Tourette syndrome – Condensed

Tourette syndrome (TS) is a chronic neurological developmental disorder with numerous diverse psychiatric manifestations. Two classes of symptoms, namely the motor and vocal (phonic) tics characterize the syndrome. The tics vary in time by their frequency of appearance, intensity and nature. Different types of stresses as well as mistreatments exacerbate the symptoms of TS.

Special symptoms

Super sensitivity to low or elevated ambient temperatures

Specific sleeping disturbances

Super or insensitivity to touch

Frequent constipation

Asthma and other specific medical conditions

Specific behavioral disturbances

Syndrome in “disguise”

Most often the symptoms used to characterize TS are mild in their neurological manner while other coexisting syndromes are more pronounced, thus masking the TS. Such syndromes include Attention Deficit and Hyperactivity Disorder, Obsessive-Compulsive Disorder, Learning Disabilities and specific medical disorders such as Asthma, aberrant Electroencephalograph recordings, Stuttering, certain Behavioral disturbances, Psychiatric disturbances etc., often leading to different misdiagnoses as to their true origin.

Diagnosing the Tourette syndrome was based in the past basically on clinical evaluation of the presenting symptoms, taking into consideration the impact and burden of the symptoms to the patient. Following a novel understanding of the brain circuitry and function, a novel, scientific, non-invasive accurate biophysical method for diagnosing Tourette syndrome has been developed in the “Clinic for Advanced Psychology”. Moreover, this method enables to monitor precisely the differential efficacy of the psychological and pharmacological (medicines) means employed.

Prior to treating the Tourette patient a comprehensive evaluation of the Psychiatric, Psychological (cognitive, emotional and behavioral), Familial, Scholastic (Schooling and Learning), Social disturbances as well as the patient’s capabilities should be evaluated in depth.

In the following page, namely “All you wanted to know about Tourette syndrome” you will find all the facts, impacts and many answers to questions about TS as well as details regarding “Choosing optimal professional assistance” to TS patients, will be addressed.

It should be born in mind that TS can be successfully tamed and managed !!!.

For a comprehensive overview please refer to “All you wanted to know about Tourette syndrome”.

Back to Contents

Back to the HomePage

All you wanted to know about Tourette syndrome

Preface

Tourette syndrome is a chronic neurological developmental syndrome called after the French neurologist, Gill De La Tourette who characterized the syndrome in 1886. TS is characterized by the appearance of both motor and vocal (phonic) tics. The two classes of tics are not required to appear simultaneously.

Examples of motor tics

Motor tics affecting the face or head such as intensive eye-blinking with later acquisition of other tics with the arms, legs, body etc.               

Examples of vocal tics

Vocal tics include throat cleaning, sniffing, barking, yelping and in some instances using fowl language (coprolalia). However, vocal tics can consist of any sound emanating from the nose or mouth (like tic of intonation) and may or may not have linguistic meaning.

At times, the patient repeats his own syllables, words or phrases (Palilalia) or others (Echolalia). The patient might mirror the motor actions of others (Echopraxia and in rare cases (Less than 15% of TS patients) he might use obscene language (Coprolalia) or use insulting gestures (Copropraxia). Frequently, the patient sniffs objects or even other individuals.

Intensity of the tic, frequency of appearance, duration and nature characterize tics. A major hallmark of the tics is their nature of sinusoidal appearance with time. The tics are classified according to their intensity (mild-moderate and severe tics) and complexity. Since the tics resemble “normal” movements or sounds, despite the fact that TS was present during early childhood, in most cases only the sever cases are diagnosed as having TS, sometime during their early adolescence.

In most cases a gradual appearance of the syndrome is evident. The tics change with time, manifesting specific tics for a period of time and then the tics change. The maximum amplitude of intensity of the tics is usually seen between the ages of ten to twelve years. Afterwards, a gradual decrease is observed in many cases seen in the clinic, under the natural proceeding profile of the syndrome without any pharmacological intervention. A positive correlation was found between the age of initial tic appearance and the age of their disappearance. Hence, the earlier appearance seems to predict an early extinction of the tics. In most cases the tics ameliorate toward early adulthood under no pharmacological treatment.

Once thought that belonging to the autonomic nervous system, the tics are under no cognitive control by the patients. It is by now agreed by all personnel treating TS that the tics are partially controlled by the patient. Often the tics are expressed solely in discrete places.

Are there more to TS then just the tics?

Yes, a lot more. In most cases, mild to moderate cases of neurological symptoms, the tics are of minor disturbance to the patient. Soon coming up.

