Talipexole and adult Gilles de la Tourette's syndrome: double-blind, placebo-controlled clinical trial

Talipexole is a new dopamine autoagonist with putative preferential activity on presynaptic dopamine receptors. In a double-blind, placebo-controlled study, we tested the drug's safety and efficacy in 13 adult men with Gilles de la Tourette's syndrome. The drug was poorly tolerated because of clinically significant sedation and dizziness. Tics did not improve at tolerable doses. These findings suggest that talipexole has no role in the regular management of tic disorders.

D2 dopamine receptor alleles do not influence severity of Tourette's syndrome. Results from four large kindreds

OBJECTIVE

We investigated the recently proposed hypothesis that the A1 allele of the Taq I polymorphic system at the D2 dopamine receptor gene (DRD2) influences the severity of Tourette's syndrome (TS). We have previously demonstrated that DRD2 is not linked to TS, establishing that it cannot be the major locus determining the susceptibility to develop TS.

METHOD

We studied alleles at the DRD2 A system in patients with TS or chronic multiple tics in four extended kindreds segregating TS. If this allelic system at DRD2 is associated with severity of TS, then among affected family members, those with the A1 allele should have more severe disease than those without it. Severity of disease was compared in affected members of the kindreds with A1 alleles and in those without A1 alleles.

RESULTS

We evaluated disease severity in two ways. First, we evaluated 17 individuals from two families using a derivative of the Yale Global Tic Severity Scale composed of subscales concerning number, frequency, and severity of motor and phonic tics, rated separately. We divided this sample (n = 17, nine with TS and eight with chronic multiple tics) by genotype at the A1/A2 system. The heterozygotes (n = 7) had an average severity score of 11.3; the A2 homozygotes had an average severity score of 14.2. (There were no A1 homozygotes.) Second, we evaluated 47 individuals from two different families (all with TS) using the TS symptomatology evaluation. We compared severity scores for these individuals by genotype at the A1/A2 system. The heterozygotes (n = 24) had a mean severity score of 3.0, and the A2 homozygotes (N = 21) had a mean severity score of 3.7.

CONCLUSION

Our data do not support alleles at the A system of DRD2 as a factor associated with severity of TS.

A behavioral neurogenetics approach to developmental disabilities: gene-brain-behavior associations

This review provides a discussion of behavioral neurogenetics' contribution to understanding neurodevelopmental pathways in learning and developmental disabilities. A brief overview is given of several common neurogenetic disorders with various genetic etiologies including Down syndrome, Turner syndrome, Prader-Willi syndrome, Angelman syndrome, and Tourette's syndrome. Special emphasis is placed on fragile X syndrome as representative of a newly-discovered class of genetic conditions characterized by an unstable trinucleotide repeat. A spectrum of cognitive, behavioral, and social-emotional phenotypic features associated with fragile X syndrome is examined. Also included are findings from recent neuroimaging research and a discussion of the need for the classification of symptoms on the basis of underlying genetic/medical conditions.

Serotoninergic agents in the treatment of Gilles de la Tourette's syndrome

A preliminary trial with fluoxetine, a 5-HT reuptake inhibitor, was carried out on two young male patients (21 and 32 years old) affected by Gilles de la Tourette syndrome. They both underwent a complete neurological evaluation also including neuroradiological, neurophysiological and neuropsychological assessment. Both patients had already been treated with benzodiazepines and amitriptyline; the older one was also given haloperidol and chlorimipramine with definite, but short-lasting improvement. During hospitalization a therapeutic trial with fluoxetine (20 mg/day in the younger patient and 40 mg/day in the older) in association with chlorimipramine (75 mg/day) was initiated, leading to a significant reduction (at least 50%) of abnormal movements and obsessive-compulsive behaviour. The older patient had no side effects while the 21 year old subject complained of insomnia, urinary retention and anorexia; despite the objective improvement, these side effects led us to modify the therapy after the first month. The favourable action of serotoninergic agents on TS symptoms supports the hypothesis that the multiple tics of the syndrome are motor compulsions.

