TOURETTE’S DISORDER

•Do you know what is Tourette’s Disorder?•Do you know anyone with this disorder?

Origin of the Disorder LabelOrigin of the Disorder Label

• Itard – Physician in 1825– Observed client with tics & copralalia

• Gilles de la Tourette– Physician in 1885– Wrote first detailed reports on disorder

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TOURETTE SYNDROME• a physical disorder of the brain which causes involuntary

movements (motor tics) and involuntary vocalizations (vocal tics)

• Prevalence: 1 in 2,500 people in US• Boys outnumber girls 3 to 1• Tics

– begin before age 21 (typically around age 7)– change in location, frequency, severity– last a lifetime– must be present for at least a year for diagnosis– other symptoms may also be present

TICS MOVEMENTS

• Tics are involuntary, sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations.

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EXAMPLES OF TICS

• MOTOR: Simple:blinking eyesjerking neckshrugging shouldersflipping headkickingtensing musclessticking tongue outfinger movements

• MOTOR: Complex:facial gestures (eye rolling)grooming behaviorssmelling thingstouchingjumpinghittingbitingechopraxia copropraxiaself-injurious behaviors

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EXAMPLES OF TICS

• VOCAL: Simple:throat-clearingsniffingcoughinggruntingspittingyellingbelching

• VOCAL: Complex:animal soundsrepeating words or phrases

out of contextcoprolalia palilaliaecholalia

• Coprolalia is the use of obscene words or phrases.

• Echolalia is the repetition of the last-heard words of others.

• Palilalia is the repetition of one’s own words.

4 TYPES OF TIC DISORDERS

• Tourette’s Disorder• Transient Tic Disorder• Chronic Motor or Vocal Tic Disorders• Tic Disorder not otherwise specified.

Excitation or Inhibition?Brain Region?Neurotransmitters?Nature or Nurture?

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WARNING SIGNS

• Most develop – eye tic first– facial tics or involuntary sounds– others within weeks or months

• common examples: head jerks, grimaces, hand-to-face movements• Symptoms can:

– change over time– vary (frequency, type, or intensity)– increase in intensity during early adolescence (12-15)– improve in less extreme cases during adulthood

• Tourette’s Disorder was 1st decribed in a patient in 1885 by George Gilles de la Tourette.

• He noted several similar symptoms among several patients and these symptoms included multiple motor tics, coprolia, palilalia, and echolalia.

PREVALENCE

• The lifetime prevalence of Tourette’s Disorder is estimated to be 4 to 5 persons per 10,000 people.

AGE GROUP

• This disorder occurs by the age 7 and vocal tics emerge at age 11.

• This disorder occurs about 3 times more often in boys than girls.

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Children’s Quotes

• “I was devastated when I found out I had TS. I thought I was going to be a normal boy. But I’m not. My life is awful. I feel like I’m missing out on a lot of things because of my tics. I will feel a lot better if my tics go. If they don’t I will learn to put up with them.” (Neil, 9yrs)

• “I used to get asked why I blinked all the time and everyone used to get angry at me because I couldn’t help looking at them and I always get harassed.”

• “My teacher treats me like an angel and manages my TS really well. The other students try to be understanding as my teacher has told them all about TS.” (Neil, 9yrs)

• Lyle who is 9 years has Aspergergs and TS, and says he feels like he’s in prison when he is at school.

DISORDER ASSOCIATION

• There’s a relation between Tourette’s disorder, ADHD( attention deficit hyperactivity disorder) and OCD (Obsessive Compulsive Disorder).

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Symptoms

• Obsessions (thoughts)

• Compulsions (actions and rituals)

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COMPULSIONS OR RITUALS:• Placing objects just right• Touching things• Rechecking• Smelling• Licking• Erasing• Writing and rewriting letters until perfect• Washing hands repeatedlyOBSESSIVE THOUGHTS:• Mental echolalia Sexual thoughts• Obscene thoughts Thinking about forbidden actions• Counting or grouping Fear of hurting someone

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CO-OCCURRENCE

• 50% HAVE OCD SYMPTOMS• 50% HAVE ADD• 25-35% HAVE TANTRUMS AND AGGRESSION• 33% HAVE SLD

• 40% of all Tourett’es disorder patients also have OCD.

Excitation or Inhibition?Brain Region?Neurotransmitters?Nature or Nurture?

• Stuttering– abnormal breathing

pattern– embarrassing physical

characteristics– can substitute more

acceptable speech patterns

– support groups– periods of fluency

• Tourette’s–abnormal

breathing pattern–embarrassing tics

–can substitute more acceptable tics

–support groups–tic free periods

subgroup of Touretters who stutter, and stutterers with Tourette’s

CRITERIA FOR TOURETTE’S DISORDER

• Multiple motor tics and one or more vocal tics have been present at some time during the illness

• Tics occur many times a day, nearly everyday or throughout a period of more than 1 year and they are never tic-free for more than 3 months

• The onset is before the age of 18 years

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DSM-IV• onset before age 18• person has both multiple motor and one or more verbal tics • tics occur many times a day (usually in clusters), nearly every day

or intermittently for more than a year--------------------------

CRITERIA

• The disturbance is not due to the direct physiological effects of a substance or a general medical condition.

