Objectives

• To be introduced the classification and diagnosis of Tic disorders

• To understand the symptomatology and diagnostic criteria of Tourette’s Disorder

• To identify and understand the causes of Tic and Tourette’s Disorder

• Prognosis and associated conditions of Tourette’s Disorder

• To explore the prevention and treatment options for Tic and Tourette’s Disorder
GLOSSARY

• Cognitive Behavior Therapy (CBT): A type of therapy used to treat a wide range of
psychological disorders, including obsessive-compulsive disorder, body dysmorphic
disorder, depression, phobias, etc. The goal is to identify and modify distorted
thoughts and replace negative and destructive behaviors with healthy behaviors.
• Comorbidity: It refers to two or more disorders occurring at the same time.
• Compulsions: They are also known as “rituals,” behaviors or thoughts that one
performs over and over again in an attempt to reduce anxiety or prevent a feared
outcome. Some common compulsions are: excessive cleaning or washing, checking
things, repeating certain behaviors, seeking constant reassurance, doing something a
certain number of times, or mental rituals such as counting, or praying to prevent
harm.
• Coprolalia: It refers to involuntary uttering of obscene words or phrases.
• Echolalia: It refers to involuntary repetition of another person’s words or phrases.
• Electroencephalogram (EEG): It is a graph that measures and records electrical
activity in the brain.
• Habit Reversal Training (HRT): A type of behavior therapy used to reduce
impulsive behaviors (e.g. hair pulling, skin picking, etc). In HRT, the patient learns
how to identify triggers that lead to compulsive behaviors, engage in alternative and
usually opposite behaviors to replace the current ones, and develop relaxation training
techniques.
• Movement disorders: Medical conditions affecting the movement systems, such as
walking or tremor.
• Neuroleptic: An older class of medications used to treat a broad range of psychiatric
disorders, including but not limited to schizophrenia, bipolar disorder, and Tourette
Disorder.
• Obsessive Compulsive Disorder (OCD): A psychiatric illness characterized by
persistent and intrusive obsessions and/or repetitive, time-consuming compulsions.
• Palilalia: It refers to involuntary repetition of one’s own words.
• Pharmacotherapy: Treatment of an illness with medication.
• Twitches: Unlike tics, the majority of muscle twitches are isolated occurrences, not
repeated actions. Muscle twitches are also known as myoclonic jerks. They are
entirely involuntary and cannot be controlled or suppressed.
Summary

A tic is a repetitive, uncontrollable, purposeless contraction of an individual muscle or group

of muscles, usually in the face, arms, or shoulders. These movements may be signs of a minor
psychological disturbance. Such tics often occur in childhood and will probably be outgrown.
There are also tics that are caused by neurological disorders that could have resulted from
brain damage at birth, head trauma, or use of some specific medication.

The most complicated and concerning tic disorder is Tourette's disorder. Tourette’s disorder
is characterized by both multiple motor and one or more vocal tics that have been present at
some time during the illness, although not necessarily concurrently. It is a nervous system
(neurological) disorder that starts in childhood. It involves unusual repetitive movements or
unwanted sounds that can't be controlled (tics). For instance, you may repeatedly blink your
eyes, shrug your shoulders or jerk your head. In some cases, you might unintentionally blurt
out offensive words.

The early symptoms of Tourette syndrome are almost always noticed first in childhood, with
the average onset between the ages of 7 and 10 years. Tourette syndrome occurs in people
from all ethnic groups; males are affected about three to four times more often than females.

Tic disorders may be inherited. Genetic analysis of numerous pairs of siblings has shown
several areas that may contain genes that, when mutated, may give rise, or increase
susceptibility to, Tourette Syndrome. There is growing evidence that Tourette Syndrome is
inherited from both parents (bilineal transmission), with the father typically affected by
childhood tics and the mother typically having some symptoms of obsessive-compulsive
disorder.
Introduction

Tics are sudden twitches, movements, or sounds that people do repeatedly. People who have
tics cannot stop their body from doing these things. For example, a person with a motor tic
might keep blinking over and over again. Or, a person with a vocal tic might make a grunting
sound unwillingly.
Tics may involve:

• Movements that occur again and again and don't have a rhythm
• An overwhelming urge to make the movement
• Motor tics (bodily movements):

§ Blinking
§ Clenching the fists
§ Curling the toes
§ Kicking
§ Raising the eyebrows
§ Shrugging the shoulders
§ Sticking out the tongue

Phonic or vocal tics (sounds):

• Clicking
• Grunting
• Moaning
• Snorting
• Squealing

Classification of Tic Disorders:

Four tic disorders are included in the revised fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR):
 • Chronic motor or vocal tic disorder: It is either single or multiple motor or phonic
tics, but not both, which are present for more than a year
• Transient tic disorder: It consists of multiple motor and/or phonic tics with duration
of at least 4 weeks, but less than 12 months.
• Tourette’s disorder (also called Tourette Syndrome [TS]). It is diagnosed when both
motor and phonic tics are present for more than a year.
• Tic Disorder not otherwise specified (NOS): It is diagnosed when tics are present,
but do not meet the criteria for any specific tic disorder.

