Tourette syndrome: Difference between revisions
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'''Tourette syndrome''' ('''TS''' or simply '''Tourette's''') is a [[neurodevelopmental disorder]] with onset in childhood |
'''Tourette syndrome''' ('''TS''' or simply '''Tourette's''') is a [[neurodevelopmental disorder]] with onset in childhood. It is characterized by multiple movement (motor) [[tic]]s and at least one vocal (phonic) tic. Common tics are blinking, coughing, throat clearing, sniffing, and facial movements. These are typically preceded by an unwanted urge or sensation in the affected muscles, can sometimes be suppressed temporarily, and characteristically change in location, strength, and frequency. Tics often go unnoticed by casual observers. |
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Once regarded as a rare and bizarre [[syndrome]], Tourette's has popularly been associated with [[coprolalia]] (the utterance of obscene words or socially inappropriate and derogatory remarks); a symptom evident in a minority of people with Tourette's.<!-- Stern2018 --> It is no longer considered rare; about 1% of school-age children and adolescents are estimated to have Tourette's,<ref name=Stern2018 /> though many go undiagnosed or never seek medical care. There are no specific tests for diagnosing Tourette's; it is not always correctly identified because most cases are mild and the severity of tics decreases for most children as they pass through adolescence. Extreme Tourette's in adulthood, though sensationalized in the media, is rare. Tourette's does not affect intelligence or [[life expectancy]]. |
Once regarded as a rare and bizarre [[syndrome]], Tourette's has popularly been associated with [[coprolalia]] (the utterance of obscene words or socially inappropriate and derogatory remarks); a symptom evident in a minority of people with Tourette's.<!-- Stern2018 --> It is no longer considered rare; about 1% of school-age children and adolescents are estimated to have Tourette's,<ref name=Stern2018 /> though many go undiagnosed or never seek medical care. There are no specific tests for diagnosing Tourette's; it is not always correctly identified because most cases are mild and the severity of tics decreases for most children as they pass through adolescence. Extreme Tourette's in adulthood, though sensationalized in the media, is rare. Tourette's does not affect intelligence or [[life expectancy]]. |
Revision as of 14:52, 24 February 2020
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Tourette syndrome | |
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Other names | Tourette's syndrome, Tourette's disorder, Gilles de la Tourette syndrome (GTS) |
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Georges Gilles de la Tourette (1857–1904), namesake of Tourette syndrome | |
Specialty | Pediatrics, neurology |
Symptoms | Tics[1] |
Usual onset | Typically in childhood[1] |
Duration | Long term[2] |
Causes | Genetic with environmental influence[2] |
Diagnostic method | Based on history and symptoms[1] |
Management | Education, behavioral therapy[1][3] |
Medication | Usually none, occasionally antipsychotics and noradrenergics[1] |
Prognosis | Improvement to disappearance of tics beginning in late teens[2] |
Frequency | About 1%[4] |
Tourette syndrome (TS or simply Tourette's) is a neurodevelopmental disorder with onset in childhood. It is characterized by multiple movement (motor) tics and at least one vocal (phonic) tic. Common tics are blinking, coughing, throat clearing, sniffing, and facial movements. These are typically preceded by an unwanted urge or sensation in the affected muscles, can sometimes be suppressed temporarily, and characteristically change in location, strength, and frequency. Tics often go unnoticed by casual observers.
Once regarded as a rare and bizarre syndrome, Tourette's has popularly been associated with coprolalia (the utterance of obscene words or socially inappropriate and derogatory remarks); a symptom evident in a minority of people with Tourette's. It is no longer considered rare; about 1% of school-age children and adolescents are estimated to have Tourette's,[1] though many go undiagnosed or never seek medical care. There are no specific tests for diagnosing Tourette's; it is not always correctly identified because most cases are mild and the severity of tics decreases for most children as they pass through adolescence. Extreme Tourette's in adulthood, though sensationalized in the media, is rare. Tourette's does not affect intelligence or life expectancy.
Education is an important part of any treatment plan, and explanation and reassurance alone are often sufficient.[1][5] In most cases, medication for tics is not necessary, and behavioral therapies are the first-line treatment. Among those who are seen in specialty clinics, attention-deficit hyperactivity disorder (ADHD) and obsessive–compulsive disorder (OCD) are present at higher rates. These co-occurring diagnoses often cause more impairment to the individual than the tics; hence it is important to correctly distinguish co-occurring conditions and treat them.
Tourette's is defined as part of a spectrum of tic disorders. While the exact cause is unknown, it is believed to involve a combination of genetic and environmental factors. The mechanism appears to involve dysfunction in neural circuits between the basal ganglia and related structures in the brain. Compared to the success in genetic research seen in other conditions, funded research into the genetics of Tourette's is lagging in the US. The condition was named by French neurologist Jean-Martin Charcot on behalf of his resident, Georges Gilles de la Tourette, who published an account of nine patients with Tourette's in 1885.
