Tourette syndrome

Tourette syndrome is a neurological disorder in which the person suffering from it presents a series of motor and vocal tics, which are involuntary, continuous and repetitive movements. It is a disorder that usually happens with other types of psychological problems, such as ADHD, OCD, anxiety or depression.Tourette syndrome

Tourette syndrome: psychological symptoms

Among the psychological aspects to consider are:

The anguish

This is a behavioral disorder, consecutive to a dramatic existential situation. The anguish is caused by a traumatic event that submerges the individual, which, unable to cope with it, reacts, according to his temper, with screams or sobs, with wear or suicide.

Every painful life situation can be felt as particularly frustrating (“as frustrating as trying to stop the Tics and not being able to do it”) and cause behavioral abnormalities, neuroses such as hysteria or phobia and also Psychosomatic disorders such as asthma, gastric ulcers, etc.), if the current traumatic event comes to realize psychological virtualities inscribed in the personal history of the individual. Although the individual tries to stop the Tics they temporarily suppress it, but these being out of voluntary control; The individual experiences an increase in internal tension that is only relieved when a new tic is executed.

This action leads the individual to a clear frustration of trying and not being able to stop those tics, leading him to anguish and leading him overtime to a clear behavioral disorder.

As data, behavioral prodromal symptoms have been described, such as irritability, attention difficulties and poor tolerance to frustration, which appear before or coincide with the appearance of tics.

Frequent episodes of anger have also been described, and they have been called “episodic anger,” which occur in 30% of patients. In the case of children with Tourette’s disorder they release bad words, insult others or make obscene gestures and movements. These children or adults find it impossible to control these sounds and movements, some are in an environment where these behaviors are misunderstood as in school and at home and are strongly repressed with punishment.

The punishment of the parents, the teasing of the friends and the scolding of the teachers do not help the child to control the tics, in some cases those children will seek the isolation to give free rein to their symptoms, and end the anguish that causes them try to suppress their Tics, since otherwise, this ease of scolding those children for their peculiar behavior would imply hurting their self-esteem or self-esteem, in some cases it is inevitable that this will happen.

Therefore we could say that one of the characteristics of one of the almost inevitable consequences of this disorder is the child’s self-isolation. This isolation, longwing, will translate in the future as a serious neuropsychiatric disorder, as it is: depression, panic attacks, mood disorders, and antisocial behaviors.

Suicide cases have been described, given the desperation caused by the destructive effect of the disease on social and working life.

Also due to its neurological nature, Tourette Syndrome probably has a great and lasting impact on his personality as well, a different way of perceiving the world, such as suffering from albinism or arthritis.

Also, if one does not understand the touristic aspects of his personality, I believe that one may be more prone to dilemmas of a more “existential” nature than “doctors.”

Other neuropsychiatric problems these children face are:

  • Learning problems
  • Attention deficit disorders. (ADD)
  • Obsessive-compulsive disorders.
  • And the frequent problems that significantly interfere with academic achievement and social adaptation.

That is why these patients, especially students, must be placed in a school environment that meets individual needs. Students with (ST) may require tutoring, special or smaller classes and in some cases special schools.

All students with ST need a tolerant and compassionate environment that encourages them to work to their full potential and that is at the same time flexible enough to accommodate their special needs. This environment may include:

  • Private study areas.
  • Tests outside the regular class.
  • Oral tests when the child’s symptoms interfere with his ability to write.
  • Exams administered without time pressure reduce stress for students with ST.

Tics in Tourette’s syndrome

Tourette Syndrome refers to an “impulsive disorder” or a “deshinibitorial disorder. ” One can, therefore, say that, on the one hand, the TS means being constantly invaded by multiple and strange impulses and on the other, being unable or less able to suppress them. Many researchers believe that they are completely accidental and meaningless “the nerve pulls sharply”, while many people who really suffer from TS, report that there seems to be some hidden pattern or meaning, which they cannot understand from them.

One way to verify if an action is a tic or not is to apply the “try to suppress” test. If he suppresses it and leads to agitation, he eventually does the act or other similar action, or a feeling of “why should I suppress it now? I want to do it anyway,” most likely it is a tic.

