Will therapy help Tourettes?
Treatment of Tourette syndrome
There is no cure for Tourette's and no medication which works universally for all individuals without significant adverse effects; knowledge and understanding are the best treatments available for tics. Management of the symptoms of Tourette's may include pharmacological, behavioral and psychological therapies. While pharmacological treatment is reserved for more severe symptoms, other types of treatments may help avoid or improve symptoms of depression or social isolation, and improve supportive family functioning. Educating the patient, family, and surrounding community (school, church, friends, etc.) is a key part of treatment.
Tic disorder
As many as 1 in 100 people may experience some form of tic disorder, usually before the onset of puberty. Tourette syndrome is the more severe expression of a spectrum of tic disorders, which are thought to be due to the same genetic vulnerability. Nevertheless, most cases of Tourette syndrome are not severe. Although a significant amount of investigative work indicates genetic linkage of the various tic disorders, further study is needed to confirm the relationship.
Tourette syndrome
Tourette's is associated with several comorbid conditions, or co-occurring diagnoses, which are often the major source of impairment for an affected child. Most individuals with tics do not seek medical attention, so epidemiological studies of TS "reflect a strong ascertainment bias", but among those who do warrant medical attention, the majority have other conditions, and up to 50% have ADHD or OCD.
Tourette syndrome
Regardless of symptom severity, individuals with Tourette's have a normal life span. Although the symptoms may be lifelong and chronic for some, the condition is not degenerative or life-threatening. Intelligence is normal in those with Tourette's, although there may be learning disabilities. Severity of tics early in life does not predict tic severity in later life, and prognosis is generally favorable, although there is no reliable means of predicting the outcome for a particular individual. The gene or genes associated with Tourette's have not been identified, and there is no potential "cure". A higher rate of migraines than the general population and sleep disturbances are reported.
Tourette syndrome
Tics are movements or sounds "that occur intermittently and unpredictably out of a background of normal motor activity", having the appearance of "normal behaviors gone wrong". The tics associated with Tourette's change in number, frequency, severity and anatomical location. Waxing and waning—the ongoing increase and decrease in severity and frequency of tics—occurs differently in each individual. Tics may also occur in "bouts of bouts", which vary for each person.
I Have Tourette's but Tourette's Doesn't Have Me
The 27-minute television documentary was produced by HBO in conjunction with the Tourette Syndrome Association (since renamed to TAA), and first aired on HBO on November 12, 2005. Ellen Goosenberg Kent is the director and producer, and Sheila Nevins is the executive producer.
Causes and origins of Tourette syndrome
Genetic studies, including twin studies, have proven that the overwhelming majority of cases of Tourette syndrome are inherited, although the exact mode of inheritance is not yet known. Tic disorders have long been thought to be inherited as an autosomal dominant gene, but recent research challenges the autosomal dominant hypothesis, and suggests an additive model involving multiple genes. According to Roger Freeman, MD, "Genes that cause tics have not yet been identified; it's very unlikely there's just one. Tics are very familial, but not in a Mendelian pattern (dominant, recessive, etc.). You can't 'inherit' the committee decision to define a problem in a specific way, so TS itself can't be inherited. It's a tic disorder that is inherited."
Tourettism
Tourettism refers to the presence of Tourette-like symptoms in the absence of Tourette syndrome, as the result of other diseases or conditions, known as "secondary causes".
Treatment of Tourette syndrome
There is increasing evidence supporting the use of HRT in the treatment of tics; a 2013 systematic review (Dutta, Cavanna) found evidence that HRT reduced tic severity in children and adults, but also identified methodological limitations in all studies, and said that more specialists need to be better trained to administer HRT so that better large-scale studies can be conducted.
Tourettes: I Swear I Can't Help It
The film follows John Davidson, who has Tourette syndrome (TS), and the changes in his life since the 1989 QED documentary "John's Not Mad". Another individual with TS, Greg, was filmed by his mother; his tics occasionally make him collapse or appear frozen. In this film, the pair meet and see how each copes with the condition.
I Have Tourette's but Tourette's Doesn't Have Me
I Have Tourette's but Tourette's Doesn't Have Me is a 2005 documentary film featuring children between the ages of six and thirteen with Tourette syndrome. The film examines the lives of more than a dozen children who have Tourette's, and explores the challenges they face.
Tic
Tic disorders occur along a spectrum, ranging from mild (transient or chronic tics) to more severe; Tourette syndrome is the more severe expression of a spectrum of tic disorders, which are thought to be due to the same genetic vulnerability. Nevertheless, most cases of Tourette syndrome are not severe. The treatment for the spectrum of tic disorders is similar to the treatment of Tourette syndrome.
History of Tourette syndrome
A French doctor, Jean Marc Gaspard Itard, reported the first case of Tourette syndrome in 1825, describing Marquise de Dampierre, an important woman of nobility in her time, whose episodes later understood to be coprolalia "were obviously in stark contrast to the lady's background, intellect, and refined manners".
Basal ganglia disease
Tourette syndrome is a disorder that is characterized by behavioral and motor tics, OCD, and Attention-deficit hyperactivity disorder (ADHD). For this reason, it is commonly believed that pathologies involving limbic, associative, and motor circuits of the basal ganglia are likely. Since the realization that syndromes such as Tourette Syndrome and OCD are caused by dysfunction of the non-motor loops of basal ganglia circuits, new treatments for these disorders, based on treatments originally designed to treat movement disorders are being developed.
Hyperkinesia
Treatment of tics present in conditions such as Tourette's syndrome begins with patient, relative, teacher and peer education about the presentation of the tics. Sometimes, pharmacological treatment is unnecessary and tics can be reduced by behavioral therapy such as habit-reversal therapy and/or counseling. Often this route of treatment is difficult because it depends most heavily on patient compliance. Once pharmacological treatment is deemed most appropriate, lowest effective doses should be given first with gradual increases. The most effective drugs belong to the neuroleptic variety such as monoamine-depleting drugs and dopamine receptor-blocking drugs. Of the monoamine-depleting drugs, tetrabenazine is most powerful against tics and results in fewest side effects. A non-neuroleptic drug found to be safe and effective in treating tics is topiramate. Botulinum toxin injection in affected muscles can successfully treat tics; involuntary movements and vocalizations can be reduced, as well as life-threatening tics that have the potential of causing compressive myelopathy or radiculopathy. Surgical treatment for disabling Tourette's syndrome has been proven effective in cases presenting with self-injury. Deep Brain Stimulation surgery targeting the globus pallidus, thalamus and other areas of the brain may be effective in treating involuntary and possibly life-threatening tics.
History of Tourette syndrome
According to Swerdlow, "the 'core' TS conundrum" is a lack of consensus about the definition of Tourette syndrome. Since vocal tics result from a "motor event (ie, a contracting diaphragm moving air through the upper airways)", TS could be defined as a disorder of motor tics, eliminating the distinction between TS and the other tic disorders. Individuals who have only tics may not be functionally impaired, raising the question of whether Tourette's as currently defined should be a DSM diagnosis. Swerdlow highlights the importance of studies in new areas such as behavioral techniques, and says that "the whole-cloth dismissal of psychologic forces in the pathobiology of TS was a strategic error". Questions remain about whether co-occurring (comorbid) conditions should be part of the core definition, and why sensory phenomena, which are a core part of Tourette's, are not part of the diagnostic criteria.
