Tourette syndrome Classification and external resources
Georges Gilles de la Tourette (1859–1904)
ICD-10	F95. Georges Albert Édouard Brutus Gilles de la Tourette ( October 30 1857 in Saint-Gervais-les-Trois-Clochers near Poitou, France – The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings 2
ICD-9	307. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. 23
OMIM	137580
DiseasesDB	5220
MedlinePlus	000733
eMedicine	med/3107  neuro/664
MeSH	D005879

Tourette syndrome (also called Tourette's syndrome, Tourette's disorder, Gilles de la Tourette syndrome, GTS or, more commonly, simply Tourette's or TS) is an inherited neuropsychiatric disorder with onset in childhood, characterized by the presence of multiple physical (motor) tics and at least one vocal (phonic) tic; these tics characteristically wax and wane. The Mendelian Inheritance in Man project is a Database that catalogues all the known Diseases with a genetic component, and—when possible—links them The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books Neuropsychiatry is the branch of Medicine dealing with Mental disorders attributable to diseases of the Nervous system. A tic is a sudden repetitive nonrhythmic stereotyped motor movement or vocalization involving discrete muscle groups Tourette's is defined as part of a spectrum of tic disorders, which includes transient and chronic tics. Spectrum disorder in Psychiatry is a term used to describe a Mental disorder when there is thought to be "not a unitary disorder but rather a syndrome composed Tic disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM based on type (motor or phonic and duration of Tics (sudden rapid nonrhythmic

Tourette's was once considered a rare and bizarre syndrome, most often associated with the exclamation of obscene words or socially inappropriate and derogatory remarks (coprolalia). In Medicine and Psychology, the term syndrome refers to the association of several clinically recognizable features signs (observed by a physician Coprolalia is involuntary Swearing or the involuntary utterance of obscene words or socially inappropriate and derogatory remarks However, this symptom is present in only a small minority of people with Tourette's. ^[1] Tourette's is no longer considered a rare condition, but it may not always be correctly identified because most cases are classified as mild. Between 1 and 11 children per 1,000 have Tourette's; as many as 10 per 1,000 people may have tic disorders,^[2][3] with the more common tics of eye blinking, coughing, throat clearing, sniffing, and facial movements. People with Tourette's have normal life expectancy and intelligence. Life expectancy is the average number of years of life remaining at a given age The severity of the tics decreases for most children as they pass through adolescence, and extreme Tourette's in adulthood is a rarity. Notable individuals with Tourette's are found in all walks of life. There are sociological and cultural aspects of living with Tourette syndrome (also Tourette's syndrome Tourette's or TS including legal advocacy and health insurance issues ^[4]

Genetic and environmental factors each play a role in the etiology of Tourette's, but the exact causes are unknown. Genetics (from Ancient Greek grc-Latn genetikos, “genitive” and that from grc-Latn genesis, “origin” a discipline of Biology, is Etiology (alternatively aetiology, aitiology) is the study of causation. In most cases, medication is unnecessary. There is no effective medication for every case of tics, but there are medications and therapies that can help when their use is warranted. Explanation and reassurance alone are often sufficient treatment;^[5] education is an important part of any treatment plan. ^[6]

The eponym was bestowed by Jean-Martin Charcot (1825–93) on behalf of his resident, Georges Albert Édouard Brutus Gilles de la Tourette (1859–1904), a French physician and neurologist, who published an account of nine patients with Tourette's in 1885. Jean-Martin Charcot ( 29 November 1825 – 16 August 1893) was a French Neurologist and professor of Anatomical pathology Georges Albert Édouard Brutus Gilles de la Tourette ( October 30 1857 in Saint-Gervais-les-Trois-Clochers near Poitou, France –

Classification

Tics are sudden, repetitive, stereotyped, nonrhythmic movements (motor tics) and utterances (phonic tics) that involve discrete muscle groups. A tic is a sudden repetitive nonrhythmic stereotyped motor movement or vocalization involving discrete muscle groups ^[7] Motor tics are movement-based tics, while phonic tics are involuntary sounds produced by moving air through the nose, mouth, or throat.

