Transient tic disorder and the spectrum of Tourette's syndrome

Transient tic disorder (TTD) has not generally been considered part of the spectrum of Tourette's syndrome (TS). We studied a large kindred affected by TS and identified two family members with TTD who are very likely obligate carriers of the TS gene. Our observations indicate that TTD is a possible expression of the TS gene and that individuals with TTD may transmit TS to their offspring.

Familial pervasive development disorder, Tourette disorder and hyperlexia

Four children and one adult have been found to have Pervasive Developmental Disorder, Tourette disorder and hyperlexia in North Dakota, a state with a population of 204,161 children ages 0-18. Assuming that these are independent disorders the probability of these three disorders occurring by chance in one child is 3.39 x 10(-12). Two of these individuals are from the same family. This suggests evidence for genetic linkage among these three disorders.

Concordant Gilles de la Tourette's syndrome in monozygotic twins: a clinical, neurophysiological and CT study

A 19-year-old male twin pair were concordant for suffering from Gilles de la Tourette's syndrome in different forms and severity. CT revealed ventricular asymmetries of varying degree within the normal range and there were no neurophysiological abnormalities. The interrelationship of genetic and environmental factors in phenotyping the syndrome is discussed.

Family data support a dominant major gene for Tourette syndrome

A dominant major gene was supported by analyses of 50 large extended Tourette syndrome (TS) pedigrees and by a subset of families defined by proband's clinical response to the neuroleptic drug haloperidol. Relatives were defined as affected if they ever had tics or TS. Assuming a nearly even sex ratio for TS and related symptoms resulted in the best fit of the genetic model to observed rates in families.

The relationship between stimulant medication and tics

Clinical evidence supports the observation that stimulant drugs increase the severity of tics in 25% to 50% of patients with TS, and occasionally can precipitate TS in a patient who did not previously manifest symptoms of this disorder. As ADD is frequently associated with TS, the clinician is often faced with a dilemma. A conservative approach to the use of stimulant medication, stringent criteria for its use, adequate counseling of the child and parents, and a thorough cost-benefit analysis before initiating treatment are required. Behavior management and environmental manipulation can be useful techniques with the child with ADD, and should be tried before medication is considered.

Tourette's syndrome in Monroe County school children

We examined children from Monroe County, New York, to establish the prevalence of Gilles de la Tourette's syndrome (TS) in the county's schools. Patients were recruited for free evaluations from physicians, other health professionals, school personnel, and through extensive coverage in the local news media. Forty-one TS patients were detected among the 142,636 pupils enrolled in the county's public and private schools at the time of the study (estimated prevalence, 28.7 per 100,000). Twenty patients had obsessive-compulsive symptoms, but only three had an impairing, diagnosable disorder. Fifty-six percent had a positive family history for TS or tics. Eighteen needed pharmacotherapy, although, for most, TS was a mild disorder requiring no drug treatment.

A controlled study of Tourette syndrome. VI. Early development, sleep problems, allergies, and handedness

Developmental milestones, problems with bladder and bowel control, sleep disturbances, allergies, and handedness were compared in 247 consecutive Tourette syndrome (TS) patients, 17 patients with attention-deficit disorder (ADD), 15 patients with ADD secondary to TS (ADD 2(0) TS), and 47 random controls. There were no significant differences in age of first talking or walking. By contrast, there were significant differences in problems with bladder and bowel control between TS patients and controls, as measured by age of first toilet training, age of last bed-wetting, frequency of enuresis, and age that bowel control was achieved. Sleep problems were pervasive in TS patients, with a significantly increased frequency of sleepwalking, night terrors, trouble getting to sleep, early awakening, and inability to take afternoon naps as a young child. In all diagnostic categories, including mild (grade 1) TS patients, a total sleep-problem score was significantly greater than that in controls. The sleep disorders and other TS symptoms are consistent with TS as a disorder of disinhibition of the limbic system. Allergies and left-handedness have been evoked as contributing to or being associated with ADD and learning disorders. There were no significant differences in the frequency of allergies or left-handedness in TS patients compared with that in controls. We conclude that when there is a clearly defined genetic cause of ADD and learning disorders, it is not associated with an increased frequency of allergies or left-handedness.