Classification
Tourette syndrome is classified as a motor disorder (a disorder of the nervous system that causes abnormal and involuntary movements). It is listed in the neurodevelopmental disorder category of the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013.[6] Tourette's is at the more severe end of the spectrum of tic disorders; its diagnosis requires multiple motor tics and at least one vocal tic to be present for more than a year. The tics must not be explained by other medical conditions or substance use.[7]
Other conditions on the spectrum include persistent (chronic) motor or vocal tics, in which one type of tic (motor or vocal, but not both) has been present for more than a year; and provisional tic disorder, in which motor or vocal tics have been present for less than one year.[8][9] The fifth edition of the DSM replaced what had been called transient tic disorder with provisional tic disorder, recognizing that "transient" can only be defined in retrospect.[10][11][12]
Some experts believe that TS and persistent (chronic) motor or vocal tic disorder should be considered the same condition, because vocal tics are also motor tics in the sense that they are also muscular contractions, albeit of nasal or respiratory muscles.[3][9] Tics are sudden, repetitive, nonrhythmic movements (motor tics) and utterances (vocal or phonic tics) that involve discrete muscle groups,[13] while phonic tics produce sounds that involve specifically laryngeal, pharyngeal, oral, nasal or respiratory muscles.[14][15]
Tic disorders are defined only slightly differently by the World Health Organization (WHO); in its ICD-10, the International Statistical Classification of Diseases and Related Health Problems, TS is described as "combined vocal and multiple motor tic disorder [de la Tourette]".[4][16] Most published research on TS originates in the United States, and in international research the DSM is preferred over the WHO classification.[10]
Genetic studies indicate that tic disorders occupy a spectrum that is not recognized by the categorical approach of the current diagnostic framework.[7] Studies have suggested since 2008 that Tourette's is not a unitary condition with a distinct mechanism as described in the existing classification systems; the studies suggest instead that subtypes should be recognized to distinguish "pure TS" from TS that is accompanied by attention-deficit hyperactivity disorder (ADHD), obsessive–compulsive disorder (OCD) or other disorders.[4][7][8] Elucidation of these subtypes awaits fuller understanding of the genetic and other causes of tic disorders (following the example of other conditions, for example, in distinguishing type 1 and type 2 diabetes).[10]
Characteristics
Tics
Tics are movements or sounds that take place "intermittently and unpredictably out of a background of normal motor activity",[17] having the appearance of "normal behaviors gone wrong".[18] The tics associated with Tourette's wax and wane; they change in number, frequency, severity and anatomical location, and each person experiences a unique pattern of fluctuation in their severity and frequency. Tics may also occur in "bouts of bouts", which also vary among people.[13] The variation in tic severity may occur over hours, days, or weeks.[8] Tics may increase when someone is experiencing stress, fatigue, anxiety, or illness,[7][19] or when engaged in relaxing activities like watching TV. They sometimes decrease when an individual is engrossed in or focused on an activity like playing a musical instrument.[7][20]
In contrast to the abnormal movements associated with other movement disorders such as choreas, dystonias, myoclonus, and dyskinesias, the tics of Tourette's are nonrhythmic, temporarily suppressible, and often preceded by an unwanted urge.[21] The ability to suppress tics varies among individuals, and may be more developed in adults than children.[22] People with tics are sometimes able to suppress them for limited periods of time, but doing so often results in tension or mental exhaustion.[1][23] People with Tourette's may seek a secluded spot to release the suppressed urge, or there may be a marked increase in tics after a period of suppression at school or work.[8][18] Children may suppress tics while in the doctor's office, so they may need to be observed when not aware of being watched.[24]
Over time, about 90% of individuals with Tourette's feel an urge preceding the onset of a tic,[8] similar to the urge to sneeze or scratch an itch. The urges and sensations that precede the expression of a tic are referred to as premonitory sensory phenomena or premonitory urges. These urges may be physical or mental.[25] People describe the urge to express the tic as a buildup of tension, pressure, or energy[26][27] which they ultimately choose consciously to release, as if they "had to do it"[28] to relieve the sensation[26] or until it feels "just right".[28][29] Examples of this urge are the feeling of having something in one's throat, or a localized discomfort in the shoulders, which lead to the need to clear one's throat or shrug the shoulders. The actual tic may be felt as relieving this tension or sensation, similar to scratching an itch or blinking to relieve an uncomfortable feeling in the eye. Because of the urges that precede them, tics are described as semi-voluntary or "unvoluntary",[1][17] rather than specifically involuntary; they may be experienced as a voluntary, suppressible response to the unwanted premonitory urge.[20][23] Some people with Tourette's may not be aware of the premonitory urge associated with tics. Children may be less aware of it than are adults,[8] but their awareness tends to increase with maturity;[17] by the age of ten, most children recognize the premonitory urge.[20] So, although this preceding urge is identified as a core symptom of the syndrome, it is not included in the diagnostic criteria.[25][27][30]
Complex tics related to speech include coprolalia, echolalia and palilalia. Coprolalia is the spontaneous utterance of socially objectionable or taboo words or phrases. Although it is the most publicized symptom of Tourette's, only about 10% of people with Tourette's exhibit it, and it is not required for a diagnosis.[1][23] Echolalia (repeating the words of others) and palilalia (repeating one's own words) occur in a minority of cases.[13] Complex motor tics include copropraxia (obscene or forbidden gestures, or inappropriate touching), echopraxia (repetition or imitation of another person's actions) and palipraxia (repeating one's own movements).[22]
Onset and progression
There is no typical case of Tourette syndrome,[31] but the age of onset and the severity of symptoms follow a fairly reliable course. Although onset may occur anytime before eighteen years, the typical age of onset of tics is from five to seven, and is usually before adolescence.[1] A 1998 study from the Yale Child Study Center showed that tic severity increased with age until it reached its highest point between ages eight and twelve.[32] Severity declines steadily for most children as they pass through adolescence, when half to two-thirds of children see a dramatic decrease in tics.[33]
The first tics to appear usually affect the head, face, and shoulders, and include blinking, facial movements, sniffing and throat clearing.[8] Vocal tics often appear months or years after motor tics but can appear first.[9][10] Among people who experience more severe tics, complex tics may develop, including "arm straightening, touching, tapping, jumping, hopping and twirling".[8] There are different movements in contrasting disorders (for example, the autism spectrum disorders), such as self-stimulation and stereotypies. These stereotyped movements typically have an earlier age of onset; are more symmetrical, rhythmical and bilateral; and involve the extremities (for example, flapping the hands).[34]
The severity of symptoms varies widely among people with Tourette's, and many cases may be undetected.[1][4][9][13] Most cases are mild and almost unnoticeable;[35][36] many people with TS may not realize they have tics. Because tics are more commonly expressed in private, Tourette syndrome may go unrecognized,[37] and casual observers might not notice tics.[23][38][39]
