Neuro-ophthalmic abnormalities in Tourette's syndrome: functional and anatomic implications

Neuro-ophthalmic findings in 29 patients with Gilles de la Tourette's syndrome are described. Twenty-eight patients had blepharospasm, and 19 had other eye tics that included forced staring and involuntary gaze deviation. These neuro-ophthalmic abnormalities and ocular disturbances are similar to those found in known basal ganglia disorders.

Electrophysiological studies in Tourette's syndrome

The value of standard electrophysiological studies using electroencephalography and evoked responses was evaluated in patients with Tourette's syndrome. Sixteen-channel electroencephalograms were obtained in 40 patients (36 males, 4 females) awake and asleep, and evoked responses were obtained in a subgroup of 17 patients. Evoked response variables evaluated included latencies and amplitudes of visual evoked responses, brainstem auditory evoked responses, and somatosensory evoked responses to median and peroneal nerve stimulation. Only 5 of the 40 patients (12.5%) demonstrated electroencephalographic abnormalities, which included central spikes, generalized and paroxysmal slow activity, and slowing of the normal basic frequency. Evoked response studies demonstrated no consistent differences between the patients with Tourette's syndrome and age- and sex-matched controls. The data demonstrate no notable diagnostic or therapeutic value for routine electroencephalographic or evoked response studies in Tourette's syndrome.

Sensory experience as a trigger in Gilles de la Tourette's syndrome

The case to be reported presented with multiple motor tics. During the course of therapy, directed along behavioural lines, a model of the nature of the movements emerged which was later found to be strikingly similar to that described by Bliss (1980). The patient (J) complained of a "horrible" sensation, similar to an "itch", which always preceded the tic movements and which could be removed by movement. Occasionally, by supreme effort, the "itch" would be resisted and movement avoided. These sensations could thus be viewed as a trigger for the movements. The implications of such an analysis for current conceptualisations of, and intervention with, motor tics are discussed.

Endocrine aspects of lithium therapy in Tourette's syndrome

The use of Lithium Carbonate (Li2CO3) therapy in Gilles de la Tourette syndrome is reported in one patient. The patient, a 22-year-old male, was treated with a daily dose of 900 mg of Li2CO3 to attain therapeutic blood serum lithium concentration between 0.76 and 0.87 mEq/L. Renal function tests, urine analysis and thyroid function tests were monitored in addition to determinations of serum gonadotropins and testosterone concentrations throughout the 8 months of the study. The neuroendocrine measurements indicate blunting of Thyrotropin Stimulating Hormone (TSH) response, to Thyrotropin Releasing Hormone (TRH) stimulation test, which may be due to lithium therapy. The patient's growth and development were normal. This case represents the first report of blunting of TSH response to TRH in Tourette's disease. The fact that this disease has an onset during childhood suggests the importance of monitoring various endocrine functions during lithium therapy.

Neuroanatomy of Gilles de la Tourette's syndrome. Possible midbrain involvement

Alterations of the dopaminergic system are well documented in Gilles de la Tourette's syndrome (TS). Dopamine (DA)-receptor blockers often relieve symptoms, whereas DA agonists acutely exacerbate them. The cluster of symptoms and known localization of lesions in encephalitis lethargica (EL), together with studies on the anatomy of vocalization, suggest that damage to the periaqueductal gray and midbrain tegmentum may be involved in TS. Pharmacologic findings in patients with TS and EL suggest that oculogyric crises and obsessions are associated with diminished DA levels and the development of supersensitive DA receptors, and that tics occur when these receptors are stimulated.

Neuropsychological abnormalities in Gilles de la Tourette's syndrome

Seven patients with Gilles de la Tourette's syndrome underwent an extensive psychological and neuropsychological examination. On psychological examination, it was found that consistent with previous reports these patients had a high incidence of Verbal IQ-Performance IQ discrepancies on the Revised Wechsler Intelligence Scale for Children, and had average mental arithmetic but poor written arithmetic. On neuropsychological examination, no single measure was performed poorly by all subjects, but there was a high incidence of poor performance on several measures from the Halstead-Reitan Battery. High frequency of abnormal performance for age was observed on the Category, Trail Making and Tactual Performance Tests. In addition, the patients had an interesting pattern of average auditory attention span but poor visual attention span. The pattern of visuomotor and visuospatial deficits was discussed with respect to possible underlying mechanisms.

Sleep in Gilles de la Tourette's syndrome: disorder of arousal

Overnight polygraphic sleep studies, which included accelerometry and video monitoring, were performed on 14 Tourette patients before therapy and on 11 age-matched controls. Tourette patients less than 23 years old had a significantly increased percentage of stage 3/4 sleep, had an increased number of awakenings, had a decreased percentage of REM sleep, experienced paroxysmal events during stage 4 sleep, and had motor tics during all stages of sleep. Three patients were treated with tetrabenazine and subsequently showed significant decreases in percentage of total sleep, number of awakenings, and number of tics during sleep. These findings suggest a disorder of arousal in Tourette patients.

