Annotation: Gilles de la Tourette syndrome--an update

Clinical features and neuropsychiatric comorbidities in pediatric patients with tic disorders: a retrospective chart review study from South Korea

BACKGROUND

Tic disorders are childhood-onset neuropsychiatric disorders characterized by multiple motor or vocal tics with frequent comorbidities and a broad spectrum of phenotypic presentations. In this study, we aimed to investigate the clinical characteristics and comorbid neuropsychiatric conditions in pediatric patients with tic disorders.

METHODS

We retrospectively reviewed the medical records of 119 pediatric patients (89 males, 30 females) who were diagnosed with tic disorders according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) at Uijeongbu St. Mary's Hospital, Republic of Korea, between January 2012 and July 2019.

RESULTS

The mean age of tic onset was 6.9 years (range, 1-14) and the mean age at diagnosis was 8 years (range, 1-17). The mean lag between tic onset and diagnosis was 13.3 months (range, 0.25-132). The most common, first-presenting tics were eye blinking (50.4%), followed by jaw or lip movement (29.4%) and throat clearing (29.4%). Thirty-seven (31.1%) patients had at least one co-occurring neuropsychiatric disorder at the time of tic diagnosis. Subtypes of tic disorders, types of initial tics, and presence of neuropsychiatric comorbidities were not associated with tic severity. Tic severity was associated with greater functional impairment and tic noticeability (p < 0.05). A relatively shorter time to diagnosis was associated with tic severity (Spearman's ρ = - 0.14, p = 0.11).

CONCLUSIONS

The evolving nature of tic expression and severity, high prevalence of neuropsychiatric comorbidities, and associated functional impairments emphasize the importance of comprehensive assessment during the disease course for determining and prioritizing goals of treatment.

Clinical and attentional effects of acute nicotine treatment in Tourette’s syndrome

Evidence from pre-clinical infrahuman investigations, open-label clinical trials, and a single controlled trial found acute nicotine treatment potentiated up to 4 weeks neuroleptic-induced reductions of dyskinetic symptoms characterizing Tourette’s syndrome (TS). Given the attentional disturbances associated with this syndrome, and the improvements in attentional processes reported with nicotine, this randomized, double-blind, placebo-controlled trial examined the acute (4 h) and sustained (2 weeks) effects of a single dose of transdermal nicotine on clinical (i.e., tics), attentional (continuous performance task, event-related potentials, patient and parental reports) and behavioral symptoms in 23 children and adolescents with TS receiving neuroleptic treatment. In the 14 evaluable patients with complete primary efficacy data, nicotine (compared to placebo) failed to alter symptoms at 4 h but counteracted ERP-P300 signs of diminished attention seen 2 weeks following placebo treatment. Secondary efficacy measures, including patient self-reports and parental ratings, found nicotine to reduce complex tics and improve behaviors related to inattention. Additional work with intermittent dosing schedules is required to characterize optimal clinical and cognitive effects with nicotine treatment.

Genetic and Epigenetic Etiology Underlying Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a pervasive neurodevelopmental disorder characterized by difficulties in social interaction, language development delays, repeated body movements, and markedly deteriorated activities and interests. Environmental factors, such as viral infection, parental age, and zinc deficiency, can be plausible contributors to ASD susceptibility. As ASD is highly heritable, genetic risk factors involved in neurodevelopment, neural communication, and social interaction provide important clues in explaining the etiology of ASD. Accumulated evidence also shows an important role of epigenetic factors, such as DNA methylation, histone modification, and noncoding RNA, in ASD etiology. In this review, we compiled the research published to date and described the genetic and epigenetic epidemiology together with environmental risk factors underlying the etiology of the different phenotypes of ASD.

Significant Tic Reduction in An Otherwise Treatment-Resistant Patient with Gilles de la Tourette Syndrome Following Treatment with Nabiximols

Early anecdotal reports and preliminary studies suggested that cannabinoid-based medicines such as delta-9-tetrahydrocannabinol (THC) are effective in the treatment of Gilles de la Tourette syndrome (TS). We report a single case study of a patient with otherwise treatment-resistant TS successfully treated with nabiximols. Our patient was a 22-year-old male suffering from severe and complex TS. Treatment with nabiximols was commenced at a dose of 1 puff/day (= 100 μL containing 2.7 mg THC and 2.5 mg cannabidiol (CBD)) and slowly increased up to a dosage of 3 × 3 puffs/day (= 24.3 mg THC and 22.5 mg CBD). Several clinical measures for tics, premonitory urges, and global impairment were acquired before and after two weeks of treatment. Treatment with nabiximols resulted in major improvements of both tics and premonitory urges, but also global impairment and health-related quality of life according to all used measurements without causing relevant adverse effects. Our results provide further evidence that treatment with nabiximols may be effective in the treatment of patients with TS. Given the positive response exhibited by the patient highlighted in this report, further investigation of the effects of nabiximols is proposed on a larger group of patients in a clinical trial setting.