Tourette syndrome
Although there is no such thing as a "typical" case of Tourette syndrome, the condition follows a fairly reliable course in terms of the age of onset and the history of the severity of symptoms. Tics may appear up to the age of eighteen, but the most typical age of onset is from five to seven. A 1998 study published by Leckman and colleagues from the Yale Child Study Center showed that the ages of highest tic severity are eight to twelve (average ten), with tics steadily declining for most patients as they pass through adolescence. The most common, first-presenting tics are eye blinking, facial movements, sniffing and throat clearing. Initial tics present most frequently in midline body regions where there are many muscles, usually the head, neck and facial region. This can be contrasted with the stereotyped movements of other disorders (such as stims and stereotypies of the autism spectrum disorders), which typically have an earlier age of onset, are more symmetrical, rhythmical and bilateral, and involve the extremities (e.g., flapping the hands). Tics that appear early in the course of the condition are frequently confused with other conditions, such as allergies, asthma, and vision problems: pediatricians, allergists and ophthalmologists are typically the first to see a child with tics.
Societal and cultural aspects of Tourette syndrome
An incident of disinformation about coprolalia and Tourette's involved Dr. Laura Schlessinger. According to the former Tourette Syndrome Association (name changed to Tourette Association of America in 2015), she berated a caller inquiring whether a child with TS should attend a family wedding, declaring that a majority of those with the condition exhibited coprolalia and should be excluded from many social situations, provoking an avalanche of angry calls about the misinformation. Garrison Keillor, radio show host of NPR's "A Prairie Home Companion", produced a segment in 2006, titled "Broadway Tourette's", about segregating people with stereotypical TS from other passengers on a cruise ship, prompting a press release from the Tourette Syndrome Association.
History of Tourette syndrome
Dropping the criteria for impairment from the diagnosis resulted in higher estimates of the prevalence of TS (the question of "who has it?"). Older estimates "came from tertiary referral samples, the sickest of the sick"; greater prevalence casts the condition in an entirely new light, and calls for new biological models of the condition and new approaches to addressing a more common disorder. Discovering the causes of Tourette's may help resolve the questions of what it is and who has it. The autosomal dominant inheritance model has not been validated, and past research has been affected by the problem of referred samples, which may not reflect broader populations of persons with Tourette's. Probabilistic genetic models may yield better clues than the "one gene equals one disorder" approach. One of the most controversial presumed causes, the PANDAS hypothesis, has sparked disagreement.
History of Tourette syndrome
The U.S. National Institutes of Health (NIH) turned down a 1972 grant proposal from the TSA because "the reviewers believed there were probably no more than 100 cases of TS in the entire nation", and a 1973 registry reported only 485 cases worldwide. Subsequent articles on Tourette's in "Good Housekeeping", "The New York Times" and "Ann Landers" produced an "enormous response, proving that there were many undiagnosed cases of TS across the United States". TS was listed as a rare disorder in the United States Orphan Drug Act of 1983, a law enacted to increase development of medications for conditions which affect small numbers of people. In 1985 pimozide was approved by the U.S. Food and Drug Administration for the treatment of the condition.
Causes and origins of Tourette syndrome
Multiple neurotransmitters, like histamine (H3R), dopamine, serotonin, GABA and glutamate are involved in the etiology. After 2010, the central role of histamine (H3-receptor in the basal ganglia) came into focus in the pathophysiology of Tourette Syndrome. The striatum is the main input nucleus of the basal ganglia circuit in the disorder, which is linked to the involvement of the histaminergic H3-receptor.
Medical cannabis research
Cannabinoid medication might be useful in the treatment of the symptoms in patients with TS, but the 2009 review found that the two relevant studies of cannibinoids in treating tics had attrition bias, and that there was "not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome".
History of Tourette syndrome
In the USA, the NIH has ongoing clinical trials, and the TSA funds ongoing research through its Research Program and Research Grant Awards. Other worldwide ongoing trials can be found by contacting Tourette syndrome advocacy groups.
History of Tourette syndrome
In 2015, the Tourette Syndrome Association changed its name to the Tourette Association of America. As of 2006, the Tourette Syndrome Association had contacts in more than 50 countries. The Tourette syndrome International database Consortium (TIC) brought together data on clinical samples of patients with Tourette syndrome from twenty-two countries (Argentina, Australia, Austria, Belgium, Brazil, Canada, Denmark, Germany, Hungary, Iceland, Israel, Italy, Japan, The Netherlands, Norway, People's Republic of China, Poland, South Africa, Sweden, Turkey, the US and the UK); Tourette's has also been studied in Chile, Colombia, Costa Rica, India, Indonesia, Korea, and Spain.
History of Tourette syndrome
In Europe, the ESSTS published the first European clinical guidelines for Tourette syndrome and tic disorders in 2011. As of 2011, the only other guidelines in Europe were for Germany. In an editorial that accompanied the release of the guidelines, its authors said that in spite of a "high level of clinical experience, particularly in specialized centers", relative to other childhood-onset disorders, TS had been neglected in the research, possibly because TS had historically been viewed as a rare disorder, and due to the "high rate of relatively mild cases and an often favorable course with good chance of spontaneous remission". They also indicated a fragmentation in clinical approach to TS, as its core symptoms can be viewed as part of a neurology specialty (movement disorder) or child and adolescent psychiatry. They hoped the guidelines would "help clinicians to offer the best clinical service ... and inspire clinical researchers as well as politicians to no longer overlook the high burden of tic disorders".
Paul R. Sanberg
In 2000, Sanberg and fellow scientist Archie Silver conducted a study of the effects of nicotine patches on Tourette's victims. The study involved seventy young people with Tourette's. Those who were administered the nicotine patch along with Haldol showed significantly increased muscle control and ability to desist from verbal outbursts. The study suggests that nicotine could also be used to treat the symptoms of mental disorders including Parkinson's and Alzheimer's.
Treatment of Tourette syndrome
Administration of nicotine via transdermal patches was found beneficial, in preliminary case studies, but these effects were not reproduced in well-controlled trials several years later. Studies of nicotine derivatives (mecamylamine, inversine) also showed that they were not effective as a single therapy for the symptoms of Tourette's. Two small, controlled studies have found that capsules of tetrahydrocannabinol (THC), the main psychoactive ingredient of cannabis, helped reduce tics. More research is needed to confirm this low-quality evidence for the effects of THC.
Causes and origins of Tourette syndrome
Causes and origins of tinnys Tourette syndrome have not been fully elucidated. Tourette syndrome (also called "Tourette's syndrome", "Tourette's disorder", "Gilles de la Tourette syndrome", "GTS" or "TS") is an inherited neurological disorder with onset in childhood, characterized by the presence of multiple motor tics and at least one phonic tic, which characteristically wax and wane. Tourette's syndrome occurs along a spectrum of tic disorders, which includes transient tics and chronic tics.
The exact cause of Tourette's is unknown, but it is well established that both genetic and environmental factors are involved. The overwhelming majority of cases of Tourette's are inherited, although the exact mode of inheritance is not yet known, and no gene has been identified. Tics are believed to result from dysfunction in the thalamus, basal ganglia, and frontal cortex of the brain, involving abnormal activity of the brain chemical, or neurotransmitter, dopamine. In addition to dopamine, multiple neurotransmitters, like serotonin, GABA, glutamate, and histamine (H3-receptor), are involved.
Societal and cultural aspects of Tourette syndrome
Other television and film productions depicting persons with TS, or using coprolalia as a plot device, include an episode of "Ally McBeal", in which Anne Heche portrays a woman with Tourette's whose leg tic causes her to run over and kill her boyfriend; "An Angel on my Tree", an episode of "Touched by an Angel" in which a father commits manslaughter in reaction to an event that involved his son who had Tourette's; an episode of "The Simpsons", in which Bart Simpson is mentioned to claimed to have Tourette's to excuse himself from a test; and an episode of "South Park", "Le Petit Tourette", in which Eric Cartman pretends to have Tourette's to get away with saying offensive things. The episode received a mixed reaction from the Tourette Syndrome Association, which commented that it provided useful information while at the same time perpetuating outright myths about coprolalia and Tourette syndrome.