Movement disorders in children: Tourette syndrome

Movement disorders in childhood are rare, but their occurrence is dramatic and frightening. Differential diagnosis depends primarily on a detailed evaluation of the history and an analysis of the characteristics of the movements. Tics are the most common movement disorder in childhood, ranging in severity for simple transient tics to the complex Tourette syndrome, which may be associated with many bizarre behaviors. Minimal defining characteristics of Tourette syndrome are the presence of multiple motor and vocal tics. Associated features may include echolalia, coprolalia, complex stereotyped movements, and compulsive behavior. There is a prominent familial occurrence of Tourette syndrome. Stimulant drugs may cause exacerbation of symptoms. The only consistency useful medication is haloperidol, but its use is associated with side effects in approximately 50% of the patients treated.

Coincidence of Tourette's disorder and infantile autism

This is a single-case report of the syndrome of Tourette's disorder (GTS) and infantile autism (IA) occurring together. Neuroleptics were not administered prior to the onset of GTS. The heuristic value of comparing the different biochemical mechanisms of the syndromes and its implication for diagnosis and etiology is discussed. Norepinephrine is thought to be at least one transmitter that differentiates the syndromes.

Cholinergic mechanisms in Tourette syndrome

To examine the role of the cholinergic system in Tourette syndrome, we administered intramuscular physostigmine and scopolamine hydrobromide to 10 patients, evaluating both motor tics and involuntary vocalizations. Patients showed a consistent abatement of motor tics and exacerbation of vocal tics after scopolamine injection. The scopolamine effect was reversed by physostigmine. These data suggest that the cholinergic system plays a role in the pharmacologic pathophysiology of Tourette syndrome. The pharmacology of vocal and motor tics may differ, and cholinergic manipulation may benefit some patients.

The electroencephalogram in Tourette syndrome

The electroencephalogram (EEG) was studied in 38 patients with Tourette syndrome. Psychometric tests and neurological evaluation identified patients with signs of additional central nervous system dysfunction. Thirteen patients (34%) had some EEG abnormality. In contrast to findings by other investigators, epileptiform activity was uncommon (only 2 out of 38). Most of the patients with EEG abnormalities either had other objective signs of neurological dysfunction or were taking haloperidol, a drug known to disturb the EEG.

Simple tics in Gilles de la Tourette's syndrome are not prefaced by a normal premovement EEG potential

EEG events prior to simple tics have been examined in six patients with Gilles de la Tourette's syndrome, and compared to EEG changes occurring when the same subjects voluntarily mimicked their own tics. Voluntary jerks were prefaced by a premovement negative potential commencing about 500 ms prior to the muscle EMG discharge and reaching an amplitude of about 7 muV. No such premovement potential was evident in the EEG prior to spontaneous tics in five of the six patients; a very small event was seen in the sixth patient but it was only about one-tenth of the size of the premovement potential seen prefacing voluntary jerks in the same subject. These data indicate that simple tics in Gilles de la Tourette's syndrome are physiologically distinct from normal self-paced willed movements.

Cortical evoked potentials in Gilles de la Tourette's syndrome--a single case study

Average cortical evoked potentials (AEPs) to auditory stimulation and AEP recovery functions were investigated in a 13-year-old boy suffering from Gilles de la Tourette's syndrome. Data obtained from the patient while on and off haloperidol were compared with data from a group of normal control subjects matched for age and sex. Latencies of the P2 and N2 components of the AEP were noticeably shorter in the Tourette's syndrome patient than in the control group. Recovery from stimulation, as estimated by the cortical evoked potential to the second of two closely spaced stimuli, was faster in the patient than the controls. After the patient's treatment with haloperidol, the latencies of the P2 and N2 components of the AEP and the speed of recovery from stimulation appeared to be no different in the patient than in the control subjects. Findings suggested that cortical excitability is higher in the Tourette's syndrome patient, whose AEPs also showed evidence of a maturational advance over the normal subjects.

Tourette syndrome, an acquired encephalopathy? A report of two cases with epileptiform dysrhythmia

The electroencephalogram, although providing no specific diagnostic information for Tourette syndrome, may be useful in evaluating the pathology in which the syndrome occurs, since it appears that at least some cases may occur in the setting of an underlying acquired encephalopathy of diverse etiology. A neurochemical basis for the Tourette syndrome expressed as an extrapyramidal circuit imbalance may also relate to a discharge threshold for epileptiform activity. A more detailed electroencephalographic evaluation of such patients using nasopharyngeal or sphenoidal recording may be useful in this regard.

Sleep in Gilles de la Tourette syndrome

The sleep of six Tourette patients (drug-free and while taking haloperidol was compared with that of nine normal volunteers. The untreated patients had 30% less delta sleep, which returned to values indistinguishable from those of volunteers when they received haloperidol.

