The symptomatology and diagnosis of Gilles de la Tourette's syndrome

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.

Tourette syndrome and other neurodevelopmental disorders: a comprehensive review

Gilles de la Tourette syndrome (TS) is a complex developmental neuropsychiatric condition in which motor manifestations are often accompanied by comorbid conditions that impact the patient's quality of life. In the DSM-5, TS belongs to the "neurodevelopmental disorders" group, together with other neurodevelopmental conditions, frequently co-occurring. In this study, we searched the PubMed database using a combination of keywords associating TS and all neurodevelopmental diagnoses. From 1009 original reports, we identified 36 studies addressing TS and neurodevelopmental comorbidities. The available evidence suggests the following: (1) neurodevelopmental comorbidities in TS are the rule, rather than the exception; (2) attention deficit/hyperactivity disorder (ADHD) is the most frequent; (3) there is a continuum from a simple (TS + ADHD or/and learning disorder) to a more complex phenotype (TS + autism spectrum disorder). We conclude that a prompt diagnosis and a detailed description of TS comorbidities are necessary not only to understand the aetiological basis of neurodevelopmental disorders but also to address specific rehabilitative and therapeutic approaches.

Factors influencing diagnosis delay in children with Tourette syndrome

BACKGROUND

Tourette syndrome (TS) is a chronic disorder characterized by motor and vocal tics. Previous studies reported a substantial lag period between disease onset and diagnosis ranging from 3 to 11.9 years.

AIMS

To determine the lag period and factors associated with diagnosis delay of TS.

METHODS

All files of 185 children with TS attending one neuropediatric unit in Jerusalem were reviewed. Lag time between disease onset, according to DSM criteria, and diagnosis was determined and the contributions of the disease course, comorbidities and epidemiological factors were assessed.

RESULTS

A relatively short lag to diagnosis following the onset of diagnosable TS was documented (mean 13.2+/-15.9 months, median 6 months). A relatively longer gap was associated with older age at TS onset (r=0.161, p<0.05) and vocal tics as the first manifestation rather than motor or combined motor and vocal tics (mean=20.3+16.3 months vs 11.9+16.5 and 12.6+15.2, respectively, p<0.05). A relatively shorter gap was associated with tic severity (r=0.13, p<0.05) and presence of comorbid obsessive-compulsive disorder (OCD) (9.5+14.7 months vs. 14.1+16 without OCD, p<0.05).

CONCLUSIONS

Lag time to diagnosis is relatively short in our population. Factors associated with a shorter lag (early age of TS onset, motor tics as the first manifestation, greater tics severity and the presence of OCD) may be perceived as disruptive, prompting patient and families to seek medical care. Conversely, vocal tics as the first manifestation, associated with a longer lag, may be misdiagnosed as features of common pediatric conditions, thus delaying diagnosis.

High presynaptic dopaminergic activity in children with Tourette's disorder

OBJECTIVE

Tourette's disorder is characterized by chronic fluctuating motor and vocal tics. Despite extensive investigation of the neuropathophysiology of the disorder by a wide array of methodologies, its neurobiochemical substrate is still unclear. Converging evidence, however, suggests a primary role of the dopaminergic system, particularly within the basal ganglia.

METHOD

This study examined the integrity of presynaptic dopaminergic function in children with Tourette's disorder, using positron emission tomography and the tracer [18F]fluorodopa (FDOPA). Accumulation of FDOPA in synaptic terminals, a measure of DOPA decarboxylase activity, was quantified in caudate nucleus, putamen, frontal cortex, and midbrain (i.e., substantia nigra and ventral tegmentum).

RESULTS

Subjects with Tourette's disorder showed higher FDOPA accumulation than controls in the left caudate nucleus (by 25%; p = .03) and right midbrain (by 53%; p = .08).

CONCLUSION

These findings provide evidence of dopaminergic dysfunction in children with Tourette's disorder which affects both cell nuclei and nerve terminals. Based on the known regulation of DOPA decarboxylase activity by post- and presynaptic receptors, and by extracellular dopamine concentration, abnormal activity in this enzyme may reflect deficits in a variety of functional elements of the dopamine system. The precise mechanism underlying an up-regulation of DOPA decarboxylase activity needs to be identified in future studies.