Gilles de la Tourette syndrome

Gilles de la Tourette syndrome is a neurological disorder characterized by the presence of motor and vocal tics. Other associated features include complex motor and vocal tics, obsessive compulsive behavior and attention-deficit disorder. Although initially thought to be a rare condition, it now appears that the gene for Tourette syndrome may be present in as many as one in a thousand people, and is transmitted as an autosomal dominant trait. However, many individuals carrying the gene may exhibit only minimal symptoms. Neuropathophysiology of Tourette syndrome is unknown but investigations have suggested that the cause may be an abnormality either in the dopaminergic or endorphin receptor system within the basal ganglia. Treatment of Tourette syndrome involves education and counseling of the patient and family. Medications such as neuroleptics, serotonin-reuptake inhibitors, and stimulants are available to treat the manifestations of Tourette syndrome and need to be individualized for each patient.

Developmental psychopathology and neurobiology of Tourette's syndrome

OBJECTIVE

The authors present a model of the developmental psychopathology and neurobiology of Tourette's syndrome that provides a framework for ongoing research and treatment.

METHOD

The model is based on clinical experience and a selective review of relevant scientific literature.

RESULTS

During the past decade, Tourette's syndrome and related conditions have emerged as model disorders to study the interplay of genetic, neurobiological, psychological, and environmental factors during development. Although prevention and treatment are paramount, the effectiveness of these interventions depends on the quality and extent of our knowledge. Programmatic research combined with sustained clinical care has led to advances in our knowledge of the natural history of these disorders over the course of development and glimpses of the pathophysiologic and psychopathological mechanisms that mediate their expression in vulnerable persons.

CONCLUSIONS

In the future, we expect that our understanding will extend from the molecular level of how specific genes and epigenetic factors confer and mediate vulnerability to an understanding of why certain symptoms emerge when they do in the course of central nervous system development.

Blunted growth hormone response to clonidine in Gilles de la Tourette syndrome

Noradrenergic mechanisms have been involved in the pathogenesis of Gilles de la Tourette Syndrome (GTS). Since the central alpha 2 adrenergic agonist clonidine is widely used as a therapeutic agent in GTS, the present study aimed at assessing whether GH release after clonidine, representing central alpha 2-adrenergic receptor sensitivity, was altered in GTS. After administration of 2 micrograms/kg body weight clonidine, the GH response was examined in nine drug-free, alcohol-abstinent GTS patients (eight men, one woman) and in nine age- and sex-matched abstinent healthy controls. A blunted response of GH release (< 5 ng/ml) was observed in seven patients and the area under the curve (AUC) of the GH-release was significantly reduced (p < .01) compared to controls. This finding indicates an involvement of the noradrenergic system in GTS.

The psychopharmacology of obsessive compulsive disorder. Implications for treatment and pathogenesis

Recent advances in the pharmacotherapy of obsessive compulsive disorder (OCD) have led to a significant reduction in suffering and a return to productive living for many patients previously considered refractory to treatment. Potent inhibitors of 5-hydroxytryptamine (5-HT) re-uptake clearly have been established as the first-line pharmacotherapy for treatment of OCD. The addition of agents that enhance 5-HT neurotransmission to ongoing treatment in patients whose OCD is refractory to 5-HT re-uptake inhibitors has not yielded impressive results. The addition of dopamine (DA) antagonists to the regimens of treatment-resistant patients appears to be a potentially useful strategy for the specific subgroup of OCD patients with a comorbid chronic tic disorder such as Tourette's syndrome. Pharmacologic studies suggest that both the 5-HT and DA systems may be critical to the treatment and possibly the pathophysiology of OCD.

An idiot savant calendrical calculator with Gilles de la Tourette syndrome: implications for an understanding of the savant syndrome

We describe the existence of the savant syndrome in association with Gilles de la Tourette's Syndrome (GTS). The presentation of savant abilities is typical of that previously described. Similarities between autism, the disorder most characteristically associated with savants, and GTS in terms of obsessionality are noted. Previously reported psychological studies of autistic savants are briefly reviewed and, together with evidence from neuroimaging in GTS, obsessive compulsive disorder (OCD), and autism, used to support a model of the underpinnings of savant skills.

