Tourette syndrome

Tourette syndrome
Classifications and external resources
Georges Gilles de la Tourette (1859 – 1904)
ICD-10 F95.2
ICD-9 307.23
OMIM 137580
DiseasesDB 5220
MedlinePlus 000733
eMedicine med/3107  neuro/664

Tourette syndrome (also called Tourette's syndrome, Tourette's disorder, Gilles de la Tourette syndrome, GTS or the more common Tourette's or TS) is an inherited neurological disorder with onset in childhood, characterized by the presence of multiple physical (motor) tics and at least one vocal (phonic) tic; these tics characteristically wax and wane. Tourette's is defined as part of a spectrum of tic disorders, which includes transient and chronic tics.

Tourette's was once considered a rare and bizarre syndrome, most often associated with the exclamation of obscene words or socially inappropriate and derogatory remarks (coprolalia). However, this symptom is present in only a small minority of people with Tourette's.[1] Tourette's is no longer considered a rare condition, but it may not always be correctly identified because most cases are classified as mild. Since the incidence may be as high as one in a hundred people, up to 530,000 U.S. school-age children may have Tourette's,[2] with the more common tics of eye blinking, coughing, throat clearing, sniffing, and facial movements. People with Tourette's have normal life expectancy and intelligence. The severity of the tics decreases for most children as they pass through adolescence, and extreme Tourette's in adulthood is a rarity. Notable individuals with Tourette's are found in all walks of life.[3]

Genetic and environmental factors each play a role in the etiology of Tourette's, but the exact causes are unknown. In most cases, medication is unnecessary. There is no effective medication for every case of tics, but there are medications and therapies that can help when their use is warranted. Explanation and reassurance alone are often sufficient treatment;[4] education is an important part of any treatment plan.[5]

The eponym was bestowed by Jean-Martin Charcot (1825–93) on behalf of his resident, Georges Albert Édouard Brutus Gilles de la Tourette (1859–1904), a French physician and neurologist, who published an account of nine patients with Tourette's in 1885.




Tics are sudden, repetitive, stereotyped, nonrhythmic, involuntary movements (motor tics) and utterances (phonic tics) that involve discrete muscle groups.[6] Motor tics are movement-based tics, while phonic tics are involuntary sounds produced by moving air through the nose, mouth, or throat.

Tourette's is one of several tic disorders, which are classified by the Diagnostic and Statistical Manual of Mental Disorders (DSM) according to type (motor or phonic tics) and duration (transient or chronic). Transient tic disorder consists of multiple motor tics, phonic tics or both, with a duration of between four weeks and twelve months. Chronic tic disorder is either single or multiple, motor or phonic tics (but not both), which are present for more than a year.[6] Tourette's is diagnosed when multiple motor tics, and at least one phonic tic, are present for more than a year.[7] Tic disorders are defined similarly by the World Health Organization (ICD-10 codes).[8]

Although Tourette's is the more severe expression of the spectrum of tic disorders,[9] most cases are mild.[10] The severity of symptoms varies widely among people with Tourette's, and mild cases may be undetected.[6]



Tics are movements or sounds "that occur intermittently and unpredictably out of a background of normal motor activity",[11] having the appearance of "normal behaviors gone wrong."[12] The tics associated with Tourette's constantly change in number, frequency, severity and anatomical location. Waxing and waning—the ongoing increase and decrease in severity and frequency of tics—occurs differently in each individual. Tics also occur in "bouts of bouts", which vary for each person.[6]

Coprolalia (the spontaneous utterance of socially objectionable or taboo words or phrases) is the most publicized symptom of Tourette's, but it is not required for a diagnosis of Tourette's. According to the Tourette Syndrome Association, fewer than 15% of Tourette's patients exhibit coprolalia.[13] Echolalia (repeating the words of others) and palilalia (repeating one's own words) occur in a minority of cases,[6] while the most common initial motor and vocal tics are, respectively, eye blinking and throat clearing.[14]

Video clips of tics
HBO documentary video clip
CBS News video clip
News10 video clip

In contrast to the stereotyped movements of other movement disorders (e.g. choreas, dystonias, myoclonus, and dyskinesias), the tics of Tourette's are temporarily suppressible and preceded by a premonitory urge.[15] Immediately preceding tic onset, most individuals with Tourette's are aware of an urge[16] that is similar to the need to sneeze or scratch an itch. Individuals describe the need to tic as a buildup of tension[17] which they consciously choose to release, as if they "had to do it".[18] Examples of the premonitory urge are the feeling of having something in one's throat, or a localized discomfort in the shoulders, leading to the need to clear one's throat or shrug the shoulders. The actual tic may be felt as relieving this tension or sensation, similar to scratching an itch. Another example is blinking to relieve an uncomfortable sensation in the eye. These urges and sensations, preceding the expression of the movement or vocalization as a tic, are referred to as "premonitory sensory phenomena". Published descriptions of the tics of Tourette's identify sensory phenomena as the core symptom of the syndrome, even though they are not included in the diagnostic criteria.[19][20]

Tics are described as semi-voluntary or "unvoluntary",[11] because they are not strictly involuntary—they may be experienced as a voluntary response to the unwanted, premonitory urge. A unique aspect of tics, relative to other movement disorders, is that they are suppressible yet irresistible;[12] they are experienced as an irresistible urge that must eventually be expressed.[11] People with Tourette's are sometimes able to suppress their tics to some extent for limited periods of time, but doing so often results in an explosion of tics afterward.[4] People with Tourette's may seek a secluded spot to release their symptoms, or there may be a marked increase in tics, after a period of suppression at school or at work.[12]

Some people with Tourette's may not be aware of the premonitory urge. Children may be less aware of the premonitory urge associated with tics than are adults, but their awareness tends to increase with maturity.[11] They may have tics for several years before becoming aware of premonitory urges. Children may suppress tics while in the doctor's office, so they may need to be observed while they are not aware they are being watched.[21] The ability to suppress tics varies among individuals, and may be more developed in adults than children.