Clinical effectiveness and patient perspectives of different treatment strategies for tics in children and adolescents with Tourette syndrome: a systematic review and qualitative analysis

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental condition characterised by chronic motor and vocal tics affecting up to 1% of school-age children and young people and is associated with significant distress and psychosocial impairment.

OBJECTIVE

To conduct a systematic review of the benefits and risks of pharmacological, behavioural and physical interventions for tics in children and young people with TS (part 1) and to explore the experience of treatment and services from the perspective of young people with TS and their parents (part 2).

DATA SOURCES

For the systematic reviews (parts 1 and 2), mainstream bibliographic databases, The Cochrane Library, education, social care and grey literature databases were searched using subject headings and text words for tic* and Tourette* from database inception to January 2013.

REVIEW/RESEARCH METHODS

For part 1, randomised controlled trials and controlled before-and-after studies of pharmacological, behavioural or physical interventions in children or young people (aged < 18 years) with TS or chronic tic disorder were included. Mixed studies and studies in adults were considered as supporting evidence. Risk of bias associated with each study was evaluated using the Cochrane tool. When there was sufficient data, random-effects meta-analysis was used to synthesize the evidence and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. For part 2, qualitative studies and survey literature conducted in populations of children/young people with TS or their carers or in health professionals with experience of treating TS were included in the qualitative review. Results were synthesized narratively. In addition, a national parent/carer survey was conducted via the Tourettes Action website. Participants included parents of children and young people with TS aged under 18 years. Participants (young people with TS aged 10-17 years) for the in-depth interviews were recruited via a national survey and specialist Tourettes clinics in the UK.

RESULTS

For part 1, 70 studies were included in the quantitative systematic review. The evidence suggested that for treating tics in children and young people with TS, antipsychotic drugs [standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -1.08 to -0.41; n = 75] and noradrenergic agents [clonidine (Dixarit(®), Boehringer Ingelheim) and guanfacine: SMD -0.72, 95% CI -1.03 to -0.40; n = 164] are effective in the short term. There was little difference among antipsychotics in terms of benefits, but adverse effect profiles do differ. Habit reversal training (HRT)/comprehensive behavioural intervention for tics (CBIT) was also shown to be effective (SMD -0.64, 95% CI -0.99 to -0.29; n = 133). For part 2, 295 parents/carers of children and young people with TS contributed useable survey data. Forty young people with TS participated in in-depth interviews. Four studies were in the qualitative review. Key themes were difficulties in accessing specialist care and behavioural interventions, delay in diagnosis, importance of anxiety and emotional symptoms, lack of provision of information to schools and inadequate information regarding medication and adverse effects.

LIMITATIONS

The number and quality of clinical trials is low and this downgrades the strength of the evidence and conclusions.

CONCLUSIONS

Antipsychotics, noradrenergic agents and HRT/CBIT are effective in reducing tics in children and young people with TS. The balance of benefits and harms favours the most commonly used medications: risperidone (Risperdal(®), Janssen), clonidine and aripiprazole (Abilify(®), Otsuka). Larger and better-conducted trials addressing important clinical uncertainties are required. Further research is needed into widening access to behavioural interventions through use of technology including mobile applications ('apps') and video consultation.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002059.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

New Insights into Clinical Characteristics of Gilles de la Tourette Syndrome: Findings in 1032 Patients from a Single German Center

Background: Gilles de la Tourette syndrome (TS) is a complex neuropsychiatric disorder defined by the presence of motor and phonic tics, but often associated with psychiatric comorbidities. The main objective of this study was to explore the clinical presentation and comorbidities of TS.

Method: We analyzed clinical data obtained from a large sample (n = 1032; 529 children and 503 adults) of patients with tic disorders from one single German TS center assessed by one investigator. Data was collected with the help of an expert-reviewed semi-structured interview, designed to assess tic severity and certain comorbidities. Group comparisons were carried out via independent sample t-tests and chi-square tests.

Results: The main findings of the study are: (1) tic severity is associated with the presence of premonitory urges (PU), copro-, echo-, and paliphenomena and the number of comorbidities, but not age at tic onset; it is higher in patients with comorbid obsessive-compulsive disorder (OCD) than in patients with comorbid attention deficit/hyperactivity disorder (ADHD). (2) PU were found to be highly associated with “not just right experiences” and to emerge much earlier than previously thought alongside with the ability to suppress tics (PU in >60% and suppressibility in >75% at age 8–10 years). (3) Self-injurious behavior (SIB) is highly associated with complex motor tics and coprophenomena, but not with OCD/obsessive-compulsive behavior (OCB). While comorbid ADHD is associated with a lower ability to suppress tics, comorbid depression is associated with sleeping problems.

Discussion: Our results demonstrate that tic severity is not influenced by age at onset. From our data, it is suggested that PU represent a specific type of “not just right experience” that is not a prerequisite for tic suppression. Comorbid ADHD reduces patients' ability of successful tic suppression. Our data suggest that SIB belongs to the coprophenomena spectrum and hence should be conceptualized as a complex tic rather than a compulsion. Finally, this study strongly supports the hypothesis that TS+OCD is a more severe form of TS and that comorbid OCD/OCB, depression, and anxiety belong to the TS spectrum, while ADHD should be better conceptualized as a separate problem.