Arthur K. Shapiro
Until the early 1970s, the preferred intervention for Tourette syndrome was psychoanalysis. Shapiro wanted to prove that Tourette's was an organic disorder, and that psychotherapy was not the treatment of choice. "The turning point in the diagnosis and treatment of Tourette Syndrome occurred in 1965", when Dr. Shapiro and his wife, Elaine Schlaffer Shapiro (Ph.D.), treated a patient with haloperidol (Haldol). The Shapiros reported the treatment in a 1968 article, published by the "British Journal of Psychiatry", after it was rejected by American journals. The paper "severely criticized" the psychoanalytic approach, which had endured throughout the previous century, to treating the condition.
Deep brain stimulation
DBS has been used experimentally in treating adults with severe Tourette syndrome that does not respond to conventional treatment. Despite widely publicized early successes, DBS remains a highly experimental procedure for the treatment of Tourette's, and more study is needed to determine whether long-term benefits outweigh the risks. The procedure is well tolerated, but complications include "short battery life, abrupt symptom worsening upon cessation of stimulation, hypomanic or manic conversion, and the significant time and effort involved in optimizing stimulation parameters". As of 2006, five people with TS had been reported on; all experienced reduction in tics and the disappearance of obsessive-compulsive behaviors.
History of Tourette syndrome
During the 1960s and 1970s, as the beneficial effects of haloperidol (Haldol) on tics became known, the psychoanalytic approach to Tourette syndrome was questioned. The first description of haloperidol in the treatment of Tourette's was published by Seignot in 1961. The turning point came in 1965, when Arthur K. Shapiro—described as "the father of modern tic disorder research"—treated a Tourette’s patient with haloperidol. Dr. Shapiro and his wife, Elaine Shapiro (PhD), reported the treatment in a 1968 article, and severely criticized the psychoanalytic approach.
Societal and cultural aspects of Tourette syndrome
Societal and cultural aspects of Tourette syndrome include legal, advocacy and health insurance issues, awareness of notable individuals with Tourette syndrome, and treatment of TS in the media and popular culture.
Central nervous system disease
Tourette's syndrome is an inherited neurological disorder. Early onset may be during childhood, and it is characterized by physical and verbal tics.TS often also includes symptoms of both OCD and ADHD indicating a link between the three disorders. The exact cause of Tourette's, other than genetic factors, is unknown.
Tic Talk: Living with Tourette Syndrome
Tic Talk: Living with Tourette Syndrome is a book written by Dylan Peters, a 9-year-old boy with Tourette syndrome (TS). In this personal narrative, Peters gives a timeline of events from his TS diagnosis to when he tells his friends and classmates he has TS.
Tic
Tics may increase as a result of stress, fatigue, boredom, or high-energy emotions, which can include negative emotions, such as anxiety, as well as positive emotions, such as excitement or anticipation. Relaxation may result in a tic increase (for instance, watching television or using a computer), while concentration on an absorbing activity often leads to a decrease in tics. Neurologist and writer Oliver Sacks described a physician with severe Tourette syndrome (Canadian Mort Doran, M.D., a pilot and surgeon in real life, although a pseudonym was used in the book), whose tics remitted almost completely while he was performing surgery.
Stereotypic movement disorder
Stereotypic movement disorder is often misdiagnosed as tics or Tourette syndrome (TS). Unlike the tics of TS, which tend to appear around age six or seven, repetitive movements typically start before age three, are more bilateral than tics, and consist of intense patterns of movement for longer runs than tics. Tics are less likely to be stimulated by excitement. Children with stereotypic movement disorder do not always report being bothered by the movements as a child with tics might.
Neurocrine Biosciences
Neurocrine announced it filed a new drug application (NDA) for its once-daily valbenazine drug treating TD on August 29, 2016. Valbenazine received a priority review designation, fast track status and a breakthrough designation from the FDA. In April 2017, the FDA approved INGREZZA (valbenazine) for the treatment of TD. At the time of approval, it was the first and only drug approved for adults with TD. Neurocrine is also studying valbenazine in clinical trials for the treatment of Tourette Syndrome. In October 2017, Neurocrine announced that it had been granted orphan drug designation status from the FDA for valbenazine for the treatment of pediatric patients with Tourette syndrome.
Treatment of Tourette syndrome
Cognitive Behavioral Therapy (CBT) is a useful treatment when OCD is present.
Causes and origins of Tourette syndrome
Non-genetic factors—while not causing Tourette's—can influence the severity of the disorder. Some forms of Tourette's may be genetically linked to obsessive-compulsive disorder (OCD), while the relationship between Tourette's and attention-deficit hyperactivity disorder (ADHD) is not yet fully understood.
Tourette Association of America
The TAA "has been the major driving force in scientific and clinical progress relevant to TS", using its resources to encourage research and scientific initiatives, and working tirelessly to promote information about TS. It has worked for recognition of Tourette syndrome as an organic disorder, lobbying the public, the government, and physicians. It is adept at winning grants and shaping media treatment of the condition. Since its inception, research spurred by the TAA has grown in volume and sophistication, including controlled treatment studies and studies of pathophysiology and etiology. Many new research findings are the direct result of the TSA's "active facilitation of large collaborative research consortia in genetics, neuro-imaging, clinical trials, and the behavioral sciences", and their "concerted effort to identify current research advances, disseminate them among the scientific and clinical communities, and establish networks of basic and clinical scientists from all over the world".
Dirty Filthy Love
His life gets even worse when, at a meeting with his employers, he finds himself swearing uncontrollably and loses his job. Accepting that he is unwell, Mark visits a doctor, already convinced he is suffering from a brain tumour or meningitis. In the doctor's waiting room, another patient, Charlotte (Henderson), recognises Mark's "habits" as symptoms of obsessive-compulsive disorder and Tourette syndrome, and invites him to a local self-help group she runs. Mark finds it comforting that others share his disorder and with Charlotte's help, hopes to face his problems and win his wife back.
Chris Crewther
In a speech to parliament in late 2016, Crewther revealed he has Tourette syndrome. He further discussed his condition during an interview on the Lateline program on 2 March 2017. He is the patron for the Tourette Syndrome Association of Australia and established the Parliamentary Friendship Group for Tourette Syndrome.
The Caretakers
Optimistic psychiatrist Dr. Donovan MacLeod wants to prove his theory that mental patients can benefit from group therapy. His method of treatment, with no violence or punishment, is met with a great deal of resistance from his unyielding and self-righteous head nurse, Lucretia Terry, who believes in traditional methods such as strait-jackets and padded cells for treating the mentally ill.
Tourette Association of America
The Tourette Association of America (TAA), based in Bayside, New York, United States, is a non-profit voluntary organization and the only US health-related organization serving people with Tourette syndrome. It was founded in 1972 as the Tourette Syndrome Association (TSA) by five couples, parents of children with Tourette syndrome including Bill and Eleanor Pearl, along with psychiatrist Arthur K. Shapiro and his wife, Elaine. In 2015, the organization's name was changed from TSA to TAA.
History of Tourette syndrome
The direction of current and future research in Tourette's was outlined in a 2005 journal article by the outgoing chairman of the TSA Scientific Advisory Board. Swerdlow divides the research landscape into five broad questions about Tourette's: what is it, who has it, what causes it, how it should be studied, and how it should be (medically) treated.
Tourettes Action
The charity was founded as the Tourette Syndrome (UK) Association in 1980 by a small group of parents of children with TS, who came together for mutual support. In 2006, the charity relocated to London and substantially expanded its services. A windfall from Big Brother 2006 winner Pete Bennett gave the organisation the opportunity to plan for future development to reach a higher percentage of the 300,000 children and adults in the UK with TS. In June 2008 the charity adopted the name Tourettes Action, a new ID and website.
