91 Tourette’s Disorder (307.23)

DSM-IV-TR criteria

• A. Both multiple motor tics and one or more vocal tics must be present at the same time, although not necessarily concurrently (A tic is a sudden, rapid, recurrent, non-rhythmic, stereotyped motor movement or vocalization).
• B. The tics must occur many times a day nearly every day(usually in bouts) nearly everyday or intermittently over more than one year, and during this period there must not have been a tic-free period of more than three consecutive months.
• C. The onset is before age 18 years.
• D. The disturbance must not be due to the direct physiological effects of a substance (e.g., stimulants) or general medical condition (e.g., Huntington’s disease or positive encephalitis).

Associated features

• According to the American Psychiatric Association (2000), “associated features of Tourette’s disorder commonly include obsessions and compulsions. These can include clicking of the tongue, squatting, sniffing, hopping, skipping, throat clearing, and stuttering. Other common associated features are hyperactivity, distractibility, and impulsivity.” Rejection by others due to the tics and other disruptions can impair both functioning and acceptance in social, school, and work settings.
• Individuals with Tourette’s may also have an increased anxiety about having tics in social situations, causing them to stray away from going out or being accepted by others. “In severe cases of Tourette’s Disorder, the tics may directly interfere with daily activities, such as reading and writing” (American Psychiatric Association, 2000). Other disorders that are frequently associated with Tourette’s include Obsessive-Compulsive Disorder, Attention-Deficit/Hyperactivity Disorder, and Learning Disorders (American Psychiatric Association, 2000).
• Epidemiology shows the high relevance of Tourette’s Disorder to Obsessive-Compulsive Disorder; around 30% of children diagnosed with OCD also have Tourette’s. On the reverse side, 60% of children with Tourette’s will also generally have some form of OCD (Wagner, 2006, p.65). Furthermore, there are also signs of self-injurous behaviors, sleep disturbances, aggression, anxiety, and depression.

Child vs. adult presentation

• Tourette’s Disorder appears to be more profound among boys than girls during early childhood, but to be more severe in women than men in adulthood.
• In most cases the disorder peaks in severity at 10-12 years of age. In about 25% of patients the disorder does not improve until adolescence. In 10% of patients the disorder is severe and persists through adulthood.

Gender and cultural differences in presentation

• Tourette’s Syndrome occurs in people from all ethnic groups; males are affected about three to four times more often than females. Through different cultures, it appears that associated features vary.
• In clinical settings the disorder is diagnosed approximately 3 to 5 times more often in males than in females, the gender ratio is perhaps low as 2:1 in community samples.

Epidemiology

• Since TS develops in the adolescence years and must be present before age 18, children are more likely to develop TS than adults. In fact, TS is known, for most cases, to decrease in severity and frequency and can even disappear entirely by early adulthood. TS has been reported in a wide variety of both racial and ethnic groups. TS occurs more frequently in males than females with a ratio of 1.5:3 times more likely (APA, 2000).
• A person with Tourette’s has about a 50% chance of passing the genes to one of his or her children. Based on cases in North America and Europe, it tends to be most common is males. There is a male to female ratio of 3:1 or 4:1 and a mean onset age of about 7 years old. Vocal tics usually occur later than motor tics, around a mean of age 11.

Etiology

The etiology of TS is purely biological, but the disorder does have some psychological disorders associated with it. Some associated co-morbid disorders include obsessive compulsive disorder (OCD), anxiety disorders, learning disorders, and attention deficit/hyperactivity disorder (ADHD). TS is a neurological disorder that comes in two forms: genetic, or vulnerability, and non-genetic. The term “vulnerability”, means that the child has developed TS genetically. Individuals are at a greater risk for TS if they have a first degree relative who has the disorder. Not everyone who inherits the disorder with express the symptoms associated with the disorder, such as tics. There are a variety of ways that vulnerability can be expressed and include full-blown Tourette’s Disorder, Chronic Motor or Vocal Disorder, OCD, and some Attention/Hyperactivity Disorders (APA, 2000). When TS is said to be non-genetic, the individual usually will not have TS since it is a biological disorder associated with genes. The non-genetic individual could be experiencing tics from having another mental disorder, certain medications, or a general medical condition.

Empirically supported treatments

• The primary supported therapy for TS is habit reversal training (HRT). In HRT, a person first learns to know when and where he/she is going to have a tic, followed by development of competing responses that prevent you from physically being able to perform the tic. These responses are held until the urge to tic dissipates. Over time, particularly with motor tics, the client learns that they do not need to tic to feel the release and relaxation. In many cases, TS can be effectively managed, and approprimately one third of child patients can outgrow TS by adulthood. If TS is severe enough, antipsychotic medications can be helpful. These include but are not limited to Chlorpromazine, Haloperidol, and Pimozide.
• Alternative treatments for treating TS have proven to be helpful for patients. These complementative treatments are herbal medicines, nutritional, vitamin, and mineral supplements and behavioral therapies. It should be known that these treatments should be used as complementary and never as a substitute.

LINKS:

• Author David Sedaris describes his childhood with Tourette’s. This story begins at minute 30:40 and ends at 45:30.
  • David Sedaris and Tourette’s
  • “Edge of Sanity.” This American Life. Chicago Public Radio. Feb. 4, 2000
• The following video discusses Tourette’s Syndrome. See Video: http://www.youtube.com/watch?v=hNSHLOI_-aU&feature=fvst. (uploaded by drmdk)
• A real life story of a young man with TS who has encouraging results with surgery. See video https://youtu.be/nDkrD1uCGsM http://www.youtube.com/watch?v=nDkrD1uCGsM. (uploaded by Westymedia)
• The following link from NPR’s Day to Day program follows writer Marcus McPeek Villatoro as he discusses his and his daughter’s Tourette’s Syndrome.