Clinical correlates of tourette's disorder across cultures: a comparative study between the United Arab Emirates and the United Kingdom

BACKGROUND AND OBJECTIVE

Tourette's disorder is a neuropsychiatric disorder characterized by motor and vocal (phonic) tics. While the disorder has been researched extensively in the Western populations, the clinical correlates and associated features are less well known in other populations and cultures. This study examines the presentation and clinical correlates of Tourette's disorder in 2 distinct populations, namely the United Kingdom and the United Arab Emirates.

METHOD

A consecutive series of 35 Tourette's disorder patients of Arab descent recruited from 2001 to 2005 from the Child Psychiatry clinics in Al Ain, United Arab Emirates (U.A.E.), were compared with 35 age- and gender-matched white Tourette's disorder patients attending the Tourette Clinic at the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom, from December 2004 to December 2005.

RESULTS

Rates of occurrence of obsessive-compulsive disorder and attention-deficit/hyperactivity disorder were similar in the 2 cohorts. Coprolalia was higher in the U.K. cohort and was noted to correlate with the severity of Tourette's disorder. Comorbid oppositional defiant disorder and conduct disorder were also higher in the U.K. cohort (54.3% [N = 19] and 20.0% [N = 7], respectively) as compared to the U.A.E. cohort (11.4% [N = 4] and 5.7% [N = 2], respectively) but were not linked to any other clinical feature or severity of Tourette's disorder.

CONCLUSION

The findings illustrate the similarity in the core clinical symptoms between the 2 populations, thus emphasizing the underlying biological and genetic basis of these symptoms. However, our finding of higher occurrence of behavioral symptoms in the Western sample has implications for our understanding of the phenotypic presentation of Tourette's disorder as well as the management.

Consanguineous Iranian kindreds with severe Tourette syndrome

The search for vulnerability genes for Tourette syndrome has been ongoing for nearly three decades. The contribution of recessive loci with reduced penetrance is one possibility that has been difficult to explore. Homozygosity mapping has been successfully used to detect recessive loci within populations with high rates of consanguinity. Using this technique, even quite small inbred families can be informative due to autozygosity in which the two alleles at an autosomal locus are identical by descent (i.e., copies of a single ancestral gene). To explore the utility of this approach, we identified 12 consanguineous Iranian families. Remarkably, these families were seen with an unusual natural history characterized by the early onset of vocal tics and coprolalia and frequent comorbidity with obsessive-compulsive disorder. Genotyping the affected and unaffected members of these pedigrees has the potential to identify rare recessive contributions to this disorder.

The prevalence and epidemiology of Gilles de la Tourette syndrome. Part 2: tentative explanations for differing prevalence figures in GTS, including the possible effects of psychopathology, aetiology, cultural differences, and differing phenotypes

As has been demonstrated, Gilles de la Tourette Syndrome (GTS) occurs in at least 1% of the population worldwide. However, earlier studies suggested a lower prevalence. In addition, the prevalence figures for different studies very between 0.4% and 3.8%. Moreover, the prevalence appears to vary in some parts of the world and races, with a lower rate in Afro-Americans and sub-Saharan black Africans. In this the second part of the review, possible reasons for the differences in prevalence and epidemiology are discussed. Tentative explanations for differing prevalence figures in GTS include problems with the diagnosis of GTS, the multidimensional nature of tics, as well as other tic factors including the waxing and waning of symptoms and the suppressibility of symptoms. Other factors inherent to GTS include the fact that there is no diagnostic test and indeed no definitive diagnosis other than clinical, the fact that psychosocial stresses can lead to increased tic severity, and that comorbid disorders may mask tics. The varying methods of study employed can also effect prevalence. There may be some regional differences in GTS as well, which may be due to a lack of awareness of GTS, or it may be a true reflection of low prevalence as in some populations GTS does appear rare. With regard to the sub-Saharan Africa data and possibly the African American data, matters are much more complex than meets the eye. The following reasons are all possible for the apparent rarity in these populations and include (i) other medical priorities and less propensity to seek health care, (ii) lack of awareness of GTS, (iii) chance, (iv) ethnic and epigenetic differences and reasons, (v) genetic and allelic differences in different races, and (vi) an admixture of races. The aetiology of GTS is also complex, with influences from complex genetic mechanisms, pre- and perinatal difficulties and, in a subgroup, some infections, possibly by epigenetic mechanisms. These may well affect phenotype and, thus, prevalence. There have even been suggestions that people with GTS are increasing. Recent data suggests that GTS is not a unitary condition and that there may well be different types of GTS. The prevalence of GTS in these individual subtypes is unknown. It is suggested that a new nomenclature be adopted for GTS in future, pending further genetic and phenomenological studies. To what extent the aetiology affects the phenotype and, thus, the prevalence is still unclear.