Diagnosis of Tic Disorders

For a person to be diagnosed with a chronic tic disorder, he or she must meet the following
criteria:

1. The person must have one or more motor tics (for example, blinking or shrugging the
shoulders) or vocal tics (for example, humming, clearing the throat, or yelling out a
word or phrase), but not both
2. The person must have tics that occur many times a day nearly every day or on and off
throughout a period of more than a year. During this period, there must not be a single
tic-free period of more than 3 months.
3. The person’s tics must start before he or she is 18 years of age.
4. The person’s symptoms must not be due to taking medicine or other drugs or to
having another medical condition (for example, seizures, Huntington disease, or
postviral encephalitis).
5. The person must not have been diagnosed with TS.

Specific Symptoms of Tourette's Disorder

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

Four characteristics are used to identify and diagnose tic disorders:

1. The age when tics began

2. Duration of the tics
3. Severity of the tics
4. Whether tics are motor or vocal or both

Characteristics of Tourette’s syndrome:

1. Both multiple motor and one or more vocal (phonic) tics are present at some time
during the illness, although not necessarily simultaneously.
2. Tics are recurrent, non-rhythmic, stereotyped (the same each time) actions or
vocalizations that can usually be suppressed for a period when a person focuses on
stopping them.
3. Less than 40 percent of people with TS have coprolalia (swearing or yelling out foul
language).
4. Most people experience a discomforting sensation prior to their tics that disappears
after they carry out the tic.
5. Tics occur many times a day, nearly every day or intermittently throughout a span of
more than one year.
6. Significant impairment or marked distress in social (at home or with friends),
occupational (work or school), or other important areas of functioning.
7. Onset occurs before the age of 21.
8. Symptoms can disappear for weeks or months at a time and severity waxes and
wanes.
 9. Most people experience less tics as they get older; nearly 50 percent of people have
significantly less tics as they reach adulthood.

Diagnosis of Tourette's Disorder:

No blood analysis, x-ray or other medical test exists to identify Tourette’s syndrome. The
first step in diagnosis occurs when a young person is brought to their doctor for evaluation.
Sometimes this happens when a parent is concerned about tics or another symptom of
Tourette’s syndrome; other times it occurs at a regularly scheduled check-up when a person’s
doctor notices these symptoms during a routine physical examination.

Many people with tics do not actually have TS. For example, transient tics of childhood are a
benign condition which can be present in a quarter of young children. Therefore upon seeing
the signs of TS, many primary care doctors (e.g., family practice doctors and pediatricians)
may refer their patient to a specialist. This is not only because Tourette’s syndrome is most
frequently managed by neurologists and psychiatrists, but also because it is important that
any person with newly diagnosed tics have a thorough medical and neurological examination.
In some people, this may include radiological tests (e.g., CT scans, MRIs), EEG
(electroencephalogram), and blood tests. The specialist’s thorough evaluation will confirm a
diagnosis of Tourette’s syndrome as opposed to an infection, a medication side-effect or
another neurological illness as the source of the tics.

Pathophysiology:

The exact mechanism affecting the inherited vulnerability to Tourette's has not been
established, and the precise etiology is unknown. Tics are believed to result from dysfunction
in cortical and subcortical regions, the thalamus, basal ganglia and frontal cortex.
Neuroanatomic models implicate failures in circuits connecting the brain's cortex and
subcortex, and imaging techniques implicate the basal ganglia and frontal cortex.

Treatment:

Tic disorders frequently do not require pharmacological treatment for tic suppression, since
they do not often cause impairment. But if required, first line treatment options include
dopamine modulators, tetrabenazine, clonidine and behavioural therapy. There is no one
medication that is helpful to all people with Tourette syndrome, nor does any medication
completely eliminate symptoms. However, effective medications are available for those
whose symptoms interfere with functioning.