Although there is no such thing as a "typical" case of Tourette syndrome,[4] the condition follows a fairly reliable course in terms of the age of onset and the history of the severity of symptoms. Tics may appear up to the age of eighteen, but the most typical age of onset is from five to seven.[6] The ages of highest tic severity are eight to twelve (average ten), with tics steadily declining for most patients as they pass through adolescence.[22] The most common, first-presenting tics are eye blinking, facial movements, sniffing and throat clearing. Initial tics present most frequently in midline body regions where there are many muscles, usually the head, neck and facial region.[4] This can be contrasted with the stereotyped movements of other disorders (such as stims and stereotypies of the autism spectrum disorders), which typically have an earlier age of onset, are more symmetrical, rhythmical and bilateral, and involve the extremities (e.g., flapping the hands).[23] Tics that appear early in the course of the condition are frequently confused with other conditions, such as allergies, asthma, and vision problems: pediatricians, allergists and ophthalmologists are typically the first to see a child with tics.[6]

Among patients whose symptoms are severe enough to warrant referral to clinics, obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD) are often associated with Tourette's. Not all persons with Tourette's have ADHD or OCD or other comorbid conditions (co-occurring diagnoses other than Tourette's), although in clinical populations, a high percentage of patients presenting for care do have ADHD.[24] One author reports that a ten-year overview of patient records revealed about 40% of patients with Tourette's have "TS-only" or "pure TS", referring to Tourette syndrome in the absence of ADHD, OCD and other disorders.[25] Another author reports that 57% of 656 patients presenting with tic disorders had uncomplicated tics, while 43% had tics plus comorbid conditions.[12] "Full-blown Tourette's" is a term used to describe patients who have significant comorbid conditions in addition to tics.[12]



The exact cause of Tourette's is unknown, but it is well established that both genetic and environmental factors are involved.[26] Genetic studies have proved that the overwhelming majority of cases of Tourette's are inherited, although the exact mode of inheritance is not yet known,[27] and no gene has been identified.[4] In some cases, tics may not be inherited; these cases are identified as "sporadic" Tourette syndrome (also known as tourettism) because a genetic link is missing.[28]

Brain structures implicated in Tourette's syndrome
Brain structures implicated in Tourette's syndrome

A person with Tourette's has about a 50% chance of passing the gene(s) to one of his or her children, but Tourette's is a condition of variable expression and incomplete penetrance.[29] Thus, not everyone who inherits the genetic vulnerability will show symptoms; even close family members may show different severities of symptoms, or no symptoms at all. The gene(s) may express as Tourette's, as a milder tic disorder (transient or chronic tics), or as obsessive compulsive symptoms without tics. Only a minority of the children who inherit the gene(s) have symptoms severe enough to require medical attention.[13] Gender appears to have a role in the expression of the genetic vulnerability; males are more likely than females to express tics.[21]

Non-genetic, environmental, infectious, or psychosocial factors—while not causing Tourette's—can influence its severity.[4] Autoimmune processes may affect tic onset and exacerbation in some cases. The unproven and contentious hypothesis that Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS) plays a role in the onset of tic disorders and OCD is a current focus of research.[30][31]

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.[26] Neuroanatomic models implicate failures in circuits connecting the brain's cortex and subcortex,[4] and imaging techniques implicate the basal ganglia and frontal cortex.[32]

Some forms of OCD may be genetically linked to Tourette's.[33] A subset of OCD is thought to be etiologically related to Tourette's and may be a different expression of the same factors that are important for the expression of tics.[34] The genetic relationship of ADHD to Tourette syndrome, however, has not been fully established.[25]



According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), Tourette’s Disorder may be diagnosed when a person exhibits both multiple motor and one or more vocal tics (although these do not need to be concurrent) over the period of a year, with no more than three consecutive tic-free months. Previous editions of the DSM included a requirement for "marked distress or significant impairment in social, occupational or other important areas of functioning", but this requirement was removed in the most recent update of the manual, in recognition that clinicians see patients who meet all the other criterion for Tourette's, but do not have distress or impairment.[6] The onset must have occurred before the age of 18, and cannot be attributed to the "direct physiological effects of a substance or a general medical condition".[7] Hence, other medical conditions that include tics or tic-like movements—such as autism or other causes of tourettism—must be ruled out before conferring a Tourette's diagnosis.

There are no specific medical or screening tests that can be used in diagnosing Tourette's.[6] The diagnosis is made based on observation of the individual's symptoms and family history, and after ruling out secondary causes of tic disorders.[13] In patients with a typical onset and a family history of tics or obsessive–compulsive disorder, a basic physical and neurological examination may be sufficient.[9]

If a physician believes that there may be another condition present that could explain tics, tests may be ordered as necessary to rule out that condition. An example of this is when diagnostic confusion between tics and seizure activity exists, which would call for an EEG, or if there are symptoms that indicate an MRI to rule out brain abnormalities.[35] TSH levels can be measured to rule out hypothyroidism, which can be a cause of tics. Brain imaging studies are not usually warranted.[35] In teenagers and adults presenting with a sudden onset of tics and other behavioral symptoms, a urine drug screen for cocaine and stimulants might be necessary. If a family history of liver disease is present, serum copper and ceruloplasmin levels can rule out Wilson's disease.[9] However, most cases are diagnosed by merely observing a history of tics.[4][13]