The prevalence and epidemiology of Gilles de la Tourette syndrome. Part 1: the epidemiological and prevalence studies

The prevalence and epidemiology of Gilles de la Tourette syndrome (GTS) are more complex than was once thought. Until fairly recently, GTS was thought to be a rare and, according to some, a psychogenically mediated disorder. Prevalence depends, at least in part, on the definition of GTS, the type of ascertainment, and epidemiological methods used. However, in dedicated specialist GTS clinics, the majority of patients were noted to have positive family histories of tics or GTS, and large, extended, multiply-affected GTS pedigrees indicated that many family members had undiagnosed tics or GTS: it was therefore realized that GTS was far from uncommon. Seven early epidemiological studies reported that GTS was uncommon or rare for a variety of reasons. More recently, however, two pilot studies and 12 large definitive studies in mainstream school and school-age youngsters in the community, using similar multistage methods, have documented remarkably consistent findings, demonstrating prevalence figures for GTS of between 0.4% and 3.8% for youngsters between the ages of 5 and 18 years. Of the 420,312 young people studied internationally, 3,989 (0.949%) were diagnosed as having GTS. It is therefore suggested that a figure of 1% would be appropriate for the overall international GTS prevalence figure. There were however, "outliers" to the figure. For instance, GTS does seem to be substantially rarer in African-American people and has been reported only very rarely in sub-Saharan black African people. GTS is found in all other cultures, although to possibly differing degrees. In all cultures where GTS has been reported, the phenomenology is similar, highlighting the biological underpinnings of the disorder.

Evaluating dopamine transporter activity with 99mTc-TRODAT-1 SPECT in drug-naive Tourette's adults

OBJECTIVES

Findings on imaging of dopamine transporter (DAT) activity in patients with Tourette's syndrome remain inconclusive. The present study was carried out to observe DAT activity in patients with well-controlled Tourette's syndrome by using (99m)Tc-TRODAT-1 single photon emission computerized tomography (SPECT).

METHODS

Six drug-naive patients with Tourette's syndrome (mean age+/-SD, 21.2+/-1.5 years) were recruited. All met the criteria for Tourette's syndrome established in the DSM-IV. Seventeen age-matched and sex-matched healthy subjects served as the controls. Brain SPECT were acquired 165-195 min after administrating 740 MBq of (99m)Tc-TRODAT-1, using a double-headed camera equipped with ultra-high-resolution fan-beam collimators. The specific uptake ratio was calculated by subtracting the mean counts per pixel in the occipital cortex from the mean counts per pixel in the striatum, putamen or caudate nucleus and by dividing the result by the mean counts per pixel in the occipital cortex. Tic-severity scores were also measured and correlated with the specific uptake ratios.

RESULTS

No significant difference in DAT activity between patients with Tourette's syndrome and control subjects was found in the striatum and its sub-regions. Tic-severity scores were also not correlated with specific uptake ratios measured from the striatum and its sub-regions.

CONCLUSIONS

In conjunction with previous findings, our results suggested that functional abnormality of the dopamine system in patients with Tourette's syndrome might be evident only in its early stage. Adaptation to tic symptoms might play a role in regulating the neural system.

Tic disorders and obsessive compulsive disorder: where is the link?

Over the last years evidence on the overlap between tic-disorders (TD) and obsessive compulsive behavior/disorder (OCB/OCD) has increased. The main focus of research have been the phenomenological and epidemiological similarities and differences in samples of different age, primary diagnosis (TD vs. OCD) including the co-occurrence of both. Unfortunately, only a minority of studies included all three groups (TD, TD + OCD, OCD). Nevertheless, new insight concerning possible subtypes for both TD and OCD has been gained. While some authors concentrated on OCD with/without tics we will summarize the field of TD and OCB/OCD from the viewpoint of tics, since OCB plays an important role in patients with TD. Thereby we will not only sharpen the clinicans' awareness of known differences in phenomenology, epidemiology, genetics and neurobiology, aimed to improve their diagnoses and treatment but also highlight the gaps of knowledge and discuss possibilities for further research in this field.

Tourette syndrome and other tic disorders in a total population of children: clinical assessment and background

AIM

To describe the symptoms, onset, heredity, pre-/perinatal events and socio-economic status in Tourette syndrome (TS) and other tic disorders.

METHODS

From a total population of 4479 children, 25 (0.6%) with TS, 58 (1.3%) with chronic motor/vocal tics (CMVT) and 214 (4.8%) with transient tics (TT) in the last year were found. A three-stage procedure was used: tic screening, telephone interview and clinical assessment. The TS group was compared with 25 children with TT and 25 controls without tics.

RESULTS

The mean age of the first symptoms of TS was significantly lower than the onset of CMVT. All except one with TS had contact with medical services. The tics of children with TS were significantly more severe than the tics of others. Younger age of onset of TS indicated more severe tics. Parents and siblings of children with TS had an increased prevalence of tic disorders, obsessive-compulsive behaviour (OCD), attention-deficit/hyperactivity disorder (ADHD) and depression. Eighty per cent had a first-degree relative with a psychiatric disorder. A non-significant increase with regards to reduced optimality score in the pre-, peri- or neonatal periods was found in children with TS compared to controls. No differences were found concerning socio-economic status.