Medication treatment of Tourette’s syndrome usually focuses on decreasing the severity,

frequency, and discomfort of tics for people with significant social and occupational
difficulties due to their symptoms. Treatment of tics often includes medications from the
antipsychotic class of drugs—referred to as dopamine-blockers or neuroleptics. These include
pimozide (Orap), haloperidol (Haldol), risperidone (Risperdal), fluphenazine (Prolixin), and
others. These medications carry the risk of substantial side effects—namely movement
disorders (including Tardive Dyskinesia), weight gain, and metabolic syndrome. Surgeries
and other procedural treatments (e.g., botulinum toxin injection, deep brain stimulation, and
transcranial magnetic stimulation) are not usually recommended and are beyond the scope of
this review.

Treatment of co-existing symptoms is very important in Tourette’s syndrome to improve self-

esteem and overall functioning. For example, a person with OCD may require cognitive
behavioral therapy (CBT) or treatment with a medication from the selective-serotonin-
reuptake-inhibitor class of medications (e.g., paroxetine [Paxil], sertraline [Zoloft],
fluvoxamine [Luvox], fluoxetine [Prozac], etc.) to control their obsessions and compulsions.
A person with ADHD may require treatment with stimulant medications (e.g., dexedrine,
methylphenidate (Ritalin), etc.) or other medications (including alpha-blockers such as
clonidine (Kapvay) and guanfacine (Tenex, Intuniv)) to improve their focus and control
impulsive behaviors. It should be noted that stimulant medications carry the risk of increasing
tic severity and therefore—as with any other medications—the pros and cons should be
discussed with one’s physicians.

In addition, behavioural therapies are often recommended as a first choice treatment for tics.
They include:
• Habit Reversal Therapy (HRT), which aims to help the client learn
'responses' (other movements) which 'compete' with tics, meaning that the tic
cannot happen at the same time. HRT teaches client to use these competing
responses when he gets the feeling that he need to tic, until the feeling goes
away.
 • Exposure with Response Prevention (ERP), which aims to help the client
get used to the overwhelming unpleasant feelings that are often experienced
just before a tic.

There are also a number of medications that can improve tics in some people. In particularly
severe adult cases, a new surgical treatment for tics called deep brain stimulation may be
used. Other treatments include psychological counseling, support groups, and biofeedback
with limited results.

The natural course and outcome of this disorder is variable and in many situations as the
individual matures the degree of the tics and the disorder tunes down gradually, regardless to
the medications effects.

Tic disorders and Tourette syndrome are frequently associated with comorbid conditions such
as obsessive compulsive symptoms, attention deficit and hyperactivity disorder, anxiety and
depression, behavioural disorders and sleep difficulties. Fronto-striatal circuits and the
dopaminergic system are believed to be involved in the pathophysiology of TS and tics.
Pharmacological options that have been studied for treatment of tic disorders are reviewed.
Behavioural therapy such as habit reversal training and surgical treatment are other options. It
is essential to identify and address comorbid conditions such as attention deficit disorder,
obsessive-compulsive symptoms, depression, behavioural disorders and sleep disturbances,
as they often cause more distress and disability than the tics themselves.

Prognosis:

Tourette syndrome is a spectrum disorder—its severity ranges over a spectrum from mild to
severe. The majorities of cases are mild and require no treatment. In these cases, the impact
of symptoms on the individual may be mild, to the extent that casual observers might not
know of their condition. The overall prognosis is positive, but a minority of children with
Tourette syndrome has severe symptoms that persist into adulthood.

The rare minority of severe cases can inhibit or prevent individuals from holding a job or
having a fulfilling social life.

Regardless of symptom severity, individuals with Tourette's have a normal life span.
Although the symptoms may be lifelong and chronic for some, the condition is not
degenerative or life-threatening. Intelligence is normal in those with Tourette's, although
there may be learning disabilities. Severity of tics early in life does not predict tic severity in
later life, and prognosis is generally favorable, although there is no reliable means of
predicting the outcome for a particular individual. The gene or genes associated with
Tourette's have not been identified, and there is no potential "cure."

A supportive environment and family generally gives those with Tourette's the skills to
manage the disorder. People with Tourette's may learn to camouflage socially inappropriate
tics or to channel the energy of their tics into a functional endeavor. Accomplished musicians,
athletes, public speakers, and professionals from all walks of life are found among people
with Tourette's. 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.