Premonitions and knowledge of sudden tics

Some tourists report that they are aware of the impulse of tic before doing it. In that case, the momentum can be expressed as a fleeting memory that you have this tic and want to do it, a sudden idea or image of frustration that seems to want to express in the tic, or as the idea that tics increase in you as you do a sneeze

Some people with (TS) are aware that tic is a set of unpleasant physical and emotional sensations, which seek to go out “into the world” and fall into the existential dilemmas where they think, on the one hand, that they have a weakness or a disturbed personality. , or they fall into the thought that they have an ungovernable neurological condition, and well, that they are even sicker because they cannot master this “disturbing” desire to deliberately pretend that one has uncontrollable impulses.

These tics seem to have no purpose unlike normal impulses such as “scratching an itch” or coughing, these if they have a purpose, the tics outwardly do not seem to have any. For example, the difference between saying bad words naturally and coprolalia is that a patient with (TS) often does not even get angry or agitated at all when he insults and often this action emerges completely out of context.

To summarize: in normal actions, “you decide to do something, like getting up and going out.” After the decision and only if you want to make it, “you really execute it.”

With the tics it is almost the opposite: there is no premeditation (thinking) about doing them and only if “you decide to suppress the tic (and are able to do it)”, “you end up not experiencing the action – for some time”. To imagine how the tics act: one can imagine that he is aware of the stimulation of sneezing without any physical sensation in his nose before doing so. One can replace the “sneeze” with any other sudden action and so one can imagine how a Tics will act.

Another example is to imagine the action of closing their eyes because a fly flies directly towards them, but without really having any flies. Now you can imagine that when you resist the urge to close your eyes, the “imaginary” fly freezes in front of your eyes forever, desperately searching between them until eventually, you have to close your eyes or shake it away from your face.

Perhaps a positive aspect of this syndrome is that it seems that neurological hyperactivity in Tourette Syndrome not only emerges as tics and compulsions but also as ideas, creative sparks, impulses, and their analogs.

“… their mental state is normal and most of them are very intelligent and it is important to clarify that this disease has no negative effect on the mental faculties of people ……” – Dr. Georges Gilles de la Tourette


It is called comorbidity of disease to the coexistence of two or more medical pathologies or unrelated pathological processes. We could call comorbidity to additional processes or problems.

Frequent coexistence of Gilles de Tourette’s disorder with Obsessive-Compulsive Disorder (OCD) , with Attention Deficit Hyperactivity Disorder (ADHD) and with learning disorders has been described. Although the results of the studies are contradictory, it has also been suggested that it coexists with depressive and anxious disorders.

As data we can mention:

  • Obsessive-compulsive symptoms have been found in 60% of patients with Gilles de la Tourette’s disorder, and in 7 to 10% the diagnosis of an obsessive-compulsive disorder (OCD) can be made. Obsessive symptoms become clinically evident 5 to 10 years after the appearance of simple tics. When the clinical manifestations of OCD have been compared among patients who have tics with patients who do not have it, patients with tics have been found to have an OCD with the following peculiarities: earlier appearance; more likely to suffer from touching, hitting, fixing, checking, rubbing and closing eyes, and less cleaning; and especially with a lower therapeutic response to specific serotonin reception inhibitors.
  • The characteristics of compulsions that typically occur in patients with tics have led some researchers to think that they are not really compulsions but simple or complex tics to which the patient subsequently gave meaning and obsessions could be constructed or invented to Explain compulsions
  • In addition to the frequent comorbidity of Gilles de la Tourette’s disorder with OCD, it is known that 79% of patients have at least one family member with tics or OCD, and vice versa, the tics rate in relatives of First degree of patients with OCD is high. This has led to a genetic relationship between these disorders, In Yale’s family study, it was found that family males of patients with Gilles de la Tourette’s disorder suffered from chronic tics or Tourette disorders and instead women suffered from OCD without tics. Since not all OCD patients have tics, it seems that OCD accompanied by tics is etiologically different than OCD without tics.
  • The Obsessions which consist of repetitions of unwanted intrusive thoughts, and Compulsions and ritualistic behavior, so that people feel they must do something over and over again or do it in a certain way. Examples include touching an object with one hand after touching it with the other, just to “balance things” or repeatedly check if the kitchen fire is off. Children sometimes ask their parents to repeat a phrase many times until it “sounds good.”

