Tourette's

Background

TS is a genetically determined neurological condition, characterised by involuntary movements and vocalisations known as tics¹. TS was once regarded as a rare syndrome associated with coprolalia (the utterance of obscene words or socially inappropriate and derogatory remarks). It is now understood that TS is not rare, affecting maybe 10% of the population, but that only a small minority of those with TS have coprolalia².

The commonest symptoms of TS are tics; sudden, rapid, repetitive movements or sounds that occur intermittently. Motor tics involve involuntary movements of specific muscle groups, such as blinking, head jerking, or shoulder shrugging. Vocal tics encompass involuntary sounds or utterances, such as throat clearing, grunting, or repeating words or phrases².

Tics in TS typically start during childhood; peak onset is between 5 and 10 years old. TS may first present with simple motor tics, such as eye blinking or facial grimacing, followed by the emergence of more complex tics, including vocalisations or gestures. The severity and frequency of tics can fluctuate over time, with periods of exacerbation (known as tic flares) and remission³.

TS can present differently in adults. Tics may become less frequent or change in character over time;  a tic can rarely present as a tremor. Adults with TS may experience a broader range of symptoms, including motor and vocal tics, as well as associated features such as obsessive-compulsive symptoms, depression anxiety, autistic spectrum disorder and attention difficulties. They may also face challenges in social and occupational functioning^1,4.

Management

While there is no cure for TS, interventions (pharmacological and non-pharmacological) can help to manage symptoms and improve quality of life. They should be tailored to specific needs and may include the following^7,8,9:

• Alpha-2 adrenergic agonists (e.g. clonidine and guanfacine) and dopamine receptor antagonists (e.g. haloperidol, pimozide, risperidone and aripiprazole). Benefits must be weighed against the risks and adverse effects, which may impact on cognitive function, cardiovascular risk and mental health.
• Behavioural therapies, such as habit reversal training (HRT) and exposure and response prevention (ERP), focus on increasing awareness of tics, identifying triggers, and implementing strategies to reduce tic frequency and intensity.
• Cognitive-behavioural therapy (CBT) may also be beneficial in addressing associated symptoms, such as obsessive-compulsive behaviours or anxiety.

Providing patients and their families with information, coping strategies, and support groups can help to enhance understanding and resilience. Encouraging a supportive and inclusive environment at home, school, and work can also contribute to improved outcomes and quality of life for individuals with TS.

References

1. NHS. Tourette’s syndrome. Jan 2021.
2. Jones KS, Saylam E, Ramphul K. Tourette Syndrome and Other Tic Disorders. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
3. CDC. What is Tourette Syndrome. May 2023.
4. Palumbo D, Kurlan R. Complex obsessive compulsive and impulsive symptoms in Tourette's syndrome. Neuropsychiatr DisTreat. 2007;3(5):687-93.
5. Oluwabusi OO, Parke S, Ambrosini PJ. Tourette syndrome associated with attention deficit hyperactivity disorder: The impact of tics and psychopharmacological treatment options. World J Clin Pediatr. 2016 Feb 8;5(1):128-35.
6. Stern JS. Tourette’s syndrome and its borderland. Practical Neurology 2018;18:262-270.
7. Seideman MF, Seideman TA. A Review of the Current Treatment of Tourette Syndrome. J Pediatr Pharmacol Ther. 2020;25(5):401-412.
8. Soerensen CB, Lange T, Jensen SN et al. Exposure and Response Prevention for Children and Adolescents with Tourette Syndrome Delivered via Web-Based Videoconference versus Face-to-Face Method. Neuropediatrics. 2023 Apr;54(2):99-106.
9. O'Connor KP, Laverdure A, Taillon A et al. Cognitive behavioral management of Tourette's syndrome and chronic tic disorder in medicated and unmedicated samples. Behav Res Ther. 2009 Dec;47(12):1090-5.