tourettes_syndrome

What is a Tic?
Tics are involuntary, rapid, repetitive, and stereotyped
movements of individual muscle groups.

Motor Tics
Simple motor tics: fast, darting, and meaningless.
Examples include: Eye blinking, grimacing, nose twitching, lip
pouting, shoulder shrugging, arm jerking, head jerking,
abdominal tensing, kicking, finger movements, jaw snapping,
tooth clicking, frowning, tensing parts of the body, and rapid
jerking of any part of the body.

Complex motor tics: slower, may appear purposeful
Examples include: Hopping, clapping, touching objects (or
others or self), throwing, arranging, gyrating, bending,
"dystonic" postures, biting the mouth, the lip, or the arm,
headbanging, arm thrusting, striking out, picking scabs,
writhing movements, rolling eyes upwards or side-to-side,
making funny expressions, sticking out the tongue, kissing,
pinching, and tearing paper or books.
Copropraxia: "Giving the finger" and other obscene gestures.
Echopraxia: Imitating gestures or movements of other people.

Vocal Tics
Simple vocal tics: meaningless sounds and noises.
Examples include: Coughing, spitting, screeching, barking,
grunting, gurgling, clacking, whistling, hissing, sucking sounds,
and syllable sounds.

Complex vocal tics: linguistically meaningful utterances such
as words and phrases.
Examples include: "Oh boy," "you know," "shut up," "you're
fat," "all right," and "what's that."
Rituals:Repeating a phrase until it sounds "just right" and
saying something over 3 times.
Speech atypicalities: Unusual rhythms, tone, accents,
loudness, and very rapid speech.
Coprolalia :Obscene, aggressive, or otherwise socially
unacceptable words or phrases.
Palilalia: Repeating one's own words or parts of words.
Echolalia:Repeating sounds, words, or parts of words of
others.

Types of Tic Disorders
Transient tic disorders often begin during the early school
years and can occur in up to 15% of all children. Common tics
include eye blinking, nose puckering, grimacing, and
squinting. Transient vocalizations are less common and
include various throat sounds, humming, or other noises.
Transient tics last only weeks or a few months and usually are
not associated with specific behavioral or school problems.
They are especially noticeable with heightened excitement or
fatigue. As with all tic syndromes, boys are three to four times
more often afflicted than girls.

Chronic tic disorders are differentiated from those that are
transient not only by their duration over many years, but by
their relatively unchanging character. While transient tics
come and go, chronic tics may persist unchanged for years.

Tourette Syndrome (TS), first described by Gilles de la
Tourette, can be the most debilitating tic disorder, and is
characterized by multiform, frequently changing motor and
phonic tics.

Diagnostic Criteria for Tourette's Disorder

Both multiple motor and one or more vocal tics have
been present at some time during the illness, although
not necessarily concurrently.
The tics occur many times a day (usually in bouts)
nearly every day or intermittently throughout a period of
more than 1 year, and during this period there was
never a tic-free period of more than 3 consecutive
months.
The disturbance causes marked distress or significant
impairment in social, occupational, or other important
areas of functioning.
The onset is before age 18 years.
The disturbance is not due to the direct physiological
effects of a substance (e.g., stimulants) or a general
medical condition (e.g., Huntington's disease or
postviral encephalitis).

Prevalance
The incidence of TS in adults is about 0.1–1%. Estimates of
TS in children have been as high as 3%. The lifetime
prevalence of TD is not known but estimates vary between 5%
and 10% of the population, with estimates of 18% in child
populations. Tics develop in childhood and simple tics usually
precede more complex tics, with phonic tics usually developing
which will often begin as breathing or sniffing noises
subsequent to motor and sensory tics. The most notorious TS
vocal tic, coprolalia (swearing), is rare.

Cognitive, behavioural and psychological
problems associated with Tourette's
Syndrome
As well as tics, there are a variety of behavioral and
psychological difficulties that are experienced by many,
though not all, patients with TS. The most frequently reported
behavioral problems are attentional deficits, obsessions,
compulsions, impulsivity, irritability, aggressivity, immaturity,
self-injurious behaviors, and depression. Some of the
behaviors (e.g., obsessive compulsive behavior) may be an
integral part of TS, while others may be more common in TS
patients because of certain biological vulnerabilities (e.g.,
ADHD). Still others may represent responses to the social
stresses associated with a multiple tic disorder or a
combination of biological and psychological reactions.

Causes of Tourette's Syndrome
Research shows that, in Tourette syndrome, something is
wrong with the way in which the brain produces or uses
important substances called neurotransmitters, which control
how signals are sent along the nerve cells. The
neurotransmitters dopamine and serotonin have been
implicated in Tourette syndrome; noradrenaline is thought to
be the most important stimulant. (Medications that mimic
noradrenaline may cause tics in susceptible patients.)
Whatever the exact defect, it is handed down through the
genes from parents to children. If one parent has Tourette
syndrome, each child has a 50% chance of getting the
abnormal gene.

Treatment of Tourette's Syndrome
Treatment of Tourette syndrome can be divided into treatment
of tics, and treatment of co-occurring conditions, which, when
present, are often a larger source of functional impairment
than the tics themselves. There is no cure for Tourette's and
no medication which works universally for all individuals
without significant adverse effects; knowledge and
understanding are the best treatments available for tics.
Management of the symptoms of Tourette's may include
pharmacological, behavioral and psychological therapies.
While pharmacological treatment is reserved for more severe
symptoms, other types of treatments may help avoid or
improve symptoms of depression or social isolation, and
improve supportive family functioning.

The majority of people with TS require no medication, but
medication is available to help when symptoms interfere with
functioning. Because children with tics often present to
physicians when their tics are at their highest severity, and
because of the waxing and waning nature of tics, medication is
not usually started immediately or changed often. Frequently,
the tics subside with understanding of the condition and a
supportive environment. When medication is necessary,
pharmaceutical intervention should be targeted at the most
impairing symptoms, taking into account co-occurring
conditions such as ADHD or OCD, which when present, may
warrant treatment even when tics are mild.

Cognitive Behavioral Therapy (CBT) is a useful treatment
when Obsessive Compulsive Diisorder (OCD) is present, and
there is good evidence supporting the use of habit reversal in
the treatment of tics. Relaxation techniques, such as exercise,
yoga or meditation, may be useful in relieving stress that may
aggravate tics, but the majority of behavioral interventions
(such as relaxation training and biofeedback, with the
exception of habit reversal) have not been systematically
evaluated and are not proven therapies for Tourette's.

What is Habit Reversal Therapy
An effective behavioral technique for treating Tourette's
disorder is habit reversal. Habit reversal training is a set of
procedures that have been used very successfully with hair
pulling (trichotillomania), nail-biting, thumb-sucking, chronic
motor tics, and the tics associated with Tourette's disorder.
Habit reversal is a therapy composed primarily of awareness
training and competing response training. If anxiety is an
issue, CBT addressing these issues should be used alongside
habit reversal, as anxiety often makes the tics not only worse
but harder to control.