Adults with TS presenting in clinics are atypical, as most adults have mild TS and do not seek medical attention.[1] While tics subside for the majority after adolescence, some of the "most severe and debilitating forms of tic disorder are encountered" in adults.[40] In some cases, what appear to be adult-onset tics can be childhood tics re-surfacing.[40]
Co-occurring conditions
![Three men and two women stand near the Mona Lisa. All are dressed formally, one woman in a spectacular pink gown.](http://upload.wikimedia.org/wikipedia/commons/thumb/d/da/JFK%2C_Marie-Madeleine_Lioux%2C_Andr%C3%A9_Malraux%2C_Jackie%2C_L.B._Johnson%2C_unveiling_Mona_Lisa_at_National_Gallery_of_Art.png/290px-JFK%2C_Marie-Madeleine_Lioux%2C_Andr%C3%A9_Malraux%2C_Jackie%2C_L.B._Johnson%2C_unveiling_Mona_Lisa_at_National_Gallery_of_Art.png)
Because children with milder symptoms are unlikely to be referred to specialty clinics, studies of Tourette's have an inherent bias towards more severe cases.[44] When symptoms are severe enough to warrant referral to clinics, ADHD and OCD are often also found.[1] In specialty clinics, 30% of those with TS also have mood or anxiety disorders or disruptive behaviors.[8][45] In the absence of ADHD, tic disorders do not appear to be associated with disruptive behavior or functional impairment,[46] while impairment in school, family, or peer relations is greater in those who have more comorbid conditions.[18][47] When ADHD is present along with tics, the occurrence of conduct disorder and oppositional defiant disorder increases.[8] Aggressive behaviors and angry outbursts in people with TS are not well understood; they are not associated with severe tics, but are connected with the presence of ADHD.[48]
Compulsions that resemble tics are present in some individuals with OCD; "tic-related OCD" is hypothesized to be a subgroup of OCD, distinguished from non-tic related OCD by the type and nature of obsessions and compulsions.[49] Compared to the more typical compulsions of OCD without tics that relate to contamination, tic-related OCD presents with more "counting, aggressive thoughts, symmetry and touching" compulsions.[8] Compulsions associated with OCD without tics are usually related to obsessions and anxiety, while those in tic-related OCD are more likely to be a response to a premonitory urge.[8]
Among individuals with TS studied in clinics, between 2.9% and 20% had autism spectrum disorders,[50] but one study indicates that a high association of autism and TS may be partly due to difficulties distinguishing between tics and tic-like behaviors or OCD symptoms seen in people with autism.[51]
Not all people with Tourette's have ADHD or OCD or other comorbid conditions, although in clinical populations, a high percentage of those under care do have ADHD.[29][52] Over time, 85% of people with Tourette's will develop a co-occurring condition, according to Dale (2017).[8] Denckla (2006) reported that a review of patient records revealed that about 40% of people with Tourette's have "TS-only" or "pure TS".[53][54] Dure and DeWolfe (2006) reported that 57% of 656 individuals presenting with tic disorders had tics uncomplicated by other conditions (pure TS).[18] In a 2017 literature review, Sukhodolsky, et al. stated that 37% of individuals in clinical samples had pure TS.[52] Children and adolescents with pure TS are not significantly different from their peers without TS on ratings of aggressive behaviors or conduct disorders, or on measures of social adaptation.[4] Similarly, adults with pure TS do not appear to have the social difficulties present in those with TS plus ADHD.[4]
There are increased rates of anxiety and depression in those adults who also have OCD.[40] Among those with an older age of onset, more substance abuse and mood disorders are found, and there may be self-injurious tics.[40]
Neuropsychological function
There are no major impairments in neuropsychological function among people with Tourette's, but conditions that occur along with tics can cause variation in neurocognitive function. A better understanding of comorbid conditions is needed to untangle any neuropsychological differences between TS-only individuals and those with comorbid conditions.[47]
Only slight impairments are found in intellectual ability, attentional ability, and nonverbal memory—but ADHD, other comorbid disorders, or tic severity could account for these differences. In contrast with earlier findings, visual motor integration and visuoconstructive skills are not found to be impaired, while comorbid conditions may have a small effect on motor skills. Comorbid conditions and severity of tics may account for variable results in verbal fluency, which can be slightly impaired. There might be slight impairment in social cognition, but not in the ability to plan or make decisions.[47] Children with TS-only do not show cognitive deficits. They are faster than average for their age on timed tests of motor coordination, and constant tic suppression may lead to an advantage in switching between tasks because of increased inhibitory control.[4][54]
Learning disabilities may be present, but whether they are due to tics or comorbid conditions is controversial; older studies that reported higher rates of learning disability did not control well for the presence of comorbid conditions.[55] There are often difficulties with handwriting, and disabilities in written expression and math are reported in those with TS plus other conditions.[55]
Causes
The exact cause of Tourette's is unknown, but it is well established that both genetic and environmental factors are involved.[7][8][56] Genetic epidemiology studies have shown that Tourette's is highly heritable,[57] and 10 to 100 times more likely to be found among close family members than in the general population.[58] The exact mode of inheritance is not known; no single gene has been identified, and hundreds of genes are likely involved.[59][58][57] Genome-wide association studies were published in 2013[1] and 2015[8] in which no finding reached a threshold for significance.[1] Twin studies show that 50 to 77% of identical twins share a TS diagnosis, while 10 to 23% of fraternal twins do.[7] But not everyone who inherits the genetic vulnerability will show symptoms.[60][61] A few rare highly penetrant genetic mutations have been found that explain only a small number of cases in single families (the SLITRK1, HDC, and CNTNAP2 genes).[62]
Psychosocial or other non-genetic factors—while not causing Tourette's—can affect the severity of TS in vulnerable individuals and influence the expression of the inherited genes.[4][31][56][58] Pre-natal and peri-natal events increase the risk that a tic disorder or comorbid OCD will be expressed in those with the genetic vulnerability. These include paternal age; forceps delivery; stress or severe nausea during pregnancy; and use of tobacco, caffeine, alcohol,[4] and cannabis during pregnancy.[1] Babies who are born premature with low birthweight, or who have low Apgar scores, are also at increased risk; in premature twins, the lower birthweight twin is more likely to develop TS.[4]
Autoimmune processes may affect the onset of tics or exacerbate them. Both OCD and tic disorders may arise in a subset of children as a result of a post-streptococcal autoimmune process.[35] Its potential effect is described by the controversial hypothesis called PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections), which proposes five criteria for diagnosis in children.[63][64] PANDAS and the newer PANS (pediatric acute-onset neuropsychiatric syndrome) hypotheses are the focus of clinical and laboratory research, but remain unproven. There is also a broader hypothesis that links immune-system abnormalities and immune dysregulation with TS.[8][23][35]
Some forms of OCD may be genetically linked to Tourette's,[29] although the genetic factors in OCD with and without tics may differ.[7] The genetic relationship of ADHD to Tourette syndrome, however, has not been fully established.[54][65][66]
Mechanism
![The basal ganglia at the brain's center with the thalamus next to it. Nearby related brain structures are also shown.](http://upload.wikimedia.org/wikipedia/commons/thumb/8/85/Basal_ganglia_and_related_structures_%282%29.svg/350px-Basal_ganglia_and_related_structures_%282%29.svg.png)
