Tourette’s Syndrome

Tourette Syndrome

Tourette Syndrome

Tourette’s syndrome is a brain and nervous system disorder characterized by abnormal, involuntary, and repetitive body jolts or vocal productions called tics. It can often appear that the individual doesn’t realize this is happening.

Typically, those with Tourette’s will either have just one speech tic and a number of different movement or motor tics.

Prevalence

A 2007 CDC study estimates that 0.6% of children aged six to seventeen have Tourette’s. Among the 0.3% diagnosed, 37% have moderate or severe Tourette’s.

The condition affects people of all backgrounds and races equally but is three to five times more prevalent in males than females, and it is more likely to be noticed in the 9 to 11 age group.

Symptoms of Tourette syndrome:

Tics are the main symptom of Tourette syndrome, and these symptoms can be more frequent, more severe, change to a different tic, or last for longer when the individual is under stress, anxious, or lacking enough sleep.

Tics are simple or complex:

  • Simple tics – Include brief and sudden tics that are repetitive and involve a few muscle groups.

    • Motor: Darting eyes, blinking, twitching nose, mouth movements, jerking head movements, shrugging, grimacing
    • Vocal or Phonic: Coughs, grunts, barking sounds, throat clearing
  • Complex tics – Include movement in distinctive coordinated patterns using multiple muscle groups

    • Motor: Touching objects, smelling items, walking or stepping a particular pattern, repeated movements, twisting, bending, hopping, making obscene gestures
    • Vocal or Phonic: Using obscene or vulgar curses, repeating others words or sentences, repeating their own words or sentences

Most individuals with Tourette syndrome experience a strong and unbearable feeling before a tic called a premonitory sensation, which only goes away after the tic happens.

Common examples of these sensations include:

  • An irritable feeling in the throat before grunting
  • A feeling that one’s eyes are burning before blinking

Teenagers often exhibit symptoms of simple tics more often than is recognized, but they are usually dismissed as peculiarities.

Diagnosing Tourette’s

A Tourette syndrome diagnosis is made using the history of symptoms and signs of Tourette’s. A diagnosis is made if:

  • Symptoms began before 18 years of age.
  • Tics occur almost every day and several times a day for over a year.
  • Vocal and motor tics are present but not necessarily at the same time.
  • Tics are not triggered by other conditions, medication, or substances.
  • Tics change in frequency, severity, type, and complexity over time.

Because both motor and vocal / phonic tics can be caused by things other than Tourette’s, a doctor will likely schedule an MRI or other imaging studies and some blood tests to rule out other possibilities before diagnosing.

The onset of Tourette syndrome can occur later in adulthood, but typically it is noticed between 2 and 15 years of age, with the majority of cases presenting at around 6 years old.

Missed Diagnosis
Because the symptoms of Tourette syndrome can mimic other conditions, including physical ailments, mild to moderate cases can be easy to overlook and never get diagnosed. For example, sniffling could be written off as allergies, and blinking could be thought of as eye problems.

Coexisting Conditions
Over 42% of children diagnosed with Tourette’s have at least one chronic coexisting health condition.
86% of children diagnosed with TS have also been diagnosed with at least one additional developmental, behavioral, or mental condition, such as:

  • Intellectual disability – 12%
  • Depression – 25%
  • Behavioral or conduct issues – 26%
  • Developmental delay affecting learning abilities – 28%
  • Speech or language difficulties – 29%
  • Obsessive compulsive disorder (OCD) – 33%
  • Learning disability – 47%
  • Anxiety problems – 49%
  • Attention-deficit hyperactivity disorder (ADHD) – 63%
  • Autism spectrum disorder – 35%

Causes of Tourette’s

The exact cause of Tourette’s syndrome remains unknown. A person is at increased risk of developing Tourette’s syndrome if there is a family history of this condition. People with Tourette’s syndrome usually have other coexistent health conditions such as obsessive-compulsive disorder, attention deficit hyperactivity disorder, or a learning disability.

A potential cause being studied could be problems with how nerves communicate in particular parts of the brain, which might also be related to an imbalance in the chemicals that receive, carry, and deliver signals in the brain.

Treatment for Tourette’s syndrome

At this time, there is no cure for Tourette syndrome.

It is very common that those trying to suppress a symptom are extremely challenged to be able to focus on anything else at that time. For those individuals, especially those in their teen years, it can be very difficult to perform well academically or have a conversation. It is not essential for most people with tics to receive treatment, but if the tics worsen, don’t show signs of lessening, or if they present problems in daily life, there are ways of better controlling and/or managing them.

One successful approach for the reduction of both the frequency and the severity of tics is behavioral therapy which includes:

  • Habit reversal training (HRT) – helps the child in the areas of awareness, choosing a competing response (with a reward system), managing thoughts and feelings, and relaxation techniques.
  • Exposure and response prevention (ERP) – teaches the child how to tolerate and accept premonitory sensations to where they don’t respond with a tic. Studies show a 30% – 40% reduction in tics.
  • Decoupling – self-help HRT
  • Comprehensive behavioral intervention (CBIT) – based on HRT, this helps with recognizing premonitory sensations and the situations where they occur, relaxation techniques, changing situations, and choosing a competing response.