Contingent negative variation in Gilles de la Tourette syndrome

The Contingent Negative Variation (CNV) may measure arousal and attention, and is affected by various dopaminergic disorders. We recorded CNVs in 12 patients fulfilling diagnostic criteria of Gilles de la Tourette Syndrome (TS). Ten of 12 patients were male, 10 had attention deficit disorder (ADD), and 3 also had obsessions and compulsions (OCD). Medication had been stopped or TS treatment not yet started. TS patients had higher CNV amplitude and more frequent postimperative negative variation than controls. CNV2 was enhanced in all TS patients, while CNV1 was attenuated in TS patients with ADD or OCD. This suggests that CNV may be increased in TS, mostly because of CNV2 and perhaps due to dopaminergic excess. CNV2, considered to reflect adrenergic arousal mechanisms, may be effected by neurobehavioral concomitants of TS. Neurophysiological categorization of TS patients may be possible and valuable.

Impairment of retinal increment thresholds in Huntington's disease

We have investigated detection thresholds for a foveal blue test light using a Maxwellian view system in 61 normal subjects, 19 patients with Huntington's chorea, 14 patients with Tourette's syndrome, and 20 patients with schizophrenia. Ten measurements were made: The blue test light (1 degree diameter, 500 msec duration) was presented either superimposed on a yellow adaptation field (5 degree diameter) or 500 msec after switching off this field (transient tritanopia effect). In both cases five different background intensities were presented. The only abnormality found was in patients with Huntington's chorea. During adaptation these patients' thresholds are significantly higher than normal (p < 0.005). No change was found in the transient tritanopia effect. Huntington's disease causes degeneration of several different transmitter systems in the brain. Increment threshold testing allows for noninvasive investigation of patients and confirms the involvement of the retina in the degenerative process in Huntington's chorea.

Definitions and classification of tic disorders. The Tourette Syndrome Classification Study Group

Tics are brief movements (motor tics) or sounds (vocal tics) that occur intermittently and unpredictably out of a background of normal motor activity. Although tics can appear as the result of direct brain injury (so-called symptomatic, eg, from head trauma or encephalitis), they most commonly are idiopathic and are part of the spectrum of Gilles de la Tourette syndrome or other idiopathic tic disorders. To aid investigators searching for the gene(s) causing Tourette syndrome, criteria are proposed to classify the idiopathic tic disorders. Although some of these separate entities may ultimately be shown to be caused by the same gene, until that is established, it is considered best when searching for the Tourette's gene to have tic disorders classified into distinct, homogeneous entities. The proposed classification will likely change over time as better diagnostic techniques become available and can both expand and consolidate, particularly after the Tourette gene is located.

Tourette's syndrome and right hemisphere dysfunction

Poor performances of patients with Tourette's syndrome (TS) on tests requiring visual-perceptual abilities had led previous authors to the suggestion of right hemisphere involvement. We have compared the results of neuropsychological examination of 16 children with TS, with those of 16 children with a lesion of the right hemisphere. No evidence was found of a dysfunction of the right hemisphere in TS.

Extrapyramidal disorders in childhood

The term extrapyramidal system originally referred to the system concerned with motor function other than the pyramidal tract. This review covers papers that concern the basal ganglia and related structures except disorders relating to the cerebellum. Because the pathophysiologies of these disorders remain unknown, I review those papers that focused or implicated these points.

Neuroendocrine and behavioral effects of the selective kappa agonist spiradoline in Tourette's syndrome: a pilot study

To evaluate the role of opioids in Tourette's syndrome (TS), we performed a dose-response study of the behavioral and neuroendocrine effects of the selective kappa agonist spiradoline mesylate (U-62066E) in five TS patients and five normal control subjects, aged 20 to 47. The intramuscularly administered doses of spiradoline were 0.0, 0.8, 1.6, and 3.2 micrograms/kg. Baseline and postdrug tic frequencies were determined from "blind" videotape tic counts and bedside clinician ratings. In comparison with placebo, the lowest dose of spiradoline was associated with significant decreases in cumulative postdrug counts of total tics and phonic tics, as well as in clinician ratings of postdrug motor tic frequencies. By contrast, there was a trend for tic frequencies to increase following the intermediate dose (1.6 micrograms/kg) of spiradoline. As a group, the TS subjects also secreted significantly more growth hormone following the 1.6 micrograms/kg dose of spiradoline than did the normal control subjects. These preliminary findings provide additional evidence for the involvement of opioids in TS and suggest (1) that opioids may exert dual modulatory effects on the expression of tic symptoms and (2) that some TS patients may be characterized by increased sensitivity of kappa receptors regulating growth hormone secretion.