The exact mechanism affecting the inherited vulnerability to Tourette's is not well established.[7] Tics are believed to result from dysfunction in cortical and subcortical brain regions: the thalamus, basal ganglia and frontal cortex.[67] Neuroanatomic models suggest failures in circuits connecting the brain's cortex and subcortex;[31] imaging techniques implicate the frontal cortex and basal ganglia.[59] In the 2010s, neuroimaging and postmortem brain studies, as well as animal and genetic studies,[47][68] made progress towards better understanding the neurobiological mechanisms leading to Tourette's.[47] These studies support the basal ganglia model, in which neurons in the striatum are activated and inhibit outputs from the basal ganglia.[48]
Cortico-striato-thalamo-cortical (CSTC) circuits, or neural pathways, provide inputs to the basal ganglia from the cortex. These circuits connect the basal ganglia with other areas of the brain to transfer information that regulates planning and control of movements, behavior, decision-making, and learning.[47] Behavior is regulated by cross-connections that "allow the integration of information" from these circuits.[47] Involuntary movements may result from impairments in these CSTC circuits,[47] including the sensorimotor, limbic, language and decision making pathways. Abnormalities in these circuits may be responsible for tics and premonitory urges.[69]
The caudate nuclei may be smaller in subjects with tics compared to those without tics, supporting the hypothesis of pathology in CSTC circuits in Tourette's.[47] The ability to suppress tics depends on brain circuits that "regulate response inhibition and cognitive control of motor behavior".[68] Children with TS are found to have a larger prefrontal cortex, which may be the result of an adaptation to help regulate tics.[68] It is likely that tics decrease with age as the capacity of the frontal cortex increases.[68] Cortico-basal ganglia (CBG) circuits may also be impaired, contributing to "sensory, limbic and executive" features.[8] The release of dopamine in the basal ganglia is higher in people with Tourette's, implicating biochemical changes from "overactive and dysregulated dopaminergic transmissions".[56]
Histamine and the H3 receptor may play a role in the alterations of neural circuitry.[8][70][71][72] A reduced level of histamine in the H3 receptor may result in an increase in other neurotransmitters, causing tics.[73] Postmortem studies have also implicated "dysregulation of neuroinflammatory processes".[7]
Diagnosis
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Tourette's may be diagnosed when a person exhibits both multiple motor tics and one or more vocal tics over a period of one year. The motor and vocal tics need not be concurrent. The onset must have occurred before the age of 18 and cannot be attributed to the effects of another condition or substance (such as cocaine).[6] Hence, other medical conditions that include tics or tic-like movements—for example, autism or other causes of tics—must be ruled out.[74]
Most Tourette's is diagnosed merely by observing a history of tics.[31] There are no specific medical or screening tests that can be used;[29] the diagnosis is made based on observation of the individual's symptoms and family history,[23] and after ruling out secondary causes of tic disorders.[75] Tics that may appear to mimic those of Tourette's—but are associated with disorders other than Tourette's—are known as tourettism.[76] Most of these conditions, including dystonias, choreas, and other genetic conditions, are rarer than tic disorders and a thorough history and examination may be enough to rule them out without medical or screening tests.[1][31][76]
Delayed diagnosis often occurs because professionals mistakenly believe that TS is rare, always involves coprolalia, or must be severely impairing.[77] The DSM has recognized since 2000 that many individuals with Tourette's do not have significant impairment;[10][74][78] diagnosis does not require the presence of coprolalia or a comorbid condition, such as ADHD or OCD.[23][77] Tourette's may be misdiagnosed because of the wide expression of severity, ranging from mild (in the majority of cases) or moderate, to severe (the rare but more widely recognized and publicized cases).[32] About 20% of people with Tourette syndrome do not recognize that they have tics.[31] Tics that appear early in the course of TS are often confused with allergies, asthma, vision problems, and other conditions. Pediatricians, allergists and ophthalmologists are among the first to identify a child as having tics,[13] although the majority of tics are first identified by the child's parents.[77] Coughing, blinking, and tics that mimic unrelated conditions such as asthma are commonly misdiagnosed.[23] In the UK, there is an average delay of three years between symptom onset and diagnosis.[4]
Assessment and screening for other conditions
- Yale Global Tic Severity Scale (YGTSS), recommended in international guidelines to assess "frequency, intensity, complexity, distribution, interference and impairment" of or due to tics
- Tourette Syndrome Clinical Global Impression (TS–CGI) and Shapiro TS Severity Scale (STSS), for a briefer assessment of tics than YGTSS
- Tourette's Disorder Scale (TODS), to assess tics and comorbidities
- Premonitory Urge for Tics Scale (PUTS), for individuals over age ten
- Motor tic, Obsessions and compulsions, Vocal tic Evaluation Survey (MOVES), to evaluate complex tics and other behaviors
- Autism—Tics, AD/HD, and other Comorbities (A–TAC), to screen for other conditions
Patients referred for a tic disorder are assessed based on their family history of tics, vulnerability to ADHD, obsessive–compulsive symptoms, and a number of other chronic medical, psychiatric and neurological conditions.[81][82] In individuals with a typical onset and a family history of tics or OCD, a basic physical and neurological examination may be sufficient.[83] If another condition might better explain the tics, tests may be done; for example, if there is diagnostic confusion between tics and seizure activity, an EEG may be ordered. An MRI can rule out brain abnormalities,[81] but such brain imaging studies are not usually warranted.[81] Measuring thyroid-stimulating hormone blood levels can rule out hypothyroidism, which can be a cause of tics. In teenagers and adults presenting with a sudden onset of tics and other behavioral symptoms, a urine drug screen for cocaine and stimulants might be necessary. If there is a family history of liver disease, serum copper and ceruloplasmin levels can rule out Wilson's disease.[83]
Although not all those with Tourette's have comorbid conditions, most presenting for clinical care exhibit symptoms of other conditions along with their tics.[54] ADHD and OCD are the most common, but autism spectrum disorders or anxiety, mood, personality, oppositional defiant, and conduct disorders may also be present.[14] Learning disabilities and sleep disorders may be present;[23] higher rates of sleep disturbance and migraine than in the general population are reported.[84] A thorough evaluation for comorbidity is called for when symptoms and impairment warrant,[83][82] and careful assessment of people with TS includes comprehensive screening for these conditions.[14][58]
Disruption from tics is commonly overshadowed by comorbid conditions that present greater interference to the child.[3][31] Disruptive behaviors, impaired functioning, or cognitive impairment in individuals with comorbid Tourette's and ADHD may be accounted for by the ADHD, highlighting the importance of identifying comorbid conditions.[8][23][29][85] According to Samuel Zinner, "It is critical to note that the comorbid conditions may determine functional status more strongly than the tic disorder."[31] Children and adolescents with TS who have learning difficulties are candidates for psychoeducational testing, particularly if the child also has ADHD.[81][82]
Management
There is no cure for Tourette's, and no medication effectively treats all symptoms without significant adverse effects.[23] Treatment is focused on identifying the most troubling or impairing symptoms and helping the individual manage them.[23] Because comorbid conditions are often a larger source of impairment than tics,[81] they are a priority in treatment.[86] The management of Tourette's is individualized and involves shared decision-making between the clinician, patient, family and caregivers.[86][87] Practice guidelines for the treatment of tics were published by the American Academy of Neurology in 2019.[86]