Tourette’s syndrome: Associated conditions

Tourette Syndrome is a spectrum disorder-it varies with each individual and may appear
anywhere on the spectrum between very mild and severe (4). It does not affect intelligence,
although in Tourette Syndrome the child may develop such additional behavioral and
developmental disorders as Attention Deficit Hyperactivity Disorder, impulsivity,
aggressivity, self-injurious behaviors, and varied learning disabilities. The two most
commonly reported conditions are described below:

• Obsessive compulsive disorder (OCD) is a condition that causes persistent

obsessive thoughts and compulsive behaviour. For example, feeling compelled
to constantly wash your hands because you are obsessed with the fear that you
will catch a serious illness if you don’t.
• Attention deficit hyperactivity disorder (ADHD) is a behavioural condition
that causes symptoms such as short attention span, being easily distracted and
being unable to sit still because you are constantly fidgeting (hyperactivity).

In addition, children with Tourette’s syndrome may have other behavioural problems, such as
flying into sudden rages or engaging in inappropriate or anti-social behaviour with other
children. In many cases, these associated conditions and behavioural problems can be more
disruptive and troublesome than Tourette’s itself.
 As the above text describes the diagnostic criteria of Tic Disorder and Tourette’s
Disorder according to the DSM-IV-TR, it is important to note the changes made
regarding this disorder in the latest edition i.e. DSM-V. Although there are no changes
made in the diagnostic criteria of these disorders, these disorders have been categorized under
a new category of disorder, i.e. “Neurodevelopmental Disorders” in the DSM-V, and
changed from their old categorization i.e. “Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence”, in DSM-IV-TR.

Case Study-1

Simon is a seventeen-year-old Caucasian boy currently managing a mild case of Tourette

syndrome. He attends mainstream high school and is a moderately successful student with a
normal amount of friends. He enjoys playing video and computer games instead of doing his
homework, although he does like his math and science classes. When he was 9, Simon's
family moved to another part of town where he had to switch schools. He began showing
signs of Tourette syndrome at his new school. He displayed peculiar physical tics as well as
repetitive throat clearings-despite the fact that he rarely had mucus or anything else bothering
his throat. His physical tics consisted mainly of accentuated blinking (hemifacial spasms) and
clenching/extending movements of the hands and sometimes feet (athetoid movements). The
former occurs irregularly, repetitively, and unilaterally and affects the eye's muscle groups.
The latter occurs slowly and also irregularly and often has a writhing appearance.

Simon has an aunt with controlled obsessive-compulsive disorder on his mother's side and
also a cousin with attention-deficit hyperactivity disorder. Both disorders are closely related
with Tourette syndrome and often can occur simultaneously. It is believed that Tourette
syndrome can be inherited; the dominant gene(s) may cause different symptoms in different
family members (Barbara A. Moe). This might explain the differences between Simon and
the disorders of his aunt and cousin. Also, at the time of perceived on-set, Simon was battling
a bad case of streptococcus infection (strep throat) which is often associated with the
worsening of Tourette syndrome tics.

Due to Simon's family financial disadvantages, his parents were unable to provide
professional psychological assistance for many years after becoming concerned about his
symptoms. In other words, Simon had to deal with his disorder on his own-and often
ineffectively-although he did read books on coping with Tourette syndrome along with his
mother. For the first few years, until about age 11, Simon dealt mainly with his eye blinking
and hand clenching tics and also the throat clearing. Since they occurred mainly in mild
bouts, Simon easily functioned in the school setting.

Around the onset of puberty, Simon's bouts began occurring more frequently, especially in
uncomfortable social situations and when his allergies began to perk up. In some extreme
cases of being uncomfortable, Simon displayed complex vocal tics like palilalia (repeating
the last word or so of a sentence) and echolalia (repeating the last word or words of others).
These instances, although rare, bothered Simon and his loved ones.

By the age of about 15, Simon outgrew these more extreme tics and dealt more effectively
with his challenge by employing "calming" techniques. Now, at age 17, Simon is attending a
support group for Tourette syndrome, although he still seeks professional help (his family's
financial situation has improved) due to his increasing sleep problems and frequency of tics.
As school work has increased, so has his stress level and in turn his ability to fall asleep
and/or stay asleep has lessened. Simon wants to take serious control of his Tourette syndrome
for good.

