Tourette Syndrome
Tics
Tic Disorders
Obsessive-Compulsive Disorder
Compulsive Behavior
Exhibitionism
Obsessive Behavior
Attention Deficit Disorder with Hyperactivity
Reactive Inhibition
Basal Ganglia
Self Mutilation
Schizoid Personality Disorder
Delirium, Dementia, Amnestic, Cognitive Disorders
Stereotyped Behavior
Learning Disorders
Chromosomes, Human, Pair 7
Severity of Illness Index
Saccadic performance characteristics and the behavioural neurology of Tourette's syndrome. (1/312)
OBJECTIVE: To better understand the neuropathological correlates of Tourette's syndrome (TS), measures of saccadic eye movement performance were examined among patients with TS. METHODS: A case-control design was used. Twenty one patients with DSM-IV TS (mean age 40.6 years (SD 11.0); 38% female) mainly recruited from UCSD Psychiatry Services, and a community based sample of 21 normal subjects (mean age 34.6 years (SD 13.4); 43% women) participated in this study. Participants were administered ocular motor tasks assessing visual fixation, and the generation of prosaccades, predictive saccades, and antisaccades. Saccadic reaction time, amplitude, duration, and mean and peak velocity were computed. Intrusive saccades during visual fixation and the proportion of correct antisaccade responses were also evaluated. RESULTS: The groups had similar visual fixation performance. Whereas patients with TS generated prosaccades with normal reaction times and amplitudes, their saccade durations were shorter and their mean velocities were higher than in normal subjects. During a prosaccade gap task, patients with TS exhibited an increased proportion of anticipatory saccades (RTs<90). The proportion of "express" saccades (90Recognition and management of Tourette's syndrome and tic disorders. (2/312)
Tic disorders and Tourette's syndrome are conditions that primary care physicians are likely to encounter. Up to 20 percent of children have at least a transient tic disorder at some point. Once believed to be rare, Tourette's syndrome is now known to be a more common disorder that represents the most complex and severe manifestation of the spectrum of tic disorders. Tourette's syndrome is a chronic familial disorder with a fluctuating course; the long-term outcome is generally favorable. Although the exact underlying pathology has yet to be determined, evidence indicates a disorder localized to the frontal-subcortical neural pathways. Tourette's syndrome is commonly associated with attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, behavior problems and learning disabilities. These comorbid conditions make the management of Tourette's syndrome more challenging. Management of Tourette's syndrome should include timely and accurate diagnosis, education, and behavior or pharmacologic interventions. Use of neuroleptic medications and dopamine D2 antagonist drugs can be effective but may be associated with significant side effects. (+info)Parent perceptions of symptom severity in Tourette's syndrome. (3/312)
The families of 66 consecutive children with Tourette's syndrome were surveyed for their perception of symptom significance using a questionnaire. Families considered attention deficit and learning difficulties to be most significant, while motor and vocal tics were least important. When present, episodic rage was the most impairing symptom. Physicians must be aware of the significance of these comorbid symptoms for patients with Tourette's syndrome. (+info)A complete genome screen in sib pairs affected by Gilles de la Tourette syndrome. The Tourette Syndrome Association International Consortium for Genetics. (4/312)
Gilles de la Tourette syndrome is a neuropsychiatric disorder characterized by waxing and waning multiple motor and phonic tics with a complex mode of inheritance. Previous attempts, which used large multigenerational families to localize susceptibility loci, have been unsuccessful. In this report, the results of the first systematic genome scan, using 76 affected-sib-pair families with a total of 110 sib pairs, are summarized. While no results reached acceptable statistical significance, the multipoint maximum-likelihood scores (MLS) for two regions (4q and 8p) were suggestive (MLS > 2.0). Four additional genomic regions also gave multipoint MLS scores between 1.0 and 2.0. (+info)Late onset startle induced tics. (5/312)
Three cases of late onset Gilles de la Tourette's syndrome are presented. The motor tics were mainly induced by an unexpected startling stimulus, but the startle reflex was not exaggerated. The tics developed after physical trauma or a period of undue emotional stress. Reflex tics may occur in Gilles de la Tourette's syndrome, but have not been described in late onset Tourette's syndrome. Such tics must be distinguished from psychogenic myoclonus and the culture bound startle syndromes. (+info)Quantitative study of spontaneous eye blinks and eye tics in Gilles de la Tourette's syndrome. (6/312)
