Gilles de la Tourette's syndrome: a clinical and psychopathological study

Psychopathology in boys with Tourette syndrome: Effects of age on the relationship between psychological and physical symptoms

Tourette syndrome (TS), a neuropsychiatric disorder that presents in childhood and is characterized by recurrent tics, is often associated with a variety of psychological problems. Most studies of concomitant problems have focused on psychiatric comorbidity, with less attention paid to nonsyndrome-specific or subsyndromal emotional and behavioral difficulties. Moreover, little is known about the factors that influence the specificity or severity of psychological problems. We hypothesized that level and type of psychological problem would be influenced by both severity of illness and developmental period. Children with severe tics were predicted to show increased levels of externalizing (undercontrolled) behavior, whereas adolescents with severe tics were predicted to show increased levels of internalizing (overcontrolled) behavior. Forty-one boys with TS were rated by their parents for tic severity (simple and complex motor tics) and psychological symptoms (Connors Parent Symptom Questionnaire and the Child Behavior Checklist). Results partially confirmed the hypothesis, indicating that greater illness severity was associated with greater psychological disturbance, but only in the younger subjects. Among the adolescents, even those with mild tics demonstrated relatively high levels of psychological symptoms. However, there was no indication that developmental period was related to the specific type of problem manifested. Regardless of age, patients with severe tics domonstrated high levels of externalizing behavior, and relatively high levels of internalizing behavior were also seen. Results are discussed in terms of the developmental factors that might influence the relationship between psychological and physical symptoms in children with TS.

The genetics of Tourette syndrome

Tourette syndrome has significant genetic determinants. The mode of transmission, while mildly controversial, generally is thought to be due to a single major locus inherited either as an autosomal dominant trait with reduced penetrance, or as a trait with intermediate inheritance in which some heterozygotes manifest the disorder. These is evidence for a Tourette syndrome spectrum of symptoms that includes obsessive-compulsive disorder. Systematic genome linkage studies of Tourette syndrome are progressing, but to date there are no significant linkage findings, although the search has included many neurologically relevant candidate genes.

Assessing risk for the Tourette spectrum of disorders among first-degree relatives of probands with Tourette syndrome

Previous studies have indicated that genetic investigations of Tourette syndrome (TS) should focus on a phenotype that includes not only TS, but chronic tics (CT) and obsessive-compulsive disorder (OCD) as well. These studies have shown that sex may play a role in determining which of the disorders in the TS spectrum is expressed in a susceptible individual. Female relatives of TS probands far more often express OCD, while male relatives more often express TS or CT. Data from the Yale Family Study of TS were used to model risk to first-degree relatives of probands with TS for a variety of TS disease phenotypes. Risk to relatives was modeled using multivariate Cox regression analysis, a method appropriate for assessing risk when there is correlation among disease onsets. This is the first known application of this method to family data. The study identified two proband characteristics that increase the risk for disease onset among both male and female relatives for all TS spectrum disorders, lending credence to the hypothesis that TS spectrum disorders share a common etiology. These were a relatively younger age-at-onset, and no experience of simple motor tics. The predictive ability of two additional factors varied by both sex and disease phenotype. These characteristics, i.e., proband onset with compulsive tics, and proband onset with range, appear to increase risk primarily in female relatives, and for the OCD part of the spectrum.

Genetic mechanisms in childhood psychiatric disorders

OBJECTIVE

This review summarizes research findings on the genetics of several childhood psychiatric disorders.

METHOD

One hundred fifty papers were reviewed from the past several decades and were selected because they have suggested that genetic factors may play a role in the etiology of certain childhood disorders. This review is not meant to be exhaustive but rather has emphasized those disorders for which a genetic etiology has been proposed by different research groups.

RESULTS

The more classical approaches to genetic research are reviewed and critiqued. The status of research for a number of childhood disorders is summarized. The molecular basis for several developmental disorders is presented and the prospects for arriving at a similar molecular understanding for other childhood psychiatric illnesses are discussed.

CONCLUSIONS

Genetic factors play a determining role for certain developmental disorders. However, the molecular basis for other psychiatric disorders has yet to be elucidated and there are complicating factors that bear on genetic research of complex behavioral disorders.

