Tourette’s syndrome is characterized by vocalization and movements that are involuntary and repetitive. It is a type of tic disorder. The pioneer Dr George Gilles De La Tourette first discovered the condition in 1885 in an eighty-six-year-old French noblewoman. Typically, in childhood, early symptoms are noticed. The average onset is between 3 and 9 years.
In males, Tourette's is prevalent more so than in females. In 200,000 Americans, the most severe form of TS has been estimated to be present and the milder and less complex symptoms out of 100, is exhibited by one. The symptoms of TS can last a lifetime, making this condition a chronic one but in the early teens the worst tic symptoms are experienced.
One of the definitive features of a group of childhood onset neurodevelopment condition collectively is known as tic disorder. Individually it is known as Tourette's syndrome, provisional tic disorder, and chronic tic disorder. By the types of tics present, the three tic disorders are distinguished. They are also distinguished depending on how long the tics have been present.
Over the course of more than a year in individuals with Tourette's syndrome in some combination they have had at least two motor tics and one vocal or phonic tic. For more than a year individuals with chronic tic disorders have had either motor tics or vocal tics and for less than a year individuals with provisional tic disorder have tics.
Repetitive movements or unwanted sounds are involved in this syndrome and these cannot be easily controlled. For example, a person may repeatedly shrug shoulders, blink eyes, and blurt out unusual sounds or words. Typically, between the ages of 2 and 15, the tics show up. Treatments are available but there is no cure.
Generally, by obtaining a description of tics and evaluating family history and by neuroimaging studies, Tourette's syndrome is diagnosed.
These are of two types
- Vocal - coughing, grunting, and shouting out words
- Physical – jumping up and down, jerking
A combination of physical and vocal tics is shown by most people diagnosed.
Tics are of two forms: simple and complex.
- Simple motor tics: The movements are sudden, brief, and repetitive. The muscle groups involved are limited. Some common simple tics include blinking, shoulder shrugging, other eye movements, facial movements, grimacing, head and shoulder jerking. Repetitive throat clearing, grunting sounds, and sniffing sounds are some simple vocalizations.
- Complex tics: The movements are distinct and happen in a coordinated pattern. Several muscle groups are involved in the movements. Head twist and shoulder shrug along with facial grimacing is a complex motor tic. Sniffing, hopping, ending, jumping, touching objects, and twisting are some other complex motor tics. These may appear purposeful.
With excitement and anxiety, tics might become worse and often may become better during any calm and focused activities. Sometimes the tics may worsen or get triggered by certain physical experiences. For example, neck tics may get triggered by tight collars or throat-clearing or hearing another person sniff. Such similar sounds may trigger the tics. During sleep, tics do not go away but significantly may get diminished.
Course of the condition
Over time tics come and go in type, location, severity, and frequency. Usually, in the head and neck area, the first symptom may occur. Slowly they may progress to the muscles of the trunk and extremities. Generally, the development of vocal tics is preceded by motor tics, and complex tics are generally preceded by simple tics.
Can tics be controlled?
The symptoms of TS are actually involuntary but in some it may camouflage or suppress. Often, people with TS report that when suppressing the tic, a build up in tension is experienced. The build up is to such a point that there is an urge to express it. In response to environment triggers, tics may appear to be purposeful or voluntary but actually they are not.
In certain rain regions, abnormalities may cause TS. These brain regions could include:
- Frontal lobes, basal ganglia, and cortex
- Circuits with which these regions are interconnected
- Neurotransmitters among nerve cells are responsible for communication. These neurotransmitters include serotonin, norepinephrine and dopamine.
Disorders associated with TS
Additional neurobehavioral problems are experienced by those with TS. This problem may cause even more impairment such as inattention, hyperactivity, impulsivity, reading, writing, and arithmetic problems.
Obsessive compulsive symptoms can include repetitive behaviors, intrusive worries, and thought.
Worrying about dirt and germs may lead to repetitive hand washing; ritualistic behavior may be associated with bad things happening such as ordering, repeating, arranging, and counting. Often, people with TS also complain about anxiety disorders, difficulties with living, and depression. These problems directly may or may not be related to TS.
Although a significant decline in motor and vocal tics is experienced by most individuals in late adolescence and early adulthood, there may be persistence of associated neurobehavioral conditions. By receiving medical care, people with TS are served best. In medical care, a comprehensive treatment plan is included.
After verifying for at least one year that the patient has had both motor and vocal tics, the doctor diagnosis TS. For diagnosis, no blood or laboratory test is done. No imaging is done.
Other conditions can be ruled out that can be confused with TS. It is not uncommon to obtain a formal diagnosis after some time after the existence of symptoms. There are many reasons for this. Even mild or moderate tic symptoms can be considered inconsequential for families and physicians that are unfamiliar with TS. They may consider it as a result of any other condition or they will think it is part of developmental phase. For example, eye blinking can be associated with vision problems. Similarly, sniffing can be associated with seasonal allergies.
By initiating slowly, it is possible to manage many neuroleptic side effects. When the side effects occur, the dose can be reduced. Side effects associated with neuroleptics are weight gain, sedation, and cognitive dulling.
Less common side effects of neuroleptics include dystonic reactions, tremor, Parkinsonian symptoms, and other involuntary movements. However, by reducing the dose, these side effects can manage. In order to avoid withdrawal, dyskinesias and rebound increases. In tics after long term use, neuroleptics should be discontinued slowly. A movement disorder such as tardive dyskinesia may result due to chronic use of neuroleptics and from TS it is distinct.
For shorter periods of time, by using lower doses of neuroleptics we can lower the risk of side effects. For reducing tic severity other medications may also be helpful.
According to recent research in people with TS, symptoms can be lessened by using stimulant medications such as methylphenidate and dextroamphetamine ADHD. It also prevents tics from becoming severe. However, in those who have a family history of TS and in children with tics/TS, this stimulant product labeling contradicts its use.
In some patients with obsessive compulsive symptoms, serotonin reuptake inhibitors have been proven to be effective. These include fluoxetine, proxetine, clomipramine, sertraline. To reduce tics, behavioral treatment can be used. Awareness training and competing response training is included in this.
Behavioral therapy can be done which includes:
- Habit reversal therapy: Pattern and frequency of tics is monitored. The aim here is to identify the trigger and with it, alternative less noticeable tics are replaced.
- Exposure with response prevention: In order to practice suppressing, the exposure to the urge to tic is increased.
Around ten years after starting medications, significant improvement in seen in almost two thirds of affected individuals. In some cases, the need for medication or therapy is reduced since the symptom becomes less troublesome. In some cases, the symptoms might completely disappear.