Case Study-2

An 18-year-old boy has experienced a variety of movements of the face and upper body since
age 5. His movements initially consisted of facial grimacing, frequent blinking, and
puckering of the lips. At age 8, he started producing various sounds, including hissing,
clucking, sudden screaming, throat clearing, and grunting. By age 10, his facial movements
became less prominent and were replaced by shoulder shrugging and sudden jerky head-
turning movements. He manifested these movements and sounds more at home while
watching television or when idle rather than in school. By age 12, his movements started to
decrease steadily in frequency and severity, and by age 18 they were completely gone. The
boy describes an irresistible urge associated with the movements, some gratification in
performing them, and an ability to suppress them partially (which is associated with a build
up of inner tension). From ages 7 to 12, he had the compulsion of repeatedly wringing his
hands or washing them. His school performance has been lower than average, with his
teachers noting hyperactivity and limited attention span in grade school and early high
school.
REFERNCES

• Connor,O.K.(2005). Cognitive –Behavioral Management of Tic Disorders. John

Wiley and Sons Ltd, England.
• Moe,B.A.(2000 ). Coping with Tourette Syndrome and Tic Disorders. Rosen
Publishing Group.
• Nobles, C. (2003). Coping With Tourette syndrome. Rosen Publishing Group.
• Woods,W.D ; Piacentini, J.C. & Walkup, J.T.(2007). Treating Tourette Syndrome and
Tic Disorders: A Guide for Practioners. The Guilford Press, Newyork.
WEB LINKS

• http://www.webmd.com/mental-health/tc/tourettes-disorder-topic-overview
• http://www.ninds.nih.gov/disorders/tourette/detail_tourette.htm
• http://www.nlm.nih.gov/medlineplus/ency/article/000747.htm
• http://www.cdc.gov/ncbddd/tourette/diagnosis.html
• http://www.nami.org/Template.cfm?Section=By_Illness&Template=/ContentManage
ment/ContentDisplay.cfm&ContentID=23053
• http://www.nhs.uk/conditions/Tourette-syndrome/Pages/Introduction.aspx
• http://www.youtube.com/watch?v=Il3QIpIogyY&playnext=1&list=PLB8D5ADF1B6
3617CB&feature=results_main
• http://www.youtube.com/watch?v=IMX1EQQtKWQ
• http://www.youtube.com/watch?v=1SEKZLivG54
• http://www.youtube.com/watch?v=V24YqHyMsVM
• http://www.youtube.com/watch?v=ZCM6YxlWKaw
http://www.youtube.com/watch?v=9ZXJ_GprCko
• http://www.youtube.com/watch?v=ZCM6YxlWKaw
• http://www.youtube.com/watch?v=t4fKEyWHZ4o
FAQs

1. What causes Tourette syndrome?

Although the cause of Tourette syndrome is unknown, current research points to

abnormalities in certain brain regions (including the basal ganglia, frontal lobes, and cortex),
the circuits that interconnect these regions, and the neurotransmitters (dopamine, serotonin,
and norepinephrine) responsible for communication among nerve cells. There is growing
scientific evidence that TS is caused by a neurological illness affecting neurons (nerve cells)
in different parts of the brain including but not limited to the basal ganglia. People with TS
may also have a dysfunction of their neurotransmitters—the chemicals that neurons use to
communicate with each other.

When it was first being studied, it was thought that Tourette’s syndrome had an autosomal-
dominant inheritance pattern—that 50 percent of children would develop this illness if one of
their parents had it. Scientists have since discovered that TS is probably more complicated
and not based on the presence of a single gene. In fact, multiple genes have been shown to
cause the symptoms of Tourette’s syndrome.

In some families, different people may have different symptoms associated with the illness.
Furthermore, boys are approximately four times more likely to have Tourette’s syndrome
than girls.

2. How is Tourette’s syndrome diagnosed?

There are no blood or laboratory tests needed for diagnosis, but neuroimaging studies, such as
magnetic resonance imaging (MRI), computerized tomography (CT), and
electroencephalogram (EEG) scans, or certain blood tests may be used to rule out other
conditions that might be confused with Tourette syndrome.

The first step in diagnosis occurs when a young person is brought to their doctor for
evaluation. Sometimes this happens when a parent is concerned about tics or another
symptom of Tourette’s syndrome; other times it occurs at a regularly scheduled check-up
when a person’s doctor notices these symptoms during a routine physical examination.

Many people with tics do not actually have TS. For example, transient tics of childhood are a
benign condition which can be present in up to a quarter of young children. Therefore upon
seeing the signs of TS, many primary care doctors (e.g., family practice doctors and
pediatricians) may refer their patient to a specialist. This is not only because Tourette’s
syndrome is most frequently managed by neurologists and psychiatrists, but also because it is
important that any person with newly diagnosed tics have a thorough medical and
neurological examination. In some people, this may include radiological tests (e.g., CT scans,
MRIs), EEG (electroencephalogram), and blood tests. The specialist’s thorough evaluation
will confirm a diagnosis of Tourette’s syndrome as opposed to an infection, a medication
side-effect or another neurological illness as the source of the tics.