Secondary causes of tics (not related to inherited Tourette syndrome) are commonly referred to as tourettism.[28] Dystonias, choreas, other genetic conditions, and secondary causes of tics should be ruled out in the differential diagnosis for Tourette syndrome.[9] Other conditions that may manifest tics or stereotyped movements include developmental disorders, autism spectrum disorders,[36] and stereotypic movement disorder;[37][38] other genetic conditions such as Huntington's disease, neuroacanthocytosis, Hallervorden-Spatz syndrome, idiopathic dystonia, Duchenne muscular dystrophy, Wilson's disease, Sydenham's chorea and tuberous sclerosis. Other possibilities include chromosomal disorders such as Down syndrome, Klinefelter's syndrome, XYY syndrome and fragile X syndrome. Acquired causes of tics include drug-induced tics, head trauma, encephalitis, stroke, and carbon monoxide poisoning.[9][28] The symptoms of Lesch-Nyhan syndrome may also be confused with Tourette syndrome.[23] Most of these conditions are rarer than tic disorders, and a thorough history and examination may be enough to rule them out, without medical or screening tests.[4]



Although not all people with Tourette's have comorbid conditions, most Tourette's patients presenting for clinical care at specialty referral centers may exhibit symptoms of other conditions along with their motor and phonic tics.[25] Associated conditions include attention-deficit hyperactivity disorder (ADD or ADHD), obsessive–compulsive disorder (OCD), learning disabilities and sleep disorders.[39] Disruptive behaviors, impaired functioning, or cognitive impairment in patients with comorbid Tourette's and ADHD may be accounted for by the comorbid ADHD, highlighting the importance of identifying and treating comorbid conditions.[24][40] Disruption from tics is commonly overshadowed by comorbid conditions that present greater interference to the child.[4] Tic disorders in the absence of ADHD do not appear to be associated with disruptive behavior or functional impairment,[2] while impairment in school, family, or peer relations is greater in patients who have more comorbid conditions and often determines whether therapy is needed.[12]

Because comorbid conditions such as OCD and ADHD can be more impairing than tics, these conditions are included in an evaluation of patients presenting with tics. "It is critical to note that the comorbid conditions may determine functional status more strongly than the tic disorder."[4] The initial assessment of a patient referred for a tic disorder should include a thorough evaluation, including a family history of tics, ADHD, obsessive–compulsive symptoms, and other chronic medical, psychiatric and neurological conditions. Children and adolescents with TS who have learning difficulties are candidates for psychoeducational testing, particularly if the child also has ADHD.[35] Undiagnosed comorbid conditions may result in functional impairment, and it is necessary to identify and treat these conditions to improve functioning. Complications may include depression, sleep problems, social discomfort and self-injury.[9]



Clonidine (or the clonidine patch) is one of the medications typically tried first when medication is needed for Tourette's.
Clonidine (or the clonidine patch) is one of the medications typically tried first when medication is needed for Tourette's.

The treatment of Tourette's focuses on identifying and helping the individual manage the most troubling or impairing symptoms.[4] Most cases of Tourette's are mild, and do not require pharmacological treatment;[10] instead, psychobehavioral therapy, education, and reassurance may be sufficient.[41] Treatments, where warranted, can be divided into those that target tics and comorbid conditions, which, when present, are often a larger source of impairment than the tics themselves.[35] Not all people with tics have comorbid conditions,[25] but when those conditions are present, they often take treatment priority.

There is no cure for Tourette's and no medication that works universally for all individuals without significant adverse effects. Knowledge, education and understanding are uppermost in management plans for tic disorders.[4] The management of the symptoms of Tourette's may include pharmacological, behavioral and psychological therapies. While pharmacological intervention is reserved for more severe symptoms, other treatments (such as supportive psychotherapy or cognitive behavioral therapy) may help to avoid or ameliorate depression and social isolation, and to improve family support. Educating a patient, family, and surrounding community (such as friends, school, and church) is a key treatment strategy.[4]

Space-filling representation of a haloperidol molecule. Haloperidol is an antipsychotic medication sometimes used to treat severe cases of Tourette's.
Space-filling representation of a haloperidol molecule. Haloperidol is an antipsychotic medication sometimes used to treat severe cases of Tourette's.

Medication is available to help when symptoms interfere with functioning.[13] The classes of medication with the most proven efficacy in treating tics—typical and atypical neuroleptics including risperidone (trade name[42] Risperdal), ziprasidone (Geodon), haloperidol (Haldol), pimozide (Orap) and fluphenazine (Prolixin)—can have long-term and short-term adverse effects.[35] The antihypertensive agents clonidine (trade name Catapres) and guanfacine (Tenex) are also used to treat tics; studies show variable efficacy, but a lower side effect profile than the neuroleptics.[1] Stimulants and other medications may be useful in treating ADHD when it co-occurs with tic disorders. Drugs from several other classes of medications can be used when stimulant trials fail, including guanfacine (trade name Tenex), atomoxetine (Strattera) and tricyclics. Clomipramine (Anafranil), a tricyclic antidepressant, and SSRIs—a class of antidepressants including fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox)—may be prescribed when a Tourette's patient also has symptoms of obsessive–compulsive disorder.[35]

Because children with tics often present to physicians when their tics are most severe, and because of the waxing and waning nature of tics, it is recommended that medication not be started immediately or changed often.[4] Frequently, the tics subside with explanation, reassurance, understanding of the condition and a supportive environment.[4] When medication is used, the goal is not to eliminate symptoms: it should be used at the lowest possible dose that manages symptoms without adverse effects, given that these may be more disturbing than the symptoms for which they were prescribed.[4]

Cognitive behavioral therapy (CBT) is a useful treatment when OCD is present,[43] and there is increasing evidence supporting the use of habit reversal in the treatment of tics.[44] Relaxation techniques, such as exercise, yoga or meditation, may be useful in relieving the stress that may aggravate tics, but the majority of behavioral interventions (such as relaxation training and biofeedback, with the exception of habit reversal) have not been systematically evaluated and are not empirically supported therapies for Tourette's.[45]



Samuel Johnson (1709 – 1784) circa 1772. Johnson wrote A Dictionary of the English Language in 1747, and was a prolific writer, poet, and critic who had Tourette syndrome.
Samuel Johnson (1709 – 1784) circa 1772. Johnson wrote A Dictionary of the English Language in 1747, and was a prolific writer, poet, and critic who had Tourette syndrome.

