Tourette\'s Disorder


Table of Contents


Tourette Syndrome And Other Tic Disorders
Definitions of Tic Disorders
Differential Diagnosis
Symptomatology
Associated Behaviors and Cognitive Difficulties
Etiology
Stimulant Medications
Epidemiology and Genetics
Non-Genetic Contributions
Clinical Assessment Of Tourette Syndrome
Treatment Of Tourette Syndrome
Monitoring
Reassurance
Pharmacological Treatment of Tourette Syndrome
Psychodynamic Psychotherapy
Family Treatment
Genetic Counseling
Academic and Occupational Interventions
Bibliography


Today the full-blown case of TS is unlikely to be confused with any other
disorder.
However, only a decade ago TS was frequently misdiagnosed as schizophrenia,
obsessive-compulsive disorder, Sydenham\'s chorea, epilepsy, or nervous habits.
The
differentiation of TS from other tic syndromes may be no more than semantic,
especially
since recent genetic evidence links TS with multiple tics. Transient tics of
childhood are
best defined in retrospect. At times it may be difficult to distinguish
children with
extreme attention deficit hyperactivity disorder (ADHD) from TS. Many ADHD
children, on
close examination, have a few phonic or motor tics, grimace, or produce noises
similar to
those of TS. Since at least half of the TS patients also have attention
deficits and
hyperactivity as children, a physician may well be confused. However, the
treating doctor
should be aware of the potential dangers of treating a possible case of TS with
stimulant
medication. On rare occasions the differentiation between TS and a seizure
disorder may be
problematic. The symptoms of TS sometimes occur in a rather sharply separated
paroxysmal
manner and may resemble automatisms. TS patients, however, retain a clear
consciousness
during such paroxysms. If the diagnosis is in doubt, an EEG may be useful. We
have seen TS
in association with a number of developmental and other neurological disorders.
It is
possible that central nervous system injury from trauma or disease may cause a
child to be
vulnerable to the expression of the disorder, particularly if there is a
genetic
predisposition. Autistic and retarded children may display the entire gamut of
TS symptoms,
but whether an autistic or retarded individual requires the additional
diagnosis of TS may
remain an open question until there is a biological or other diagnostic test
specifically
for TS. In older patients, conditions such as Wilson\'s disease, tardive
dyskinesia, Meige\'s
syndrome, chronic amphetamine abuse, and the stereotypic movements of
schizophrenia must be
considered in the differential diagnosis. The distinction can usually be made
by taking a
good history or by blood tests. Since more physicians are now aware of TS,
there is a
growing danger of overdiagnosis or over-treatment. Prevailing diagnostic
criteria would
require that all children with suppressible multiple motor and phonic tics,
however
minimal, of at least one year, should be diagnosed as having TS. It is up to
the clinician
to consider the effect that the symptoms have on the patient\'s ability to
function as well
as the severity of associated symptoms before deciding to treat with medication.


TABLE 1. RANGE OF SYMPTOMS OF TS

Motor
Simple motor tics: fast, darting, and meaningless.
Complex motor tics: slower, may appear purposeful

Vocal
Simple vocal tics: meaningless sounds and noises.
Complex vocal tics: linguistically meaningful utterances such as
words and
phrases (including coprolalia, echolalia, and palilalia).

Behavioral and Developmental

Attention deficit hyperactivity disorder, obsessions and compulsions,
emotional problems, irritability, impulsivity, aggressivity, and self-
injurious
behaviors; various learning disabilities



Symptomatology

The varied symptoms of TS can be divided into motor, vocal, and behavioral
manifestations
(Table 2). Complex motor tics can be virtually any type of movement that the
body can
produce including gyrating, hopping, clapping, tensing arm or neck muscles,
touching people
or things, and obscene gesturing. At some point in the continuum of complex
motor tics, the
term "compulsion" seems appropriate for capturing the organized, ritualistic
character of
the actions. The need to do and then redo or undo the same action a certain
number of times
(e.g., to stretch out an arm ten times

Definitions of Tic Disorders

Tics are involuntary, rapid, repetitive, and stereotyped movements of
individual muscle
groups. They are more easily recognized than precisely defined. Disorders
involving tics
generally are divided into categories according to age of onset, duration of
symptoms, and
the presence of vocal or phonic tics in addition to motor tics. Transient tic
disorders
often begin during the early school years and can occur in up to 15% of all
children.
Common tics include eye blinking, nose puckering, grimacing, and squinting.
Transient
vocalizations are less common and include various throat sounds, humming, or
other noises.
Childhood tics may be bizarre, such as licking the palm or poking and pinching
the
genitals. Transient tics last only weeks or a few months and usually