3. What disorders are associated with Tourette syndrome?

Many with Tourette syndrome experience additional neurobehavioral problems including
inattention; hyperactivity and impulsivity (attention deficit hyperactivity disorder-ADHD)
and related problems with reading, writing, and arithmetic; and obsessive-compulsive
symptoms such as intrusive thoughts/worries and repetitive behaviors. For example, worries
about dirt and germs may be associated with repetitive hand-washing, and concerns about bad
things happening may be associated with ritualistic behaviors such as counting, repeating, or
ordering and arranging. People with Tourette syndrome have also reported problems
with depression or anxiety disorders, as well as other difficulties with living, that may or may
not be directly related to Tourette syndrome. Given the range of potential complications,
people with Tourette syndrome are best served by receiving medical care that provides a
comprehensive treatment plan.

4. What treatments are available for Tourette’s syndrome?

Unfortunately, there is no one medication that is helpful to all people with Tourette
syndrome, nor does any medication completely eliminate symptoms. However, effective
medications are available for those whose symptoms interfere with functioning. Neuroleptics
are the most consistently useful medications for tic suppression. Not everyone with
Tourette’s syndrome is disabled by his or her symptoms and medication may not be
necessary. Relaxation techniques and behavioral therapies (often called habit-reversal
training) may be very useful in the treatment of tics. Many people with Tourette’s syndrome
may also benefit from psychotherapy (talking therapy) to address some of the self-esteem and
self-consciousness issues associated with their illness. This can be a great resource for
developing coping skills as well.
Medication treatment of Tourette’s syndrome usually focuses on decreasing the severity,
frequency, and discomfort of tics for people with significant social and occupational
difficulties due to their symptoms. Treatment of tics often includes medications from the
antipsychotic class of drugs—referred to as dopamine-blockers or neuroleptics. These include
pimozide (Orap), haloperidol (Haldol), risperidone (Risperdal), fluphenazine (Prolixin), and
others. These medications carry the risk of substantial side effects—namely movement
disorders (including Tardive Dyskinesia), weight gain, and metabolic syndrome. Surgeries
and other procedural treatments (e.g., botulinum toxin injection, deep brain stimulation, and
transcranial magnetic stimulation) are not usually recommended and are beyond the scope of
this review.

Treatment of co-existing symptoms is very important in Tourette’s syndrome to improve self-

esteem and overall functioning. For example, a person with OCD may require cognitive
behavioral therapy (CBT) or treatment with a medication from the selective-serotonin-
reuptake-inhibitor class of medications (e.g., paroxetine [Paxil], sertraline [Zoloft],
fluvoxamine [Luvox], fluoxetine [Prozac], etc.) to control their obsessions and compulsions.
A person with ADHD may require treatment with stimulant medications (e.g., dexedrine,
methylphenidate (Ritalin), etc.) or other medications (including alpha-blockers such as
clonidine (Kapvay) and guanfacine (Tenex, Intuniv)) to improve their focus and control
impulsive behaviors. It should be noted that stimulant medications carry the risk of increasing
tic severity and therefore—as with any other medications—the pros and cons should be
discussed with one’s physicians.Through effective treatment of their tics (and other
coexisting psychiatric illnesses), the overwhelming majority of people with Tourette’s
syndrome can expect to see their symptoms decrease and can continue living the lives they
want to live.

5. What are the benefits of seeking early treatment of Tourette’s syndrome symptoms?

When a child’s behavior is viewed as disruptive, frightening, or bizarre, it may provoke

ridicule and rejection by uninformed peers, family, teachers or friends. Some people can feel
scared or threatened and exclude the child from activities or interpersonal activities and
relationships. A child’s difficulties in social situations may increase as he or she reaches
adolescence. Therefore, it is very important for the child’s self-esteem and emotional well-
being that treatment be sought as early as possible to avoid these difficulties.
Tourette’s syndrome alone does not affect the IQ of a child. Many children who have
Tourette’s syndrome, however, also have learning disabilities and/or difficulties paying
attention. Therefore special education is frequently needed for a child with Tourette’s
syndrome. Teachers should be given factual information about the disorder and, if learning
difficulties appear, the child should be referred through the school system for assessment of
other learning problems.