Tourette syndrome is a spectrum disorder—its severity ranges over a spectrum from mild to severe. The majority of cases are mild and require no treatment.[10] 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 have severe symptoms that persist into adulthood.[26] A study of 46 subjects at 19 years of age found that the symptoms of 80% had minimum to mild impact on their overall functioning, and that the other 20% experienced at least a moderate impact on their overall functioning.[6] The rare minority of severe cases can inhibit or prevent individuals from holding a job or having a fulfilling social life. In a follow-up study of thirty-one adults with Tourette's, all patients completed high school, 52% finished at least two years of college, and 71% were full-time employed or were pursuing higher education.[46]

Regardless of symptom severity, individuals with Tourette's can expect to live 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.[13] 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".[13]

Several studies have demonstrated that the condition in most children improves with maturity. Tics may be at their highest severity at the time that they are diagnosed, and often improve with understanding of the condition by individuals and their families and friends. The statistical age of highest tic severity is typically between eight and twelve, with most individuals experiencing steadily declining tic severity as they pass through adolescence. One study showed no correlation with tic severity and the onset of puberty, in contrast with the popular belief that tics increase at puberty. In many cases, a complete remission of tic symptoms occurs after adolescence.[22][47] However, a study using videotape to record tics in adults found that, although tics diminished in comparison with childhood, and all measures of tic severity improved by adulthood, 90% of adults still had tics. Half of the adults who considered themselves tic-free still displayed evidence of tics.[46]

It is not uncommon for the parents of affected children to be unaware that they, too, may have had tics as children. Because Tourette's tends to subside with maturity, and because milder cases of Tourette's are now more likely to be recognized, the first realization that a parent had tics as a child may not come until their offspring is diagnosed. It is not uncommon for several members of a family to be diagnosed together, as parents bringing children to a physician for an evaluation of tics become aware that they, too, had tics as a child.

Children with Tourette's may suffer socially if their tics are viewed as "bizarre". If a child has disabling tics, or tics that interfere with social or academic functioning, supportive psychotherapy or school accommodations can be helpful.[13] Because comorbid conditions (such as ADHD or OCD) can cause greater impact on overall functioning than tics, a thorough evaluation for comorbidity is called for when symptoms and impairment warrant.[9]

A supportive environment and family generally gives those with Tourette's the skills to manage the disorder.[48][49] 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. A person who was misunderstood, punished, or teased at home or at school will fare worse than children who enjoyed an understanding and supportive environment.[6]

A controlled study on a small group of individuals with Tourette's found that young people with the syndrome have greater cognitive control over movements than their age-matched controls, possibly because the need to suppress tics results in a more efficient control over inhibitory movements, a skill that confers an advantage when switching between tasks. Children with Tourette's (in the absence of comorbid ADHD) performed more accurately on a goal-oriented eye-movement task, requiring active inhibition of automatic eye movements, and they made fewer errors than their unaffected peers, suggesting compensatory changes in the brain resulting in greater cognitive control.[50]



Tourette syndrome has historically been described as a rare disorder, with about 5 to 10 people in 10,000 having the condition.[4][9] However, multiple studies published since 2000 demonstrate that the prevalence is much higher than previously thought, and that Tourette syndrome can no longer be considered rare. Contemporary prevalence estimates range from 1 to 3 per 1,000[51] to 10 per 1,000;[52] the latter yields an estimate of 530,000 school-age children with Tourette's in the United States, based on 2000 US census data.[2]

A large, community-based study suggested that over 19% of school-age children have tics, with almost 4% of children in regular education fulfilling the diagnostic criteria for Tourette syndrome. The children with tic disorders in that study were usually undiagnosed.[53] As many as 1 in 100 people may experience some form of tic disorder, which includes transient tics, chronic tics, or Tourette syndrome.[39] Tourette syndrome is found among all social, racial and ethnic groups,[39][54] and males are affected 3 to 4 times more often than females.[4]

Tourette syndrome is frequently misdiagnosed or underdiagnosed, partly because of the wide expression of severity, ranging from mild (the majority of cases) or moderate, to severe (the rare, but more widely-recognized and publicized cases). Because the tics of Tourette syndrome tend to remit or subside with maturity, such that a diagnosis may no longer be warranted for many adults, prevalence rates in pediatric populations are higher than those in adult populations.[22]

Mild cases of Tourette syndrome are less likely to come to tertiary or clinical attention, raising the possibility of ascertainment bias in referred populations. There are few broad-based population studies, and most older epidemiological studies of Tourette's were based on individuals referred to specialty clinics.[1][55] Children with milder symptoms are not likely to be referred to specialty clinics, so most studies of Tourette's patients have an inherent bias towards more severe cases.[1][56] Epidemiologic methods are vulnerable to errors, because of the variance in symptom severity and because symptoms are not always recognized by the patient or family.[57]


History and research directions

Jean-Martin Charcot (1825 - 1893) was a French neurologist and professor who bestowed the eponym for Tourette syndrome on behalf of his resident, Georges Albert Édouard Brutus Gilles de la Tourette.  Charcot is shown here during a lesson with a "hysterical" woman patient at the Salpêtrière hospital.
Jean-Martin Charcot (1825 - 1893) was a French neurologist and professor who bestowed the eponym for Tourette syndrome on behalf of his resident, Georges Albert Édouard Brutus Gilles de la Tourette. Charcot is shown here during a lesson with a "hysterical" woman patient at the Salpêtrière hospital.