Tourette's syndrome: what are the influences of gender and comorbid obsessive-compulsive disorder?

OBJECTIVE

To explore the influence of gender and comorbid obsessive-compulsive disorder (OCD) on the phenomenology of Tourette's syndrome (TS).

METHOD

TS proband groups defined by gender and comorbid OCD status were compared on a variety of sociodemographic variables, clinical characteristics, and perinatal complications.

RESULTS

Compared to females, males more often onset with rage and had ever experienced any form of simple tics. Females onset with compulsive tics more often than males. Probands with comorbid OCD were more likely than those without OCD to onset with complex tics. Delivery complications, especially forceps deliveries, were associated with being male and with having OCD. Fetal exposure to relatively high levels of coffee, cigarettes, or alcohol predicted OCD in TS probands. Diagnosis of TS occurred at later ages among females than among males. Males and females displayed different age distributions.

CONCLUSIONS

Males and females tend to experience different kinds of symptoms at onset. However, the overall experience of TS appears to be similar for both groups. Perinatal brain injury is implicated in the etiology of TS in some boys. Early brain injury may cause or exacerbate the development of OCD in some TS sufferers.

Segregation and linkage analyses of Tourette's syndrome and related disorders

Segregation and linkage analyses were performed with data from a large Tourette's syndrome (TS) multigenerational kindred. Results of segregation analyses were remarkably similar to some reported earlier and suggest that the mode of transmission is consistent with autosomal dominant inheritance. The analyses were done using three diagnostic schemes to specify affected family members (TS only; TS or chronic tics [CT]; and TS, CT or obsessive compulsive disorder [OCD]). The estimates of penetrance for the genotypes AA, Aa and aa (A denotes the susceptibility allele) in the analyses including relatives with TS, CT or OCD were 0.99, 0.99 and 0.00, respectively, for males and 0.70, 0.70 and 0.00 for females. Pairwise linkage analyses with 140 marker loci failed to identify a linked marker. However, approximately 30 percent of the genome was excluded as the site of the hypothesized locus for TS.

Self-injurious behaviour and the Gilles de la Tourette syndrome: a clinical study and review of the literature

Thirty (33%) of 90 patients with the Gilles de la Tourette syndrome exhibited self-injurious behaviour. Fourteen were head bangers, of whom two had cavum septum pellucidum. Clinical correlates of self-injury were the severity of Gilles de la Tourette syndrome symptoms and psychopathology, with special reference to obsessionality and hostility. We discuss an additional patient who died from a subdural haematoma as a result of head banging, and three who had permanent vision impairment from self inflicted eye injuries.

The Gilles de la Tourette syndrome: the current status

The Gilles de la Tourette Syndrome is a movement disorder characterised by both motor and vocal (phonic) tics. It was once thought to be rare, and the literature until the 1970s consisted predominantly of case reports, both highlighting the fascinating clinical manifestations and speculating as to their aetiology. Many areas of GTS are under investigation, including the neurology, psychopathology, neurophysiology, biochemistry, and genetics. This review briefly considers early descriptions of GTS as well as current research, highlighting the areas of agreement and controversy.

A clinical study of Gilles de la Tourette's syndrome in Korea

Clinical data on 30 Korean patients of the authors with Gilles de la Tourette's syndrome are described, as well as data on seven other Korean cases from the literature. The overall characteristics and EEG findings were similar to those of Western patients, but there were fewer obsessive-compulsive behaviour problems, and family histories were less often positive.

Psychological aspects of Gilles de la Tourette syndrome

The unmistakable symptoms of Gilles de la Tourette Syndrome are classically of muscular spasms or tics, often accompanied by uncontrolled verbal outbursts or shouting of obscenities. Anecdotal as well as clinical reports suggest that these patients also suffer some psychological distress. This study used traditional MMPI scales to evaluate the psychopathological features that may underlie or accompany this disorder. In addition, we analyzed individual items of the MMPI to learn more of the phenomenology of this disorder. Data were collected from 29 Tourette patients and 29 normal controls matched for age and sex. A multivariate analysis of the clinical MMPI scales revealed group differences in score profiles. Univariate analyses indicated that Tourette subjects scored higher on the following scales: Schizophrenia, Depression, Psychopathic Deviate, Psychasthenia and Hypochondriasis. The results indicate that Tourette patients are in considerable psychological distress.