Education, reassurance and psychobehavioral therapy are often sufficient for the majority of cases.[1][5][23][88] In particular, psychoeducation targeting the patient and their family and surrounding community (such as friends, school, and church) is a key management strategy.[89] Watchful waiting "is an acceptable approach" for those who are not functionally impaired.[86] Symptom management may include behavioral, pharmacological and psychological therapies. Pharmacological intervention is reserved for more severe symptoms, other treatments; psychotherapy or cognitive behavioral therapy (CBT) may ameliorate depression and social isolation, and improve family support.[23] The decision to use behavioral or pharmacological treatment is "usually made after the educational and supportive interventions have been in place for a period of months, and it is clear that the tic symptoms are persistently severe and are themselves a source of impairment in terms of self-esteem, relationships with the family or peers, or school performance".[80]
Psychoeducation and social support
Knowledge, education and understanding are uppermost in management plans for tic disorders,[23] and psychoeducation is the first step.[90] Parents are typically the first to notice a child's tics,[77] and often feel worried, or guilty that they are responsible, or are burdened by misinformation about Tourette's.[90] Before seeing a doctor, many parents have researched TS on the internet,[91] or have seen media portrayals that focus on severe cases.[92] Parents may be overly concerned,[91] and not realize that they, too, have tics, while the child may not be bothered by tics.[90] Informing a parent who is unaware of their own tics about them can be disturbing, and they have a "right not to be informed".[90] When their child receives a Tourette's diagnosis, both parent and child usually feel relieved, although the diagnosis can also cause distress for the parents as they confront a chronic condition that can be hard to treat.[90] Effectively educating parents about the diagnosis and providing social support can ease parents' anxiety and lower the chance that a child will be unnecessarily medicated[91] or experience an increase in tics related to parental emotional response.[14] Psychoeducation that encourages a "matter of fact" attitude and helps dispel stigma and misconception is most effective when provided to parents.[14]
Even children with milder tics may be angry, depressed or have low self-esteem as a result of increased teasing, bullying, rejection by peers or social stigmatization, and this can lead to social withdrawal; some feel empowered by presenting a peer awareness program to their classmates.[58][87][93] It can be helpful to educate teachers and school staff about what typical tics are, how they fluctuate during the day, how they impact the child, how to distinguish tics from naughty behavior, and to not ask or expect a child to stop ticcing,[93][94] because "tic suppression can be exhausting, unpleasant, and attention-demanding and can result in a susequent rebound bout of tics".[94] Strategies to help the child at school can be established and include such things as allowing the child to chew gum to help reduce vocal tics, to avoid handwriting by using a laptop, to be allowed breaks from the classroom when tics are high, to have additional time on tests, and to take oral tests when needed.[94]
In adults with persistent tics, depression may have a larger impact on their quality of life than the tics do, there is a greater effect on their overall functioning than in children, and there is often a financial burden.[92] They may withdraw socially to avoid stigmatization and discrimination because of their tics.[92] Depending on the laws of the country they live in, they may receive social services or help from support groups.[95]
Behavioral
Behavioral therapies using habit reversal training (HRT) and exposure and response prevention (ERP) are first-line interventions,[96] and have been shown to be effective.[7] Because tics are somewhat suppressible, when people with TS are aware of the premonitory urge that precedes a tic, they can be trained to develop a response to the urge that competes with the tic.[8][96]
Comprehensive behavioral intervention for tics (CBIT) is based on HRT, the best researched behavioral therapy for tics.[96] CBIT has been shown with a high level of confidence to be more likely to lead to a reduction in tics than other behavioral therapies or psychoeducation.[3] CBIT has some limitations. Children under ten may not understand the treatment, and people with severe tics or ADHD may not be able to suppress their tics or sustain the focus required to benefit from behavioral treatments. There is a lack of therapists trained in behavioral interventions,[97] and finding practitioners outside of specialty clinics can be difficult.[7] Costs may also limit accessibility.[96] TS experts debate whether increasing a child's awareness of tics with HRT/CBIT (as opposed to ignoring tics) can lead to more tics later in life.[96]
When comorbid disruptive behaviors exist, anger control training and parent management training can be effective.[4][98][99] CBT is a useful treatment when OCD is present.[8] Relaxation techniques, such as exercise, yoga and meditation, may be useful in relieving the stress that may aggravate tics. Beyond HRT, the majority of behavioral interventions for Tourette's (for example, relaxation training and biofeedback) have not been systematically evaluated and are not empirically supported.[100]
Medication
![Little white pills on a counter, next to a pill bottle and labels](http://upload.wikimedia.org/wikipedia/commons/thumb/6/69/Clonidine_pills_and_patch.jpg/250px-Clonidine_pills_and_patch.jpg)
Children with tics typically present when their tics are most severe, but because the condition wax and wanes, medication is not started immediately or changed often.[31] Tics may subside with education, reassurance and a supportive environment.[31] When medication is used, the goal is not to eliminate symptoms. Instead, the lowest dose that manages symptoms without adverse effects is used, because adverse effects may be more disturbing than the symptoms being treated with medication.[31]
The classes of medication with proven efficacy in treating tics—typical and atypical neuroleptics—can have long-term and short-term adverse effects.[81] Some antihypertensive agents are also used to treat tics; studies show variable efficacy but a lower side effect profile than the neuroleptics.[101] There is moderate evidence that the antihypertensive clonidine, along with aripiprazole, haloperidol, risperidone, and tiapride, reduce tics more than placebo.[3] Clonidine may produce sedation; aripiprazole and risperidone are likely to lead to weight gain and sedation or fatigue; haloperidol may increase prolactin levels; and tiapride may produce sleep disturbances and tiredness. Risperidone and haloperidol may also produce extrapyramidal symptoms.[3]
Stimulants and other medications may be useful in treating ADHD when it co-occurs with tic disorders. Drugs from several other classes of medication can be used when stimulants fail.[81] There is moderate evidence supporting that methylphenidate alone (or combined with clonidine) reduces tics more than placebo when ADHD is also present; desipramine also reduces tics but is rarely used following reports of sudden death in children.[3] Atomoxetine, another treatment for ADHD, does not increase tics but may lead to weight loss and an increased heart rate.[3]
Clomipramine, a tricyclic, and SSRIs—a class of antidepressants including fluoxetine, sertraline, and fluvoxamine—may be prescribed when a person also has OCD, and they can augment the effect of cognitive behavioral therapy.[8][81]
Other