A thorough history of Tourette syndrome is published in Kushner's A Cursing Brain? : The Histories of Tourette Syndrome.[58] A French doctor, Jean Marc Gaspard Itard, reported the first case of Tourette syndrome in 1825,[59] describing Marquise de Dampierre, an important woman of nobility in her time.[10] Jean-Martin Charcot, an influential French physician, assigned his resident Georges Albert Édouard Brutus Gilles de la Tourette, a French physician and neurologist, to study patients at the Salpêtrière Hospital, with the goal of defining an illness distinct from hysteria and from chorea.[21]

In 1885, Gilles de la Tourette published an account of nine patients, Study of a Nervous Affliction, concluding that a new clinical category should be defined.[60] The eponym was later bestowed by Charcot after and on behalf of Gilles de la Tourette.[21][61]

Little progress was made over the next century in explaining or treating tics, and a psychogenic view prevailed well into the 20th century.[21] The possibility that movement disorders, including Tourette syndrome, might have an organic origin was raised when an encephalitis epidemic from 1918-1926 led to a subsequent epidemic of tic disorders.[62]

During the 1960s and 1970s, as the beneficial effects of haloperidol (Haldol) on tics became known, the psychoanalytic approach to Tourette syndrome was questioned.[63] The turning point came in 1965, when Dr. Arthur K. Shapiro—described as "the father of modern tic disorder research"[64]—treated a Tourette’s patient with haloperidol, and published a paper criticizing the psychoanalytic approach.[62]

Since the 1990s, a more neutral view of Tourette's has emerged, in which biological vulnerability and adverse environmental events are seen to interact.[4][21] In 2000, the American Psychiatric Association published the DSM-IV-TR, revising the text of DSM-IV to no longer require that symptoms of tic disorders cause distress or impair functioning.[65]

Findings since 1999 have advanced TS science in the areas of genetics, neuroimaging, neurophysiology, and neuropathology. Questions remain regarding how best to classify Tourette syndrome, and how closely Tourette's is related to other movement disorders or psychiatric disorders. Good epidemiologic data is still lacking, and available treatments are not risk free and not always well tolerated.[66] High-profile media coverage focuses on treatments that do not have established safety or efficacy e.g., deep brain stimulation, and alternative therapies involving unstudied efficacy and side effects are pursued by many parents.[30]


Social impact and notable cases

Discussions with adults who have Tourette's reveal that not everyone wants treatment or a "cure", especially if that means they may "lose" something else in the process.[67][68] Some people believe that there may be latent advantages associated with genetic vulnerability to the syndrome.[68] Cognitive control may be enhanced in young people with Tourette's because the need to suppress tics results in a more efficient control of inhibitions.[69] There is evidence to support the clinical lore that children with "TS-only" (Tourette's in the absence of comorbid conditions) are unusually gifted: neuropsychological studies have identified advantages in children with TS-only.[25][70] One study found that children with TS-only are faster than the average for their age group on timed motor coordination.[71]

Wolfgang Amadeus Mozart in 1777, aged twenty-one.  Speculation that he may have had Tourette's is not based on reliable evidence.
Wolfgang Amadeus Mozart in 1777, aged twenty-one. Speculation that he may have had Tourette's is not based on reliable evidence.

Notable individuals with Tourette syndrome are found in all walks of life, including musicians, athletes and authors. The best-known example of a person who may have used obsessive–compulsive traits to advantage is Dr Samuel Johnson, the 18th-century English man of letters, who had Tourette syndrome as clearly evidenced by the writings of James Boswell.[72] Johnson wrote A Dictionary of the English Language in 1747, and was a prolific writer, poet, and critic.

Some authors have speculated that Mozart may have had Tourette's. Benjamin Simkin, a medical doctor, argued that Mozart had Tourette syndrome.[73][74] Simkin is an endocrinologist[73]—not a psychiatrist or a neurologist, the medical fields which specialize in the neurological disorder. His claim was picked up by newspapers worldwide, causing an international sensation, and internet websites have fueled the speculation.[75] However, no Tourette's expert or organization has presented credible evidence to show that this was the case,[75] and noted neurologist and author Oliver Sacks published an editorial disputing Simkin's claim.[76]

The entertainment industry often depicts those with Tourette syndrome as social misfits whose only tic is coprolalia, which has furthered stigmatization and the public's misunderstanding of those with Tourette's.[77] The coprolalic symptoms of Tourette's are also fodder for radio and television talk shows such as Dr. Phil and Garrison Keillor's Prairie Home Companion;[78] the British media has profiled two people with coprolalia — Pete Bennett of Big Brother and John Davidson of BBC documentaries John's Not Mad (1989) and The Boy Can't Help It (2000).[79]


See also

Topics related to Tourette syndrome
Main Causes and origins | Sociological and cultural aspects | Treatment
Terms Coprolalia | Copropraxia | Echolalia | Echopraxia | Palilalia | Sensory phenomena |Tic | Tic disorder | Tourettism
History Jean-Martin Charcot | Georges Gilles de la Tourette | Jean Marc Gaspard Itard | Arthur K. Shapiro
Organizations Tourette Syndrome Association | Tourette Syndrome Foundation of Canada
Media I Have Tourette's But Tourette's Doesn't Have Me | John's Not Mad
Notable people Mahmoud Abdul-Rauf |Howard Ahmanson, Jr | Brad Cohen | Jim Eisenreich | Tim Howard | Samuel Johnson | Andre Malraux | Tobias Picker | Michael Wolff