Spontaneous eye blink rate and frequency of eye tics were studied in nine Tourette patients during periods of rest, conversation, and video watching. In comparison with controls, the Tourette patients showed a significantly higher blink rate during rest and video watching. Conversation induced a significant increase in blink rate in the control group, but not in the Tourette patients, whereas video watching significantly increased blink rate in both groups. The frequency of eye tics showed a significant decrease during conversation and increased significantly during video watching in Tourette patients. In five patients, a significant positive correlation between blink rate and eye tic frequency was found, whereas one patient showed a significant negative correlation. Our results show that, even though some of our patients were on neuroleptic treatment, blink rate was about twofold to threefold increased versus healthy controls, suggesting increased central dopaminergic activity. Furthermore, these first quantitative data illustrate task specific effects on eye tic frequency and the complexity of their relation with eye blinks. (+info)Tourette syndrome, associated conditions and the complexities of treatment. (7/312)
Tourette syndrome (TS) is characterized by multiple motor tics plus one or more vocal (phonic) tics, which characteristically wax and wane. It can no longer be considered the rare and bizarre syndrome that it was once thought to be. The concepts surrounding TS, and our understanding of it, are also becoming increasingly complex and, in some individuals, TS is now recognized to be associated with a wide variety of associated behaviours and psychopathologies. It is suggested that TS is heterogeneous from a variety of standpoints including clinical presentation and psychopathology, and thus neuropharmacological responses and possibly even aetiological and genetic mechanisms. In this paper, mention is made of recent findings in epidemiology and genetics, highlighting the complexities of the disorder; these have been chosen because findings in both areas have clinical and management implications. The literature on the clinical manifestations, associated behaviours, psychopathology (and/or comorbid conditions) and management, in particular, is reviewed in detail. (+info)Adult onset tic disorders. (8/312)
BACKGROUND: Tic disorders presenting during adulthood have infrequently been described in the medical literature. Most reports depict adult onset secondary tic disorders caused by trauma, encephalitis, and other acquired conditions. Only rare reports describe idiopathic adult onset tic disorders, and most of these cases represent recurrent childhood tic disorders. OBJECTIVE: To describe a large series of patients with tic disorders presenting during adulthood, to compare clinical characteristics between groups of patients, and to call attention to this potentially disabling and underrecognised neurological disorder. METHODS: Using a computerised database, all patients with tic disorders who presented between 1988 and 1998 to the movement disorders clinic at Columbia-Presbyterian Medical Center after the age of 21 were identified. Patients' charts were retrospectively reviewed for demographic information, age of onset of tics, tic phenomenology, distribution, the presence of premonitory sensory symptoms and tic suppressibility, family history, and associated psychiatric features. These patients' videotapes were reviewed for diagnostic confirmation and information was obtained about disability, course, and response to treatment in a structured follow up interview. RESULTS: Of 411 patients with tic disorders in the database, 22 patients presented for the first time with tic disorders after the age of 21. In nine patients, detailed questioning disclosed a history of previous childhood transient tic disorder, but in 13 patients, the adult onset tic disorder was new. Among the new onset cases, six patients developed tics in relation to an external trigger, and could be considered to have secondary tic disorders. The remaining patients had idiopathic tic disorders. Comparing adult patients with recurrent childhood tics and those with new onset adult tics, the appearance of the tic disorder, the course and prognosis, the family history of tic disorder, and the prevalence of obsessive-compulsive disorder were found to be similar. Adults with new onset tics were more likely to have a symptomatic or secondary tic disorder, which in this series was caused by infection, trauma, cocaine use, and neuroleptic exposure. CONCLUSIONS: Adult onset tic disorders represent an underrecognised condition that is more common than generally appreciated or reported. The clinical characteristics of adults newly presenting to a movement disorder clinic with tic disorders are reviewed, analysed, and discussed in detail. Clinical evidence supports the concept that tic disorders in adults are part of a range that includes childhood onset tic disorders and Tourette's syndrome. (+info)Tourette Syndrome (TS) is a neurological disorder characterized by the presence of multiple motor tics and at least one vocal (phonic) tic. These tics are sudden, repetitive, rapid, involuntary movements or sounds that occur for more than a year and are not due to substance use or other medical conditions. The symptoms typically start before the age of 18, with the average onset around 6-7 years old.