Severe disturbances in speech, swallowing, and gait following stereotactic infrathalamic lesions in Gilles de la Tourette's syndrome

A 40-year-old man with severe Gilles de la Tourette's syndrome characterized by forceful self-injurious motor tics, coprolalia, and obsessive-compulsive disorder had bilateral anterior cingulotomies and bilateral infrathalamic lesions placed stereotactically during two neurosurgical procedures. During the second procedure, the patient acutely developed a marked dysarthria. Postoperatively, he manifested a severe gait disturbance with postural instability, bradykinesia, axial rigidity, micrographia, and a profound swallowing disorder. MRI showed asymmetric (left > right) low-density areas in an infrathalamic region as well as low-density areas bilaterally in the anterior cingulate gyri. Although the patient's tic and obsessive-compulsive symptoms improved, the self-injurious motor tics along with other motor and phonic tics have recurred. The patient's speech remains largely unintelligible 8 months following the last surgical procedure, and the other neurologic deficits remain unchanged.

Volumetric MRI changes in basal ganglia of children with Tourette's syndrome

To define the site of pathology in Tourette's syndrome (TS), we performed a volumetric MRI study of basal ganglia structures and lateral ventricles on 37 children with this disorder and 18 controls. There were no statistically significant differences in the size of the right or left caudate, putamen, globus pallidus, or ventricles in these populations. In contrast, there were significant differences for measures of symmetry in the putamen and the lenticular region. Virtually all controls (17 right- and one left-handed) had a left-sided predominance of the putamen, whereas in 13 of 37 TS subjects, a right predominance exceeded that of any control. Statistical comparisons among TS patients, with (n = 18) or without (n = 19) attention-deficit hyperactivity disorder (ADHD), and controls showed significant differences for the volume of the left globus pallidus and for lenticular asymmetry. Post hoc evaluations showed that in the TS + ADHD group, the volume of the left globus pallidus was significantly smaller than the volume of the right and that lenticular asymmetry was due to a greater right-sided predominance in the TS+ADHD group. This study lends further support to proposals that claim the basal ganglia is involved in the pathogenesis of TS and also suggests that the comorbid problem of ADHD is related to regional changes that differ from those primarily associated with tics.

Exclusion of close linkage of Tourette's syndrome to D1 dopamine receptor

OBJECTIVE

The authors' goal was to establish if a mutation in D1 dopamine receptor locus (DRD1), or one genetically close to it, could cause Gilles de la Tourette's syndrome.

METHOD

DRD1 and linked markers (D5S36, D5S61, and D5S62) were studied in a large Mennonite Tourette's syndrome kindred. Only individuals with the full Tourette's syndrome were considered to be affected in one series of analyses; in another series the diagnostic spectrum was broadened to include chronic multiple tics. Liability classes were defined to take into account age at onset and sex differences; dominant inheritance was assumed. The authors' version of the LINKMAP program of the LINKAGE package modified to run under distributed parallel processing (Linda LINKMAP) was used for the multipoint linkage analysis.

RESULTS

Complete (theta = 0.0) linkage of Tourette's syndrome with DRD1 was ruled out (lod score of -10.1) when the disease was defined narrowly. The area of exclusion of linkage (lod score between -2 and -10.5) extended from map position -0.10 to map position 0.50. The authors conducted an additional (centromeric) multipoint analysis with D5S36 as well as glucocorticoid receptor (GRL) and D5S22, resulting in an overlapping area of exclusion to map position -0.30 when the disease was defined narrowly.

CONCLUSIONS

This result provides strong evidence against linkage of the DRD1 D1 dopamine receptor locus with Tourette's syndrome. This exclusion extends the authors' earlier work with the dopamine system in Tourette's syndrome to exclude the two best characterized dopamine receptors from linkage with Tourette's syndrome.

"Signing tics"--insights into the pathophysiology of symptoms in Tourette's syndrome

We describe the case of a young woman with Tourette's syndrome who incorporated sign language into her tic behavior. Sign language was used in complex "phonic tics" such as swearing, echoing what others said, or repeating what she said, read, or thought. We suggest the descriptive terms "coprolaliopraxia," "echolaliopraxia," and "palilaliopraxia" to denote these symptoms. The incorporation of such complex, learned movements into the repertoire of hyperkinesias further emphasizes the complicated association between purposeful and automatic execution of movements comprising tic behavior. This case also provides strong evidence against the suggestion that obscenities vocalized in Tourette's syndrome are due to a random generation of high-probability sequences of letters or phonemes.