CONCLUSION

Almost all children from a total population with TS have sought help from medical services. An increased prevalence of tics, OCD, depression or ADHD was found in the parents/siblings of children with TS, which draws attention to the importance of thorough investigation of family members.

Dopamine transporter binding in Gilles de la Tourette syndrome: a [123I]FP-CIT/SPECT study

OBJECTIVE

To investigate dopamine transporter binding in Gilles de la Tourette syndrome (GTS) with SPECT and [123I]FP-CIT.

METHOD

Ten neuroleptic naïve/free patients with GTS, and 10 age- and gender-matched normal volunteers were studied. Subjects were clinically evaluated. GTS severity and affective symptoms were measured and the presence of GTS-related behaviours were recorded.

RESULTS

The GTS group showed significantly higher binding in both caudate and putamen nuclei than the controls. No associations were found between striatal binding ratios and measures of affect or GTS-related behaviours.

CONCLUSION

Patients with GTS show higher striatal binding of FP-CIT to the striatum in comparison with age- and gender-matched control subjects, indicating that dopamine transporter abnormalities are involved in the pathophysiology of GTS. These abnormalities appear to be distributed across both caudate and putamen.

Diagnosing Tourette syndrome: is it a common disorder?

OBJECTIVES

The evaluate the prevalence of Tourette syndrome (TS).

METHODS

A review of the literature on TS was undertaken to examine the prevalence of TS in mainstream children as well as those in special education.

RESULTS

Recent studies have indicated that TS occurs in around 1% of youngsters in mainstream schools between the ages of 5 and 16 years. It is even more common in youngsters with special educational needs.

CONCLUSIONS

TS is more common than was previously documented.

Adult-onset tic disorders

We report on 8 patients with adult-onset motor tics and vocalisations. Three had compulsive tendencies in childhood and 3 had a family history of tics or obsessive-compulsive behaviour. In comparison with DSM-classified, younger-onset Gilles de la Tourette syndrome, adult-onset tic disorders are more often associated with severe symptoms, greater social morbidity, a potential trigger event, increased sensitivity, and poorer response to neuroleptic medication.

Neuropsychiatry of the basal ganglia

This review aims to relate recent findings describing the role and neural connectivity of the basal ganglia to the clinical neuropsychiatry of basal ganglia movement disorders and to the role of basal ganglia disturbances in "psychiatric"' states. Articles relating to the relevant topics were initially collected through MEDLINE and papers relating to the clinical conditions discussed were also reviewed. The anatomy and connections of the basal ganglia indicate that these structures are important links between parts of the brain that have classically been considered to be related to emotional functioning and brain regions previously considered to have largely motor functions. The basal ganglia have a role in the development and integration of psychomotor behaviours, involving motor functions, memory and attentional mechanisms, and reward processes.

Comparative study of the behavioral and neuropsychologic characteristics of tic disorder with or without attention-deficit hyperactivity disorder (ADHD)

To study the nature of the comorbidity of tic disorder and attention-deficit hyperactivity disorder (ADHD), patients with tic disorder with or without ADHD were compared on the basis of clinical ratings and neuropsychologic tests. Seventy-eight children were involved in this study: 16 with tic disorder, 19 with comorbid tic disorder and ADHD, 21 with ADHD, and 22 normal controls. Rating scales for ADHD, the Child Behavior Checklist and the Yale Global Tic Severity Scale, were completed in clinical groups. To identify differences in neuropsychologic function among the four groups, the results of seven neuropsychologic tests of global cognitive abilities, attention, information-processing capacity, and fine motor skill were compared. On most behavioral and neuropsychologic tests, the tic disorder with ADHD and the ADHD groups demonstrated similar performance patterns and marked deficits compared with the tic disorder and the control groups, whereas in most of the attention tests, the ADHD group made more commission errors than the tic disorder with ADHD group. These findings suggest that the tic disorder with ADHD group has marked cognitive deficits and behavioral disturbance similar to the ADHD group, whereas the tic disorder group is more similar to the controls. The tic disorder with ADHD group might represent a true comorbidity of the two disorders.

[Gilles de la Tourette syndrome: a clinical study on 58 cases]

Gilles de la Tourette's syndrome (GTS) is a neuropsychiatric disorder with a childhood onset and is characterized by motor and vocal tics. Fifty-eight patients with GTS were evaluated during a period of three years. Thirty-six patients were male and twenty two female, with an age range of 7 to 51 years (mean 20.33 years). The male to female ratio was 1.6:1. The age of onset ranged from 3 to 15 years (mean 7.81 years). Seventy nine percent of the patients presented motor tics as the initial symptom of the disease. In terms of complex tics, coprolalia was present in 27.6% of the patients; copropraxia in 20.1%; palilalia in 20.1%; ecolalia in 27.6%; and ecopraxia in 27,6%. Associated manifestations, such as attention deficit, hyperactivity disorder and obsessive-compulsive disorder were present in 25.8% and 39.6%, respectively. Sensory phenomena were present in 54.8% of the patients.