Societal and cultural aspects of Tourette syndrome
A controlled study on a small (13) group of individuals with TS found that cognitive control may be enhanced in young people with Tourette's because the need to suppress tics results in more efficient control of inhibitions. A subsequent study confirmed and extended the paradoxical result that individuals with Tourette's exhibit greater levels of cognitive control than age-matched healthy peers. There is some evidence to support the clinical lore that children with "TS-only" (Tourette syndrome in the absence of other comorbid conditions) are unusually gifted: neuropsychological studies have identified advantages in children with TS-only. A study of full-scale intelligence quotient (IQ) testing showed that children with TS-only had higher IQ scores, relative to their parents, than predicted by statistical models. Another neurological examination of motor function found that 76% of children with TS-only were faster than average on timed motor coordination, although similar results were not found among children with TS who also had ADHD. In a study of eight children, ages 8–17, those with Tourette syndrome were found to be much quicker at processing certain mental grammar skills than children without the condition. The abnormalities that lead to tics may also lead to "other rapid behaviors, including the cognitive processing of rule-governed forms in language and other types of procedural knowledge". The investigator, Michael Ullman, PhD, said, "These children were particularly fast, as well as largely accurate, in certain language tasks. This tells us that their cognitive processing may be altered in ways we have only begun to explore, and moreover in a manner that may provide them with performance that is actually enhanced compared [to] that of typically developing children".
Antipsychotic
In children they may be used in those with disruptive behavior disorders, mood disorders and pervasive developmental disorders or intellectual disability. Antipsychotics are only weakly recommended for Tourette syndrome, because although they are effective, side effects are common. The situation is similar for those on the autism spectrum.
Much of the evidence for the off-label use of antipsychotics (for example, for dementia, OCD, PTSD, Personality Disorders, Tourette's) was of insufficient scientific quality to support such use, especially as there was strong evidence of increased risks of stroke, tremors, significant weight gain, sedation, and gastrointestinal problems. A UK review of unlicensed usage in children and adolescents reported a similar mixture of findings and concerns. A survey of children with pervasive developmental disorder found that 16.5% were taking an antipsychotic drug, most commonly for irritability, aggression, and agitation. Risperidone has been approved by the US FDA for the treatment of irritability in autistic children and adolescents.
Societal and cultural aspects of Tourette syndrome
Singer Pete Bennett, the winner of the 2006 edition of British TV reality show, "Big Brother 7", has Tourette syndrome. The show has been accused of exploiting Bennett's Tourette's syndrome; and the British Psychological Society (BPS) expressed concern and the possibility that BPS members involved in the series could face censure. His condition was reported to have been aggravated by drug use. Some viewers expressed concern that the show had exploited Tourette's, while others felt it was educational.
Trick or Treatment?
The truth about chiropractic therapy
Tourette syndrome
Most cases of Tourette's in older individuals are mild and almost unrecognizable. Adults with TS presenting in clinics are atypical and represent a biased sample. When symptoms are severe enough to warrant referral to clinics, obsessive–compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD) are often associated with Tourette's. In children with tics, the additional presence of ADHD is associated with functional impairment, disruptive behavior, and tic severity. Compulsions resembling tics are present in some individuals with OCD; "tic-related OCD" is hypothesized to be a subgroup of OCD, distinguished from non-tic related OCD by the type and nature of obsessions and compulsions. Not all persons with Tourette's have ADHD or OCD or other comorbid conditions, although in clinical populations, a high percentage of patients presenting for care do have ADHD. One author reports that a ten-year overview of patient records revealed about 40% of people with Tourette's have "TS-only" or "pure TS", referring to Tourette syndrome in the absence of ADHD, OCD and other disorders. Another author reports that 57% of 656 patients presenting with tic disorders had uncomplicated tics, while 43% had tics plus comorbid conditions. People with "full-blown Tourette's" have significant comorbid conditions in addition to tics.
Societal and cultural aspects of Tourette syndrome
Several documentaries have attempted to portray Tourette's syndrome accurately and to advocate for greater understanding of persons with Tourette's, while others focus on sensationalizing coprolalia. The Emmy Award-winning television documentary film "I Have Tourette's but Tourette's Doesn't Have Me" was produced by HBO in conjunction with the Tourette Syndrome Association, featuring children between the ages of six and 13. It was described by the "Cincinnati Enquirer" as "the best simple overview yet of Tourette's". "John's Not Mad" (1989) and "The Boy Can't Help It" (2000) are documentaries about a young man from Scotland, who has severe Tourette's and coprolalia. "Twitch and Shout" examines a society that is quick to judge a person who strays outside the limits of conventional behavior and was nominated for an Emmy. A 2007 British documentary, "Tourette De France", followed a group of teenagers with Tourette's on a trip to Paris; many of the teenagers featured in the program had coprolalia. "Movements and Madness: Gusti Ayu" is a documentary about the struggles of a young woman with severe Tourette's in a small village in Indonesia. A 2011 BBC documentary, "Tourettes: I Swear I Can Sing", followed aspiring musician Ruth Ojadi as she explains her experience of TS and her struggle to find self-confidence in her singing.
Tourette syndrome
Tic disorders are defined only slightly differently by the World Health Organization International Statistical Classification of Diseases and Related Health Problems, ICD-10; code F95.2 is for combined vocal and multiple motor tic disorder [de la Tourette].
Tourette syndrome
There is no cure for Tourette's and no medication that works universally for all individuals without significant adverse effects. Knowledge, education and understanding are uppermost in management plans for tic disorders. The management of the symptoms of Tourette's may include pharmacological, behavioral and psychological therapies. While pharmacological intervention is reserved for more severe symptoms, other treatments (such as supportive psychotherapy or cognitive behavioral therapy) may help to avoid or ameliorate depression and social isolation, and to improve family support. Educating a patient, family, and surrounding community (such as friends, school, and church) is a key treatment strategy, and may be all that is required in mild cases.
Medication is available to help when symptoms interfere with functioning. The classes of medication with the most proven efficacy in treating tics—typical and atypical neuroleptics including risperidone (trade name Risperdal), ziprasidone (Geodon), haloperidol (Haldol), pimozide (Orap) and fluphenazine (Prolixin)—can have long-term and short-term adverse effects. The antihypertensive agents clonidine (trade name Catapres) and guanfacine (Tenex) are also used to treat tics; studies show variable efficacy, but a lower side effect profile than the neuroleptics. Stimulants and other medications may be useful in treating ADHD when it co-occurs with tic disorders. Drugs from several other classes of medications can be used when stimulant trials fail, including guanfacine (trade name Tenex), atomoxetine (Strattera) and tricyclic antidepressants. Clomipramine (Anafranil), a tricyclic, and SSRIs—a class of antidepressants including fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox)—may be prescribed when a Tourette's patient also has symptoms of obsessive–compulsive disorder. Several other medications have been tried, but evidence to support their use is unconvincing.
Treatment of Tourette syndrome
Deep brain stimulation has been used to treat adults with severe Tourette's that does not respond to conventional treatment, but is regarded as an experimental and dangerous procedure that is unlikely to become widespread.
Jess Thom
According to guidance notes for journalists written by the team at Touretteshero, and published by the Guardian:Although some aspects of [Tourette's Syndrome] are challenging, Jess does not describe herself as a 'Tourette's sufferer' under any circumstances. Instead she likes to be referred to as a 'person with Tourette's' or as simply as 'having Tourette's'. She is 'brave' for all sorts of reasons, but not because she is disabled.Thom has stated that she finds herself talking about and explaining Tourette's everyday in her day-to-day interactions: "It doesn't always feel like a choice, more a tool for living...Often this is very functional, like explaining at the start of a phone call that I have Tourettes, answering a question or addressing sniggers on public transport." Thom regularly experiences discrimination as a result of having Tourette's. She has recounted one particularly bad experience in multiple interviews, when she went to see comedian Mark Thomas perform at Tricycle Theatre. Other audience members complained about the noise she was making as a result of her vocal tics and the venue's staff asked her to move into a sound booth, so she wouldn't be heard by other customers. Although initially the experience made her vow never to go to the theatre again, it eventually became the catalyst for her becoming a performer: "The creative way to respond was to occupy that space as an artist".