The clinical features of Tourette's disorder: an Australian study using a structured interview schedule

The clinical features of an Australian series of patients fulfilling DSM-III-R criteria for Tourette's Syndrome (TS) were examined. Fifty patients, recruited from a hospital-based outpatient clinic and a self-help group, were interviewed using a structured schedule. TS is a complex disorder with wide ranging manifestations. Forty male and ten female TS patients with a mean age of 20.8 years (SD 11.2) were assessed. The mean age of onset of tics was 8.3 years (SD 3.3). Simple motor tics occurring in the rostral body regions were more common (eye 86%, face and head 80%) when compared both to simple tics occurring caudally (leg 52%) and complex motor tics (58%). Simple vocal tics were more common (94%) than complex ones (44%). There was a rostrocaudal pattern in the age of onset and severity of simple motor tics. Rates of comorbidity were 32%, 18% and 30% for Attention-Deficit Hyperactivity Disorder, Major Depression and Generalised Anxiety Disorder respectively and this was reflected in the considerable proportion (32%) of the sample who first presented for reasons other than their tics. There were substantial delays between the age of first presentation and diagnosis of TS owing to the insidious onset of the disorder, misdiagnosis and delays in presentation for help. A comparison of the features of the present patients with those of other published studies revealed similarities with some differences. Better clinical recognition of the symptoms and modes of presentation of TS may improve existing delays in diagnosis and treatment.

Trace amines and Tourette's syndrome

There has been considerable interest in recent years in possible neurochemical abnormalities in Tourette's Syndrome (TS). In studies combining neuropsychological and neurochemical measurements, we have investigated the possible roles of trace amines in this disorder. Urinary levels of free beta-phenylethylamine (PEA) and plasma levels of its precursor amino acid phenylalanine were decreased in TS patients when compared to values in normal children. These urinary PEA levels in TS patients were inversely related to several scores from the Tourette's Syndrome Global Scale (TSGS). Further investigation of the group of subjects with low urinary PEA indicated that they also had low levels of MHPG, normetanephrine, 5-HT and m- and p-tyramine. Patients with low PEA were also compared on an extensive battery of neuropsychological measures and observed to perform significantly worse than TS patients with normal urinary PEA levels. Biochemical measurements also suggest a possible abnormality in tryptamine turnover in TS since urinary levels of indole-3-acetic acid (IAA; the acid metabolite of tryptamine) are significantly lower in TS patients than in normal controls.

Gilles de la Tourette syndrome in India: two cases

Two cases of Gilles de la Tourette syndrome from India are presented. The symptomatology of Tourette syndrome is the same as that documented in western populations which suggests biological factors in the aetiology of the syndrome.

Dental treatment of patients with Gilles de la Tourette's syndrome

Gilles de la Tourette's syndrome, a familial neurologic disorder with onset in early life, is characterized by chronic intermittent motor and vocal tics. Many of the orofacial tics and compulsive behaviors seen in this disorder may cause destructive oral lesions. The medications used in treating the syndrome may adversely interact with dental therapeutic agents, frequently cause hyposalivation associated with the development of dental caries and periodontal disease, and may produce tardive dyskinesia with buccolingual choreiform movements. The oral signs and symptoms associated with the syndrome are reviewed, and modifications in dental treatment on the basis of the patient's behavioral alterations, and current drug therapy are suggested.

Tourette syndrome: issues in diagnosis

Information was accumulated by self-report questionnaire from 462 Canadian Tourette syndrome (TS) patients. The mean age of onset of the syndrome was 7.4 years, while the mean age of medical diagnosis was 15.2 years, suggesting that the mean lag between onset of symptoms and diagnosis was 7.8 years. Seventy-three percent of patients reported initial misdiagnosis by physicians and only 33% of the patients reported receiving their first information about TS from physicians. Respondents indicated that they were typically diagnosed as having Attention Deficit Disorder, Hyperactivity, or Minimal Brain Dysfunction prior to the establishment of the TS diagnosis. Factors involved in the delay in physician diagnosis of the syndrome, as well as the association between TS and other neuropsychiatric disorders, are also discussed.