Complementary and alternative medicine approaches, such as dietary modification, neurofeedback and allergy testing and control have popular appeal, but they have no proven benefit in the management of Tourette syndrome.[102][103] Despite this lack of evidence, up to two-thirds of parents, caregivers and individuals with TS use dietary approaches and alternative treatments and do not always inform their physicians;[19][87] according to Müller-Vahl (2013), treating professionals "should feel obliged to inform their patients about not only effective but also ineffective treatments".[87] There is low confidence that tics are reduced with tetrahydrocannabinol,[3] and insufficient evidence for other cannabis-based medications in the treatment of Tourette's.[86]
There is no good evidence supporting the use of acupuncture or transcranial magnetic stimulation; neither is there evidence supporting intravenous immunoglobulin, plasma exchange, or antibiotics for the treatment of PANDAS.[4]
Deep brain stimulation (DBS) has become a valid option for individuals with severe symptoms that do not respond to conventional therapy and management.[56] There is low-quality, limited evidence that DBS is safe, well tolerated, and yields symptom reduction ranging from no change to complete remission.[56] Selecting candidates who may benefit from DBS is challenging, and the appropriate lower age range for surgery is unclear.[14] The ideal brain location to target has not been identified as of 2019.[86][104]
Pregnancy
There is no consistent evidence of a change in frequency or severity of tics related to pregnancy (about a quarter of women report that their tics increase before menstruation).[105][106] Overall, women's symptoms respond better to haloperidol than do men's,[105] and one report found that haloperidol was the preferred medication during pregnancy.[106] Most women report that withdrawing from medication during pregnancy is well tolerated.[106]
Prognosis
![Top half of a male athlete who appears to be running](http://upload.wikimedia.org/wikipedia/commons/thumb/2/20/TimHoward_USMNT_20060511.jpg/330px-TimHoward_USMNT_20060511.jpg)
Tourette syndrome is a spectrum disorder—its severity ranges from mild to severe.[75] Symptoms typically subside as children pass through adolescence.[56] In a group of ten children at the average age of highest tic severity (around ten or eleven), almost four will see complete remission by adulthood. Another four out of those ten will have minimal or mild tics in adulthood, but not complete remission. The remaining two will have moderate or severe tics as adults, but only rarely will they be more severe.[33]
Regardless of symptom severity, individuals with Tourette's have a normal life span. Symptoms may be lifelong and chronic for some, but the condition is not degenerative or life-threatening.[109] Intelligence among those with pure TS follows a normal curve, although there may be small differences in intelligence in those with comorbid conditions.[55] The severity of tics early in life does not predict their severity in later life.[23] There is no reliable means of predicting the course of symptoms for a particular individual,[84] but the prognosis is generally favorable.[84] By the age of fourteen to sixteen, when the highest tic severity has typically passed, a more reliable prognosis might be made.[92]
Tics may be at their highest severity at the time that they are diagnosed, and often improve with understanding of individuals with the condition from their families and friends. Studies report that almost eight out of ten children with Tourette's experience a reduction in the severity of their tics by adulthood,[8][33] but adults may not be aware that they continue to tic. A study using videotape to record tics in adults found that nine out of ten adults still had tics, and half of the adults who considered themselves tic-free displayed evidence of mild tics.[8][110]
Children with Tourette's may suffer socially if their tics are viewed as "bizarre". If a child has disabling tics, or tics that interfere with social or academic functioning, supportive psychotherapy or school accommodations can be helpful.[75] In children with tics, the additional presence of ADHD is associated with functional impairment, disruptive behavior, and tic severity.[111] Decreased measures in quality of life are observed in children whose tics are accompanied by ADHD, which can severely impact the child's well-being in all realms, and extend into adulthood.[112] As ADHD symptoms improve with maturity, adults report less negative impact in their occupational lives than do children in their educational lives.[112] Adults are more likely to report a reduced quality of life due to depression or anxiety.[112]
A supportive family and environment generally give those with Tourette's the skills to manage the disorder.[112][113][114] People with Tourette's may learn to camouflage socially inappropriate tics or to channel the energy of their tics into a functional endeavor. Outcomes in adulthood are associated more with the perceived significance of having severe tics as a child than with the actual severity of the tics. A person who was misunderstood, punished or teased at home or at school is likely to fare worse than a child who enjoyed an understanding environment.[13]
Epidemiology
Tourette syndrome is a common but underdiagnosed condition that reaches across all social, racial and ethnic groups.[4][23][29][115] It is three to four times more frequent in males than in females.[52] Observed prevalence rates are higher among children than adults because tics tend to remit or subside with maturity and a diagnosis may no longer be warranted for many adults.[32] Up to 1% of the overall population experiences tic disorders, including chronic tics and transient (provisional or unspecified) tics of childhood.[46] Chronic tics affect 5% of children and transient tics affect up to 20%.[52][99]
Most individuals with tics do not seek a diagnosis, so epidemiological studies of TS "reflect a strong ascertainment bias" towards those with co-occurring conditions.[59] The reported prevalence of TS varies "according to the source, age, and sex of the sample; the ascertainment procedures; and diagnostic system",[29] with a range reported between 0.15% and 3.0% for children and adolescents.[52] Sukhodolsky, et al. wrote in 2017 that the best estimate of TS prevalence in children was 1.4%,[52] and Stern stated in 2018 that the prevalence in children was 1%.[1] Prevalence rates in special education populations are higher.[35]
Fernandez, State and Pittenger wrote in 2018 that the rate of Tourette's in the general population is between 0.5 and 0.7%,[7] and Robertson (2011) suggested 1%.[35] A prevalence range of 0.1% to 1% yields an estimate of 53,000 to 530,000 school-age children with Tourette's in the United States, using 2000 census data.[46] In the United Kingdom, a prevalence estimate of 1.0% based on the 2001 census meant that about half a million people aged five or older would have Tourette's, although symptoms in older individuals would be almost unrecognizable.[36]
Tourette syndrome was once thought to be rare: in 1972, the US National Institutes of Health (NIH) believed there were fewer than 100 cases in the United States,[116] and a 1973 registry reported only 485 cases worldwide.[117] However, numerous studies published since 2000 have consistently demonstrated that the prevalence is much higher.[118] The discrepancy between current and prior prevalence estimates arises from several factors: the ascertainment bias caused by samples that were drawn from clinically referred cases; assessment methods that failed to detect milder cases; and the use of different diagnostic criteria and thresholds.[118] There were few broad-based community studies published before 2000, and most older epidemiological studies were based only on individuals referred to tertiary care or specialty clinics.[119] People with mild symptoms may not have sought treatment and physicians may have avoided an official diagnosis of TS in children due to concerns about stigmatization.[37] Studies are vulnerable to further error because tics vary in intensity and expression, are often intermittent, and are not always recognized by clinicians, individuals with TS, family members, friends or teachers.[31][120] Recognizing that tics may often be undiagnosed and hard to detect, newer studies use direct classroom observation and multiple informants (parents, teachers and trained observers), and therefore record more cases than older studies.[88][121] As the diagnostic threshold and assessment methodology have moved towards recognition of milder cases, the estimated prevalence has increased.[118]