The severity, frequency, and types of tics can vary greatly among individuals with TS and may change over time. Common motor tics include eye blinking, facial grimacing, shoulder shrugging, and head or limb jerking. Vocal tics can range from simple sounds like throat clearing, coughing, or barking to more complex phrases or words.
In some cases, TS may be accompanied by co-occurring conditions such as attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, and depression. These associated symptoms can sometimes have a greater impact on daily functioning than the tics themselves.
The exact cause of Tourette Syndrome remains unclear, but it is believed to involve genetic factors and abnormalities in certain brain regions involved in movement control and inhibition. There is currently no cure for TS, but various treatments, including behavioral therapy and medications, can help manage the symptoms and improve quality of life.
A tic is a sudden, repetitive, involuntary movement or vocalization that occurs frequently. Tics can be simple, involving only one muscle group, or complex, involving several muscle groups or coordinated patterns of movements. Common motor tics include eye blinking, facial grimacing, and shoulder shrugging, while common vocal tics include throat clearing, sniffing, and grunting.
Tics can vary in severity and frequency over time, and they may be exacerbated by stress, anxiety, or fatigue. In some cases, tics may be suppressible for brief periods of time, but this can lead to a buildup of tension that eventually results in an explosive release of the tic.
Tourette syndrome is a neurological disorder characterized by the presence of both motor and vocal tics that persist for more than one year. However, tics can also occur as a symptom of other medical conditions, such as Huntington's disease, Wilson's disease, or certain infections. In some cases, tics may be caused by medication side effects or substance abuse.
Tic disorders are a group of conditions characterized by the presence of repetitive, involuntary movements or sounds, known as tics. These movements or sounds can vary in complexity and severity, and they may be worsened by stress or strong emotions.
There are several different types of tic disorders, including:
1. Tourette's disorder: This is a neurological condition characterized by the presence of both motor (movement-related) and vocal tics that have been present for at least one year. The tics may wax and wane in severity over time, but they do not disappear for more than three consecutive months.
2. Persistent (chronic) motor or vocal tic disorder: This type of tic disorder is characterized by the presence of either motor or vocal tics (but not both), which have been present for at least one year. The tics may wax and wane in severity over time, but they do not disappear for more than three consecutive months.
3. Provisional tic disorder: This type of tic disorder is characterized by the presence of motor or vocal tics (or both) that have been present for less than one year. The tics may wax and wane in severity over time, but they do not disappear for more than three consecutive months.
4. Tic disorder not otherwise specified: This category is used to describe tic disorders that do not meet the criteria for any of the other types of tic disorders.
Tic disorders are thought to be caused by a combination of genetic and environmental factors, and they often co-occur with other conditions such as attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). Treatment for tic disorders may include behavioral therapy, medication, or a combination of both.
Obsessive-Compulsive Disorder (OCD) is a mental health disorder characterized by the presence of obsessions and compulsions. Obsessions are recurrent and persistent thoughts, urges, or images that are intrusive, unwanted, and often distressing. Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rigid rules, and which are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation. These obsessions and/or compulsions cause significant distress, take up a lot of time (an hour or more a day), and interfere with the individual's daily life, including social activities, relationships, and work or school performance. OCD is considered a type of anxiety disorder and can also co-occur with other mental health conditions.
Compulsive behavior is a type of repetitive behavior that an individual feels driven to perform, despite its negative impact on their daily life and mental health. It is often driven by an overwhelming urge or anxiety, and the person may experience distress if they are unable to carry out the behavior. Compulsive behaviors can be associated with various psychiatric conditions, including obsessive-compulsive disorder (OCD), body dysmorphic disorder, eating disorders, and impulse control disorders.
