Tourette Syndrome (TS) is a neurological disorder characterized by involuntary motor tics and, sometimes, vocal tics (Walkup, 2013). The syndrome is named after the French medical scholar, Gilles de la Tourette. In 1885, Gilles de la Tourette published an article in the medical journal,
Archives de Neurologie,
which described “a bizarre neurological condition that he referred to as ‘maladie des tics’ (Kevin St. P. McNaught, 2010).” In more recent times, researchers have theorized that the disorder has origins in the basal ganglia; specifically in the caudate nucleus area. In Tourette syndrome, the neurotransmitter, dopamine is produced in excess in the nerve cells, causing the caudate nucleus to be inundated with the extra dopamine. This excess causes a reduction in the messages regarding motor control sent from the brain to the other parts of the body creating spurts of involuntary movement. Researchers surmise that the tics are the brain’s method of compensating for and correcting the chemical imbalance the body is experiencing. Other researchers have attributed the uncontrolled motor movements to an underdevelopment of serotonin and norepinephrine (Brill, 2002). Tourette syndrome is believed to be hereditary. It has also been suggested that environmental conditions and infections may play a role in the development of Tourette syndrome, but more research is needed to either prove or disprove that theory (Kevin St. P. McNaught, 2010).
For an individual to be diagnosed with Tourette syndrome, the following criteria must be met, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5):
- have two or more motor tics (for example, blinking or shrugging the shoulders) and at least one vocal tic (for example, humming, clearing the throat, or yelling out a word or phrase), although they might not always happen at the same time.
- have had tics for at least a year. The tics can occur many times a day (usually in bouts) nearly every day, or off and on.
- have tics that begin before he or she is 18 years of age.
- have symptoms that are not due to taking medicine or other drugs or due to having another medical condition (for example, seizures, Huntington disease, or postviral encephalitis) (CDC, 2014).
Typically, individuals will begin to show signs of Tourette syndrome in early childhood. As the individual ages, other more complex motor tics, and sometimes vocal tics, appear (Samuel H. Zinner, 2014). Tics can be classified as simple or complex. Simple motor tics involve movement of only one body part. Examples include neck twisting, eye blinking, leg jerking, and finger flexing. Complex motor tics involve more than one muscle group. Examples include leaping, twirling, touching other people or things, and biting oneself. Simple vocal tics involve moving air through the nose or mouth to create a noise. Examples include tongue clicking, whistling, throat clearing, and sniffing. Complex vocal tics involve multiple noises or words. Examples include repeating the same phrase as someone else, repeating the last sound or word multiple times, and the less common vocal tic of swearing or using obscenities (Brill, 2002).
“A Centers for Disease Control and Prevention (CDC) study has found that 1 of every 360 children 6 through 17 years of age and living in the United States have been diagnosed with TS based on parent report; this represents about 138,000 children. Other studies using different methods have estimated the rate of TS at 1 per 162 children (CDC, Data & Statistics, 2014).” All ethnic groups can be affected by the disorder. Males tend to be affected five times more often than females. Diagnosis occurs more frequently in the 12-17 year old range. Caucasians have twice as many occurrences than Hispanic Americans or African Americans (CDC, Data & Statistics, 2014). 90% of individuals with Tourette syndrome have other comorbid conditions, such as Attention Deficit Hyperactivity Disorder (ADHD), Obsessive Compulsive Disorder (OCD), Oppositional Defiant Disorder (ODD), anxiety, mood or sleep disorders, and learning disabilities (Samuel H. Zinner, 2014).
Two approaches are commonly used once the diagnosis of Tourette syndrome has been made: the behavioral approach and the medication approach. In the behavioral approach, the therapists concentrate on Habit Reversal Training (HRT) or Comprehensive Behavioral Intervention for Tics (CBIT). HRT has the most success in adults because its success depends on the person’s awareness of their tics in general, as well as, the sensation just prior to the tic occurring. In HRT, the individual can initiate a competing response to either lessen the appearance of the tic or inhibit the tic from occurring altogether (Martin L. Kutscher, 2014). For example, if the person has a wrist flexion tic, they can perform and sustain a wrist extension until the tic urge passes (Samuel H. Zinner, 2014). Adults have had the most success with HRT because they are more aware of their bodies due to their maturity level. Therapists do not typically try to use this technique with young children. CBIT is considered a more comprehensive behavioral approach because it combines education, relaxation techniques, and an individualized approach of recognizing lifestyle factors that exasperate the frequency of tics. This approach has had success in both adults and children. The major drawback to the behavioral approach is the fact that the benefits are not immediate and that it takes commitment from and maturity of the patient to see the most benefits. (Martin L. Kutscher, 2014).
In the medication approach, doctors prescribe medications to treat only the symptoms, since there is no medication that will cure Tourette syndrome nor eliminate tics entirely. Catapres and Tenex are most often prescribed when starting a drug therapy program. These drugs can also be helpful with managing ADHD, anxiety, and insomnia. Other medications, such as Risperdal, Orap, Haldol, and Klonopin, can be prescribed for more severe tics. Most medication trials have been performed on adults and the use of these drugs in children are considered off-label, but some younger individuals have had success with drug therapy. Some drawbacks to the medication approach are: unpleasant side effects, difficulty with compliance in regards to patients actually taking their medication, and lack of response from the medication itself in controlling tics (Samuel H. Zinner, 2014).
Occupational therapists can contribute to the treatment of Tourette syndrome. The occupational therapist can treat the patient using HBT and CBIT techniques. Education of Tourette syndrome for the patient and caregiver should be addressed prior to any OT intervention. An occupational therapist can help a patient to identify and emphasize their strengths rather than focus on the shame and social stigma that often accompanies movement disorders or vocal tics (Samuel H. Zinner, 2014). Other areas an OT can work on with the patient are: deep breathing and relaxation techniques, guided imagery, and progressive muscle relaxation. Implementing a home exercise program (HEP) and encouraging the patient to practice yoga or tai chi have been shown to also be beneficial (Brill, 2002).
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