History
The first presentation of Tourette syndrome is thought to be in the 15th-century book Malleus Maleficarum (Hammer of Witches), which describes a priest whose tics were "believed to be related to possession by the devil".[122][123]
A French doctor, Jean Marc Gaspard Itard, reported the first case of Tourette syndrome in 1825,[124] describing the Marquise de Dampierre, an important woman of nobility in her time.[125] In 1884, Jean-Martin Charcot, an influential French physician, assigned his resident Georges Gilles de la Tourette, to study patients at the Salpêtrière Hospital, with the goal of defining a condition distinct from hysteria and chorea.[126] In 1885, Gilles de la Tourette published an account in Study of a Nervous Affliction of nine people with "convulsive tic disorder", concluding that a new clinical category should be defined.[127][128] The eponym was bestowed by Charcot after and on behalf of Gilles de la Tourette.[24]
Following the 19th-century descriptions, a psychogenic view prevailed and little progress was made in explaining or treating tics until well into the 20th century.[24] The possibility that movement disorders, including Tourette syndrome, might have an organic origin was raised when an encephalitis lethargica epidemic from 1918 to 1926 was linked to an increase in tic disorders.[24][129]
During the 1960s and 1970s, as the beneficial effects of haloperidol (Haldol) on tics became known, the psychoanalytic approach to Tourette syndrome was questioned.[130] The turning point came in 1965, when Arthur K. Shapiro—described as "the father of modern tic disorder research"[131]—used haloperidol to treat a person with Tourette's, and published a paper criticizing the psychoanalytic approach.[129] In 1975, The New York Times headlined an article with "Bizarre outbursts of Tourette's disease victims linked to chemical disorder in brain", and Shapiro said: "The bizarre symptoms of this illness are rivaled only by the bizarre treatments used to treat it."[132]
During the 1990s, a more neutral view of Tourette's emerged, in which a genetic predisposition is seen to interact with non-genetic and environmental factors.[24][133][134] The fourth revision of the DSM (DSM-IV) in 1994 added a diagnostic requirement for "marked distress or significant impairment in social, occupational, or other important areas of functioning", which led to an outcry from TS experts and researchers, who noted that many people were not even aware they had TS, nor were they distressed by their tics; clinicians and researchers resorted to using the older criteria in research and practice.[10] In 2000, the American Psychiatric Association revised its diagnostic criteria in the fourth text revision of the DSM (DSM-IV-TR) to remove the impairment requirement,[74] recognizing that clinicians often see people who have Tourette's without distress or impairment.[78]
Society and culture
![Half-length portrait of a large, squinting man with a fleshy face, dressed in brown and wearing an 18th-century wig](http://upload.wikimedia.org/wikipedia/commons/thumb/2/20/Samuel_Johnson_by_Joshua_Reynolds.jpg/290px-Samuel_Johnson_by_Joshua_Reynolds.jpg)
Not everyone with Tourette's wants treatment or a "cure", especially if that means they may "lose" something else in the process.[90][135] The researchers Leckman and Cohen believe that there may be latent advantages associated with an individual's genetic vulnerability to developing Tourette syndrome that may have adaptive value, such as heightened awareness and increased attention to detail and surroundings.[136][137]
Accomplished musicians, athletes, public speakers and professionals from all walks of life are found among people with Tourette's.[77][138] The athlete Tim Howard, described by the Chicago Tribune as the "rarest of creatures—an American soccer hero",[139] and by the Tourette Syndrome Association as the "most notable individual with Tourette Syndrome around the world",[140] says that his neurological makeup gave him an enhanced perception and an acute focus that contributed to his success on the field.[108]
Samuel Johnson is a historical figure who likely had Tourette syndrome, as evidenced by the writings of his friend James Boswell.[141][142] Johnson wrote A Dictionary of the English Language in 1747, and was a prolific writer, poet, and critic. There is little support[143][144] for speculation that Mozart had Tourette's:[145] the potentially coprolalic aspect of vocal tics is not transferred to writing, so Mozart's scatological writings are not relevant; the composer's available medical history is not thorough; the side effects of other conditions may be misinterpreted; and "the evidence of motor tics in Mozart's life is doubtful".[146]
Likely portrayals of TS or tic disorders in fiction predating Gilles de la Tourette's work are "Mr. Pancks" in Charles Dickens's Little Dorrit and "Nikolai Levin" in Leo Tolstoy's Anna Karenina.[147] The entertainment industry has been criticized for depicting those with Tourette syndrome as social misfits whose only tic is coprolalia, which has furthered the public's misunderstanding and stigmatization of those with Tourette's.[148][149][150] The coprolalic symptoms of Tourette's are also fodder for radio and television talk shows in the US[151] and for the British media.[152] High-profile media coverage focuses on treatments that do not have established safety or efficacy, such as deep brain stimulation, and alternative therapies involving unstudied efficacy and side effects are pursued by many parents.[153]
Research directions
Research since 1999 has advanced knowledge of Tourette's in the areas of genetics, neuroimaging, neurophysiology, and neuropathology, but questions remain about how best to classify it and how closely it is related to other movement or psychiatric disorders.[4][7][8][9] Modeled after genetic breakthroughs seen with large-scale efforts in other neurodevelopmental disorders, three groups are collaborating in research of the genetics of Tourette's:
- The Tourette Syndrome Association International Consortium for Genetics (TSAICG)
- Tourette International Collaborative Genetics Study (TIC Genetics)
- European Multicentre Tics in Children Studies (EMTICS)
Compared to the success in genetic research seen in other conditions (autism, schizophrenia and bipolar disorder), the funded efforts in the United States are lagging.[7][154]
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The individuals with TS who do the best, we believe, are: those who have been able to feel relatively good about themselves and remain close to their families; those who have the capacity for humor and for friendship; those who are less burdened by troubles with attention and behavior, particularly aggression; and those who have not had development derailed by medication.
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Tic disorder is a common neurodevelopmental disorder of childhood. It is one of the commonest condition encountered by a pediatrician in office practice, especially in developed countries.
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- ^ Kushner HI (2000), pp. 142, 143, 187, 204, 208–12.
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[Pathogenesis of tic disorders involves] interactions among genetic factors, neurobiological substrates, and environmental factors in the production of the clinical phenotypes. The genetic vulnerability factors that underlie Tourette's syndrome and other tic disorders undoubtedly influence the structure and function of the brain, in turn producing clinical symptoms. Available evidence ... also indicates that a range of epigenetic or environmental factors ... are critically involved in the pathogenesis of these disorders.
- ^ Leckman & Cohen (1999), p. 408.
- ^ Leckman & Cohen (1999), pp. 18–19, 148–51, 408.
- ^ Müller-Vahl KR (2013) in Martino D, Leckman JF, eds. p. 624."... a few 'positive' aspects may be closely linked to TS. People with TS, for example, may have positive personality characterisics and talents such as punctuality, correctness, conscientiousness, a sense of justice, quick comprehension, good intelligence, creativity, musicality, and athletic abilities. For that reason, some people with TS even hesitate when asked whether they wish the disorder would disappear completely."