Examples of compulsive behaviors include:
1. Excessive handwashing or cleaning
2. Repeatedly checking locks, light switches, or appliances
3. Ordering or arranging items in a specific way
4. Compulsive hoarding
5. Compulsive shopping or spending
6. Compulsive eating or purging behaviors (such as those seen in bulimia nervosa)
7. Compulsive sexual behavior (sex addiction)
8. Compulsive exercise
9. Compulsive hair pulling (trichotillomania)
10. Compulsive skin picking (excoriation disorder)
Treatment for compulsive behaviors typically involves a combination of medication, psychotherapy (such as cognitive-behavioral therapy), and lifestyle changes to help manage the underlying causes and reduce the urge to engage in the compulsive behavior.
In medical terms, "rage" is not a diagnosis or a specific medical condition. However, it may be used to describe a symptom of certain medical conditions, such as intermittent explosive disorder (IED) or certain types of dementia. In IED, "rage" refers to recurrent, sudden episodes of uncontrolled anger and aggression that are out of proportion to the situation. In dementia, "sundowning" or "late-day confusion" can lead to increased agitation, confusion, and sometimes aggressive behavior in the late afternoon and early evening. It is important to consult with a healthcare professional for proper evaluation and diagnosis if experiencing issues related to anger or behavior.
Exhibitionism is a psychological disorder in which a person has the urge to expose their genitals to other people, usually strangers. This behavior is often motivated by the desire to shock or impress the other person, or to achieve sexual arousal and gratification. Exhibitionism is considered a paraphilic disorder when it causes distress or impairment in the individual's social, occupational, or other important areas of functioning, or when it involves non-consenting individuals. It is classified as a type of sexually deviant behavior and is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a mental disorder.
A syndrome, in medical terms, is a set of symptoms that collectively indicate or characterize a disease, disorder, or underlying pathological process. It's essentially a collection of signs and/or symptoms that frequently occur together and can suggest a particular cause or condition, even though the exact physiological mechanisms might not be fully understood.
For example, Down syndrome is characterized by specific physical features, cognitive delays, and other developmental issues resulting from an extra copy of chromosome 21. Similarly, metabolic syndromes like diabetes mellitus type 2 involve a group of risk factors such as obesity, high blood pressure, high blood sugar, and abnormal cholesterol or triglyceride levels that collectively increase the risk of heart disease, stroke, and diabetes.
It's important to note that a syndrome is not a specific diagnosis; rather, it's a pattern of symptoms that can help guide further diagnostic evaluation and management.
Obsessive behavior is defined in the medical context as repetitive, persistent, and intrusive thoughts, images, or urges that cause distress or anxiety. These obsessions are not simply excessive worries about real-life problems, but rather they are irrational and uncontrollable. Often, individuals with obsessive behavior attempt to ignore or suppress their obsessions, which can lead to increased distress and anxiety. In some cases, the obsessions may become so overwhelming that they interfere with a person's daily life and ability to function.
Obsessive behavior is a key feature of several mental health conditions, including obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), and hoarding disorder. In these conditions, the obsessions are often accompanied by compulsive behaviors that are performed in an attempt to alleviate the anxiety or distress caused by the obsessions.
It is important to note that everyone experiences unwanted thoughts or urges from time to time. However, when these thoughts become so frequent and distressing that they interfere with a person's daily life, it may be indicative of an underlying mental health condition. In such cases, it is recommended to seek professional help from a qualified mental health provider.
Attention Deficit Hyperactivity Disorder (ADHD) with hyperactivity is a neurodevelopmental disorder that affects both children and adults. The condition is characterized by symptoms including:
1. Difficulty paying attention or staying focused on a single task
2. Impulsivity, or acting without thinking
3. Hyperactivity, or excessive fidgeting, restlessness, or talking
In order to be diagnosed with ADHD with hyperactivity, an individual must exhibit these symptoms to a degree that is developmentally inappropriate and interferes with their daily functioning. Additionally, the symptoms must have been present for at least six months and be present in multiple settings (e.g., at home, school, work).
It's important to note that ADHD can manifest differently in different people, and some individuals may experience predominantly inattentive or impulsive symptoms rather than hyperactive ones. However, when the hyperactive component is prominent, it is referred to as ADHD with hyperactivity.
Effective treatments for ADHD with hyperactivity include a combination of medication (such as stimulants) and behavioral therapy. With appropriate treatment, individuals with ADHD can learn to manage their symptoms and lead successful, fulfilling lives.
