Causes & course of the tic disorder

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What is Tourette Syndrome?

Tourette syndrome is a neuropsychiatric disease that manifests itself through the occurrence of tics and is one of the tic disorders.

A tic is an involuntary movement (motor) or vocalization (vocal). To make the diagnosis, at least two motor tics and one vocal tic must be present. The tics can occur repeatedly, individually or in series.

The chronic disorder usually begins at primary school age, i.e. at the age of seven to eight. Sometimes the tics only appear in adolescence, but always before the age of 21. Boys develop the disorder about ten times more often than girls. According to studies, around 0.5 to 1 percent of people worldwide are affected, making the disorder quite common.

Tourette syndrome: causes of tic disorder

The exact cause of Tourette syndrome has not yet been clarified. However, experts assume a neurodevelopmental disorder, which results in an impairment of movement control. This assumption is also supported by abnormalities in certain brain regions in people with Tourette syndrome. The thalamus and basal ganglia, which are essential for movement coordination, are particularly affected. In addition, a disruption of neurotransmitters in the brain, especially dopamine, also plays a role.

It is scientifically proven that the development of the disease is influenced by genes. Not least because children whose parents have Tourette’s are up to 50 percent more likely to also develop the disease. Sons have a four times higher risk than daughters. However, not every child who has the corresponding genetic predisposition develops Tourette’s disorder that requires treatment.

That’s why experts assume that there must be other risk factors for the development of the disease.

Risk factors include:

• psychosocial stress during pregnancy and early childhood
• Lack of oxygen at birth
• Premature birth
• Smoking, alcohol, drugs or medication abuse during pregnancy
• Bacterial infections with group A streptococci (e.g. otitis media, angina, scarlet fever)

Symptoms of Tourette syndrome

The main symptom of Tourette syndrome is the appearance of tics. A distinction is made between simple and complex motor and vocal tics. Motor tics often occur in the head area, examples include blinking or nodding. Vowel tics are sounds like syllables. Tics can occur in series or sporadically.

Before the tic, adult patients often feel a so-called premonition, which is expressed through internal pressure and, for example, warmth. The tic announces itself in a similar way to a sneeze. However, this is rare in children. This is why adults can usually control their tics better.

Complex tics usually only occur in severe cases of Tourette syndrome. Several muscle groups are involved or several syllables and words are called out. This severe form, in which obscene swear words and the like are uttered, only occurs in ten to 20 percent of cases.

Simple motor and vocal tics

Complex motor and vocal tics

Factors that increase tics

Tics occur more often under stress. If those affected are very focused and concentrated, they disappear for the time being, but then return stronger in a relaxation phase.

In a familiar environment, for example with family or friends, those affected let their tics run wild and do not suppress them, as is the case at work or at school.

Concomitant illnesses in Tourette syndrome

In the vast majority of cases (80 to 90 percent), those affected with Tourette syndrome also suffer from other psychological symptoms or illnesses such as depression, obsessive-compulsive disorder or sleep disorders. 50 to 75 percent of all children with Tourette syndrome also suffer from ADHD.

Diagnosis: How is Tourette syndrome diagnosed?

There is no specific test that can be used to reliably diagnose Tourette syndrome. Doctors make the diagnosis based on the symptoms and the previous course of the disease.

If the syndrome is present, motor tics in the form of muscle twitches and one or more vocal tics must be present. Questionnaires and estimation scales help to assess the type and severity of the tic disorder and to rule out other movement disorders.

There are specific diagnostic criteria for tic disorders based on ICD-10, according to which the following criteria must be present in order to speak of Tourette syndrome:

• at least two motor and one vocal tics
• Starts in childhood or adolescence
• Duration of at least one year (with possible interruption)
• Fluctuations (fluctuations) of the tics over time

Using various neurological examinations such as an electroencephalogram, other diseases can be ruled out as the cause of the tics.

Treatment of Tourette syndrome

There is no cure for Tourette syndrome. However, since many patients are hardly restricted in their everyday lives, treatment is rarely required.

However, in severe cases, therapy can be useful. Treatment for Tourette syndrome consists of a combination of approaches. Targeted therapy for tics is necessary if they cause pain, sleep disorders or impaired performance. Even if the level of suffering is high, for example due to bullying at school, treatment can make sense.

A particularly important component of therapy is psychoeducation, i.e. knowledge and information about the disease. This applies to those affected themselves, but also to the environment, such as the family or school. In this way, consequences resulting from the disease, such as social anxiety, can be avoided.

Medication

Depending on the severity of the tics in Tourette syndrome, they can be treated and alleviated with medication. Eligible:

• Benzamidessuch as tiapride and sulpiride

• atypical antipsychoticssuch as risperidone and aripiprazole.

• classic antipsychoticsHalperidol and Pimozide

If these medications do not help against the tics or cannot be used for other reasons, tetrabenazine (dopamine depletor), topiramate (anti-epileptic) or tetrahydrocannabinol (THC from the cannabis plant) can be considered. If ADHD is present at the same time, possible medications include clonidine, guanfacine and atomoxetine.

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Non-drug treatment

Psychotherapy is useful for Tourette syndrome. Habit Reversal Training (HRT) and “Exposure and Response Prevention Training” (ERPT) from behavioral therapy have proven particularly useful.

• Habit reversal training: Alternative behaviors instead of the tic are practiced. It is important that those affected learn to pay attention to their anticipation and then carry out a different reaction instead of the tic.

• Exposure and Response Prevention Training: Here too, anticipation plays a central role. People with tic disorder learn that the anticipation does not always have to be followed by a tic and are therefore better able to suppress it.

Self-awareness is promoted and learning to interrupt automated actions through active intervention. With this technique, tics can be reduced by up to 35 percent. However, it is usually only suitable for children aged ten and over, as small patients are less likely to feel foreboding.

Learning the relaxation technique of progressive muscle relaxation according to Jacobson makes sense as an accompanying treatment. A self-help group can also help those affected to deal with the illness.

Only in very rare cases, when no drug treatment helps, is an operation (deep brain stimulation) necessary to prevent the most severe tics and self-harm.

Prognosis and course of Tourette’s

Tourette syndrome cannot be cured and usually progresses in different phases in which the tics vary in severity. The disease usually begins before the age of ten. The peak of the disease is usually reached at the age of twelve; from the age of 14 to 15, the severity of the tics decreases significantly. Some of those affected become completely symptom-free (data varies between 20 and 70 percent).

In most cases, Tourette syndrome does not significantly limit those affected; they can work a job and lead a normal life.

Affected children should be cared for by child and adolescent psychology. The majority develop further symptoms or abnormalities as Tourette syndrome progresses:

• low frustration tolerance and learning problems

• Attention Deficit Hyperactivity Disorder (ADHD)

• Obsessive Compulsive Disorder

• sleep disorders

• depressions

• Anxiety disorders

• Social phobias