  1. 1.0 1.1 1.2 1.3 Schapiro NA. "Dude, you don't have Tourette's": Tourette's syndrome, beyond the tics. Pediatr Nurs. 2002 May-Jun;28(3):243-6, 249-53. PMID 12087644
  2. 2.0 2.1 2.2 Scahill L, Williams S, Schwab-Stone M, Applegate J, Leckman JF. Disruptive behavior problems in a community sample of children with tic disorders. Adv Neurol. 2006;99:184-90. PMID 16536365
  3. Tourette Syndrome Association. Portraits of adults with TS. Accessed online 4 January 2007.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 Zinner SH. Tourette disorder. Pediatr Rev. 2000;21(11):372. PMID 11077021
  5. Peterson BS, Cohen DJ. The Treatment of Tourette's Syndrome: Multimodal, Developmental Intervention. Presented at a closed symposium held in New Orleans, Louisiana on April 12, 1996. No longer online at "Because of the understanding and hope that it provides, education is also the single most important treatment modality that we have in TS."
  6. 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 Leckman JF, Bloch MH, King RA, Scahill L. Phenomenology of tics and natural history of tic disorders. Adv Neurol. 2006;99:1–16. PMID 16536348
  7. 7.0 7.1 Behavenet. Tourette's disorder. Accessed 10 Mar 2005.
  8. World Health Organization. ICD Version 2006. Accessed 25 October 2006.
  9. 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Bagheri MM, Kerbeshian J, Burd L. Recognition and management of Tourette's syndrome and tic disorders. Am Fam Physician. 1999; 59:2263–74. PMID 10221310Full text, Accessed 28 October 2006.
  10. 10.0 10.1 10.2 10.3 Tourette Syndrome Association. What is Tourette syndrome? Accessed 24 May 2006.
  11. 11.0 11.1 11.2 11.3 The Tourette Syndrome Classification Study Group. Definitions and classification of tic disorders. Arch Neurol. 1993 Oct;50(10):1013-16. PMID 8215958 Full text, Accessed 28 October 2006.
  12. 12.0 12.1 12.2 12.3 12.4 12.5 Dure LS 4th, DeWolfe J. Treatment of tics. Adv Neurol. 2006;99:191-96. PMID 16536366
  13. 13.0 13.1 13.2 13.3 13.4 13.5 13.6 13.7 Tourette Syndrome Association. Tourette Syndrome: Frequently Asked Questions Accessed online 6 Jan 2006.
  14. Malone DA Jr, Pandya MM. Behavioral neurosurgery. Adv Neurol. 2006;99:241-47. PMID 16536372
  15. Jankovic J. Differential diagnosis and etiology of tics. Adv Neurol. 2001;85:15–29. PMID 11530424
  16. Cohen AJ, Leckman JF. Sensory phenomena associated with Gilles de la Tourette's syndrome. J Clin Psychiatry. 1992 Sep;53(9):319–23. PMID 1517194
  17. Bliss J. Sensory experiences of Gilles de la Tourette syndrome. Arch Gen Psychiatry. 1980 Dec;37(12):1343–47. PMID 6934713
  18. Kwak C, Dat Vuong K, Jankovic J. Premonitory sensory phenomenon in Tourette's syndrome. Mov Disord. 2003 Dec;18(12):1530–33. PMID 14673893
  19. Scahill LD, Leckman JF, Marek KL. Sensory phenomena in Tourette's syndrome. Adv Neurol. 1995;65:273–80. PMID 7872145
  20. Miguel EC, do Rosario-Campos MC, Prado HS, et al. Sensory phenomena in obsessive-compulsive disorder and Tourette's disorder. J Clin Psychiatry. 2000 Feb;61(2):150–56. PMID 10732667
  21. 21.0 21.1 21.2 21.3 21.4 21.5 Black, KJ. Tourette Syndrome and Other Tic Disorders. eMedicine (March 22, 2006). Accessed 27 June 2006.
  22. 22.0 22.1 22.2 Leckman JF, Zhang H, Vitale A, et al. Course of tic severity in Tourette syndrome: the first two decades. Pediatrics. 1998;102 (1 Pt 1):14–19. PMID 9651407 p. 14. Full-text PDF, Accessed 28 October 2006.
  23. 23.0 23.1 Rapin I. Autism spectrum disorders: relevance to Tourette syndrome. Adv Neurol. 2001;85:89–101. PMID 11530449
  24. 24.0 24.1 Spencer T, Biederman J, Harding M, et al. Disentangling the overlap between Tourette's disorder and ADHD. J Child Psychol Psychiatry. 1998 Oct;39(7):1037–44. PMID 9804036
  25. 25.0 25.1 25.2 25.3 25.4 Denckla MB. Attention deficit hyperactivity disorder: the childhood co-morbidity that most influences the disability burden in Tourette syndrome. Adv Neurol. 2006;99:17–21. PMID 16536349
  26. 26.0 26.1 26.2 Walkup JT, Mink JW, Hollenback PJ, (eds). Advances in Neurology, Vol. 99, Tourette Syndrome. Lippincott, Williams & Wilkins, Philadelphia, PA, 2006, p. xv. ISBN 0-7817-9970-8
  27. Robertson MM. Tourette syndrome, associated conditions and the complexities of treatment. Brain. 2000;123 Pt 3:425–62. p. 425. PMID 10686169
  28. 28.0 28.1 28.2 Mejia NI, Jankovic J. Secondary tics and tourettism. Rev Bras Psiquiatr. 2005;27(1):11–17. PMID 15867978 Full-text PDF, Accessed 28 October 2006.
  29. van de Wetering BJ, Heutink P. The genetics of the Gilles de la Tourette syndrome: a review. J Lab Clin Med. 1993 May;121(5):638–45. PMID 8478592
  30. 30.0 30.1 Swerdlow, NR. Tourette Syndrome: Current Controversies and the Battlefield Landscape. Curr Neurol Neurosci Rep. 2005, 5:329–31. PMID 16131414
  31. Kurlan R, Kaplan EL. The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) etiology for tics and obsessive-compulsive symptoms: hypothesis or entity? Practical considerations for the clinician. Pediatrics. 2004 Apr;113(4):883–86. PMID 15060240
  32. Haber SN, Wolfer D. Basal ganglia peptidergic staining in Tourette syndrome. A follow-up study. Adv Neurol. 1992;58:145–50. PMID 1414617