Other disorders such as:

  • Developmental learning disorders, which should include: reading difficulties, ie the ability to read (dyslexia), writing, arithmetic, and perceptual problems.
  • Impulse control problems, in which they can result in very aggressive behaviors or socially inappropriate events.
  • Sleep disorders, which include waking up frequently or talking in dreams, and walking asleep.
  • Attention Deficit Disorder, with or without Hyperactivity (ADD or ADHD), is one of the most common companions of (TS) – as many as 50% of the tourists have some of it. In previous years people talked about “hyperactive children.” The least known is that these children can grow up and be ADD adults. Early in the life of many people with ADD, they experience problems at school and it is for this reason that their parents often seek help. The norm seems to be that the majority of diuretics who are diagnosed in childhood or adolescence suffer from “Tourette’s syndrome with ADD”. Children often show signs of hyperactivity before the symptoms of (TS) appear. Symptoms of hyperactivity and ADD may include: difficulty concentrating; not finish what started; pretend not to be heard; be easily distracted; act often without thinking; constantly change from one activity to another, need a lot of attention, and restlessness in general. Adults may have residual signs of ADHD such as impulsive behavior and difficulty concentrating, and the need to move constantly. ADD without hyperactivity includes all the symptoms mentioned above the high level of activity. As children with ADHD grow, the need to move is expressed by restlessness and restless behavior. Difficulties with concentration and poor impulse control persist. and the need to move constantly. ADD without hyperactivity includes all the symptoms mentioned above the high level of activity. As children with ADHD grow, the need to move is expressed by restlessness and restless behavior. Difficulties with concentration and poor impulse control persist. and the need to move constantly. ADD without hyperactivity includes all the symptoms mentioned above the high level of activity. As children with ADHD grow, the need to move is expressed by restlessness and restless behavior. Difficulties with concentration and poor impulse control persist.
  • Obsessive-Compulsive Disorder (OCD) that is among the most common symptoms of (TS) areas mentioned above, obsessions and obligations (compulsions), which are classified as Obsessive-Compulsive Transformation (OCD). One could see the second as extremely complex tics.
  • The obsessions are recurring ideas (which are repeated) or thoughts that seem to invade and take command of your mind, without your consent. The volume of obsessions may vary. Examples of these are obsessions about violence and repeatedly imagine violent scenes obsessions regarding numbers and quantify everything (tell) obsessions about words and spelling obsessively have to ask everything

The obligations (compulsions) are repetitive actions, provisions that one feels compelled to do, often in a ritualistic manner. Frequently these acts go to the end despite the fact that he does not really want to do them, and despite wanting to resist them. Examples of these are:

  • have to do small things right now
  • always align all books perpendicularly with the table
  • have to leave the same way you entered
  • check and recheck “check” something

Whims, Episodes and Singular Feelings: Many tourists report that they are inclined to whims such as discouragement, and singular feelings such as “that the world is just a movie” or “that there is something terribly important there in the specific outline of your pencil sharpener desk”.

The main feature of all this seems to be that they suddenly appear and disappear “unexpectedly” in the same way. Also, in a rationally clever way, these deceptions do not always help – a deeper part of the mind seems to have found its livelihood in them. They only appear again without notice.

Tourette syndrome diagnosis

The diagnosis is made by means of the clinical observation of the symptoms and by the evaluation of the beginning of the same. There is no specific laboratory test for diagnosis. Many patients with Gilles de la Tourette disorder have nonspecific abnormal electroencephalogram findings. Computed axial tomography and magnetic resonance imaging of the brain do not show specific structural lesions.

However, a doctor may request an “EEG”, a scanner or a “cranial resonance, or a certain kind of blood test to rule out other types of diseases that could be confused with ST.

Neuroimaging studies, such as magnetic resonance imaging (MRI), computed tomography (CT) and electroencephalographic scans, or different blood tests can be used to exclude other conditions that may be confused with ST

Criteria for the diagnosis of Gilles de la Tourette’s disorder

Gilles de la Tourette’s disorder is characterized by multiple motor tics and one or more vocal tics

According to the DSM-IV, the diagnostic criteria for Gilles de la Tourette’s disorder are as follows:

  • At some point throughout the disease, there have been multiple motor tics and one or more vocal tics, although not necessarily simultaneously.
  • Tics appear several times a day (usually in waves) almost daily or intermittently over a period of more than one year.
  • During this time there is never a tics-free period greater than more than three consecutive months. The disorder causes significant discomfort or significant social, occupational or other deterioration of the individual’s life.
  • The beginning is before 18 years of age.
  • The alteration is not due to the direct physiological effects of a drug (an eg, stimulant) or a medical disease (eg, Huntington’s disease or postviral encephalitis).