Premonitory urges in Tourette's syndrome

OBJECTIVE

Tourette's syndrome traditionally has been viewed as a hyperkinetic movement disorder characterized by involuntary motor and phonic tics. Many patients, however, describe their tics as a voluntary response to premonitory urges. This cross-sectional study evaluated premonitory urges and related phenomena in subjects with tic disorders.

METHOD

A total of 135 subjects with tic disorders, aged 8 to 71 years, completed a questionnaire concerning their current and past tic symptoms. Subjects were asked to describe and, if possible, localize their premonitory urges. The Yale Global Tic Severity Scale was used to assess current tic severity. The method of case finding does not provide prevalence data for premonitory urges.

RESULTS

Ninety-three percent of the subjects reported premonitory urges. Anatomical regions with the greatest density of urges were the palms, shoulders, midline abdomen, and throat. Eighty-four percent of the subjects reported that tics were associated with a feeling of relief. A substantial majority (92%) also indicated that their tics were either fully or partially a voluntary response to the premonitory urges.

CONCLUSIONS

While epidemiological studies of tic disorders have yet to incorporate questions concerning premonitory urges, these results suggest that such urges may be commonplace in adolescent and adult subjects with tic disorders. These results challenge the conventional wisdom that tic behaviors are wholly involuntary in character. They also implicate brain regions involved in the processing of sensorimotor information in the pathobiology of tic disorders.

Gilles de la Tourette's syndrome: a case study

Tourette's Syndrome was first described by Gilles de la Tourette in 1885. Previously thought to be a rare neuropsychiatric disorder, its prevalence is now estimated at 0.05%. In Canada, this would mean approximately 12,000 people are affected. The rapid growth of knowledge in the neurosciences has led to better understanding and treatment of this disorder. Tourette's Syndrome is characterized by motor tics, usually beginning in the face and progressing to other areas, and by vocal tics, such as hissing, snorting, and barking. Fifty percent also develop copralalia. The age of onset is between 2 and 15 years of age but its complex symptomatology and its waxing and waning course delays diagnosis. This paper will describe the disease process including etiology, signs and symptoms, and treatment. The main focus will be on a case study which will depict how this syndrome affected the life of one woman. The multidisciplinary approach required to assist the severely affected individual to return to her family following successful treatment will be described.

Anatomy of self-injurious, stereotypic, and aggressive movements: evidence for involuntary explanation

Self-injurious movements, common in persons diagnosed with Tourette syndrome, or mental retardation, are typically difficult to eliminate. The author considers the possibility that certain self-injurious movements are involuntary phenomena. An anatomical analysis of high-frequency movements in a patient with severe head slapping is presented by tracing the muscles and nerves involved. The median nerve innervates muscles that bring the hand/arm to the head and also muscles that control this patient's other frequent movements, viz., pill-rolling, thumb-gouging, wrist-flapping, and pinching the neck or cheek. Other patients underwent similar investigation: one who headbangs, one who hits out repetitively, and one with non-injurious stereotypic movements. An anatomical explanation suggests that certain self-injurious, aggressive, and stereotypic movements are involuntary muscle contractions that reflect abnormal innervation along specific nerves.

Steroid hormones and CNS sexual dimorphisms modulate symptom expression in Tourette's syndrome

We present our hypothesis that various steroid hormones play an important role in the symptom expression of Gilles de la Tourette's syndrome (TS) and that androgenic hormones, in particular, are likely to exacerbate symptoms of the disorder. We review the clinical evidence supporting our hypothesis. Sex steroids establish brain sexual dimorphisms early in CNS development, and we suggest mechanisms whereby androgenic and other hormonal changes later in human development might act at dimorphic brain regions to influence the natural history of TS. Finally, we discuss the various ways in which neuroendocrine studies might assist in genetic and neurobiologic research programs in TS.