    * Peterson B, Riddle MA, et al. Reduced basal ganglia volumes in Tourette's syndrome using three-dimensional reconstruction techniques from magnetic resonance images. Neurology. 1993;43:941–49. PMID 8492950
    * Moriarty J, Varma AR, et al. A volumetric MRI study of Gilles de la Tourette's syndrome. Neurology. 1997;49:410-5. PMID 9270569
  33. Pauls DL, Towbin KE, Leckman JF, et al. Gilles de la Tourette's syndrome and obsessive-compulsive disorder. Evidence supporting a genetic relationship. Arch Gen Psychiatry. 1986 Dec;43(12):1180–82. PMID 3465280
  34. Miguel EC, do Rosario-Campos MC, Shavitt RG, et al. The tic-related obsessive-compulsive disorder phenotype and treatment implications. Adv Neurol. 2001;85:43–55. PMID 11530446
  35. 35.0 35.1 35.2 35.3 35.4 35.5 Scahill L, Erenberg G, Berlin CM Jr, Budman C, Coffey BJ, Jankovic J, Kiessling L, King RA, Kurlan R, Lang A, Mink J, Murphy T, Zinner S, Walkup J; Tourette Syndrome Association Medical Advisory Board: Practice Committee. Contemporary assessment and pharmacotherapy of Tourette syndrome. NeuroRx. 2006 Apr;3(2):192–206. PMID 16554257
  36. Ringman JM, Jankovic J. "Occurrence of tics in Asperger's syndrome and autistic disorder." J Child Neurol. 2000 Jun;15(6):394–400. PMID 10868783
  37. Jankovic J, Mejia NI. Tics associated with other disorders. Adv Neurol. 2006;99:61-8. PMID 16536352
  38. Freeman, RD. Tourette's Syndrome: minimizing confusion. Accessed 8 February 2006.
  39. 39.0 39.1 39.2 National Institutes of Health (NIH). Tourette Syndrome Fact Sheet Accessed 3 June 2006.
  40. Sukhodolsky DG, Scahill L, Zhang H, et al. Disruptive behavior in children with Tourette's syndrome: association with ADHD comorbidity, tic severity, and functional impairment. J Am Acad Child Adolesc Psychiatry. 2003 Jan;42(1):98–105. PMID 12500082
    * Hoekstra PJ, Steenhuis MP, Troost PW, et al. Relative contribution of attention-deficit hyperactivity disorder, obsessive-compulsive disorder, and tic severity to social and behavioral problems in tic disorders. J Dev Behav Pediatr. 2004 Aug;25(4):272–79. PMID 15308928
    * Carter AS, O'Donnell DA, Schultz RT, et al. Social and emotional adjustment in children affected with Gilles de la Tourette's syndrome: associations with ADHD and family functioning. Attention Deficit Hyperactivity Disorder. J Child Psychol Psychiatry. 2000 Feb;41(2):215–23. PMID 10750547
  41. Robertson MM, (2000), p. 435. PMID 10686169
  42. Medication trade names may differ between countries. In general, this article uses North American trade names.
  43. Coffey BJ, Shechter RL. Treatment of co-morbid obsessive compulsive disorder, mood, and anxiety disorders. Adv Neurol. 2006;99:208–21. PMID 16536368
  44. Himle MB, Woods DW, Piacentini JC, Walkup JT. Brief review of habit reversal training for tourette syndrome. J Child Neurol. 2006 Aug;21(8):719–25. PMID 16970874
  45. Woods DW, Himle MB, Conelea CA. Behavior therapy: other interventions for tic disorders. Adv Neurol. 2006;99:234–40. PMID 16536371
  46. 46.0 46.1 Pappert EJ, Goetz CG, Louis ED, et al. "Objective assessments of longitudinal outcome in Gilles de la Tourette's syndrome." Neurology. 2003 Oct 14;61(7):936–40. PMID 14557563
  47. Burd L, Kerbeshian PJ, Barth A, et al. Long-term follow-up of an epidemiologically defined cohort of patients with Tourette syndrome. J Child Neurol. 2001;16(6):431–37. PMID 11417610
  48. Leckman JF, Cohen DJ. Tourette's Syndrome—Tics, Obsessions, Compulsions: Developmental Psychopathology and Clinical Care. John Wiley & Sons, Inc., New York, 1999, p. 37. ISBN 0-471-16037-7 "For example, individuals who were misunderstood and punished at home and at school for their tics or who were teased mercilessly by peers and stigmatized by their communities will fare worse than a child whose interpersonal environment was more understanding and supportive."Outline, Accessed 28 October 2006.
  49. Cohen DJ, Leckman JF, Pauls D. Neuropsychiatric disorders of childhood: Tourette’s syndrome as a model. Acta Paediatr Suppl 422; 106–11, Scandinavian University Press, 1997. "The individuals with TS who do the best, we believe, are: those who have been able to feel relatively good about themselves and remain close to their families; those who have the capacity for humor and for friendship; those who are less burdened by troubles with attention and behavior, particularly aggression; and those who have not had development derailed by medication."
  50. Mueller SC, Jackson, GM, et al. Enhanced Cognitive Control in Young People with Tourette's Syndrome. Current Biology. 2006 Mar 21;16(6):570–73. PMID 16546080
  51. Scahill L, Tanner C, Dure L. The epidemiology of tics and Tourette syndrome in children and adolescents. Adv Neurol. 2001;85:261-71. PMID 11530433
  52. Kadesjo B, Gillberg C. Tourette's disorder: epidemiology and comorbidity in primary school children. J Am Acad Child Adolesc Psychiatry. 2000 May;39(5):548-55. PMID 10802971
  53. Kurlan R, McDermott MP, Deeley C, et al. Prevalence of tics in schoolchildren and association with placement in special education. Neurology. 2001 Oct 23;57(8):1383-8. PMID 11673576