Gilles de la Tourette syndrome and the neurological basis of obsessions and compulsions

Gilles de la Tourette syndrome (GTS) is a chronic neurological disorder manifested by involuntary motor tics and vocalizations. Many GTS patients also suffer from obsessions and compulsions. The clinical similarities between GTS and obsessive-compulsive disorder (OCD), their occurrence among members of the same families, and the fact that both can be observed as symptoms of known basal ganglia disturbances suggest that GTS and OCD share common neurological mechanisms. It is hypothesized that the tics and vocalizations of GTS are aberrant manifestations of simple motor programs that are spontaneously generated by the basal ganglia and that obsessions and compulsions represent more complex motor plans initiated by similar anomalous activities.

Developmental perspective of the Gilles de la Tourette syndrome

This paper concerned developmental perspectives of the Gilles de la Tourette Syndrome. Topics addressed included birth, developmental and family histories, and symptom picture. The neglected area of academic achievement was examined. Results of the first systematic investigation of neuro-psychological functioning of Tourette children undertaken in the United States was presented. Subjects were 13 diagnosed male Tourette patients between 10 and 13 yr. of age. Parents completed the Developmental History and Tourette Syndrome Questionnaires while subjects were administered the WISC-R, Wide Range Achievement Test, Bender-Gestalt, and Halstead Neuropsychological Test Battery for Children. There was no supporting evidence that pre-/postnatal trauma was significant in the etiology of the disorder. Again, evidence suggested a genetic component. Finally, academic difficulties appear related to the visuographic dysfunction noted on neuropsychological assessment.

The electroencephalogram in Tourette syndrome

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

Dilemmas in diagnosis and treatment of Gilles de la Tourette syndrome

Gilles de la Tourette syndrome (TS) is a neurological disorder which has an inordinate risk of being diagnosed as psychogenic in nature because of commonly shared behavioral symptomes with syndromes of psychological origin. An overview of TS is presented including its history, symptomatology, and treatment of choice. The problems and pitfalls inherent in the diagnostic process which lead to psychogenic misconceptions are discussed. Treatment considerations include the secondary emotional problems and the negative consequences of the medication for TS. The implications for training professionals are discussed, but the essential point is that without an adequate history of the onset of symptoms, the potential for misdiagnosis is dramatically increased.

Tourette's syndrome symptom onset at age thirty-five

It is apparent to the authors that the primary factors influencing this particular case of Tourette's Syndrome are psychological. The condition appeared to result from threatening environmental conditions causing repression. The repressed material manifested itself in multiple tics, echolalia and coprolalia. Because of this patients's extreme resistance to accept the true conditions of his situation, individual and group psychotherapy have been difficult modes of treatment.

Six cases of Gilles de la Tourette's syndrome

Six cases of Gilles de la Tourette's syndrome are discussed in the light of conflicting views on the aetiology of the condition. It is hypothesized that the onset of coprolalia in patients with persistent childhood tics indicates a disturbances of the normal balance between a need for tension relief by swearing and a capacity to control such vocal activity. Some conclusions are drawn on the management of the syndrome by the use of butyrophenones, massed practice of tics, and the promotion of personality development. A flexible approach geared to the individual patient's particular needs is recommended.

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

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

A behavioral treatment program for the Gilles de la Tourette syndrome

The reinforcement of incompatible behavior in both structured and natural environments was examined as a treatment paradigm for multiple tics displayed by an adolescent boy. The procedure was shown to be effective in reducing the frequency of the behavioral tics and in increasing the rate of more appropriate behaviors. The treatment program concentrated on procedures which maximized the transfer of changes occurring in the clinic to more natural environments and the utilization of nonpsychologists and behavioral change agents.

Organic factors in Gilles de la Tourette's syndrome

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

Neurological features of Gilles de la Tourette's syndrome

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