The role of the amygdaloid complex in Gilles de la Tourette's syndrome

Gilles de la Tourette's syndrome (GTS) is a relatively rare neuropsychiatric disorder characterised by multiple motor tics accompanied by vocalisations. It usually starts in early childhood and is more common in males than females. Obsessional compulsive disorder (OCD) is an integral part of GTS (Robertson, 1989). GTS is also associated with coprolalia, copropraxia, and other echophenomena, as well as attention-deficit disorder, self-injury, and other behaviour problems (Robertson et al, 1988; Robertson, 1989). Family pedigree studies have demonstrated that most GTS cases in the community are mild and do not receive medical attention (Kurlan et al, 1987; Robertson & Gourdie, 1990).

Tourette's syndrome and neonatal anoxia: further evidence of an organic etiology

Studies of Tourette's syndrome have indicated that the etiology may be either primary or secondary. Secondary Tourette's syndrome has been reported in association with numerous neurological conditions, but there have been no previous reports of Tourette's syndrome and its relationship to neonatal anoxia. This report presents the case of a 15-year-old boy with a history of Tourette's syndrome and neonatal anoxia and examines whether or not there is a connection between the two. To test the hypothesis that this is the first documented case of cerebral anoxia at birth followed by Tourette's, a review of the pertinent literature on secondary Tourette's syndrome is presented. Evidence of perinatal anoxia, subsequent Tourette's syndrome, a negative family history, as well as an examination of the statistical chances of anoxia and Tourette's syndrome co-existing and of all previous reports of acquired Tourette's syndrome tend to favor an organic perinatal insult as having caused the later development of Tourette's syndrome in the case of this adolescent.

Sensory phenomena associated with Gilles de la Tourette's syndrome

BACKGROUND

Our study was conducted to characterize sensory phenomena experienced by Gilles de la Tourette's syndrome (TS) sufferers. Specific foci of the study were premonitory urges associated with motor and phonic tics, site sensitization, and disinhibition behaviors.

METHOD

Twenty-eight subjects were recruited for participation in the study from the Tourette's Syndrome Association and from neurologists' patient lists. All had been diagnosed as having TS at least 2 years prior to the study. Patients were contacted by telephone and questioned in an attempt to screen for participants who experienced some sensory phenomena preceding or accompanying their tics. Interviews were conducted in person with 27 of the participants and by telephone with 1 participant.

RESULTS

Twenty-two (82%) of the 28 subjects experienced premonitory urges prior to motor and vocal tics. Of these 22, 13 (57%) found the premonitory urges more bothersome than the tics themselves, and 12 (55%) thought the premonitory urges enhanced their ability to suppress tics. Of 20 subjects questioned about site sensitization, 14 (70%) had heightened sensitivity to tactile, auditory, and/or visual stimuli. Disinhibition-complex behaviors the subject knows are dangerous or inappropriate but feels incapable of refraining from--was found in 10 (36%) of the 28 subjects and occurred only in subjects experiencing premonitory urges. Premonitory urges and site sensitivity can occur alone or together. Several excellent narrative descriptions of sensory phenomena associated with TS were also obtained.

CONCLUSION

Much information was gained that adds to the ongoing attempt to characterize sensory phenomena associated with TS. The sensory phenomena must be understood by clinicians who treat TS sufferers, as this study shows that they add significantly to the impairment caused by TS.

Cassette EEG sleep recordings in Gilles de la Tourette syndrome

Tourette syndrome (TS) patients often complain of sleep problems, and questionnaire studies indicate that sleep disturbance is frequent. Decreased slow wave sleep and increased awakenings have been reported in laboratory polysomnography in TS patients, and a serotoninergic disorder of arousal has been postulated. We recorded outpatient sleep in 20 patients newly diagnosed with TS utilizing a 4-channel cassette EEG system. The newly-diagnosed patients were predominantly male, and ranged in age from 10 to 36 years. Some had taken psychotropic medications in the past, but none had been treated systematically for TS. Seven patients had chronic tics only, 8 had tics and attention deficit-hyperactivity, and 5 had tics plus obsessions and compulsions. None had other medical, neurologic, or psychiatric disorders. All were nocturnal sleepers, and were recorded in their usual sleeping environments and routines. TS patients had reduced sleep, decreased sleep efficiency, increased awakenings, and decreased slow wave sleep. Tic patients had increased nocturnal awakenings and movements, particularly those who had tics during sleep. Sleep fragmentation and loss of slow wave sleep was most marked in TS patients with attention deficit-hyperactivity. Sleep latency was increased, REM sleep reduced, and REM sleep latency decreased in TS patients with obsessions and compulsions. These findings accord with previous reports of sleep disturbance in TS, and suggest that these disturbances may vary with TS symptoms. Chronic tics may persist in sleep and cause awakenings, TS with attention deficit may be associated with a disorder of arousal and alertness, and obsessions and compulsions may be manifestations of a biochemical disturbance involving paradoxical sleep.