  54. Robertson MM, (2000), p. 427. PMID 10686169
  55. Zohar AH, Apter A, King RA et al. Epidemiological studies. In J.F. Leckman, & D.J. Cohen (Eds.), Tourette's syndrome - tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 177-92). Wiley & Sons, 1999. ISBN 0-471-16037-7
  56. Coffey BJ, Park KS. Behavioral and emotional aspects of Tourette syndrome. Neurol Clin. 1997 May;15(2):277-89. PMID 9115461
  57. Soliman, E. Tourette Syndrome. eMedicine (August 5, 2005). Accessed 28 June 2006.
  58. Kushner, HI. A cursing brain?: The histories of Tourette syndrome. Harvard University Press, 2000. ISBN 0-674-00386-1
  59. Itard JMG. Mémoire sur quelques functions involontaires des appareils de la locomotion, de la préhension et de la voix. Arch Gen Med. 1825;8:385-407. From Newman, Sara. Study of several involuntary functions of the apparatus of movement, gripping, and voice by Jean-Marc Gaspard Itard (1825) History of Psychiatry. 2006 17: 333-39. DOI 10.1177/0957154X06067668 Abstract online, Accessed 28 October 2006.
  60. Gilles de la Tourette G, Goetz CG, Llawans HL, trans. Étude sur une affection nerveuse caractérisée par de l'incoordination motrice accompagnée d'echolalie et de coprolalie. In: Friedhoff AJ, Chase TN, eds. Advances in Neurology: Volume 35. Gilles de la Tourette syndrome. New York: Raven Press; 1982;1-16. Discussed at Black, KJ. Tourette Syndrome and Other Tic Disorders. eMedicine (March 22, 2006). Accessed 27 June 2006.
  61. Who Named It? Georges Albert Édouard Brutus Gilles de la Tourette. Accessed 28 June 2006.
  62. 62.0 62.1 Pagewise, Inc. Tourette syndrome. Accessed 29 June 2006.
  63. Rickards H, Hartley N, Robertson MM. Seignot's paper on the treatment of Tourette's syndrome with haloperidol. Classic Text No. 31. Hist Psychiatry. 1997 Sep;8 (31 Pt 3):433-36. PMID 11619589
  64. Gadow KD, Sverd J. Attention deficit hyperactivity disorder, chronic tic disorder, and methylphenidate. Adv Neurol. 2006;99:197-207. PMID 16536367
  65. What is DSM-IV-TR? Accessed 28 October 2006.
  66. Walkup JT, Mink JW, Hollenback PJ, (eds). (2006) pp. xvi - xviii
  67. Sacks, O. The man who mistook his wife for a hat: and other clinical tales (pp. 92–100). Harper and Row, New York, 1985. ISBN 0-684-85394-9
  68. 68.0 68.1 Leckman & Cohen (1999), p. 408. ISBN 0-471-16037-7
  69. Mueller SC, Jackson, GM, et al. Enhanced cognitive control in young people with Tourette's syndrome. Current Biology. 2006 Mar 21;16(6):570–73. PMID 16546080
  70. Schuerholz LJ, Baumgardner TL, Singer HS, et al. Neuropsychological status of children with Tourette's syndrome with and without attention deficit hyperactivity disorder. Neurology. 1996 Apr;46(4):958–65. PMID 8780072
  71. Schuerholz LJ, Cutting L, Mazzocco MM, et al. Neuromotor functioning in children with Tourette syndrome with and without attention deficit hyperactivity disorder. J Child Neurol. 1997 Oct;12(7):438–42. PMID 9373800
  72. Tourette Syndrome Association. Samuel Johnson. Accessed 10 February 2005.
  73. 73.0 73.1 Simkin, Benjamin. Medical and Musical Byways of Mozartiana. Fithian Press, 2001. ISBN 1-56474-349-7 Review, Accessed 28 October 2006.
  74. Simkin B. Mozart's scatological disorder. BMJ. 1992 Dec 19–26;305(6868):1563–67. PMID 1286388
  75. 75.0 75.1 Tourette Syndrome Association:Did Mozart really have TS? Accessed online 14 Aug 2002.
  76. Sacks O. Tourette's syndrome and creativity. BMJ. 1992 Dec 19-26;305(6868):1515-6. PMID 1286364
  77. Holtgren, Bruce. "Truth about Tourette's not what you think." Cincinnati Enquirer, January 11, 2006. Accessed 16 January 2006.
  78. Tourette Syndrome Association. Oprah and Dr. Laura - Conflicting Messages on Tourette Syndrome. Oprah Educates; Dr. Laura Fosters Myth of TS as "Cursing Disorder". (May 31, 2001). Accessed 6 October 2001.
    * Tourette Syndrome Association. Letter of response to Dr. Phil. Accessed 8 May 2006.
    * Tourette Syndrome Association. Letter of response to Garrison Keillor radio show. Accessed 8 May 2006.
    * Born, Matt. Tourette's man 'exploited by Big Brother' Accessed 22 May 2006.
  79. Guldberg, Helene. Stop celebrating Tourette’s. Spiked (26 May 2006). Accessed January 12, 2007.



Further reading

Olson, S. Making Sense of Tourette's (PDF). Science. 2004 Sep 3;305(5689):1390-92. PMID 15353772 Also available at FindArticles and Science Magazine.


External links

Retrieved from "http://localhost../../../art/a/m/1.html"

This text comes from Wikipedia the free encyclopedia. Permission is granted to copy, distribute and/or modify this document under the terms of the GNU Free Documentation License, Version 1.2 or any later version published by the Free Software Foundation; with no Invariant Sections, no Front-Cover Texts, and no Back-Cover Texts. For a complete list of contributors for a given article, visit the corresponding entry on the English Wikipedia and click on "History" . For more details about the license of an image, visit the corresponding entry on the English Wikipedia and click on the picture.