Tourettes Syndrome

Tourette's syndrome (TS) is a disorder characterized most noticeably by chronic vocal and motor tics that occur many times virtually every day for at least a year. These motor tics may include repetitive eye squinting, nose twitching, facial grimacing, mouth opening, or shoulder shrugging. Sometimes more complex movements such a lifting an elbow and rotating a wrist may occur, but the simple tics are more common. Vocal tics may include throat clearing, sniffing, snorting, or other repetitive noises. Many patients with TS report that patterns of their tics tend to shift from one movement or noise to another over time, and that they can suppress them under certain conditions, but usually the tics tend to reemerge after suppression, sometimes in a more intense way.

Elkhonen Goldberg (2001) described two other characteristics often seen in patients with TS: an excessive urge to explore by touching, looking at, or smelling incidental objects that catch their interest, and "verbal incontinence," by which he means not only coprolalia, the tendency to make obscene or profane comments in socially inappropriate situations, but also a broader pattern of making critical or derisive comments in social settings where they are likely to hurt others' feelings or provoke anger or rejection.

This "verbal incontinence" includes impulsively uttering observations or reactions to others that many non-TS individuals might think, but never say aloud. As Goldberg explains: "What is on his mind may immediately be on his lips. It may be unflattering epithets, slurs of various kinds, obnoxious editorial comments—anything forbidden" (p. 183). Many TS patients describe themselves as having chronic difficulty in suppressing the impulse to say or do what is forbidden, once that possibility enters their mind. Goldberg observed that "in Tourette's the urge to release internal tension may be ever present and unquenchable" (p. 183). He quotes one of his TS patients who described irrepressible urges to touch or smell: "It is a heightened sensory curiosity and lack of inhibition. I become focused on a body part or an object. Once I focus on it, the urge becomes uncontrollable" (p. 185).

The chronic difficulty of many TS patients in resisting the impulse to say or do the socially inappropriate, the forbidden, suggests that they suffer from a particular failure of the brain to control emotional reactions such as frustration, curiosity, or anger. They seem unable to employ an awareness of others' emotions to hold back the comment or gesture that may be hurtful or embarrassing to that person or themselves. The resulting outbursts cause some TS patients to experience frequent rejection and sometimes dangerous punitive reactions.

Although tics can become embarrassing and problematic for those who suffer with TS, they are not usually the most troubling symptoms for those with this disorder. As David Comings (1988) and others have pointed out, most patients diagnosed with TS also suffer from ADHD and often also from OCD as well. Often it is symptoms of these other disorders, especially the ADHD, that cause most of the impairment suffered by those with TS.

Thomas Spencer and colleagues (1998) studied children with Tou-rette's syndrome and found that the vast majority, 81 percent, also fully met diagnostic criteria for ADHD. Spencer concluded: "Little doubt remains that ADHD is highly prevalent in patients with Tourette's syndrome and often represents the main clinical concern and the principal source of dysfunction and disability" (p. 1041). The group also found that OCD was much more prevalent in the children with TS (21 to 28 percent) than in the normal controls (2 percent). These findings suggest that TS may essentially be an especially severe variant of ADHD complicated by tics and often also by OCD and other disorders. For those with these complex impairments, a combination of treatment strategies is likely to be needed.

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