TS patients are remarkably sensitive to both the inner and outer milieu surrounding them. Being super sensitive, different stimuli, which often are disregarded by others, are stressful stimuli to the TS patient, affecting their neurological and behavioral symptoms. Complains regarding “everyone is picking on me…, everyone is looking at me (which are not paranoid symptoms) are common despite the fact that no such things are encountered in reality. Often, physical stress (hot and cold weather and noise), physiological stress (hunger, thirst, tiredness or need for toilets) or psychological stress (threat, fear, need to conform to laws, rules and authority) may

exacerbate the symptoms for the child or adult with TS.

Back to Contents

Back to the HomePage

Special unrecognized symptoms

Tendency to switch day-night cycles.

Tendency to go to sleep late at night.

Difficulties waking up in the morning despite long sleeping hours.

Super or insensitivity to ambient temperatures (hot or cold).

Super or insensitivity to pain and sometimes tendency to hurt oneself (SIB).

Tendency to excessive drinking (soft drinks and water).

Super sensitivity to specific odors.

Tendency to specific medical disorders ( asthma, “running” nose, bed wetting (after age 6 years),  allergies, nervous bowel syndrome, bronchitis), aberrant electroencephalograph,  speech disorders and

stuttering, hypotonus (low muscle tone).

Super or insensitivity to touch (objects or human).

Hair pulling (Trichotilomania).

Specific ocular disturbances (blurred vision or flashes in visual field).

Back to Contents

Back to the HomePage

Tourette - the “Elusive Syndrome in Disguise”

Often, the patient with TS has other syndromes that coexist alongside TS. Usually, especially in the mild and moderate TS cases, it is those additional syndromes that cause the unbearable burden to the TS patient rather than the tics. Unfortunately, in many instances it would be those subsiding syndromes masking the TS, that would receive the intense care disregarding their origin, thus leading only to minor relieve.

Examples to such syndromes:

Attention Deficit and Hyperactivity Disorder (AD(H)D

More than 60% of the children expressing TS, have been demonstrated to have shown symptoms of attention deficit, hyperactivity and impulsive behavior in their past that has been misattributed to ADHD.

Behavior Disturbances

In many cases of TS, marked behavioral disturbances are manifested. Children with TS often express neurological tendency to pick on others and show argumentative and oppositional defiant behaviors. Moreover, explosive behavior is frequent over what seems to be evaluated by others as minor things.

Learning Disabilities

Frequently, learning disabilities are common among children and adults with TS. Specific learning disabilities have been identified. Disturbances in attention capacity, graphomotor abilities, different fine motor and eye-hand coordination difficulties, visual and auditory perception disturbances and other specific learning disorders like dyslexia (mastering reading capabilities), dyscalculia (mathematical calculation, understanding and reasoning) have all been demonstrated among children and adults with TS.

Obsessive-Compulsive Disorder (OCD)

Compiled from obsessive thinking of different, uncontrolled thoughts penetrating the stream of thoughts without any control, the patient finds himself in the midst of repetitive thinking. Often the patients feel that “things have got to be performed specifically in a certain order or fashion” thus they plan every sentence, act or thought order. 

The second arm of OCD are the compulsive rituals and acts the patients are compelled to perform like counting, putting things in order, cleaning etc. in order to relief marked uneasy tensions.

Social and emotional disturbances

Along with the former difficulties the patients often find themselves confronting harsh social reactions to their ”strange” actions, vocalizations and behaviors. Not understanding themselves, they struggle with their friends, teachers and family who all point to their “poor” control and more often they find themselves expelled from social contacts, with poor self-concept, confidence and hostility to the alien society.

Psychiatric disturbances

Certain psychiatric disorders like anxiety, depression, phobias, eating disorders have all been demonstrated to accompany TS more often than in the general population.

All the above mentioned syndromes, if characterized and treated with no reference to their TS related etiology, may in many instances be treated with frustrating small improvements. Only the comprehensive diagnosis evaluating all relevant aspects may unravel the true nature of TS underlying the disorders, thus leading to marked improvement.

Back to Contents

Back to the HomePage

Conventional clinical diagnosis of Tourette

Diagnosis of TS has been based on clinical evaluation of the symptoms (Tics) evaluating the differential debilitating effects of the symptoms to the day to day living of the patient. The clinical observation was based on the physician conventional examination of the symptoms and gathering substantiating

reports.

Back to Contents

Back to the HomePage

Leading factors for misdiagnosis of TS

Due to the classical diagnosis of TS based on clinical observation and gathering of substantiating evidence a number of factors have been reported as leading to misdiagnoses:

The fact that the patient with TS can monitor and restrict his symptoms to specific milieus, can mislead the professional evaluating the patient.

Since the tics resemble “normal” movements and gestures, most often mild to moderate TS remain

undiagnosed and unattended.

