Tourette's Syndrome - The Symptoms, Treatment, Epidemiology and Genetic Basis

Description of the Area

Tourette’s Syndrome is a tic disorder that is characterized by the presence of more than one motor tic, and one or more vocal tics for a period more than a year that causes impairment or distress to the patient. (McGuire, Piacentini, Brennan, Lewin, Murphy, Small, & Storch (2014) Tic disorders are widely known for their very obvious and sometimes embarrassing symptoms. Though there are various types of tic disorders, Tourette’s Syndrome is by far one of the most prevalent. The themes of my research are the symptoms, treatment, epidemiology, and genetic basis, of Tourette’s Syndrome(TS). While discussing the symptoms of TS, readers will understand the in-depth symptoms and characteristics of TS. Through treatment, readers will learn about the different options that a patient diagnosed with TS has. Continuing in my review, the readers will then discover the epidemiology and genetic importance when it comes to Tourette’s Syndrome. The information that was obtained through review has helped strengthen the connection between the topic of research and the sources.

The main treatment method that is learned is about Habit Reversal (Martin & Pear, 2015). Not only is it used to treat Tourette’s Syndrome, it is also used to treat several other tic disorders. The method consists of three phases that include the behavioral analyst, the patient, and the family of the patient.

First, the client learned to describe and identify the problem behavior. Second, the client learns and practices a behavior that is incompatible with or competes with the problem behavior. The client practices the competing behavior daily in front of a mirror and also engages in it immediately after an occurrence of the problem behavior. Third, for motivation, the client reviews the inconvenience caused by the disorder, record and graphs the behavior, and has a family member provide reinforcement for engaging in treatment (Martin & Pear 2015).

Evidence and Research

McGuire, Piacentini, Brennan, Lewin, Murphy, Small, & Storch (2014) state in their article that Chronic tic disorders are normally defined by the symptoms that it carries along with it. These symptoms include motor tics and vocal tics and these tics can range from simple to complex. In order for someone to be diagnosed with Tourette’s Syndrome, these symptoms would have to persist for at least a year. Müller-Vahl, Ludolph, Roessner, & Münchau, state that Tourette’s Syndrome (TS) is also defined by having at least two types of motor tics and one type of vocal tic. This information is also agreed upon by Douglass Woods, in an interview that was observed online (2015). In addition to this, the researchers also explain that a tic is a repeated, rapid, movement or vocalization that has no rhythm and no purpose. In addition to this information, tics have carrying classifications. There is quality and complexity when it comes to tics. When talking about the quality of tics, there are motor tics, which are movements, and vocal tics, which are sounds or outbursts. The complexity of tics are either simple or complex, simple tics affect a small number of muscles and are short-lasting, while complex tics affect more than a small group of muscles and can carry on for longer periods of time (2012). McGuire et al., explains that since tics do not seem to differ with age, the most common tics are eye-blinking, head jerking, mouth movements, and simple sounds (2014). Albin & Mink, in 2006 expressed that TS is specifically defined by the motor and vocal tics that the patient has, these tics normally start during adolescence, and then persist and change in type, frequency, and are distributed throughout different parts of the body over time. Certain tics can be present and then suddenly disappear for no reason at all. The researchers also explain that complex motor tics can often resemble voluntary movements, although they are not. In addition to this information, Albin & Mink also provide us with a possible timeline in which tics occur. It is known that tics occur in attacks that fluctuate from hours or even as long as months. These attacks are likely to increase during times of stress, and relax when the patient is focused on something (2006).

To continue, the researchers then focused on the treatment aspects of each source. The treatments that are discussed in this research are those that are found most effective when put to the test of treating the tics of those diagnosed with Tourette’s Syndrome Although Müller-Vahl, Ludolph, Roessner, & Münchau believe that when it comes to tic disorder, Psychoeducation should be the first step (2012). Leclerc, O’Connor, Forget, & Lavoie believe that a combination of medications and cognitive-behavioral-therapy is, more times than not, a desirable treatment plan for Tourette’s Syndrome (2010). Tallur & Minns, present an insight into Psychological and Pharmacotherapy treatment.

Psychological Training in self-awareness, self-monitoring, and relaxation are helpful if available. Behavioral techniques such as ‘response prevention’ involving prolonged exposure to the premonitory sensation thus resulting in ‘habituation’ have been found to be effective. ‘Cognitive behavioral therapy’ which has been found to be effective for OCD will also work for TS and Tics… Pharmacotherapy The decision to begin drug treatment for tics in TS must be carefully considered and risks of adverse effects weighed against the potential benefits…medications showing significant improvement in tics treatment include (Antipsychotics, epilepsy inhibitors, and sometimes anti-depressants) (2010).

