39 Tourette’s Disorder
Name: Lionel Essrog
Source: Motherless Brooklyn by Jonathan Lethem (book, 1999)
Background Information
Lionel Essrog is a Caucasian male and presumably in his mid to late thirties. Lionel Essrog is an orphan and the whereabouts of his biological parents is unknown. Essrog spent his childhood and adolescence in the St. Vincent’s Home for Boys in Brooklyn, New York, which is a publicly funded boarding house for orphaned young males. The residents of St. Vincent’s are required to attend public school and Essrog acquired his high school diploma but has not received any further education. Essrog currently works for a man named Frank Minna with three other of his housemates from St. Vincent’s. The four of them call themselves “Minna Men” and they specialize in unconventional and frequently illegal types of jobs as provided by Frank Minna. Any familial mental health history is unknown. Essrog has no history of drug or alcohol abuse. He does not seem to have any long term goals, other than to continue working for Frank Minna. Beginning in early childhood, Essrog began experiencing compulsions which involved twitching and jerking his neck. These compulsions soon turned into various forms of motor tics, including incessant tapping of the metal-pipe legs of schoolroom desks and chairs as if in search of certain ringing tones, reaching for doorframes, and kneeling to grab at untied shoe laces of other classmates. One of his compulsions actually involved grabbing and kissing his fellow classmates and housemates at St. Vincent’s. Because of his behavior, Essrog did not have very much social interaction with peers his age and spent a lot of time alone. Around the time he was thirteen years old, the kissing compulsion ended but was replaced with others. He was prone to tapping, whistling, tongue-clicking, winking, rapid head turns, wall stroking, and other various tics. During this time, Essrog began experiencing rapid thoughts that were becoming more and more of a compulsion to speak out loud. Many of these thoughts were echoic variations to things he heard. For example, when Essrog heard “Alfred Hitchcock” he would silently rephrase it as “Altered Houseclock”. Essrog found it more and more difficult to withhold these compulsions and began exhibiting simple vocal tics by barking like a dog and chirping like a bird. While he still has the compulsion to do simple vocal tics, he also exhibits complex vocal tics as well.
Description of the Problem
Essrog currently displays simple and complex motor tics as well as simple and complex vocal tics. Examples of simple motor tics are eye blinking, nose wrinkling, neck jerking, shoulder shrugging, facial grimacing, and abdominal tensing. Complex motor tics include hand gestures, jumping, touching, pressing, stomping, facial contortions, repeatedly smelling an object, squatting, deep knee bends, retracing steps, twirling when walking, and assuming and holding unusual postures (including dystonic tics, such as holding the neck in a particular tensed position). Simple vocal tics include meaningless sounds such as throat clearing, sniffing, grunting, snorting, and chirping. Complex vocal tics more clearly involve speech and language and include the sudden, spontaneous expression of single words or phrases; speech blocking; sudden and meaningless changes in pitch, emphasis, or volume of speech; palilalia (repeating one’s own sounds or words); and echolalia (repeating the last-heard sound, word, or phrase). Essrog also shows coproplalia, which is the sudden, inappropriate expression of a socially unacceptable word or phrase. Essrog describes his vocal tics as follows; “My words begin plucking at threads nervously, seeking purchase, a weak point, a vulnerable ear. It’s an itch at first. Inconsequential. But that itch is soon a torrent behind a straining dam. Once I’m able to scratch that itch, it let’s off the pressure in my head and I am able to concentrate”. Essrog’s tics cause him anxiety in social situations but the men with whom he works have learned to accept his behavior. Essrog also claims that his tics are more difficult to suppress when he is anxious or nervous.
Diagnosis
The diagnosis that seems to fit appropriately for Essrog is Tourette’s Disorder (307.23)
Diagnostic Criteria for Tourette’s Disorder (DSM-IV-TR)
- Both multiple motor tics and one or more vocal tics must be present at the same time, although not necessarily concurrently
- Essrog exhibits multiple motor and vocal tics.
- 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.
- Essrog’s experiences tics everyday and has not shown any evidence of a tic-free period.
- The onset is before age 18 years.
- Essrog’s symptoms began in early childhood. Motor tics normally develop at about 6 – 7 years of age and vocal tics normally occur at after the onset of motor tics. Essrog’s onset fits this criteria.
- 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).
- Essrog shows no signs of substance abuse or any symptoms of medical conditions.
Accuracy of Portrayal
Jonathan Lethem’s characterization of Lionel Essrog was very accurate in the portrayal of a person diagnosed with Tourette’s Disorder. The age of onset was the same as listed in the DSM-IV-TR and the description of the compulsions and tics the character exuded were also accurately portrayed when compared to the diagnostic criteria of Tourette’s Disorder.
Treatment
Treatment for Essrog should include a specific kind of psychotherapy. The primary supported therapy for Tourette’s Disorder is habit reversal training (HRT), commonly known now as Cognitive-Behavior Intervention for Tics (CBITS). 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, Tourette’s Disorder can be effectively managed. If the Tourette’s Disorder is severe enough, antipsychotic medications can be helpful. These include but are not limited to Chlorpromazine, Haloperidol, and Pimozide. The severity of the tics may be exacerbated by administration of central nervous system stimulants, such as those used in the treatment for Attention-Deficit/Hyperactivity Disorder. Alternative treatments for treating Tourette’s Disorder have proven to be helpful for some patients. These 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.