Otolaryngologic presentation of tic-like disorders

Common otolaryngologic symptoms such as coughing and sneezing may not be manifestations of disease of the upper respiratory tract. Two cases are reported in which these symptoms were the first evidence of tic-like disorders. A short discussion of one such disorder, Gilles de la Tourette's syndrome, is presented. The entity of paroxysmal sneezing is also mentioned. It is pointed out that, in the absence of otolaryngologic disease, these disorders may first present to an otolaryngologist for diagnosis.

Gilles de la Tourette syndrome: further studies and thoughts

A possible association between the Gilles de la Tourette and Lesch-Nyhan syndromes has recently been postulated. Fourteen patients with Tourette syndrome demonstrated no similarity to Lesch-Nyhan based upon patterns of inheritance, behavioral changes, or alterations of purine metabolism. Despite a strong male predominance, a sex-linked pattern of inheritance could not be confirmed. Self-mutilating behavior was found in 4 male patients but was readily differentiated from that characteristic of the Lesch-Nyhan syndrome. Quantitation of hypoxanthine-guanine phosphoribosyltransferase and isoelectric focusing of its isoenzymes produced results that were indistinguishable from those in controls. We speculate that, pathophysiologically, Tourette syndrome represents an imbalance between the central neurotransmitters dopamine and serotonin rather than an alteration in purine metabolism.

Chronic, multiple tics of Gilles de la Tourette's disease. CSF acid monoamine metabolites after probenecid administration

Central nervous system metabolism in six children and one adult with the syndrome of chronic multiple tics was studied by measuring the accumulation of acid metabolites of dopamine and serotonin (homovanillic acid [HVA] and 5-hydroxyindole-acetic acid [5-HIAA], respectively) in the CSF following probenecid administration. The accumulation of 5-HIAA was reduced in patients with multiple tics in contrast with other pediatric patients (N = 27). The degree of reduction in 5-HIAA relative to HVA appeared to be associated with the severity of the tic disorder. With dextroamphetamine, tic symptoms worsened, CSF HVA level decreased, and CSF 5-HIAA concentration increased. These findings suggest an association in Gilles de la Tourette's disease of reduced functioning of inhibitory serotonergic mechanisms and functional dopaminergic overactivity.

Seven cases of Gilles de la tourette's syndrome: partial relief with clonazepam: a pilot study

The histories of seven consecutive cases of Gilles de la Tourette's syndrome are presented to exemplify the range of clinical manifestations in this disease and to collate preliminary results with the new benzodiazepine, clonazepam, as possible adjuvant therapy of this disorder. Controlled trials with clonazepam alone and in association with haloperidol are now justified. Five of our 7 patients had a positive family history of tics, and 2 a confirmed family history of gout. Because clonazepam improves myoclonia and tics and because its mechanism of action possibly involves serotonin, we thought it worthwhile to study simultaneously the relative roles of serotonin and dopamine metabolism in the production of tics, and their relationship to possible defects in purine metabolism in Gilles de la Tourette's syndrome.

The effects of haloperidol upon temporal information processing by patients with Tourette's syndrome

Tourette's syndrome patients treated successfully with haloperidol, untreated patients, and healthy controls were studied with tests of temporal discrimination and measures of transmitted information shown previously to be sensitive to brain dysfunction. Untreated patients showed no impairment of temporal processing while those treated with haloperidol showed significant deficit in amount of transmitted information comparable to prior studies of brain syndromes.

Two cases of Gilles de la Tourette's syndrome treated with haloperidol

Two cases of Gilles de la Tourette's syndrome occurring in Sri Lanka are reported. Both patients had the characteristics of the syndrome as described by Fernando (1967): (1) Childhood onset (below 16 years of age); (2) Multiple motor tics; (3) Unprovoked vocal utterances which may progress to coprolalia. Both responded to haloperidol, withdrawal of medication being followed by relapse, and reintroduction by remission. The literature on the aetiology of the condition has been reviewed. The weight of evidence favours an organic cause, although psychological precipitation cannot be ruled out.

Organic factors in Gilles de la Tourette's syndrome

Gilles de la Tourette's syndrome had been considered an organic, often hereditary illness for many years after it was first described in 1885 (1, 2), but when medicine became psychologically oriented, the syndrome was more frequently classified as a psychological illness (3), and patients have been said to be schizophrenic, psychotic, obsessive-compulsive, hysteric, to have inhibited aggression, and eventually to deteriorate intellectually and psychologically. However, no support for common psychopathological and dynamic factors was found in our previous study of 34 patients or in a review of the literature (4). Recently, as medicine has shifted back from a psychological orientation, and as case histories have accumulated, an organic aetiology has been more frequently postulated.

Neurological features of Gilles de la Tourette's syndrome

Clinical neurological examinations of 22 patients with Gilles de la Tourette's syndrome and written reports of examinations of seven other patients are reported. Half the personally examined patients had minor motor asymmetries in addition to the typical motor and vocal tics found in all the patients. Thirty-six per cent of patients were left handed or ambidextrous. Electroencephalograms performed on 17 of the 22 patients showed non-specific abnormalities in 12 of them. These findings suggest that a neurological disorder underlies Tourette's syndrome, but they do not clarify its nature.