To elaborate on what Tallur & Minns state, they provide a list of medications that are typically used for the treatment of Tourette’s, as well as some adverse effects that come with each of them. The information is given in a table, which starts out with classifications of medications that consist of Dopamine Synaptic blockers, Atypical Antipsychotics, and Non-Antipsychotics. One of the first medications talked about is Pimozide, which is an antipsychotic, also known as a neuroleptic. The way pimozide works is by blocking dopamine receptors in the brain. The dopamine receptors are involved in transmitting messages between brain cells (netdoctor.co.uk,2013). Another medication that is brought up is Risperidone. Risperidone is classified as an atypical antipsychotic and works at rebalancing dopamine and serotonin levels (name.org, 2013). The last medication to be discussed is a non-antipsychotic called Clonidine, which is normally used to treat blood pressure. It works at decreasing levels of certain chemicals in the blood so that the blood vessels are more relaxed and the heart beats slower (drugs.com, 2013)

When researchers did further research on all of these medications, it was found that Clonidine, although it is sometimes prescribed for treatment of tics, it is not as effective as neuroleptics and is not actually FDA approved for this use (Packer, 2011).

Although medications can help a person diagnosed with TS, Müller-Vahl et al., introduces the idea of Habit Reversal Training (HRT). HRT has been used in recent studies as an alternative to drug therapy for tics. Habit reversal therapy is simple. When the tic occurs, instead of performing the desired tic, the patient performs an alternate action that was learned previously instead, this then prevents the occurrence of a tic. In several of the studies viewed by the researchers, HRT and CBT are highly praised. Leclerc et al., believe that HRT has been most commonly reported and has the highest success rate when it comes to diminishing the presence of tics (2010). The researchers also introduce the idea of cognitive behavioral therapy (CBT). CBT decreases the occurrence of a tic by re-teaching the patient alternate acts and patterns. Although it has a different title, it is very similar to Habit reversal, as they both work on decreasing the tics by using different behavioral techniques.

Mechanisms of Action

To gather information on the mechanism of action when relating to Tourette’s Syndrome, the researchers observed an online interview with Douglas Woods. He elaborates on the underlying processes of Tourette’s Syndrome. Woods states that there is a part of the brain that consists of abnormalities which causes the tics, called the basal ganglia. Woods states also that the pathways that are responsible for the inhibition of movement appear to be 10% smaller in those affected by Tourette’s Syndrome (2015). He then explains that when a person with tics uses behavioral change methods to stop the tics, it activates another part of the brain that appears to be normal. In other words, it is a catch 22. The basal ganglia’s job is to stop the movements that are undesired, and to allow the ones which are reinforced, and if the basal ganglia is not functioning correctly, it will allow undesired behaviors to be elicited. The example that Dr. Woods brings up is when Billy is in the den of his home watching television with his sister, he starts to tic, which causes his sister to tease him for it, and then his mother yells at his sister and sends her upstairs. Billy now gets to watch television on his own and watch whatever he wants as well as all the attention from his mother. Getting to watch whatever he wants, and his mothers’ attention, works as an indirect reinforcer for the tics, because it causes a desirable outcome. Tics, as stated before, can also occur more in a certain setting, such as a specific room, maybe even in cars, or whenever someone is at the beach. Even though Billy does not necessarily find the tics themselves reinforcing, the act of getting the things he wants after a chain of events started by the tics, becomes reinforcing. So, when Billy is in the den, it is more likely that he would experience an increase in the frequency of the tics, due to prior experiences.

Indications

For the treatment options introduced through my research above to have the best results, there are some characteristics and situations that are desirable. To elaborate, if a patient is diagnosed with Tourette’s Syndrome and they seek the help of a behavior analyst, He or She will more than likely go through a behavioral assessment in order to determine which treatment method is best for them specifically.

Due to the obvious interruption that the tics cause in their daily lives, it is more likely for adults to work harder at decreasing the frequency of the tics by using CBT. In a study with Douglas Woods et. al., 4 out of 5 children aged 10-13, showed a reduction in frequency of vocal tics with the use of Habit Reversal.

Contraindications

When someone is diagnosed with TS, the first thing that is explored are treatment options. For children, CBT is not exactly ideal because of the lack of motivation and sometimes attention span in kids. In addition to this, an ideal candidate for these treatment methods are firstly those who have no underlying or comorbid disorders. “The treatment of TS is clearly complicated by the frequent presence of comorbid conditions such as OCD, ADHD, anxiety or depression. The presence of particular comorbidities may make certain treatment options for tics less likely to be effective” (Eddy, Rickards, & Cavanna, 2011). When a patient has a comorbid disorder in addition to Tourette’s, it is challenging to treat the tics without either possibly making the other disorder worse, or wasting time and not changing anything at all. For example, Eddy et. al. talk about the difficulty in treating a patient who has ADHD in addition to Tourette’s (2011). With ADHD, the patient has a high likelihood of forgetting to partake in the treatment method outside of the doctors office or professional setting with their behavior analyst or psychologist, whether it is habit reversal at home or taking medications.