Tourette syndrome attributed to frontal lobe dysfunction: numerous etiologies involved

The etiology of Tourette Syndrome (TS) according to prevailing views is unknown; there is evidence for both familial and sporadic cases. The author theorizes that abnormal discharges in the frontal lobes comprise the "final common dysfunction" that results in numerous phenomena labelled Tourette syndrome. Facial, vocal, and other motor symptoms of TS are catalogued in parallel with facial, vocal, and body movements that occur during frontal lobe seizures. The variety of etiologies that cause frontal lobe seizures--when applied to TS--can account more readily for heterogeneity of clinical presentations, the numerous "dual diagnosis" cases, and differential response to medication than can a single-gene theory.

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.

Prenatal methylazoxymethanol treatment potentiates d-amphetamine- and methylphenidate-induced motor activity in male and female rats

The effects of the stimulant drugs, d-amphetamine and methylphenidate, upon the motor activity of male and female off-spring of pregnant rats, treated on gestation day 15 with the antimitotic agent methylazoxymethanol (MAM, 25 mg/kg) were studied in four experiments. Cortical and striatal hypoplasia induced by prenatal administration of MAM resulted in increased concentrations of catecholamines in those regions. Administration of d-amphetamine and methylphenidate caused significant increases in motor activity; this effect was markedly potentiated in the MAM-treated rats, both the male and female off-spring. Thus, the locomotion and total activity parameters showed similar, but not identical, drastic increases in behaviour induced by the stimulant drugs as a result of the prenatal MAM treatment whereas for the rearing parameter a lesser potentiation by the MAM treatment was observed. This potentiation of the excitatory effects of the stimulant compounds upon the behavioural parameters is interpreted in terms of a relative increase in the density of catecholaminergic terminals in the forebrain regions of the central nervous system. The present results are discussed with regard to the utility of prenatal MAM treatment as a possible animal model for certain neurological disorders.

Mental health needs associated with Tourette syndrome

Tourette Syndrome (TS) is an uncommon developmental disability characterized by repetitive and involuntary verbal and motor tics. A survey of all known affiliates of the Tourette Syndrome Association of Ohio was conducted. A total of 431 questionnaires was returned, and behavioral problems were found to be pervasive in Tourette people. Some 53.1 per cent of the sample had sought some form of counseling for these problems, but this counseling was generally not perceived as being very helpful. Medication was not reported to ameliorate behavioral problems. When compared to a normal population sample, self-ratings of mental health status were low among Tourette persons. Problems experienced by TS persons were aggregated into a Behavioral Problem Scale, which successfully discriminated between levels of need in TS persons.

Hyperekplexia: a syndrome of pathological startle responses

We describe a family and three sporadic cases of startle disease, or hyperekplexia. Sudden unexpected noises caused the patients to fall rigidly, often injuring themselves but retaining consciousness. This unusual entity differs from startle epilepsy and cataplexy. Clonazepam proved ineffective in three patients. Valproic acid, 5-hydroxytryptophan, or piracetam markedly reduced the abnormal startle in three patients.

Electrophysiological studies in Tourette's syndrome

The value of standard electrophysiological studies using electroencephalography and evoked responses was evaluated in patients with Tourette's syndrome. Sixteen-channel electroencephalograms were obtained in 40 patients (36 males, 4 females) awake and asleep, and evoked responses were obtained in a subgroup of 17 patients. Evoked response variables evaluated included latencies and amplitudes of visual evoked responses, brainstem auditory evoked responses, and somatosensory evoked responses to median and peroneal nerve stimulation. Only 5 of the 40 patients (12.5%) demonstrated electroencephalographic abnormalities, which included central spikes, generalized and paroxysmal slow activity, and slowing of the normal basic frequency. Evoked response studies demonstrated no consistent differences between the patients with Tourette's syndrome and age- and sex-matched controls. The data demonstrate no notable diagnostic or therapeutic value for routine electroencephalographic or evoked response studies in Tourette's syndrome.