Since the TS patient possesses partial control of the tics manifesting them only in specific places, the doctor needs to rely on substantiating evidence from teachers and parents which makes the pharmacological treatment of the disorder difficult.  

Often the neurological tics are only mild to moderate while the true burden resolves from the associated syndromes which draw the focus of attention in the overall evaluation.

Advanced diagnosis of TS

Novel understanding of the brain’s circuitry and function, has lead to better understand the leading factors involved in TS and thus to further develop a new, scientific, biophysical non-invasive, accurate and reliable method (BDTAK) to diagnose TS. The patient performs the test autonomously, at his home setting.

Moreover, the BDTAK enables accurate biophysical monitoring of differential efficacy of the therapy employed leading to a better medication adjustment. BDTAK has been tested with patients with a wide age span ranging from 4 to 63 years for specific disorders.

Back to Contents

Back to the HomePage

Prevalence of TS in the general population

Once believed to be a rare disorder, it is by now estimated to be a common neurological disorder in the general population. The exact prevalence of the patients suffering from TS is still unknown because of the divers phenomenological manifestation of TS among patients and crucial diagnostic limitations.

Back to Contents

Back to the HomePage

Treatment

Receiving the diagnosis of TS involves startling fears, threats and confusion, which are seen many times in the clinic. Such a diagnosis leads to serious, balanced handling of the syndrome overcoming the stress it imposes. It certainly does not foster a pharmacological handling rather a comprehensive evaluation of the symptoms, their differential severity, impact on the patient’s life and treatment options.

A balanced genuine handling of the syndrome is suggested to start with a detailed scanning of all the data, symptoms and facts that has lead to the diagnosis and their severity. Most important are the treatment options. Being stressful, it is important to supply all the medical and psychological relevant information in plain simple rather than “scientific-medical” language leaving a fair amount of time for questions.

The policy of the “Clinic of Advanced Psychology” is to evaluate in depth all the relevant aspects implicated by the TS and to advocate the recommended psychological and polypharmacological relevant treatment options, focused at ameliorating the patient’s condition. We at the clinic treat TS by the psychological, behavioral, medical means in broad sense, psychiatric and learning disabilities fostered by the syndrome rather focus on the neurological tics themselves. Such a policy has proven itself in the past by a high diagnostic efficacy and successfully helping all aspects of the syndrome.  

 

Back to Contents

Back to the HomePage

Outstanding abilities of children with Tourette syndrome

Probably related to their super sensitivity to any stimuli in the world, the children with TS possess unique capabilities. Examples of such capabilities can be observed in fine arts (drawing, quire singing, theatrical performing,, playing musical instruments. composing, stand-up comedienne imitating etc.). Nevertheless, despite their extraordinary capabilities, often only the behavioral disturbances, odd symptoms as well as disadvantages are bolstered. One of the major therapeutic goals should focus attention, along with learning the symptoms, coping strategies as well as many other implications of the syndrome, would be to bolster these special dear advantages and abilities and by doing so, improving the patient’s self concept and raising his hindered self esteem.

 

Back to Contents

Back to the HomePage

“Life Saving" resources

Successful coping with TS may often impose recruiting different types of help resources. It is highly recommended that the professional dealing with TS have an initial thorough familiarity with TS. For assistance or emergency consult

Choosing an optimal assistance

Realizing that successful handling of the profound consequences TS may impose, a search for an optimal assistance is initiated and numerous questions arise. A few basic guidelines will be outlined for finding your way in the jungle of “Help”.

It should be emphasized again and again, that despite professional guidelines the crucial determinant for your evaluation must be your innate-gut feeling.

The expert past familiarity with TS is most important as is his experience in treating TS patients. Since such issues raise different queries, another way to approach these topics may be by scanning the

literature and past publications regarding TS in the clinic.

Recommendations received may indicate possible lines of interest, focus and strength offered by specific personnel yet as outlined earlier, it should be your inner feeling that should be used for your guidance.

Back to Contents

Back to the HomePage

Frequently asked questions

Must  I treat my TS with medication?

Are there any alternative medications to TS?

Is it recommended to give psychotherapy to my child having TS?

Does the child with TS must be placed in special schooling programs?

Do medications used to treat TS have any side effects?

What are the side effects of the medications used to treat TS?

Is "Ritaline" permitted for use in case of children with TS?

Will my child develop “dependence” on the medications used to treat his TS?

Can an individual with TS study in regular school-plans or universities?

Answers to these and many other questions will be addressed in the Clinic of Advanced Psychology.

Dr. A. Kessler, writing this page is a psychologist and a neuropsychologist in the “Clinic of Advanced Psychology”, engaged in treating patients and clinical research, a member of the Israeli Psychological Association, an affiliate member of the APA and a member of the TIC consortium.