Reactive inhibition is a concept in physiology, particularly in the context of muscle contraction and exercise. It refers to the decrease in the ability of a muscle to continue contracting after it has been repeatedly or maximally activated. This phenomenon was first described by physiologist Charles Scott Sherrington.
Reactive inhibition is thought to be a safety mechanism that prevents muscle damage and fatigue. When a muscle contracts repetitively or at high intensity, it generates waste products such as lactic acid and hydrogen ions. These substances can accumulate in the muscle tissue and interfere with its ability to function properly. Reactive inhibition helps to prevent this by reducing the muscle's activation level, which allows it to recover and clear out the waste products.
Reactive inhibition is distinct from other forms of inhibition that may occur in the nervous system, such as reciprocal inhibition, which refers to the suppression of antagonistic muscles during movement. Reactive inhibition specifically refers to the decrease in muscle activation that occurs after a muscle has been maximally or repeatedly activated.
The basal ganglia are a group of interconnected nuclei, or clusters of neurons, located in the base of the brain. They play a crucial role in regulating motor function, cognition, and emotion. The main components of the basal ganglia include the striatum (made up of the caudate nucleus, putamen, and ventral striatum), globus pallidus (divided into external and internal segments), subthalamic nucleus, and substantia nigra (with its pars compacta and pars reticulata).
The basal ganglia receive input from various regions of the cerebral cortex and other brain areas. They process this information and send output back to the thalamus and cortex, helping to modulate and coordinate movement. The basal ganglia also contribute to higher cognitive functions such as learning, decision-making, and habit formation. Dysfunction in the basal ganglia can lead to neurological disorders like Parkinson's disease, Huntington's disease, and dystonia.
Self-mutilation, also known as self-injury or self-harm, refers to the deliberate infliction of pain or damage to one's own body without the intention of committing suicide. It can take many forms, including cutting, burning, scratching, hitting, or piercing the skin. The behavior is often used as a coping mechanism to deal with emotional distress, trauma, or other psychological issues. Self-mutilation can be a sign of serious mental health concerns and should be treated as such. It's important to seek professional help if you or someone you know is engaging in self-harm behaviors.
Schizoid Personality Disorder is defined by the American Psychiatric Association's Diagnostic and Statistical Manual, Fifth Edition (DSM-5) as a long-standing pattern of detachment from social relationships, a reduced capacity for emotional expression, and an unusual degree of introversion. This disorder is characterized by:
1. A lack of desire for close relationships,
2. Difficulty expressing emotions and finding enjoyment in most activities,
3. Limited range of emotional expression,
4. Inattention to social norms and conventions,
5. Preference for being alone,
6. Indifference to praise or criticism from others.
These symptoms must be stable and of long duration, typically present for at least a year. The individual's lifestyle, attitudes, and behavior are often seen as eccentric and distant by others. It is important to note that this disorder is different from Schizophrenia and does not include psychotic symptoms such as hallucinations or delusions.
Delirium, Dementia, Amnestic, and Other Cognitive Disorders are conditions that affect cognitive abilities such as thinking, memory, perception, and judgment. Here are brief medical definitions of each:
1. Delirium: A serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment. It can cause hallucinations, delusions, and disorientation. Delirium often comes on suddenly and can be caused by various factors such as medication side effects, infection, or illness.
2. Dementia: A chronic and progressive decline in cognitive abilities that affects memory, language, problem-solving, and judgment. Alzheimer's disease is the most common cause of dementia, but other conditions such as vascular dementia, Lewy body dementia, and frontotemporal dementia can also cause it. Dementia can significantly interfere with daily life and activities.
3. Amnestic Disorders: A group of conditions that primarily affect memory. These disorders can be caused by brain injury, illness, or substance abuse. The most common amnestic disorder is Korsakoff's syndrome, which is caused by alcohol abuse and results in significant memory loss and confusion.
4. Other Cognitive Disorders: This category includes a range of conditions that affect cognitive abilities but do not fit into the categories of delirium, dementia, or amnestic disorders. Examples include mild cognitive impairment (MCI), which is a decline in cognitive abilities that does not interfere significantly with daily life, and various cognitive disorders caused by brain injury or disease.