Criteria for the diagnosis of chronic motor or vocal tics disorder

  • At some time throughout the disease there have been simple or multiple vocals or motor tics (that is, vocalizations or sudden, rapid, recurring, non-rhythmic or stereotyped movements), but not both.
  • The tics appear several times a day almost every day or intermittently over a period of more than 1 year, and during this time there is never a tics-free period greater than 3 consecutive months.
  • The alteration causes significant discomfort or significant deterioration in social, labor or other important areas of the individual’s activity.
  • The onset is before 18 years of age.
  • The disorder is not due to the direct physiological effects of a substance (e.g., stimulants) or to a medical illness (e.g., Huntington’s disease or post-viral encephalitis).

Criteria for the diagnosis of transient tics disorder

  • Single or multiple motor and/or vocal tics (that is, vocalizations or sudden, rapid, recurring, non-rhythmic and stereotyped movements).
  • The tics appear several times a day, almost every day for at least 4 weeks, but no more than 12 consecutive months.
  • The alteration causes a significant malaise or a significant deterioration in social, labor or other important areas of the individual’s activity.
  • The onset is before 18 years of age.
  • The alteration is not due to the direct physiological effects of a substance (e.g., stimulants) or to a medical illness (e.g., Huntington’s disease or post-viral encephalitis).

Differential diagnosis of Tourette syndrome

Differential diagnosis should be made with other abnormal movements (for example dystonia, dyskinesia, chorea, athetosis, myoclonus, and hemibalism) and neurological diseases in which these movements are characteristic, such as Huntington’s chorea, Sydenham’s chorea, the disease of Parkinson’s and Wilson’s disease. They must also be distinguished from compulsions, mannerisms and stereotyped movements. It differs from stereotyped movements because of their voluntary nature and because they do not cause subjective discomfort such as tics.

Many patients with Gilles de la Tourette syndrome have abnormal, but nonspecific, electroencephalogram findings. The scanner and the MRI of the brain do not show specific structural lesions.

“If exams are requested, it is only to make a differential diagnosis, and rule out other neurological alterations, such as myoclonus or choreic syndrome. A differential diagnosis should be made with other abnormal movements (for example: dystonia, dyskinesia, chorea, athetosis , myoclonus and hemibalism) and the neurological diseases in which these movements are characteristic, such as Huntington’s chorea, Sydenham’s chorea, Parkinson’s disease, and Wilson’s disease, should also be distinguished from compulsions, mannerisms and stereotyped movements. unlike stereotyped movements because of their voluntary nature and because they do not cause subjective discomfort such as tics2.

Tourette syndrome prognosis

There is no cure for Gilles de la Tourette syndrome. However, the condition in many patients improves as they mature. Individuals with (ST) can expect a normal life span. Although the disorder is chronic and endures throughout life, it is not a degenerative disease. The (ST) does not impair intelligence. Tics tend to decrease as the patient’s age progresses, allowing some patients to discontinue the use of medications. In some cases, a complete remission occurs after adolescence.

When making a disease prognosis, there are studies in which the different types of scales of evaluation of the severity of tics are compared, these have shown that they are better than those that combine history and direct observation. And by comparing the scales that combine history and direct observation, it has been shown that all are equally effective. Work is being done to develop a scale to unify and minimize the mistakes of others. Also, scales have been designed to measure the degree of interference of social activity.

The two most widely used scales are:

  • The Global Assessment Scale (GAS).
  • The Children’s Global Assessment Scale (CGAS).

To obtain a more objective and portable description of the severity of the tics, video recordings are made. The tics are usually counted in intervals of 2 to 16 minutes. Video measurements made under controlled conditions can offer very reliable results. They have also been used to document changes in treatment studies. To increase the validity of the measurement, the patient should not know that they are examining it.

So the scales that combine history and direct observation are the most widely used and address various dimensions of the tics, including number, anatomical distribution, complexity, intensity, frequency, suppression, interference, and social deterioration. Each dimension is applied separately for motor and vocal tics. The number refers to the variety of discrete tics or sounds.

So, summarizing with respect to prognosis we must be optimistic and say that many people experience a complete remission or a marked improvement in late adolescence or when they turn twenty-a few years old. Most people with TS improve, do not get worse, as they mature, and can anticipate that they will lead a normal life. Approximately one-third of patients experience a marked decrease in tics in adulthood.