A controlled study of Tourette syndrome. V. Depression and mania

To evaluate the role of depression and mania in Tourette syndrome (TS), we have examined 246 TS patients, 17 attention-deficit disorder (ADD) patients, 15 patients with ADD associated with TS, and 47 controls, using (1) the standardized National Institutes of Mental Health Diagnostic Interview Schedule questions for a life history of major depression and/or mania and (2) a modified Beck depression score for evaluation of depression at the time of the examination. The results were combined into depression, Beck, and mania scores. Among the controls, 2.1% had a depression score greater than 9, and none had a score greater than 10. Among the TS patients, 22.9% had a score greater than 9 and the scores ranged up to the maximum of 18 (P less than .0005). None of the pure ADD patients had a score greater than 6, whereas 20% of the ADD-secondary-to-TS (ADD 2(0) TS) patients had scores greater than or equal to 9. Among grade 3 TS patients, 46.6% had scores greater than or equal to 9. There were no differences in the frequency of depression in the TS patients with or without ADD. Comparable results were obtained for the Beck depression score, except that the percent with a score greater than or equal to 8 was higher for the TS patients with ADD (23.7%) than for those without ADD (9.3%). There was a good correlation between the depression score and the Beck score (r = .63), but no correlation between the ADD-with-hyperactivity (ADDH) score and either the depression score (r = .086) or the Beck score (r = .077). Among the controls, none had a mania score greater than or equal to 4, compared with 19.1% of the total TS patients (P = less than .0005), 11.8% of the ADD patients (P = .002), and 26.6% of the ADD 2(0) TS patients (P = .0005). Although some of the mania questions would be expected to be answered positively by ADDH patients, the correlation coefficient between the ADDH scores and the mania scores was only moderate (r = .29), whereas the correlation with the depression score was much higher (r = .63). There was minimal correlation between the number of tics and either the depression score (r = .267) or the Beck score (r = .193). We conclude that depression and manic-depressive symptoms are common in TS patients and are an integral part of the disorder rather than being secondary to motor or vocal tics.

A controlled study of Tourette syndrome. IV. Obsessions, compulsions, and schizoid behaviors

To determine the frequency of obsessive, compulsive, and schizoid behaviors in Tourette syndrome (TS), we prospectively questioned 246 patients with TS, 17 with attention-deficit disorder (ADD), 15 with ADD due to a TS gene, and 47 random controls. The comparative frequency of obsessive, compulsive, and repetitive behaviors--such as obsessive unpleasant thoughts, obsessive silly thoughts, echolalia, palilalia, touching things excessively, touching things a specific number of times, touching others excessively, sexual touching, biting or hurting oneself, head banging, rocking, mimicking others, counting things, and occasional or frequent public exhibitionism--were significantly more common in TS patients than in controls. The frequency of each of these was much higher for grade 3 (severe) TS. Most of these behaviors also occurred significantly more often in individuals with ADD or in individuals with ADD secondary to TS (ADD 2(0) TS). When these features were combined into an obsessive-compulsive score, 45.4% of TS patients had a score of 4-15, whereas 8.5% of controls had a score of 4 or 5. These results indicate that obsessive-compulsive behaviors are an integral part of the expression of the TS gene and can be inherited as an autosomal dominant trait. Schizoid symptoms, such as thinking that people were watching them or plotting against them, were significantly more common in TS patients than in controls. Auditory hallucinations of hearing voices were present in 14.6% of TS patients, compared with 2.1% of controls (P = .02). These symptoms were absent in ADD patients but present in ADD 2(0) TS patients. These voices were often blamed for telling them to do bad things and were frequently identified with the devil. None of the controls had a total schizoid behavior score greater than 3, whereas 10.9% of the TS patients had scores of 4-10 (P = .02). This frequency increased to 20.6% in the grade 3 TS patients. These quantitative results confirm our clinical impression that some TS patients have paranoid ideations, often feel that people are out to get them, and hear voices.

A controlled study of Tourette syndrome. VII. Summary: a common genetic disorder causing disinhibition of the limbic system

Tourette syndrome (TS) is one of the most common genetic disorders affecting man. Approximately one in 100 individuals manifests one or more of the aspects of the TS gene. This series of papers has emphasized that although motor and vocal tics are the hallmark of TS, the complete range of behavioral problems is much broader. This spectrum of behavior can be explained on the basis of the TS gene causing an imbalance of the mesencephalic-mesolimbic dopamine pathways, resulting in disinhibition of the limbic system.