Olanzapine
Olanzapine has not been rigorously evaluated in generalized anxiety disorder, panic disorder, delusional parasitosis, or post-traumatic stress disorder. Olanzapine is no less effective than lithium or valproate and more effective than placebo in treating bipolar disorder. It has also been used for Tourette syndrome and stuttering.
Marc Elliot
Marc Elliot is an American author and inspirational speaker who has been diagnosed with Tourette syndrome. Once he completed his graduation, Elliot embarked on a nationwide speaking tour outlining his experiences on growing up with Tourette's and advocating tolerance. He has given about 300 inspirational talks in roughly 40 states. He has penned a book about his condition and the importance of tolerance titled, "What Makes You Tic?: My Journey From Tourette's To Tolerance".
He is now based in Manhattan.
Treatment of Tourette syndrome
Other medications that can be used to treat tics include pergolide (brand name Permax), botulinum toxin, and with less empirical support for efficacy, tetrabenazine and baclofen.
Neurexin
Similar to schizophrenia, studies have shown that intellectual disability and Tourette syndrome are also associated with NRXN1 deletions. A recent study shows that NRXN genes 1-3 are essential for survival and play a pivotal and overlapping role with each other in neurodevelopment. These genes have been directly disrupted in Tourette syndrome by independent genomic rearrangements. Another study suggests that NLGN4 mutations can be associated with a wide spectrum of neuropsychiatric conditions and that carriers may be affected with milder symptoms.
Tourette syndrome
Non-genetic, environmental, post-infectious, or psychosocial factors—while not causing Tourette's—can influence its severity. Autoimmune processes may affect tic onset and exacerbation in some cases. In 1998, a team at the US National Institute of Mental Health proposed a hypothesis based on observation of 50 children that both obsessive–compulsive disorder (OCD) and tic disorders may arise in a subset of children as a result of a poststreptococcal autoimmune process. Children who meet five diagnostic criteria are classified, according to the hypothesis, as having Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). This contentious hypothesis is the focus of clinical and laboratory research, but remains unproven.
History of Tourette syndrome
Findings reported in published studies of Tourette syndrome since 1999 have advanced TS science in the areas of genetics, neuroimaging, neurophysiology, and neuropathology. The TAA supports a clinical database that may help identify genes involved in Tourette syndrome, and the TSA International Genetic Consortium has collected a database on large extended families for future studies. Novel neuroimaging studies are being employed to study tic expression and functional or cognitive deficits in TS patients. Studies of Tourette's neurophysiology and neuropathology are attempting to link deficits in Tourette's to specific brain mechanisms, and have taken advantage of a brain bank sponsored by the TSA. Clinical trials have focused on understanding tic suppression, comorbid conditions, novel treatment approaches such as botulinum toxin, and targeted behavioral therapies. Controversy remains in the areas of deep brain stimulation and PANDAS.
Neuropsychiatry
To further sketch psychiatry's history shows a departure from structural neuropathology, relying more upon ideology (Sabshin, 1990). A good example of this is Tourette syndrome, which Ferenczi (1921), although never having seen a patient with Tourette syndrome, suggested was the symbolic expression of masturbation caused by sexual repression. However, starting with the efficacy of neuroleptic drugs in attenuating symptoms (Shapiro, Shapiro and Wayne, 1973) the syndrome has gained pathophysiological support (e.g. Singer, 1997) and is hypothesized to have a genetic basis too, based on its high inheritability (Robertson, 2000). This trend can be seen for many hitherto traditionally psychiatric disorders (see table) and is argued to support reuniting neurology and psychiatry because both are dealing with disorders of the same system.
Tourette syndrome
Cognitive behavioral therapy (CBT) is a useful treatment when OCD is present, and there is increasing evidence supporting the use of habit reversal (HRT) in the treatment of tics. There is evidence that HRT reduces tic severity, but there are methodological limitations in the studies, and a need for more trained specialists and better large-scale studies.
Hyperkinesia
When both motor and vocal tics are present and persist for more than one year, a diagnosis of Tourette syndrome (TS) is likely. TS is an inherited neurobehavioral disorder characterized by both motor and vocal tics. Many individuals with TS may also develop obsessions, compulsions, inattention and hyperactivity. TS usually begins in childhood. Up to 5% of the population suffers from tics, but at least 20% of boys will have developed tics at some point in their lifetimes.
Arthur K. Shapiro
Working with the New York patient families who founded the Tourette Syndrome Association (TSA, since renamed to TAA) in 1972, the Shapiros advanced the argument that Tourette's was neurological rather than psychological, and the medical view of Tourette syndrome was "freed from its century-long submission to discredited psychoanalytic theory". In 1978, the Shapiros published a "landmark book" on the disorder, "Gilles de la Tourette Syndrome". In 1981, Shapiro was chosen honorary co-president of the First International Tourette Syndrome Symposium, held in New York. Since the 1990s, a more neutral view of Tourette's is emerging as a condition involving an interaction between biological vulnerability and adverse environmental events.
Tourette syndrome
Although it has been speculated that Mozart had Tourette's, no Tourette's expert or organization has presented credible evidence to support such a conclusion, and there are problems with the arguments supporting the diagnosis: tics are not transferred to the written form, as is supposed with Mozart's scatological writings; the medical history in retrospect is not thorough; side effects due to other conditions may be misinterpreted; "it is not proven whether written documents can account for the existence of a vocal tic" and "the evidence of motor tics in Mozart's life is doubtful."
Pre-dating Gilles de la Tourette's 1885 publication, likely portrayals of TS or tic disorders in fictional literature are Mr. Pancks in "Little Dorrit" by Charles Dickens and Nikolai Levin in "Anna Karenina" by Leo Tolstoy. The entertainment industry has been criticized for depicting those with Tourette syndrome as social misfits whose only tic is coprolalia, which has furthered stigmatization and the public's misunderstanding of those with Tourette's. The coprolalic symptoms of Tourette's are also fodder for radio and television talk shows in the US and in the British media.
Treatment of Tourette syndrome
The majority of people with TS require no medication, but medication is available to help when symptoms interfere with functioning. Because children with tics often present to physicians when their tics are at their highest severity, and because of the waxing and waning nature of tics, medication is not usually started immediately or changed often. Frequently, the tics subside with understanding of the condition and a supportive environment. When medication is necessary, pharmaceutical intervention should be targeted at the most impairing symptoms, taking into account co-occurring conditions such as ADHD or OCD, which when present, may warrant treatment even when tics are mild.
Tinnitus retraining therapy
There is no evidence that TRT or any other treatment can eliminate or decrease tinnitus. Tinnitus is a symptom, not a disease. As such, the optimal treatment strategy should be directed toward eliminating the disease, rather than simply alleviating the symptom. More than half of people with tinnitus have a comorbid psychological injury or illness (e.g., post-traumatic stress disorder, depression, anxiety, obsessive compulsive disorder, stress, dysfunction of the temporomandibular joint, etc.) that can exacerbate the tinnitus.