It's important to note that these conditions can overlap and may co-occur with other mental health or neurological disorders. Proper diagnosis and treatment require a comprehensive evaluation by a qualified healthcare professional.
Stereotyped behavior, in the context of medicine and psychology, refers to repetitive, rigid, and invariant patterns of behavior or movements that are purposeless and often non-functional. These behaviors are not goal-directed or spontaneous and typically do not change in response to environmental changes or social interactions.
Stereotypies can include a wide range of motor behaviors such as hand flapping, rocking, head banging, body spinning, self-biting, or complex sequences of movements. They are often seen in individuals with developmental disabilities, intellectual disabilities, autism spectrum disorder, and some mental health conditions.
Stereotyped behaviors can also be a result of substance abuse, neurological disorders, or brain injuries. In some cases, these behaviors may serve as a self-soothing mechanism or a way to cope with stress, anxiety, or boredom. However, they can also interfere with daily functioning and social interactions, and in severe cases, may cause physical harm to the individual.
A learning disorder is a neurodevelopmental disorder that affects an individual's ability to acquire, process, and use information in one or more academic areas despite normal intelligence and adequate instruction. It can manifest as difficulties with reading (dyslexia), writing (dysgraphia), mathematics (dyscalculia), or other academic skills. Learning disorders are not the result of low intelligence, lack of motivation, or environmental factors alone, but rather reflect a significant discrepancy between an individual's cognitive abilities and their academic achievement. They can significantly impact a person's ability to perform in school, at work, and in daily life, making it important to diagnose and manage these disorders effectively.
Human chromosome pair 7 consists of two rod-shaped structures present in the nucleus of each cell in the human body. Each member of the pair is a single chromosome, and together they contain the genetic material that is inherited from both parents. They are identical in size, shape, and banding pattern and are therefore referred to as homologous chromosomes.
Chromosome 7 is one of the autosomal chromosomes, meaning it is not a sex chromosome (X or Y). It is composed of double-stranded DNA that contains approximately 159 million base pairs and around 1,200 genes. Chromosome 7 contains several important genes associated with human health and disease, including those involved in the development of certain types of cancer, such as colon cancer and lung cancer, as well as genetic disorders such as Williams-Beuren syndrome and Charcot-Marie-Tooth disease.
Abnormalities in chromosome 7 have been linked to various genetic conditions, including deletions, duplications, translocations, and other structural changes. These abnormalities can lead to developmental delays, intellectual disabilities, physical abnormalities, and increased risk of certain types of cancer.
A Severity of Illness Index is a measurement tool used in healthcare to assess the severity of a patient's condition and the risk of mortality or other adverse outcomes. These indices typically take into account various physiological and clinical variables, such as vital signs, laboratory values, and co-morbidities, to generate a score that reflects the patient's overall illness severity.
Examples of Severity of Illness Indices include the Acute Physiology and Chronic Health Evaluation (APACHE) system, the Simplified Acute Physiology Score (SAPS), and the Mortality Probability Model (MPM). These indices are often used in critical care settings to guide clinical decision-making, inform prognosis, and compare outcomes across different patient populations.
It is important to note that while these indices can provide valuable information about a patient's condition, they should not be used as the sole basis for clinical decision-making. Rather, they should be considered in conjunction with other factors, such as the patient's overall clinical presentation, treatment preferences, and goals of care.
Deep brain stimulation (DBS) is a surgical procedure that involves the implantation of a medical device called a neurostimulator, which sends electrical impulses to specific targets in the brain. The impulses help to regulate abnormal brain activity, and can be used to treat a variety of neurological conditions, including Parkinson's disease, essential tremor, dystonia, and obsessive-compulsive disorder.
During the procedure, electrodes are implanted into the brain and connected to the neurostimulator, which is typically implanted in the chest. The neurostimulator can be programmed to deliver electrical impulses at varying frequencies, amplitudes, and pulse widths, depending on the specific needs of the patient.
DBS is generally considered a safe and effective treatment option for many patients with neurological conditions, although it does carry some risks, such as infection, bleeding, and hardware complications. It is typically reserved for patients who have not responded well to other forms of treatment, or who experience significant side effects from medication.