Tics and its disorders

Tourette syndrome (TS) is familial neuropsychiatric disorder that is characterized by motor and phonic tics that begin in childhood. Once thought of as a rare and debilitating disorder, in the last decade new scientific knowledge suggests that TS and related tic disorders are more common and less debilitating for the majority of individuals. Evidence points toward a spectrum of TS symptomatology that extends beyond the tics disorder to probably include obsessive-compulsive disorder, attention deficit hyperactivity disorder, and mood disorders. Tourette syndrome and its differential diagnosis are discussed in this article with a focus on new developments in classification, etiology, epidemiology, genetics, pathophysiology, and clinical management.

Disruption of a novel gene (IMMP2L) by a breakpoint in 7q31 associated with Tourette syndrome

Gilles de la Tourette syndrome (GTS) is a complex neuropsychiatric disorder characterized by multiple motor and phonic tics. We identified a male patient with GTS and other anomalies. It was determined that he carried a de novo duplication of the long arm of chromosome 7 [46,XY,dup(7)(q22.1-q31.1)]. Further molecular analysis revealed that the duplication was inverted. The distal chromosomal breakpoint occurred between the two genetic markers D7S515 and D7S522, which define a region previously shown to be disrupted in a familiar case of GTS. Yeast and bacterial artificial chromosome clones spanning the breakpoints were identified by means of FISH analysis. To further characterize the distal breakpoint for a role in GTS, we performed Southern blot hybridization analysis and identified a 6.5-kb SacI junction fragment in the patient's genomic DNA. The DNA sequence of this fragment revealed two different breaks in 7q31 within a region of approximately 500 kb. IMMP2L, a novel gene coding for the apparent human homologue of the yeast mitochondrial inner membrane peptidase subunit 2, was found to be disrupted by both the breakpoint in the duplicated fragment and the insertion site in 7q31. The cDNA of the human IMMP2L gene was cloned, and analysis of the complete 1,522-bp transcript revealed that it encompassed six exons spanning 860 kb. The possible role of IMMP2L and several other candidate genes within the region of chromosomal rearrangement, including NRCAM, Leu-Rch Rep, and Reelin, is discussed. The 7q31 breakpoint interval has also been implicated in other neuropsychiatric diseases that demonstrate some clinical overlap with GTS, including autism and speech-language disorder.

Gilles de la Tourette syndrome: symptomatic treatment based on evidence

The treatment of the Gilles de la Tourette syndrome has evolved from case reports, clinical experience and more recently blinded trials usually in small numbers of patients. We have reviewed the evidence available to clinicians. The oldest and still most widely prescribed drug, haloperidol, should now not be considered the first-line agent in children as other agents have superior adverse effects profiles. Symptomatic treatment should be targeted to the specific additional psychopathologies seen in the syndrome. For the treatment of tics, sulpiride, tiapride, possibly pimozide and in some cases clonidine may be considered first-line agents. Although a body of data supports pimozide, caution has to be exercised in relation to possible cardiac effects. Antidepressants and stimulants have an important place in the management of depression, obsessionality and attention deficit hyperactivity disorder. The latter also responds to clonidine making it a rational first choice where ADHD coexists with GTS. There are a multitude of other drugs advocated in the literature in addition to reports of neurosurgery and the novel use of immune modulation. Therapeutic trials for GTS are challenging. However, further data from blinded trials are required before many of these treatments can be considered to be mainstream treatment options.

Disgust implicated in obsessive-compulsive disorder

Psychiatric classificatory systems consider obsessions and compulsions as forms of anxiety disorder. However, the neurology of diseases associated with obsessive-compulsive symptoms suggests the involvement of fronto-striatal regions likely to be involved in the mediation of the emotion of disgust, suggesting that dysfunctions of disgust should be considered alongside anxiety in the pathogenesis of obsessive-compulsive behaviours. We therefore tested recognition of facial expressions of basic emotions (including disgust) by groups of participants with obsessive-compulsive disorder (OCD) and with Gilles de la Tourette's syndrome (GTS) with an without co-present obsessive-compulsive behaviours (GTS with OCB; GTS without OCB). A group of people suffering from panic disorder and generalized anxiety were also included in the study. Both groups with obsessive-compulsive symptoms (OCD; GTS with OCB) showed impaired recognition of facial expressions of disgust. Such problems were not evident in participants with panic disorder and generalized anxiety, or for participants with GTS without obsessions or compulsions, indicating that the deficit is closely related to the presence of obsessive-compulsive symptoms. Participants with OCD were able to assign words to emotion categories without difficulty, showing that their problem with disgust is linked to a failure to recognize this emotion in others and not a comprehension or response criterion effect. Impaired recognition of disgust is consistent with the neurology of OCD and with the idea that abnormal experience of disgust may be involved in the genesis of obsessions and compulsions.

Psychophysiological aspects of Tourette's syndrome

Tourette's syndrome (TS), once considered a rare disorder, has been investigated extensively in the last two decades. It is inherited, usually beginning in childhood, and waxes and wanes, usually decreasing in frequency and severity in adolescence and early adulthood. Pharmacotherapy is the usual treatment approach, reducing frequency and severity of symptoms, but it is not a cure and often has side effects. Psychological help for people with TS and their families may be needed for this complex disorder.