Tourette syndrome
Findings since 1999 have advanced TS science in the areas of genetics, neuroimaging, neurophysiology, and neuropathology. Questions remain regarding how best to classify Tourette syndrome, and how closely Tourette's is related to other movement disorders or psychiatric disorders. Good epidemiologic data is still lacking, and available treatments are not risk free and not always well tolerated. High-profile media coverage focuses on treatments that do not have established safety or efficacy, such as deep brain stimulation, and alternative therapies involving unstudied efficacy and side effects are pursued by many parents.
History of Tourette syndrome
In 1885, Gilles de la Tourette published an account of nine patients, "Study of a Nervous Affliction", concluding that a new clinical category should be defined. His description included accounts of Marquise de Dampierre, previously described by Itard, as a reclusive aristocratic lady who "ticked and blasphemed" from the age of seven until her death at the age of 80 years. Gilles de la Tourette describes the common feature of involuntary movements or tics in all nine patients. The eponym was later bestowed by Charcot after and on behalf of Gilles de la Tourette.
Societal and cultural aspects of Tourette syndrome
"Quit It" is a 2002 novel by Marcia Byalic, targeted at teens, about a seventh-grade girl recently diagnosed with TS. A protagonist with Tourette's is presented in Jonathan Lethem's detective novel, "Motherless Brooklyn". The Gwyn Hyman Rubio novel "Icy Sparks" was an Oprah Book Club selection about a teenage girl who may have TS.
Deep brain stimulation
Robertson reported that DBS had been used on 55 adults by 2011, remained an experimental treatment at that time, and recommended that the procedure "should only be conducted by experienced functional neurosurgeons operating in centres which also have a dedicated Tourette syndrome clinic". According to Malone "et al" (2006), "Only patients with severe, debilitating, and treatment-refractory illness should be considered; while those with severe personality disorders and substance-abuse problems should be excluded." Du "et al" (2010) say, "As an invasive therapy, DBS is currently only advisable for severely affected, treatment-refractory TS adults". Singer (2011) says, "pending determination of patient selection criteria and the outcome of carefully controlled clinical trials, a cautious approach is recommended". Viswanathan "et al" (2012) say DBS should be used for people with "severe functional impairment that cannot be managed medically".
Tic Talk: Living with Tourette Syndrome
Peters introduces himself by telling the reader how old he is and about his family. To delve further into his personality he states what sports and school subjects he likes most. When he was four years old he began to have tics, and his parents took him to a neurologist who prescribed medicine which would help reduce the intensity of the tics. The tics still occurred with medication. As the tics progressed in strength and intensity, Peters began to wonder if his friends would notice and if they would think he was strange. His friends began to ask questions about why he would do certain things such as blink twice or jerk his head. In the third grade, he decided to tell his friends and classmates of his Tourette syndrome. As the date of getting in front of his class to tell of his syndrome approached, his tics worsened. The day came and his mother went in to define Tourette syndrome for the class. Dylan then told his friends of his story so they could better understand him. After he did this his tics decreased in intensity. In the end he stated that this was most likely because he was not scared or nervous about what his friends would think anymore. In his last paragraph Peters stated that having Tourette syndrome does not change a person, it is just what makes that person who they are as a part of their personality.
History of Tourette syndrome
Multiple studies published since 2000 have consistently demonstrated that the prevalence of TS and tic disorders is much higher than previously thought. The emerging consensus is that 1–10 children per 1,000 have Tourette's, with several studies supporting a tighter range of 6–8 children per 1,000. Using year 2000 census data, a prevalence range of 1–10 per 1,000 yields an estimate of 53,000–530,000 school-age children with Tourette's in the US and a prevalence range of 6–10 per 1,000 means that 64,000–106,000 children aged 5–18 years may have Tourette's in the UK. Most of these children are undiagnosed and have mild symptoms without distress or impairment. Since the 1990s, a more neutral view of Tourette's has emerged, in which biological vulnerability and adverse environmental events are seen to interact.
Tourette syndrome
There is no requirement that other comorbid conditions (such as ADHD or OCD) be present, but if a physician believes that there may be another condition present that could explain tics, tests may be ordered as necessary to rule out that condition. An example of this is when diagnostic confusion between tics and seizure activity exists, which would call for an EEG, or if there are symptoms that indicate an MRI to rule out brain abnormalities. TSH levels can be measured to rule out hypothyroidism, which can be a cause of tics. Brain imaging studies are not usually warranted. In teenagers and adults presenting with a sudden onset of tics and other behavioral symptoms, a urine drug screen for cocaine and stimulants might be necessary. If a family history of liver disease is present, serum copper and ceruloplasmin levels can rule out Wilson's disease. Most cases are diagnosed by merely observing a history of tics.
Tourette syndrome
Tourette syndrome was once thought to be rare: in 1972, the US National Institutes of Health (NIH) believed there were fewer than 100 cases in the United States, and a 1973 registry reported only 485 cases worldwide. However, multiple studies published since 2000 have consistently demonstrated that the prevalence is much higher than previously thought. Discrepancies across current and prior prevalence estimates come from several factors: ascertainment bias in earlier samples drawn from clinically referred cases, assessment methods that may fail to detect milder cases, and differences in diagnostic criteria and thresholds. There were few broad-based community studies published before 2000 and until the 1980s, most epidemiological studies of Tourette syndrome were based on individuals referred to tertiary care or specialty clinics. Individuals with mild symptoms may not seek treatment and physicians may not confer an official diagnosis of TS on children out of concern for stigmatization; children with milder symptoms are unlikely to be referred to specialty clinics, so prevalence studies have an inherent bias towards more severe cases. Studies of Tourette syndrome are vulnerable to error because tics vary in intensity and expression, are often intermittent, and are not always recognized by clinicians, patients, family members, friends or teachers; approximately 20% of persons with Tourette syndrome do not recognize that they have tics. Newer studies—recognizing that tics may often be undiagnosed and hard to detect—use direct classroom observation and multiple informants (parent, teacher, and trained observers), and therefore record more cases than older studies relying on referrals. As the diagnostic threshold and assessment methodology have moved towards recognition of milder cases, the result is an increase in estimated prevalence.
Le Petit Tourette
While shopping in a toy store, Cartman sees a boy named Thomas who continuously shouts obscenities, as his mother tries to explain that he has Tourette syndrome (TS). Cartman decides to pretend he has the disorder as well so he can get away with shouting obscenities himself, and successfully convinces his mother and a doctor, who diagnoses him with TS and notifies the school. When Kyle finds out about Cartman's "disorder", he immediately deduces that he is faking, which Cartman quickly admits to him. Nevertheless, Cartman continues to enjoy his newfound freedom. Kyle decides to complain to Principal Victoria, saying that Cartman is faking, but she misinterprets him as saying that all people with TS are faking. She sends Kyle to a local support group for children with the disorder, who explain their various tics and how they are not faking it. Kyle at first tries to defend his position, but realizing that Cartman was far too manipulative for anybody else to realize, he gives up and apologizes to the group. He visibly struggles when he has to apologize to Cartman, however, who continues to take advantage of his "disorder" by screaming vulgar anti-Semitic remarks at Kyle's parents. But when Cartman runs to Thomas and tells him, "Isn't having Tourette's awesome?" Thomas realizes Cartman is lying and faking.
Klazomania
Jankovic and Mejia describe klazomania as due to tourettism (tics having Tourette syndrome-like features but not due to TS). According to the revised fourth edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-IV-TR), Tourette's may be diagnosed when the other diagnostic criteria are met and symptoms cannot be attributed to another general medical condition. Hence, other medical conditions that include tics or tic-like movements—such as tourettism—must be ruled out before a TS diagnosis can be conferred. There are no specific tests; the diagnosis is based on history and symptoms.
