Tourette Syndrome

       Tourette syndrome (TS) is a developmental neuropsychiatric disorder. An estimated 4-6 out of every 10,000 children have TS¹. According to the DSM-IV-TR, a manual published by the American Psychiatric Association, which provides diagnostic criteria for mental disorders, Tourette syndrome is characterized by short, stereotyped, non-rhythmic motor and vocal tics. Common tics include blinking, jaw thrusting, jerking movements of the neck, shoulder, or limbs, sniffing, throat clearing and grunting. Presently (2008) there is no known diagnostic examination for this syndrome.

    The onset of motor tics is mostly between 3-8 years of age, several years before the onset of vocal tics. The tics typically wax and wane in frequency and intensity. Tics are usually at their worst in the early years of the second decade of life, and most patients experience an improvement towards the end of adolescence. Having said that, in cases where TS persists into adulthood, it may be accompanied by more severe symptoms, including violent episodes of self-injurious motor tics, involving hitting and biting. Vocal tics at this stage may include obscenities and racially derogatory remarks directed against others.

    Current treatments: Despite the progress made over the past 10 years, no ideal treatment for tics has been established. The decision to initiate treatment is based on the severity of tics, and also on the degree to which they interfere with daily life, in terms of self-image, interpersonal relationships, and learning ability. In many cases, the disorder is more disruptive to patients' environment than to the patients themselves, and it can be successfully managed without medication. Moreover, as the severity of the disorder tends to wax and wane, some people feel that it is better to initiate a treatment program involving educational and habit reversal interventions, than it is to begin drug therapy. In patients who suffer from additional disorders, such as attention deficit disorder, obsessive compulsive disorder, depression or bipolar disorder, it is best to first treat the other condition, as this treatment will often reduce tics.

    Educational interventions for the disorder take the form of support groups in which awareness of the disorder and its manifestations is raised and understanding and tolerance are encouraged. These may have a positive effect on the general development of the disorder. Dietary treatment of Tourette syndrome is also available. Although various studies indicate that a patient's diet does not affect the disorder, it is clearly better to maintain a healthy, balanced diet. In addition, it is best to minimize patients' caffeine consumption, as caffeine can precipitate tics in susceptible children. Psychotherapy has been found to be potentially effective in improving patients' self-esteem, helping them cope in social situations and at school, and helping relieve stress on their families. However, it is unclear whether this form of treatment can directly influence the severity of tics.

    There is also a behavioral and cognitive therapy used to treat Tourette syndrome. This treatment is the treatment of choice for obsessive compulsive disorder, and it has also proven effective for Tourette syndrome, both in reducing the severity of tics and in developing social skills that help to cope with the disorder.

Preliminary studies have shown a therapy called habit reversal training (HRT) to be effective in treating children and adults with Tourette syndrome. This treatment aims to attain awareness of tics, and of factors that precede, relieve and worsen tics; and to train patients to generate a competing response when they feel a tic coming on. Patients thus learn to force a competing voluntary movement to counteract impending tics. Gradually, the patient is learns to control tics without the need for this competing response. This form of treatment is not in wide use, and studies are being performed to establish its effectiveness.

Drug therapy for Tourette syndrome should begin with low doses of alpha-adrenergic drugs, which reduce adrenergic neurotransmission in the central nervous system. The most common of these drugs is Clonidine.

    Anti-psychotic medications, which act on the dopaminergic system by blocking dopamine receptors, are also used to treat the disorder. These drugs are administered in the event that the aforementioned group of drugs fails to produce a positive reaction, and only in severe cases, as they produce many side effects. Additional treatment regimens that have been explored include anti-Parkinsonian medications, muscle relaxants and injections of botulinum toxin into specific muscle groups (for the most part patients have one major tic which is abolished by the injection).

¹Peterson, B.S., Leckman, J.F., & Cohen, D.J. (1995). Tourette's syndrome: a genetically predisposed and an environmentally specified developmental  psychopathology. In D.Cicchtti, & D.J. Cohen (Eds.), Developmental Psychopathology:Vol.2 (pp. 213-242). N.Y: John Wiley & Sons, Inc