Tourette syndrome treatment

As noted in the preceding section, the tics disorder and Tourette’s Syndrome has multiple treatments, from different fields of science ranging from Medicine with psychopharmaceutical treatment to Psychology, within which the behavioral approach has Developed different interventions.

The treatment of this syndrome is approached in a multidisciplinary way. As it is a complex disorder, it requires a comprehensive approach, from medicine, pharmacology, and information to the family, teachers and the patient’s classmates, about their situation. Although there are medications to combat the problem today, it has been seen that the relief they produce is transient and that they have side effects.

Therefore, especially in the case of children, behavioral therapy may be necessary. Sometimes it is enough only for the neurologist to talk with the parents, explaining what the disorder is, what the prognosis is and how to manage the environment so that it does not leave psychological and behavioral sequelae.

But most importantly, it is to discover both adults and children if other disorders are present, such as obsessive-compulsive syndrome, which usually accompany the problem. Treating them properly, apart from improving the lives of these patients, generally reduces stress and, in this way, the frequency with which the tics are repeated.

Due to the fact that the symptoms are not limited to most patients and their development proceeds normally, most people with ST do not require medication. However, there are medications available to help patients when symptoms interfere with daily tasks.

In other words, medication is only available to help control symptoms when they interfere with their functions. Unfortunately, there is no single useful medication for every person with ST. There is also no medication that eliminates all symptoms and all medications have side effects.

In addition, medications available for ST can only reduce specific symptoms. Some patients who need medications to reduce the frequency and intensity of tics may be treated with neuroleptic drugs such as haloperidol (Haldol or Haloperidol), clonidine (papers) and pimozide (pimozide or wrap).

These drugs are usually administered in very small doses which are slowly increased until the best possible balance between symptoms and side effects is achieved.

In the case of tardive dyskinesia. It usually disappears when the medicine is discontinued. Short-term side effects of haloperidol and pimozide include muscle stiffness, drooling, tremor, lack of facial expression, slow movement and restlessness. These side effects can be reduced by drugs commonly used to treat Parkinson’s disease. Clonidine, an antihypertensive drug, is also used to treat tics. Research shows that this drug is more effective in reducing motor tics than phonic tics. Common side effects associated with the use of clonidine are fatigue, dry mouth, irritability, dizziness, headaches, and insomnia.

Flufenacin (Prolixin, Permit) and clonazepam (Klonopin) may be prescribed to help control the symptoms of tics, some neutralize the activity of dopamine and may cause a marked decrease in tics, compulsions and the like. There are also medications available to treat some of the behavioral disorders associated with ST. Stimulants such as methylphenidate, pemoline and dextroamphetamine, although their use is controversial because they have been reported to increase tics.

For obsessive-compulsive behaviors that significantly interfere with daily functioning, fluoxetine (Prozac), clomipramine (Anafranil), sertraline and paroxetine may be prescribed. Some of the side effects, including depression and cognitive disorders, can be relieved by Dose reduction or medication replacement. Tourette syndrome

The child can be threatened, excluded from family activities, and prevent him from enjoying a normal personal relationship. These difficulties can become more serious during adolescence, a special test for young people and even more for a person who is suffering from a neurological disorder.

To avoid psychological damage, early treatment and diagnosis are crucial. Moreover, in severe cases, it is possible to control the symptoms with medication. Tourette syndrome

Psychotherapy is always recommended, as this can help the person or family to manage not only the disorder but also the social and emotional problems that sometimes occur. Some behavior therapies can teach you to replace a tic with another that is more acceptable. Tourette syndrome

Other techniques such as relaxation or relaxation and biofeedback can be useful for relieving stress that can lead to increased symptoms of tics. Tourette syndrome

With regard to support groups, these allow families to exchange their ideas and feelings in relation to their common problems. Tourette syndrome

Often, family therapy helps, parents of children with TS have to think and understand the difference between understanding and overprotection. They are constantly deciding if some behaviors are due to a manifestation of the TS or simply an imitation. Parents must then determine the best answer. Children should be motivated to control what they can socially unacceptable behaviors and try to replace them with socially acceptable behaviors or tics. Parents are encouraged to give their children with TS the opportunity to gain as much independence as possible, and in the meantime, gently but firmly, limiting the attempts of some children to use their symptoms to control those around them. Tourette syndrome

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