Dopaminergic dsyfunction in Tourette syndrome

A prospective clinical and biochemical study on the effects of treatment with haloperidol has been performed in seven patients with Tourette syndrome. Pretreatment cerebrospinal fluid levels of homovanillic acid (CSF HVA) were significantly reduce in all patients, whereas 5-hydroxyindoleacetic acid was reduced in only two. With haloperidol treatment, symptoms decreased in all cases (21 to 88%) and clinical improvement was associated with an increased level of CSF HVA, often returning to the normal range. Optimal therapeutic response was found with serum levels of haloperidol between 1 and 4 ng/ml; however, disturbing side effects also occurred within this range. These results support the hypothesis that Tourette syndrome may result from a supersensitivity of dopaminergic receptors.

Dopamine autoreceptor stimulation: clinical significance

Recent studies of the effects of low doses of dopamine agonists, designed to stimulate dopamine autoreceptors and hence diminish the synthesis and release of dopamine, were based on a series of basic research studies which demonstrated the existence of autoreceptors on dopamine neurones of the nigrostriatal, mesolimbic and mesocortical dopaminergic neurones. Evidence for autoreceptors on the tuberoinfundibular dopamine neurones which participate in the regulation of prolactin and growth hormone secretion is lacking. Some recent reports have questioned the existence of dopamine autoreceptors on the mesolimbic and nigrostriatal dopamine neurones. Specificity of various dopamine agonists and antagonists for the dopamine autoreceptor will be reviewed. The sedative, anxiolytic, antipsychotic, antidyskinetic and neuroendocrine effects of low dose dopamine agonists in man will be described. Low dose apomorphine, N-propylapomorphine and bromocriptine have been reported to have antipsychotic effects in the major psychoses, to diminish tardive dyskinesia and to enhance extrapyramidal insufficiency. A unique depressive state which developed in a small proportion of psychiatric patients after low dose apomorphine will be described. Further evidence for the lack of dopamine autoreceptors on the tuberoinfundibular dopamine neurones in man will be presented. Strategies for further study of the dopamine autoreceptor concept in man will be discussed.

Increased body movements during sleep in Gilles de la Tourette syndrome

Overnight sleep polygrams were recorded form 9 patients with Gilles de la Tourette syndrome (GTS). Six of 9 patients had abnormal electroencephalograms, but no specific abnormalities were detected. Body movements and twitch movements during sleep were analyzed. At all stages of sleep, body movements during sleep were more frequent in cases of GTS than those in normal controls. Twitch movements in stage REM of sleep were significantly increased in GTS. These results are consistent with the idea that GTS is due to an imbalance between the central neurotransmitters, catecholamine and serotonin.

Monoamine oxidase and catechol-O-methyltransferase activities in cultured fibroblasts and blood cells from children with autism and the Gilles de la Tourette syndrome

Monoamine oxidase (MAO) and catechol-O-methyltransferase (COMT) activities were measured in cells from children with autism (n = 5) and the Gilles de la Tourette syndrome (n = 5). Monoamine oxidase activities in cultured skin fibroblasts (type A) and platelets (type B) from the same individual were not correlated. COMT activities in fibroblasts and red blood cells showed a negative but not significant correlation (r = -0.42). Fibroblast MAO and COMT activities from patients were similar to values from controls matched for age, race, and sex. Increasing clinical severity of illness in both disorders, however, correlated significantly with higher fibroblast MAE activity. Cultured fibroblasts provide a means of measuring enzyme activities independently of the individual's current physiological and psychological state.

Otolaryngologic presentation of tic-like disorders

Common otolaryngologic symptoms such as coughing and sneezing may not be manifestations of disease of the upper respiratory tract. Two cases are reported in which these symptoms were the first evidence of tic-like disorders. A short discussion of one such disorder, Gilles de la Tourette's syndrome, is presented. The entity of paroxysmal sneezing is also mentioned. It is pointed out that, in the absence of otolaryngologic disease, these disorders may first present to an otolaryngologist for diagnosis.

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.

