this definitely some kind of link, I would say, majority of cases have some for some of the senate. So that is actually a really important piece to bring up and needs further explanation. I don’t think it’s a cause, But I think if you look at functional disorders as or functional conditions as having some sort of dissociation involves, or, you know, it’s kind of a a way where the brain takes extreme stress and kind of translates into a physical physiological response. 84:11 It kind of makes sense, because if you’re and also the age that a lot of these girls are experiencing and journaling, if they’re not having, you know, gender identity, just, it’s a tough time for, you know, as for a girl at 13, 50. Not that I could personally speak to it. 84:24 But as far as, you know, just kind of identifying, kind of, going from middle school to high school, early high school, and I think that there’s, there’s a lot of stress there in general, but I have seen a link. 84:34 So I’m glad that question was asked. And I didn’t pointed out when I was talking about. I think I had it on one of my slides. 84:42 Pattern. 84:44 for any questions that did not get answered this evening, I will be putting them up on the chat board and doctor hierarchy will have an opportunity to answer them there. 84:58 I want to thank you all for joining us on our webinar on Understanding and Responding to Sudden Onset Tics in Teens. There is an exit survey, which we need everyone attending to fill out. 85:10 The webinar blog is open and available for the next seven days on the NJ NJCTS website, for any questions that were not covered in tonight’s presentation. 85:21 That Web site is NJCTS dot org. 85:26 Also, an archived recording of tonight’s webinar will be posted to our website. 85:32 Our next presentation is Next Wednesday, the Benefits of a Neuropsychological Evaluation, and it will be presented by doctor Cristine Sperrazza 85:43 And is scheduled for March second, 2022, this ends tonight’s webinar. Thank you, doctor Hartke, for your presentation and your 8 previous ones. And, thank you, everyone, for attending. Goodnight.