In addition, deep brain stimulation and psychotherapy can play a key role in bringing significant changes for someone diagnosed with Tourette’s.

  • Deep brain stimulation (DBS) – an effective treatment in addressing severe tics that haven’t yet responded favorably to other treatment options. Through surgery, a battery-operated medical device is inserted in the brain, and it precisely delivers stimulation to specific areas in the brain that control functions like movement. Being a newer treatment, it is still in the earlier stages of research to determine if it’s an effective and safe treatment for people with Tourette syndrome.
  • Psychotherapy and psychoeducation – gives understanding to the disorder and can help the individual with coexisting conditions or disorders like obsessions, anxiety, depression, or ADHD.

Medication – is reserved for more severe symptoms that profoundly interfere with functioning, but these meds have adverse effects and should only be used sparingly and with caution.

Examples of possible medications as part of a treatment plan include:

  • Central adrenergic inhibitors – usually prescribed for high blood pressure, these might control behavioral symptoms like rage attacks or impulse control issues. Drowsiness is listed as a possible side effect.
  • Dopamine receptor blockers – such as risperidone have been shown to help control tics. Side effects from these medications include the potential for involuntary repetitive movements as well as possible weight gain or severe depression.
  • Dopamine balancers – Aripiprazole either blocks or enhances the existing amount of dopamine in the brain and has fewer side effects to those of dopamine blockers.
  • ADHD stimulants – Medications with methylphenidate, as well as medications that have dextroamphetamine, may result in increased concentration and focus, but they also might make tics worse for some individuals. Atomoxetine is showing promise in trials.
  • Anti-seizure medicine – Topamax, which is prescribed to treat epilepsy, has shown favorable results in recent studies.
  • Botulinum (Botox) injections – Simple tics or some vocal tics may see relief with a Botox injection in specific muscles.
  • Antidepressants / SSRIs (Selective Serotonin Reuptake Inhibitors) – can be prescribed for individuals with symptoms of OCD, anxiety, or depression.

Symptoms of Tourette syndrome:

Tics are the main symptom of Tourette syndrome, and these symptoms can be more frequent, more severe, change to a different tic, or last for longer when the individual is under stress, anxious, or lacking enough sleep.

Tics are simple or complex:

  • Simple tics – Include brief and sudden tics that are repetitive and involve a few muscle groups.

    • Motor: Darting eyes, blinking, twitching nose, mouth movements, jerking head movements, shrugging, grimacing
    • Vocal or Phonic: Coughs, grunts, barking sounds, throat clearing
  • Complex tics – Include movement in distinctive coordinated patterns using multiple muscle groups

    • Motor: Touching objects, smelling items, walking or stepping a particular pattern, repeated movements, twisting, bending, hopping, making obscene gestures
    • Vocal or Phonic: Using obscene or vulgar curses, repeating others words or sentences, repeating their own words or sentences

Most individuals with Tourette syndrome experience a strong and unbearable feeling before a tic called a premonitory sensation, which only goes away after the tic happens.

Common examples of these sensations include:

  • An irritable feeling in the throat before grunting
  • A feeling that one’s eyes are burning before blinking

Teenagers often exhibit symptoms of simple tics more often than is recognized, but they are usually dismissed as peculiarities.

Diagnosing Tourette’s syndrome:

A Tourette syndrome diagnosis is made using the history of symptoms and signs of Tourette’s. A diagnosis is made if:

  • Symptoms began before 18 years of age.
  • Tics occur almost every day and several times a day for over a year.
  • Vocal and motor tics are present but not necessarily at the same time.
  • Tics are not triggered by other conditions, medication, or substances.
  • Tics change in frequency, severity, type, and complexity over time.

Because both motor and vocal / phonic tics can be caused by things other than Tourette’s, a doctor will likely schedule an MRI or other imaging studies and some blood tests to rule out other possibilities before diagnosing.

The onset of Tourette syndrome can occur later in adulthood, but typically it is noticed between 2 and 15 years of age, with the majority of cases presenting at around 6 years old.

Missed Diagnosis
Because the symptoms of Tourette syndrome can mimic other conditions, including physical ailments, mild to moderate cases can be easy to overlook and never get diagnosed. For example, sniffling could be written off as allergies, and blinking could be thought of as eye problems.