Biogenic amine metabolism in Tourette syndrome

Biogenic amine metabolism in the central nervous system of 9 children with Tourette syndrome was evaluated by quantitation of their metabolites in cerebrospinal fluid by a gas chromatographic/mass spectrometric method. Homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA), and 3-methoxy-4-hydroxyphenylethylene glycol (MHPG) were measured in CSF before and after oral administration of probenecid. Dopamine metabolism appeared defective, as both baseline and accumulated levels of HVA after probenecid were decreased. Serotonin metabolism also appeared defective in some patients with low baseline and low accumulated levels of 5-HIAA after probenecid. Taken together with other clinical features of this disease, the results suggest an underlying disorder of dopamine and serotonin metabolism in Tourette syndrome.

Significance of genetic factors in Gilles de la Tourette syndrome: a review

Observations suggesting a genetic basis for Gilles de la Tourette syndrome are reviewed with particular emphasis on the finding of familial aggregation. Studies of both Tourette syndrome and simple tic have found that approximately 30% of patients have a positive family history of tic. The significance of this figure depends on a number of factors, in particular the prevalence of positive tic histories in the population. If the latter figure is 10%, which the best available evidence suggests is a reasonable estimate, approximately 30% of families in the general population would be expected to contain at least one present or former tiquer. It is argued, therefore, that the family aggregation findings in Tourette syndrome do not support the hypothesis that the condition has a significant genetic component. Methodological considerations for future research are discussed.

Tics and Tourette's: a continuum of symptoms?

Analysis of the families of 39 unselected children with Tourette syndrome revealed other members with tic disorders in twenty kindreds. In eight families there were 13 individuals with chronic multiple tics, usually motor, not vocal. Twelve different families contained 18 subjects with Tourette syndrome other than the index patient. In three of these families there were 6 additional individuals with chronic motor tics, forming a bridge to the first group. An autosomal dominant mode of inheritance was suggested in all cases. Tourette syndrome and chronic motor tics appear to represent conditions along a continuum and have, in many instances, a hereditary basis.

Gilles de la Tourette syndrome: further studies and thoughts

A possible association between the Gilles de la Tourette and Lesch-Nyhan syndromes has recently been postulated. Fourteen patients with Tourette syndrome demonstrated no similarity to Lesch-Nyhan based upon patterns of inheritance, behavioral changes, or alterations of purine metabolism. Despite a strong male predominance, a sex-linked pattern of inheritance could not be confirmed. Self-mutilating behavior was found in 4 male patients but was readily differentiated from that characteristic of the Lesch-Nyhan syndrome. Quantitation of hypoxanthine-guanine phosphoribosyltransferase and isoelectric focusing of its isoenzymes produced results that were indistinguishable from those in controls. We speculate that, pathophysiologically, Tourette syndrome represents an imbalance between the central neurotransmitters dopamine and serotonin rather than an alteration in purine metabolism.

Seven cases of Gilles de la tourette's syndrome: partial relief with clonazepam: a pilot study

The histories of seven consecutive cases of Gilles de la Tourette's syndrome are presented to exemplify the range of clinical manifestations in this disease and to collate preliminary results with the new benzodiazepine, clonazepam, as possible adjuvant therapy of this disorder. Controlled trials with clonazepam alone and in association with haloperidol are now justified. Five of our 7 patients had a positive family history of tics, and 2 a confirmed family history of gout. Because clonazepam improves myoclonia and tics and because its mechanism of action possibly involves serotonin, we thought it worthwhile to study simultaneously the relative roles of serotonin and dopamine metabolism in the production of tics, and their relationship to possible defects in purine metabolism in Gilles de la Tourette's syndrome.

The effects of haloperidol upon temporal information processing by patients with Tourette's syndrome

Tourette's syndrome patients treated successfully with haloperidol, untreated patients, and healthy controls were studied with tests of temporal discrimination and measures of transmitted information shown previously to be sensitive to brain dysfunction. Untreated patients showed no impairment of temporal processing while those treated with haloperidol showed significant deficit in amount of transmitted information comparable to prior studies of brain syndromes.