Another advanced test of theory of mind: evidence from very high functioning adults with autism or asperger syndrome

Previous studies have found a subgroup of people with autism or Asperger Syndrome who pass second-order tests of theory of mind. However, such tests have a ceiling in developmental terms corresponding to a mental age of about 6 years. It is therefore impossible to say if such individuals are intact or impaired in their theory of mind skills. We report the performance of very high functioning adults with autism or Asperger Syndrome on an adult test of theory of mind ability. The task involved inferring the mental state of a person just from the information in photographs of a person's eyes. Relative to age-matched normal controls and a clinical control group (adults with Tourette Syndrome), the group with autism and Asperger Syndrome were significantly impaired on this task. The autism and Asperger Syndrome sample was also impaired on Happé's strange stories tasks. In contrast, they were unimpaired on two control tasks: recognising gender from the eye region of the face, and recognising basic emotions from the whole face. This provides evidence for subtle mindreading deficits in very high functioning individuals on the autistic continuum.

Personality disorder and psychopathology in Tourette's syndrome: a controlled study

BACKGROUND

Some specialists associate a wide variety of psychopathologies with Tourette's syndrome (TS), while others suggest that there is no psychopathology specifically associated. Few controlled studies have been conducted to address this issue, and none has investigated personality disorder in TS.

METHOD

Adults with TS and controls were evaluated using standardised psychiatric rating scales, including self-rated (STPCD) and clinician-rated (SCID-II) assessments of personality disorder, to investigate associations between personality disorder, other psychopathology and TS.

RESULTS

Significantly more TS patients (25/39 (64%)) than controls (2/34 (6%)) had one or more personality disorders. TS subjects were also more likely to have more personality disorders. TS patients had significantly more depression, anxiety and obsessionality than controls. The SCID-II and STCPD were moderately well correlated.

CONCLUSIONS

TS patients have a high prevalence of personality disorder and psychopathology when compared with controls. These results are the first to suggest a high level of personality disorder in a TS clinic population.

A neurobiological model for Tourette syndrome centered on the nucleus accumbens

Tourette syndrome is a genetic disorder characterized by chronic multiple motor and vocal tics with a fluctuating course and modulated by internal and external environmental events. Tourette syndrome is more prevalent in males than females, and is associated with behavioural disorders such as obsessive-compulsive disorder and attention deficit hyperactivity disorder. Tourette syndrome symptoms are commonly attenuated by dopaminergic antagonists and adrenergic agonists, and usually exacerbated by psychostimulants. In this paper, I propose that dysfunction centered on the nucleus accumbens represents the neurobiological basis of Tourette syndrome. Recent evidence indicates that nucleus accumbens has a micro-organization characterized by modules of distinct neurochemical and neuroanatomical features. Our model assumes that external and internal events occurring during the development of the nervous system interact with products derived from the expression of the putative gene for Tourette syndrome, thereby inducing modular changes in nucleus accumbens. The clinical presentation, associated behavioural disturbances and response to drugs would depend on the pattern of modular dysfunction.

Vomiting and retching in Gilles de la Tourette syndrome: a report of ten cases and a review of the literature

Retching and vomiting are common symptoms in childhood. We describe the cases of 10 patients with Gilles de la Tourette syndrome (GTS) for whom vomiting or retching tics were part of the clinical picture, and discuss other instances where retching and vomiting occur with neuropsychiatric or movement disorders.

Tics associated with autistic and pervasive developmental disorders

Coincident cases of Tourette syndrome and Pervasive Developmental Disorders increasingly have been reported in the literature. Coincident cases currently number around 90. A minority of cases have been associated with cases of Tourette syndrome and tics in other family members; this has led some authors to suggest that Tourette syndrome may be responsible for some of the genetic heterogeneity in Pervasive Developmental Disorders. The literature is reviewed, along with some aspects of the neurobiology of the two conditions with arguments for and against this hypothesis.

Tourette disorder: a cross-cultural review

Tourette's disorder (TD) is a complex disorder of motor and vocal tics starting in childhood or adolescence. Although the disorder has been researched extensively in North America and Europe, clinical features and associated conditions of TD are less well known in other cultures. The English-language literature relating to TD was searched for cross-cultural case reports, clinical investigations, and epidemiological studies, and the subsequent database was analyzed. The clinical characteristics of TD displayed a strong similarity across cultures. Demography, family history, clinical features, associated conditions, comorbidity, and treatment outcome were essentially the same in the various cultures investigated. The disorder appears world-wide, has similar clinical characteristics, and most likely has an underlying biological and genetic basis.