- ^ Portraits of adults with TS. Tourette Syndrome Association. Retrieved from July 16, 2011 archive.org version on December 21, 2011.
- ^ Keilman J (January 22, 2015). "Reviews: The Game of Our Lives by David Goldblatt, The Keeper by Tim Howard". Chicago Tribune. Archived from the original on April 2, 2015. Retrieved March 21, 2015.
- ^ Tim Howard receives first-ever Champion of Hope Award from the National Tourette Syndrome Association. Archived March 30, 2015, at the Wayback Machine Tourette Syndrome Association. October 14, 2014. Retrieved on March 21, 2015.
- ^ Samuel Johnson. Tourette Syndrome Association. Retrieved from April 7, 2005 archive.org version on December 30, 2011.
- ^ Pearce JM (July 1994). "Doctor Samuel Johnson: 'the great convulsionary' a victim of Gilles de la Tourette's syndrome". J R Soc Med (Historical biography). 87 (7): 396–99. PMC 1294650. PMID 8046726.
- ^ Powell H, Kushner HI (2015). "Mozart at play: the limitations of attributing the etiology of genius to tourette syndrome and mental illness". Prog. Brain Res. (Historical biography). 216: 277–91. doi:10.1016/bs.pbr.2014.11.010. PMID 25684294.
- ^ Bhattacharyya KB, Rai S (2015). "Famous people with Tourette's syndrome: Dr. Samuel Johnson (yes) & Wolfgang Amadeus Mozart (may be): Victims of Tourette's syndrome?". Ann Indian Acad Neurol. 18 (2): 157–61. doi:10.4103/0972-2327.145288. PMC 4445189. PMID 26019411.
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: CS1 maint: unflagged free DOI (link) - ^ Simkin B (1992). "Mozart's scatological disorder". BMJ (Historical biography). 305 (6868): 1563–67. doi:10.1136/bmj.305.6868.1563. PMC 1884718. PMID 1286388. Also see: Simkin, Benjamin. Medical and musical byways of Mozartiana. Fithian Press. 2001. ISBN 1-56474-349-7 Review Archived December 7, 2005, at the Wayback Machine, Retrieved on May 14, 2007.
- ^ Mozart:
- Kammer T (2007). "Mozart in the neurological department - who has the tic?" (PDF). Front Neurol Neurosci (Historical biography). Frontiers of Neurology and Neuroscience. 22: 184–92. doi:10.1159/000102880. ISBN 978-3-8055-8265-0. PMID 17495512. Archived from the original (PDF) on February 7, 2012.
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- ^ Holtgren B (January 11, 2006). "Truth about Tourette's not what you think". Cincinnati Enquirer.
As medical problems go, Tourette's is, except in the most severe cases, about the most minor imaginable thing to have. ... the freak-show image, unfortunately, still prevails overwhelmingly. The blame for the warped perceptions lies overwhelmingly with the video media—the Internet, movies and TV. If you search for 'Tourette' on Google or YouTube, you'll get a gazillion hits that almost invariably show the most outrageously extreme examples of motor and vocal tics. Television, with notable exceptions such as Oprah, has sensationalized Tourette's so badly, for so long, that it seems beyond hope that most people will ever know the more prosaic truth.
- ^ US media:
- "Oprah and Dr. Laura" (Press release). Tourette Syndrome Association. May 31, 2001. Archived from the original on October 6, 2001. Retrieved December 21, 2011.
- "Letter of response to Dr. Phil" (Press release). Tourette Syndrome Association. Archived from the original on August 31, 2008. Retrieved December 21, 2011.
- "Letter of response to Garrison Keillor radio show" (Press release). Tourette Syndrome Association. Archived from the original on February 7, 2009. Retrieved December 21, 2011.
- ^ Guldberg H (May 26, 2006). "Stop celebrating Tourette's". Spiked. Archived from the original on March 14, 2017. Retrieved December 26, 2006.
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- ^ Georgitsi M, Willsey AJ, Mathews CA, State M, Scharf JM, Paschou P (2016). "The genetic etiology of Tourette syndrome: large-scale collaborative efforts on the precipice of discovery". Front Neurosci. 10: 351. doi:10.3389/fnins.2016.00351. PMC 4971013. PMID 27536211.
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: CS1 maint: unflagged free DOI (link)
Book sources
- Cohen DJ, Jankovic J, Goetz CG, eds (2001). Advances in Neurology, Tourette Syndrome. 85. Philadelphia, PA: Lippincott, Williams & Wilkins. ISBN 0-7817-2405-8
- Kushner HI (2000). A Cursing Brain?: The Histories of Tourette Syndrome. Harvard University Press. ISBN 0-674-00386-1.
- Leckman JF, Cohen DJ (1999). Tourette's Syndrome—Tics, Obsessions, Compulsions: Developmental Psychopathology and Clinical Care. John Wiley & Sons, Inc., New York. ISBN 0-471-16037-7
- Martino D, Leckman JF, eds (2013). Tourette syndrome. Oxford University Press. ISBN 978-0199796267.
- Bloch MH (2013). "Clinical course and adult outcome in Tourette syndrome". In Martino D, Leckman JF, eds. Tourette syndrome. Oxford University Press. pp. 107–20.
- Müller-Vahl KR (2013). "Information and social support for patients and families". In Martino D, Leckman JF, eds. Tourette syndrome. Oxford University Press. pp. 623–35.
- Pruitt SK, Packer LE (2013). "Information and support for educators". In Martino D, Leckman JF, eds. Tourette syndrome. Oxford University Press. pp. 636–55.
- Sukhodolsky DG, Gladstone TR, Kaushal SA, Piasecka JB, Leckman JF (2017). "Tics and Tourette Syndrome". In Matson JL, ed. Handbook of Childhood Psychopathology and Developmental Disabilities Treatment. Autism and Child Psychopathology Series. Springer. pp. 241–56. doi:10.1007/978-3-319-71210-9_14.
- Walkup JT, Mink JW, Hollenback PJ, eds (2006). Advances in Neurology, Tourette Syndrome. 99. Philadelphia, PA: Lippincott, Williams & Wilkins. ISBN 0-7817-9970-8.
Further reading
- McGuire JF, Murphy TK, Piacentini J, Storch EA, eds (2018). The Clinician’s Guide to Treatment and Management of Youth with Tourette Syndrome and Tic Disorders. Academic Press. ISBN 978-0128119808
- Olson S (September 2004). "Neurobiology. Making sense of Tourette's". Science. 305 (5689): 1390–92. doi:10.1126/science.305.5689.1390. PMID 15353772.
External links
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