» DSM-IV

TREATMENTS

• Pharmacological treatments are most effective for Tourette’s disorder, but patients with mild cases may not require medications.

Psychotherapy will help patients cope with the symptoms, personality, and behavioral tendencies; however, it is ineffective as a primary treatment.

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Facts• Tics can worsen with the use of caffeinated

beverages, cough syrup, recreational drugs and diet medication

• Identical twins, whose genes are identical, may have tics that differ in the intensity and frequency. This means that non-genetic factors underlie these differences.

(Neuroscience for Kids-Tourette Syndrome.)

Excitation or Inhibition?Brain Region?Neurotransmitters?Nature or Nurture?

SOCIALIZATION

• Children with Tourette’s disorder or any tic disorder can be socially strained.

• Severe social, academics, and vocational consequences can reap havoc on a child’s social life.

• Socialization can be damaged so severe that suicide is contemplated in some cases.

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Academics• Normal levels of

intelligence• Personal distress• Low self esteem &

social problems• School failure• Tics can make simple

routine activities difficult - ex. reading & writing

• Cause anxiety

• Involuntary multiple motor and vocal tics

• Obsessive compulsive tendencies

• Short attention span / ADD

• High anxiety• Learning disabilities

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Treatment Strategies

• Provide access to a private room for tension and tic release

• Offer short breaks• Break long assignments into

smaller parts• Allow movement around the

room• Have a rest/safe area- Ex.

bean bag chair• Try to ignore tic behaviors

that are not seriously disruptive

(Wilson, Jeni. Shrimpton, Bradely. Planning Learning for students with Tourette Syndrome. Student Disability Conference, 2003).

• Modify abusive vocal tic patterns

• Modify socially inappropriate or disruptive vocal tics / noises

• Monitor expressive suprasegmentals

• Monitor receptive language development and processing (LLD)

• Teach good vocal hygiene habits

PROGNOSIS

• Tourette’s disorder is usually a chronic, lifelong disease with relative remissions and exacerbations.

• Initial symptoms may decrease, persist, or increase, and old symptoms may be replaced by new ones.

PROGNOSIS

• Severely afflicted persons may have serious emotional problems, including major depressive disorder.

• Some of these difficulties appear to be associated with Tourette’s disorder.

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Etiology

• Theories or explanations of causes

FACTS OF INTERESTFACTS OF INTEREST

• Genetic predisposition– autosomal (non-sex chromosome) dominant– male has 99% chance; female has 70% chance

• Incidence– 1 in 2,500– 3 to 1 male/female

• Characteristics fluctuate over time• Onset before age 18; average 7 years

Linkage AnalysisLinkage Analysis• Somatic cells contain paired chromosomes, one

from each parent• At gamete formation, paired chromosomes coil

around each other and exchange material• Portions of DNA close together tend to be inherited

together• Many genes take same form in everyone• Some genes have several different versions (alleles)• Noncoding “junk” DNA can vary considerably

between people; can be genetic marker to identify parent DNA

• Genetic investigations have supported the role of both dopamine D4 receptor gene (DRD4) and dopamine transporter gene (DAT1) in the vulnerability to the disorder.

• The DRD4 gene has been postulated as a candidate gene for attention-deficit-hyperactivity disorder

– Lower DA binding in basal ganglia

– Increased DA transport in frontal lobes

Dopamine• Up to 40% of OCD patients do not respond to SSRIs• Cocaine worsens compulsions in Tourette syndrome• Family studies show OCD and Tourettes are linked

leading • Use of older antipsychotics that block DA receptors

added to ongoing SSRI reduces severity of symptoms in resistant clients (especially those with Tourettes)

genesbrainstructure

behaviour learning feeling

conduct- dyslexia anxiety

disorder dyscalculia depression

ADHD Autism

TD

Etc …..

Chemistry : noradrenaline, serotonine, etc

• Tourettes: believed to be caused by abnormally high dopamine levels in some part of brain

MEDICATIONS

• Haloperidol is the most frequently prescribed drug for Tourette’s disorder.

• As many as 70 to 90% of patient’s symptoms decrease with this drug and this drug is used on 80% of the patients.

Tourettes = conventional antipsychotics and SSRIs

Haloperidol–somewhat effective–strange side effects:halucinations

SUMMARY COMMENTSSUMMARY COMMENTS

• Tourette’s Syndrome difficult to diagnose due to variability of symptoms

• Primary intervention in pharmacological treatment; not always accepted by adults due to side effects

• Can have significant social, emotional, vocational impact

• Team approach with SLP as member

Responsibility to Tourette’s patients

• Clinicians should prescribe the proper diagnosis and prognosis to the patient with Touette’s disorder.

• Parents should ensure that their child receive proper care for this disorder.

• Parents should have open communication with the child(ren) to know what he/she is feeling.