History of Tourette syndrome
Jean-Martin Charcot, an influential French physician, assigned his resident Georges Albert Édouard Brutus Gilles de la Tourette, a French physician and neurologist, to study patients at the Salpêtrière Hospital, with the goal of defining an illness distinct from hysteria and from chorea. Charcot and Gilles de la Tourette believed that the "tic illness" they had observed was an untreatable, chronic, and progressive hereditary condition. History is unclear on whether Charcot had examined the Marquise de Dampierre, but his publications mention having met her socially and overhearing her most common utterances of ""merde" and "foutu cochon" (which translates literally as filthy pig but the truer colloquial meaning is 'fucking pig')".
Causes and origins of Tourette syndrome
A person with Tourette syndrome has about a 50% chance of passing the gene(s) to one of his/her children. Gender appears to have a role in the expression of the genetic vulnerability, with males more likely to express tics than females. Tourette syndrome is a condition of incomplete penetrance, meaning not everyone who inherits the genetic vulnerability will show symptoms. Tourette's also shows variable expression—even family members with the same genetic makeup may show different levels of symptom severity. The gene(s) may express as Tourette syndrome, as a milder tic disorder (transient or chronic tics), or as obsessive compulsive symptoms with no tics at all. Only a minority of the children who inherit the gene(s) will have symptoms severe enough to require medical attention. There is currently no way to predict the symptoms a child may display, even if the gene(s) are inherited.
History of Tourette syndrome
Little progress was made over the next century in explaining or treating tics. With limited clinical experience, involving typically one or two patients, authors advanced different ideas, including brain lesions similar to those resulting from rheumatic chorea or encephalitis lethargica as a cause of tics, faulty mechanisms of normal habit formation, and treatment with Freudian psychoanalysis. The psychogenic view prevailed well into the 20th century.
Tourette syndrome
Secondary causes of tics (not related to inherited Tourette syndrome) are commonly referred to as tourettism. Dystonias, choreas, other genetic conditions, and secondary causes of tics should be ruled out in the differential diagnosis for Tourette syndrome. Other conditions that may manifest tics or stereotyped movements include developmental disorders, autism spectrum disorders, and stereotypic movement disorder; Sydenham's chorea; idiopathic dystonia; and genetic conditions such as Huntington's disease, neuroacanthocytosis, pantothenate kinase-associated neurodegeneration, Duchenne muscular dystrophy, Wilson's disease, and tuberous sclerosis. Other possibilities include chromosomal disorders such as Down syndrome, Klinefelter syndrome, XYY syndrome and fragile X syndrome. Acquired causes of tics include drug-induced tics, head trauma, encephalitis, stroke, and carbon monoxide poisoning. The symptoms of Lesch-Nyhan syndrome may also be confused with Tourette syndrome. Most of these conditions are rarer than tic disorders, and a thorough history and examination may be enough to rule them out, without medical or screening tests.
Therapeutic support staff
Therapeutic Support Staff - (TSS) are special education assistants within the commonwealth of Pennsylvania. They are trained to provide therapy to students with attention deficit hyperactivity disorder, Tourette syndrome, autism, or other emotional support needs.
Free will
For example, people with Tourette syndrome and related tic disorders make involuntary movements and utterances (called tics) despite the fact that they would prefer not to do so when it is socially inappropriate. Tics are described as semi-voluntary or "unvoluntary", because they are not strictly "involuntary": they may be experienced as a "voluntary" response to an unwanted, premonitory urge. Tics are experienced as irresistible and must eventually be expressed. People with Tourette syndrome are sometimes able to suppress their tics for limited periods, but doing so often results in an explosion of tics afterward. The control exerted (from seconds to hours at a time) may merely postpone and exacerbate the ultimate expression of the tic.
Le Roy, New York
Eventually, as doctors encouraged their patients to stay away from the media and the media attention died down, many of the girls' symptoms improved. By the end of the school year in June, one girl was diagnosed with Tourette syndrome, likely the source of the mass psychogenic illness, and most of the girls who received treatment for conversion disorder were back to normal in time for graduation. No environmental causes were found after repeated testing around the school and surrounding areas of town.
Tourette syndrome
Relaxation techniques, such as exercise, yoga or meditation, may be useful in relieving the stress that may aggravate tics, but the majority of behavioral interventions (such as relaxation training and biofeedback, with the exception of habit reversal) have not been systematically evaluated and are not empirically supported therapies for Tourette's. Deep brain stimulation has been used to treat adults with severe Tourette's that does not respond to conventional treatment, but it is regarded as an invasive, experimental procedure that is unlikely to become widespread.
Tourette syndrome
Several studies have demonstrated that the condition in most children improves with maturity. Tics may be at their highest severity at the time that they are diagnosed, and often improve with understanding of the condition by individuals and their families and friends. The statistical age of highest tic severity is typically between eight and twelve, with most individuals experiencing steadily declining tic severity as they pass through adolescence. One study showed no correlation with tic severity and the onset of puberty, in contrast with the popular belief that tics increase at puberty. In many cases, a complete remission of tic symptoms occurs after adolescence. However, a study using videotape to record tics in adults found that, although tics diminished in comparison with childhood, and all measures of tic severity improved by adulthood, 90% of adults still had tics. Half of the adults who considered themselves tic-free still displayed evidence of tics.
Many people with TS may not realize they have tics; because tics are more commonly expressed in private, TS may go unrecognized or undetected. It is not uncommon for the parents of affected children to be unaware that they, too, may have had tics as children. Because Tourette's tends to subside with maturity, and because milder cases of Tourette's are now more likely to be recognized, the first realization that a parent had tics as a child may not come until their offspring is diagnosed. It is not uncommon for several members of a family to be diagnosed together, as parents bringing children to a physician for an evaluation of tics become aware that they, too, had tics as a child.
Tourette syndrome
Tourette syndrome is a spectrum disorder—its severity ranges over a spectrum from mild to severe. The majority of cases are mild and require no treatment. In these cases, the impact of symptoms on the individual may be mild, to the extent that casual observers might not know of their condition. The overall prognosis is positive, but a minority of children with Tourette syndrome have severe symptoms that persist into adulthood. A study of 46 subjects at 19 years of age found that the symptoms of 80% had minimum to mild impact on their overall functioning, and that the other 20% experienced at least a moderate impact on their overall functioning. The rare minority of severe cases can inhibit or prevent individuals from holding a job or having a fulfilling social life. In a follow-up study of thirty-one adults with Tourette's, all patients completed high school, 52% finished at least two years of college, and 71% were full-time employed or were pursuing higher education.
Tourettes Action
Tourettes Action's services include a Helpline, information packs, conferences and workshops, support groups, camps for teenagers, help finding specialists, networks among professionals, ID cards for people with a diagnosis of TS, free monthly email newsletters and an online forum.
Treatment of Tourette syndrome
The classes of medication with the most proven efficacy in treating tics—typical and atypical neuroleptics including risperidone (trade name Risperdal), ziprasidone (Geodon), haloperidol (Haldol), pimozide (Orap) and fluphenazine (Prolixin)—can have long-term and short-term adverse effects. The antihypertensive agents, clonidine (Catapres) and guanfacine (Tenex), are also used to treat tics; studies show variable efficacy, but a lower side effect profile than the neuroleptics. Stimulants and other medications may be useful in treating ADHD when it co-occurs with tic disorders. Drugs from several other classes of medications can be used when stimulant trials fail, including guanfacine (Tenex), atomoxetine (Strattera) and tricyclics. Clomipramine (Anafranil), a tricyclic antidepressant, and SSRIs—a class of antidepressants including fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox)—may be prescribed when a Tourette's patient also has symptoms of obsessive–compulsive disorder.