Non-invasive assessment of autonomic nervous function in Gilles de la Tourette syndrome

Autonomic nervous function was investigated in 18 Gilles de la Tourette (GTS) patients and in 23 controls, who matched the patients in age, sex, baseline blood pressure and baseline heart rate. Four heart rate tests were used (variation at rest, during deep breathing, following standing up and during a Valsalva manoeuvre), and two blood pressure tests (standing up and sustained handgrip). The only significant difference between the groups was found in the Valsalva test. This was due to the initial heart rate increase which was higher in the GTS group; the subsequent decrease did not differ between the groups. Increased sympathetic activity is a possible explanation for this finding, but no additional evidence in its favour was found. No signs of autonomic failure were found.

Tics and myoclonus

This article describes advances occurring over the last year in the pathophysiology, etiology and treatment of tics and myoclonus. Progress is being made in the clinical definition of Tourette syndrome (TS). The search for the TS gene has already excluded more than 50% of the autosomal genome. Progress in the understanding of myoclonus is slow but continuous. Several paper are devoted to clinical aspects but much recent attention has been focused on the pathophysiological mechanisms underlying myoclonus.

Autosomal dominant gene transmission in a large kindred with Gilles de la Tourette syndrome

A multiplex kindred ascertained through a single proband with GTS has been systematically investigated with standardised diagnostic instruments for other cases of GTS and related disorders. Complex segregation analysis supported the hypothesis that a single major gene inherited in autosomal dominant fashion but with incomplete penetrance contributed most of the variance in the liability to develop GTS and related disorders. This result is consistent with previous segregation analyses which have employed different methods of ascertainment, and tends to confirm that a proportion of GTS is due to a dominant gene and is suitable for investigation with genetic markers for linkage analysis.

Decreased (3H) quinuclidinyl benzilate binding to lymphocytes in Gilles de la Tourette syndrome

In spite of an unknown pathophysiology, it has been suggested that central dopaminergic hyperactivity exists in Gilles de la Tourette syndrome (TS). Cholinergic influences have also been postulated as a dopaminergic-cholinergic balance seems to be important in other movement disorders. If TS is due to alterations of cholinergic activity, this may also be expressed at postsynaptic levels. Recently, we showed that circulating lymphocytes may serve as useful peripheral markers reflecting induced alterations or inherent changes in muscarinic receptors in the central nervous system (CNS). In the present study, we compared the muscarinic binding characteristics in peripheral lymphocytes as measured by (3H) quinuclidinyl benzilate [(3H)-QNB] in 27 unmedicated TS patients, against 22 healthy (age and gender-matched) controls. B(max) and Kd values were determined using Lineweaver-Burke plots. The mean B(max) values in nontreated TS patients was markedly and significantly lower than in controls (10.59 +/- 8.4 versus 40.16 +/- 9.2 fmole/10(6) cells, p less than 10(-6), while Kd values were similar in both groups. Our findings suggest that changes in cholinergic receptors may play a role in the pathophysiology of Tourette syndrome.

Adult tics in Gilles de la Tourette's syndrome: description and risk factors

We studied 58 adults with Gilles de la Tourette's syndrome diagnosed during childhood. Tics persisted in all patients but were moderate/severe in only 24%, compared with 60% at the time of worst function. Coprolalia persisted in 4%, compared with 22% at the time of worst function. For most patients, worst function occurred in adolescence (mode = 13 years). In spite of a high frequency of school and behavioral problems during development, 98% graduated high school and 90% were full-time students or fully employed. Features predictive of mild tic severity in adulthood were mild tics during the patient's worst pre-adulthood function and mild tics during early and late adolescence. Childhood tic severity had no predictive value, and likewise, coprolalia during development did not increase the risk for adult moderate/severe tics.