Urine patterns, peptide levels and IgA/IgG antibodies to food proteins in children with dyslexia

There is an association between psychiatric disorders and dyslexia. In some psychiatric disorders abnormal urinary peptide patterns and peptide levels, and elevated levels of IgA antibodies to food proteins have been detected. These abnormalities are probably due to insufficient breakdown of the proteins gluten and casein. The aim of this study was to discover whether such abnormalities could be found in urine samples and serum of children with dyslexia. After screening 291 pupils in the fourth grade, 15 dyslexics and 15 controls were pairwise matched by gender, age, and cognitive level. Word decoding, spelling, and short-term memory tests were carried out, and information on handedness, immune and other disorders was obtained. Analyses of 24-h urine samples and of serum were performed. The reading abilities significantly differentiated the groups, and significant differences were found in frequency of left-handedness, immune disorders and other disorders. Three dyslexic children had elevated IgA antibodies. Two of these had positive endomycium tests, and coeliac disease was confirmed by biopsy. One had antibodies to proteins in milk. Our findings may suggest weak urinary peptide abnormalities in the dyslexic children, and they show significant differences in levels of IgA of antibodies to food proteins.

Pathogenesis of Tourette's syndrome

This review presents a models of disease pathogenesis in the context of CNS development. It begins with an exploration of the clinical features and natural history of Tourette's syndrome. This is followed by a consideration of the role of genetic and nongenetic factors. An effort is then made to review the anatomical organization of the basal ganglia and related cortical sites. These circuits are intimately involved in the normal processing of sensorimotor, cognitive, and emotionally laden information. Evidence implicating these circuits in the pathobiology of Tourette's syndrome is then considered. The review closes with the prospects for advances in interdisciplinary research and therapeutics using this model as a guide.

Tourette's syndrome in the year 2000

OBJECTIVE

To examine the current status of knowledge of Tourette's syndrome (TS) and to highlight those areas of research that are most likely to have the most significant advances in the next few years into the 21st century.

METHOD

Index Medicus was consulted from its beginning in 1885 until 1964 (inclusive), looking initially under the title 'tics' and subsequently under 'Tourette's Disorder'. From 1965 and the advent of MEDLINE, a search was performed looking for 'Tourette's'. A chronological examination of TS in the medical literature is presented. Some issues surrounding Huntington's Disease (HD) research are pertinent to TS and may serve as a guide in the future direction of TS research; these issues have been identified and illustrated in the context of TS. Where relevant, other medical disorders are also commented on.

RESULTS

There has been a steady increase in the volume of TS literature since 1885, with a marked increase since 1980, changing in focus from a psychological to a neurobiological viewpoint. Current areas of interest include genetics, comorbid psychopathologies, neuroimaging, treatments, epidemiology and educational considerations. Issues raised by HD and other movement disorders such as Parkinson's Disease (PD) are predictive testing, gene therapy and neural transplants.

CONCLUSIONS

The year 2000 is likely to herald a significant increase in our knowledge of the genetics and neuroimaging of TS, with new developments in therapy. A broadening of awareness of TS among health workers and teachers in particular is likely to increase the number of diagnosed patients and, hence, new challenges will be posed to existing resources for health and educational provision.

Synaesthesia: prevalence and familiality

Synaesthesia is a condition in which a mixing of the senses occurs; for example, sounds trigger the experience of colour. Previous reports suggest this may be familial, but no systematic studies exist. In addition, there are no reliable prevalence or sex-ratio figures for the condition, which is essential for establishing if the reported sex ratio (female bias) is reliable, and if this implicates a sex-linked genetic mechanism. Two independent population studies were conducted in the city of Cambridge, England (studies 1 and 2 here), as necessary background to the family genetic study of synaesthesia (study 3). Studies 1 and 2 arrived at an almost identical prevalence rate for synaesthesia: approximately 1 case in 2000. The sex ratio found was 6:1 (female:male). A third of cases also reported familial aggregation. In study 3 six families were examined, and first-degree relatives were tested for genuineness of the condition. All six families were indeed multiplex for synaesthesia. Alternative modes of inheritance are discussed.

Sensorimotor gating in boys with Tourette's syndrome and ADHD: preliminary results

Deficits in sensorimotor gating, defined by prepulse inhibition (PPI), have been associated with subcortical dopaminergic overactivity in animal and clinical studies. Utilizing supraorbital nerve electrical stimulation, we produced adequate blink responses and measured decreases in amplitude resulting from electric prestimuli just above sensory threshold. Seven boys comorbid for attention-deficit hyperactivity disorder (ADHD) and a tic disorder had significantly reduced PPI, compared to 14 screened controls and seven boys with ADHD alone. If independently replicated, these results may reflect greater neurologic immaturity in these comorbid subjects. Alternatively, these findings, together with other converging lines of evidence, suggest that deficient pallidal inhibition may be etiologically related to tic and movement disorders.

Risperidone in the treatment of Tourette syndrome: a retrospective case note study

Nineteen patients with Tourette syndrome (TS) were treated with risperidone, at a mean daily dose of 1.5 mg. Of those, 41% responded positively, 35% felt that it had made no difference, while it made 24% worse. Although 53% of the patients experienced side-effects, none had extrapyramidal side-effects. At follow-up, 8 to 11 months later, only two of 19 (11 %) patients were still taking risperidone. We suggest that risperidone does have a role in a minority of TS sufferers but it is not suggested as the first line treatment. More placebo-controlled studies using risperidone are clearly indicated.