SLITRK1 (gene)
A subsequent examination of the region of the SLITRK1 gene found the mutation in none of 82 patients with Tourette syndrome. The authors concluded that tests to detect variant(s) in the gene probably would have little diagnostic utility. An experiment in the effects of a microdeletion in chromosome 13q31.1 was done in a fetus, the mother had passed the microdeletion to the child and both did not have tourettes or any other OCD symptoms, showing that it may not be a direct cause of tourettes. Further attempts to replicate the study were done in multiple studies. In a Japanese study, next-gen sequencing was used to screen 92 TS patients and 361 healthy controls, none of TS patients were found to have mutations at either variant or any new mutations in the gene. In a European study it was found that the 2 original variations were not found in any of the 222 trios that were studied. However, tests were also done on SNPs in the groups and 3 were found to have variations. Two of the three variations were found to be associated with the formation of Tourette syndrome. In a different study of 381 Caucasians with some form of OCD with 356 non-OCD control patients, 3 genetic changes were found after genetic screening. Of the 3, 2 were identified only once each and the third was found in 4 OCD patients but also in a non-OCD patient. The non-OCD patient did have compulsive nail biting, but these studies show that a genetic link between SLITRK1 and patients with TS may exist they are more complex in nature than previously understood.
Treatment of Tourette syndrome
Newer neuroleptics, the atypical neuroleptics, are an alternative to the traditional medications used for treating tics. These medications have more selective dopamine blocking effects, or block serotonin with some blocking of dopamine. The medications in this class used to treat tics include risperidone (brand name Risperdal), olanzapine (brand name Zyprexa), ziprasidone (brand name Geodon), quetiapine (brand name Seroquel), clozapine (brand name Clozaril), tiapride, and sulpiride. They seem to have lower risks of neurological side effects (such as tardive dyskinesia) when used short-term, but longer trials are needed to confirm this. Some of the side effects associated with these medications are insomnia, weight gain, and school phobia. Abnormalities in metabolism, cardiac conduction times, and increased risk of diabetes are concerns with these medications. There is good empirical support for the use of risperidone, and less support for the others.
The α-adrenergic receptor agonists (antihypertensive agents) show some efficacy in reducing tics, as well as other comorbid features of some people with Tourette's. Originally developed to treat high blood pressure, these medications are a safer alternative to neuroleptic medications for the people with TS that respond to them. This class of medication is often the first tried for tics, as the antihypertensives have a lower side effect profile than some of the medications which more proven efficacy. The evidence for their safety and efficacy is not as strong as the evidence for some of the standard and atypical neuroleptics, but there is fair supportive evidence for their use, nonetheless. This class of medication takes about six weeks to begin to work on tics, so sustained trials are warranted. Because of the blood pressure effects, antihypertensive agents should not be discontinued suddenly. Clonidine (brand name Catapres) works on tics for about half of people with TS. Maximal benefit may not be achieved for 4–6 months. A small number of patients may worsen on clonidine. Guanfacine (brand name Tenex) is another antihypertensive that is used in treating TS. Side effects can include sedation, dry mouth, fatigue, headaches and dizziness. Sedation can be problematic when treatment is first initiated, but may wear off as the patient adjusts to the medication.
History of Tourette syndrome
The eponym was bestowed by Jean-Martin Charcot (1825–93) on behalf of his resident, Georges Albert Édouard Brutus Gilles de la Tourette (1859–1904), a French physician and neurologist, who published an account of nine patients with Tourette's in 1885. The possibility that movement disorders, including Tourette syndrome, might have an organic origin was raised when an encephalitis epidemic from 1918–1926 led to a subsequent epidemic of tic disorders. Research in 1972 advanced the argument that Tourette's is a neurological, rather than psychological, disorder; since the 1990s, a more neutral view of Tourette's has emerged, in which biological vulnerability and adverse environmental events are seen to interact.
Tourette syndrome
In contrast to the abnormal movements of other movement disorders (for example, choreas, dystonias, myoclonus, and dyskinesias), the tics of Tourette's are temporarily suppressible, nonrhythmic, and often preceded by an unwanted premonitory urge. Immediately preceding tic onset, most individuals with Tourette's are aware of an urge, similar to the need to sneeze or scratch an itch. Individuals describe the need to tic as a buildup of tension, pressure, or energy which they consciously choose to release, as if they "had to do it" to relieve the sensation or until it feels "just right". Examples of the premonitory urge are the feeling of having something in one's throat, or a localized discomfort in the shoulders, leading to the need to clear one's throat or shrug the shoulders. The actual tic may be felt as relieving this tension or sensation, similar to scratching an itch. Another example is blinking to relieve an uncomfortable sensation in the eye. These urges and sensations, preceding the expression of the movement or vocalization as a tic, are referred to as "premonitory sensory phenomena" or premonitory urges. Because of the urges that precede them, tics are described as semi-voluntary or ""unvoluntary"", rather than specifically "involuntary"; they may be experienced as a "voluntary", suppressible response to the unwanted premonitory urge. Published descriptions of the tics of Tourette's identify sensory phenomena as the core symptom of the syndrome, even though they are not included in the diagnostic criteria.
While individuals with tics are sometimes able to suppress their tics for limited periods of time, doing so often results in tension or mental exhaustion. People with Tourette's may seek a secluded spot to release their symptoms, or there may be a marked increase in tics after a period of suppression at school or at work. Some people with Tourette's may not be aware of the premonitory urge. Children may be less aware of the premonitory urge associated with tics than are adults, but their awareness tends to increase with maturity. They may have tics for several years before becoming aware of premonitory urges. Children may suppress tics while in the doctor's office, so they may need to be observed while they are not aware they are being watched. The ability to suppress tics varies among individuals, and may be more developed in adults than children.
Guanfacine
Results of studies using guanfacine to treat Tourette's have been mixed.
Tourette Association of America
The TAA's mission is to identify the cause of, find the cure for and control the effects of Tourette syndrome. As of 2008, it had 35 US chapters, 300 support groups, and international contacts around the world.
Societal and cultural aspects of Tourette syndrome
In 2012 the Tourettes awareness project Touretteshero was set up in the UK by Jessica Thom and Matthew Pountney, as a place to "celebrate the humour and creativity of Tourettes".
Tourette syndrome
Not everyone with Tourette's wants treatment or a "cure", especially if that means they may "lose" something else in the process. Researchers Leckman and Cohen, and former US Tourette Syndrome Association (TSA) national board member Kathryn Taubert, believe that there may be latent advantages associated with an individual's genetic vulnerability to developing Tourette syndrome, such as a heightened awareness and increased attention to detail and surroundings that may have adaptive value. There is evidence to support the clinical lore that children with "TS-only" (Tourette's in the absence of comorbid conditions) are unusually gifted: neuropsychological studies have identified advantages in children with TS-only. Children with TS-only are faster than the average for their age group on timed tests of motor coordination.
Notable individuals with Tourette syndrome are found in all walks of life, including musicians, athletes, media figures, teachers, physicians, and authors. The best-known example of a person who may have used obsessive–compulsive traits to advantage is Samuel Johnson, the 18th-century English man of letters, who likely had Tourette syndrome as evidenced by the writings of James Boswell. Johnson wrote "A Dictionary of the English Language" in 1747, and was a prolific writer, poet, and critic. Tim Howard, described by the "Chicago Tribune" as the "rarest of creatures – an American soccer hero" and by the TSA as the "most notable individual with Tourette Syndrome around the world" says that his neurological makeup gave him an enhanced perception and an ability to hyper-focus that contributed to his success on the field.
Societal and cultural aspects of Tourette syndrome
There is no reason to believe that persons with Tourette's have diminished capacity in regards to understanding legal issues. Examples of federal legislation which protects some rights of individuals with TS in the United States include the Individuals with Disabilities Education Act (IDEA) and the Americans with Disabilities Act (ADA). Legal and other advocacy information regarding the challenges associated with TS can be found on the website of the Tourette Association of America.