Coexisting Conditions
Over 42% of children diagnosed with Tourette’s have at least one chronic coexisting health condition.
86% of children diagnosed with TS have also been diagnosed with at least one additional developmental, behavioral, or mental condition, such as:

  • Intellectual disability – 12%
  • Depression – 25%
  • Behavioral or conduct issues – 26%
  • Developmental delay affecting learning abilities – 28%
  • Speech or language difficulties – 29%
  • Obsessive compulsive disorder (OCD) – 33%
  • Learning disability – 47%
  • Anxiety problems – 49%
  • Attention-deficit hyperactivity disorder (ADHD) – 63%
  • Autism spectrum disorder – 35%

Causes of Tourette’s syndrome:

The exact cause of Tourette’s syndrome remains unknown. A person is at increased risk of developing Tourette’s syndrome if there is a family history of this condition. People with Tourette’s syndrome usually have other coexistent health conditions such as obsessive-compulsive disorder, attention deficit hyperactivity disorder, or a learning disability.

A potential cause being studied could be problems with how nerves communicate in particular parts of the brain, which might also be related to an imbalance in the chemicals that receive, carry, and deliver signals in the brain.

Treatment for Tourette’s syndrome:

At this time, there is no cure for Tourette syndrome.

It is very common that those trying to suppress a symptom are extremely challenged to be able to focus on anything else at that time. For those individuals, especially those in their teen years, it can be very difficult to perform well academically or have a conversation. It is not essential for most people with tics to receive treatment, but if the tics worsen, don’t show signs of lessening, or if they present problems in daily life, there are ways of better controlling and/or managing them.

One successful approach for the reduction of both the frequency and the severity of tics is behavioral therapy which includes:

  • Habit reversal training (HRT) – helps the child in the areas of awareness, choosing a competing response (with a reward system), managing thoughts and feelings, and relaxation techniques.
  • Exposure and response prevention (ERP) – teaches the child how to tolerate and accept premonitory sensations to where they don’t respond with a tic. Studies show a 30% – 40% reduction in tics.
  • Decoupling – self-help HRT
  • Comprehensive behavioral intervention (CBIT) – based on HRT, this helps with recognizing premonitory sensations and the situations where they occur, relaxation techniques, changing situations, and choosing a competing response.

In addition, deep brain stimulation and psychotherapy can play a key role in bringing significant changes for someone diagnosed with Tourette’s.

  • Deep brain stimulation (DBS) – an effective treatment in addressing severe tics that haven’t yet responded favorably to other treatment options. Through surgery, a battery-operated medical device is inserted in the brain, and it precisely delivers stimulation to specific areas in the brain that control functions like movement. Being a newer treatment, it is still in the earlier stages of research to determine if it’s an effective and safe treatment for people with Tourette syndrome.
  • Psychotherapy and psychoeducation – gives understanding to the disorder and can help the individual with coexisting conditions or disorders like obsessions, anxiety, depression, or ADHD.

Medication – is reserved for more severe symptoms that profoundly interfere with functioning, but these meds have adverse effects and should only be used sparingly and with caution.

Examples of possible medications as part of a treatment plan include:

  • Central adrenergic inhibitors – usually prescribed for high blood pressure, these might control behavioral symptoms like rage attacks or impulse control issues. Drowsiness is listed as a possible side effect.
  • Dopamine receptor blockers – such as risperidone have been shown to help control tics. Side effects from these medications include the potential for involuntary repetitive movements as well as possible weight gain or severe depression.
  • Dopamine balancers – Aripiprazole either blocks or enhances the existing amount of dopamine in the brain and has fewer side effects to those of dopamine blockers.
  • ADHD stimulants – Medications with methylphenidate, as well as medications that have dextroamphetamine, may result in increased concentration and focus, but they also might make tics worse for some individuals. Atomoxetine is showing promise in trials.
  • Anti-seizure medicine – Topamax, which is prescribed to treat epilepsy, has shown favorable results in recent studies.
  • Botulinum (Botox) injections – Simple tics or some vocal tics may see relief with a Botox injection in specific muscles.
  • Antidepressants / SSRIs (Selective Serotonin Reuptake Inhibitors) – can be prescribed for individuals with symptoms of OCD, anxiety, or depression.
Source KIDS HEALTH | CDC – Prevalence of Diagnosed Tourette | JOURNAL OF DEVELOPMENTAL & BEHAVIORAL PEDIATRICS – A National Profile of Tourette Syndrome | CDC – Data & Statistics on Tourette Syndrome | MAYO CLINIC – Tourette’s Syndrome, Causes, Diagnosis, and Treatment | CINCINNATI CHILDRENS – Cognitive Behavioral Intervention for Tics | TOURETTES ACTION – Behavioural therapies and Tourette Syndrome | Fründt O, Woods D, Ganos C (April 2017). “Behavioral therapy for Tourette syndrome and chronic tic disorders”. Neurol Clin Pract (Review). 7 (2): 148–56. | Fernandez TV, State MW, Pittenger C (2018). “Tourette disorder and other tic disorders”. Handb Clin Neurol (Review). Handbook of Clinical Neurology. 147: 343–54. | Leckman, JF, Zhang, H, Vitale, A, Lahnin, F, Lynch, K, Bondi, C, et al. Course of tic severity in Tourette Syndrome: the first two decades. Pediatrics. 1998; 102(1 Pt 1): 14-19.