A controlled study of Tourette syndrome. III. Phobias and panic attacks

Comparison was made of the frequency of phobias and panic attacks in normal controls and in patients with Tourette syndrome (TS), attention-deficit disorder (ADD), and ADD secondary to a TS gene. For phobias the most significant difference between controls and TS patients was with respect to fear of public transportation (P = .002), followed by fear of being alone (P = .009), fear of being in a crowd (P = .01), fear of being in water (P = .025), fear of animals (P = .04), fear of public speaking (P = .05), and other fears (P = .05). Only 8.5% of controls had more than three simple phobias and none had more than five, whereas 26% of TS patients had more than three (P = .008) and some had as many as 13. As opposed to 19% of TS patients, none of the controls had phobias that interfered with their life (P = .001). Among female TS patients 55.1% had 3-13 phobias, compared with 8.7% of the female controls (P less than .0005). There was no correlation between the ADD score and the number of phobias (r = -.010) and little correlation with the total number of tics (r = .14). Panic attacks were present in 8.3% of the controls and 33% of the TS patients (P = .0008). This frequency increased to 55.2% (P less than .0005) for grade 3 (severe) TS patients. None of the controls, 15.9% of all TS patients (P = .002), and 31% of grade 3 TS patients (P less than .0005) had more than three panic attacks in 1 wk. Total panic-symptom score (12 possible symptoms) was significantly greater than that in the controls in all grades of TS. The presence or absence of ADD had little effect on the total panic-symptom score, but the presence of ADD resulted in a significantly lower average age at onset of panic attacks (8.8 years) compared with those TS patients without ADD (15.4 years) (P = .03). These observations indicate that phobias and panic attacks are a significant part of the symptomatology of TS and provide the first clear indication that phobias and panic attacks can be due to the presence of a major gene.

Hereditary agoraphobia and obsessive-compulsive behaviour in relatives of patients with Gilles de la Tourette's syndrome

We present 11 pedigrees in which a propositus with Gilles de la Tourette's syndrome had first or second-degree relatives with obsessive-compulsive behaviour or agoraphobia with panic attacks, but only partially expressed the TS gene (i.e. had only motor tics or vocal tics, or neither). Of 90 females over the age of 18 presenting with TS, or with motor or vocal tics alone, nine had severe agoraphobia with panic attacks. There may be genetic subtypes of both obsessive-compulsive disorder and agoraphobia with panic attacks that are due to partial expression of the TS gene.

Onset of Gilles de la Tourette's syndrome before 1 year of age

The authors report on three patients in North Dakota with an apparent onset of Gilles de la Tourette's syndrome before 1 year of age. Infantile onset may occur in 4.1% of the child patients with Tourette's disorder in that state. It is suggested that the diagnostic criteria for Tourette's disorder be revised to include patients who develop the illness before they are 1 year old.

Tics and heredity. A study of the relatives of child tiqueurs

The limited literature on the pedigrees of tiqueurs, including those with Gilles de la Tourette's syndrome, is reviewed. Most statistical analyses have been restricted to affected family members without specifying the unaffected ones. The present statistical analysis of a series of child tiqueurs, including 91 probands and 1293 first- and second-degree relatives, 46 of whom were tiqueurs, predicts the odds on being a tiqueur for individuals, and establishes how those odds are affected by certain explanatory variables using log-linear models. The data do not confirm a familial pattern beyond reasonable doubt, but if the suggested prevalence of tics in the population is 10% then the figure for parents is large enough to support a familial hypothesis. The pedigrees do not indicate a simple mode of genetic transmission. Further research is needed to confirm that there is a connection between childhood tics and Gilles de la Tourette's syndrome, to establish that the predisposition to tics is familial, and, if so, whether there is a complex genetic mechanism involved, or some other environmental aetiology so far undisclosed.

Severity of Tourette's syndrome in one large kindred. Implication for determination of disease prevalence rate

An accurate prevalence rate for Tourette's syndrome (TS) has not been established. To assess severity of illness, a potential source of bias in determining prevalence rate, we administered standardized questionnaires and examinations to 159 members of a large Mennonite kindred showing apparent autosomal dominant transmission of motor and vocal tics (TS) or chronic motor tics (CMTs). Fifty-four family members were diagnosed as having definite or probable TS or CMTs. For these 54 subjects, 30% (n = 16) were unaware of tics noted by the examiners and only 18.5% (n = 10) had sought medical care. Our findings suggest that most cases of TS and CMTs are mild and do not come to medical attention. These tic disorders are probably much more prevalent than generally appreciated.