Tourette's is one of several tic disorders, which are classified by the Diagnostic and Statistical Manual of Mental Disorders (DSM) according to type (motor or phonic tics) and duration (transient or chronic). Tic disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM based on type (motor or phonic and duration of Tics (sudden rapid nonrhythmic The Diagnostic and Statistical Manual of Mental Disorders' ( DSM) is published by the American Psychiatric Association Transient tic disorder consists of multiple motor tics, phonic tics or both, with a duration between four weeks and twelve months. Chronic tic disorder is either single or multiple, motor or phonic tics (but not both), which are present for more than a year. ^[7] Tourette's is diagnosed when multiple motor tics, and at least one phonic tic, are present for more than a year. ^[8] Tic disorders are defined similarly by the World Health Organization (International Statistical Classification of Diseases and Related Health Problems, ICD-10 codes). The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings ^[9]

Although Tourette's is the more severe expression of the spectrum of tic disorders,^[10] most cases are mild. Spectrum disorder in Psychiatry is a term used to describe a Mental disorder when there is thought to be "not a unitary disorder but rather a syndrome composed ^[11] The severity of symptoms varies widely among people with Tourette's, and mild cases may be undetected. ^[7]

Characteristics

Tics are movements or sounds "that occur intermittently and unpredictably out of a background of normal motor activity",^[12] having the appearance of "normal behaviors gone wrong. "^[13] The tics associated with Tourette's constantly change in number, frequency, severity and anatomical location. Waxing and waning—the ongoing increase and decrease in severity and frequency of tics—occurs differently in each individual. Tics also occur in "bouts of bouts", which vary for each person. ^[7]

Coprolalia (the spontaneous utterance of socially objectionable or taboo words or phrases) is the most publicized symptom of Tourette's, but it is not required for a diagnosis of Tourette's. Coprolalia is involuntary Swearing or the involuntary utterance of obscene words or socially inappropriate and derogatory remarks According to the Tourette Syndrome Association, fewer than 15% of Tourette's patients exhibit coprolalia. The Tourette Syndrome Association ( TSA) based in Bayside New York United States is a Non-profit voluntary organization and the only national health-related organization ^[14] Echolalia (repeating the words of others) and palilalia (repeating one's own words) occur in a minority of cases,^[7] while the most common initial motor and vocal tics are, respectively, eye blinking and throat clearing. Echolalia is the repetition of vocalizations made by another person Palilalia is the repetition or echoing of one's own spoken words and may sound like stuttering ^[15]

In contrast to the abnormal movements of other movement disorders (for example, choreas, dystonias, myoclonus, and dyskinesias), the tics of Tourette's are stereotypic, temporarily suppressible, nonrhythmic, and often preceded by a premonitory urge. Movement disorders include Akathisia Akinesia ( lack of movement) Athetosis ( contorted torsion Chorea sancti viti (Latin for " St Vitus' dance " is an abnormal involuntary movement disorder one of a group of neurological disorders called Dyskinesias Dystonia is a neurological Movement disorder in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures Myoclonus (maɪˈɒklənəs is brief involuntary twitching of a Muscle or a group of muscles Dyskinesia refers to involuntary movements similar to a Tic or Chorea. ^[16] Immediately preceding tic onset, most individuals with Tourette's are aware of an urge^[17][18] that is similar to the need to sneeze or scratch an itch. Individuals describe the need to tic as a buildup of tension, pressure, or energy^[18][19] which they consciously choose to release, as if they "had to do it"^[20] to relieve the sensation. ^[18] Examples of the premonitory urge are the feeling of having something in one's throat, or a localized discomfort in the shoulders, leading to the need to clear one's throat or shrug the shoulders. The actual tic may be felt as relieving this tension or sensation, similar to scratching an itch. Another example is blinking to relieve an uncomfortable sensation in the eye. These urges and sensations, preceding the expression of the movement or vocalization as a tic, are referred to as "premonitory sensory phenomena". Sensory phenomena are general feelings urges or bodily sensations that precede or accompany repetitive behaviors associated with Tourette syndrome and Tic disorders Published descriptions of the tics of Tourette's identify sensory phenomena as the core symptom of the syndrome, even though they are not included in the diagnostic criteria. A symptom' (from Greek σύμπτωμα, "accident misfortune that which befalls" from συμπίπτω, "I befall" from ^[19][21][22]

Tics are described as semi-voluntary or "unvoluntary",^[12] because they are not strictly involuntary—they may be experienced as a voluntary response to the unwanted, premonitory urge. A unique aspect of tics, relative to other movement disorders, is that they are suppressible yet irresistible;^[13] they are experienced as an irresistible urge that must eventually be expressed. ^[12] People with Tourette's are sometimes able to suppress their tics to some extent for limited periods of time, but doing so often results in an explosion of tics afterward. ^[5] People with Tourette's may seek a secluded spot to release their symptoms, or there may be a marked increase in tics, after a period of suppression at school or at work. ^[13]

Some people with Tourette's may not be aware of the premonitory urge. Children may be less aware of the premonitory urge associated with tics than are adults, but their awareness tends to increase with maturity. ^[12] They may have tics for several years before becoming aware of premonitory urges. Children may suppress tics while in the doctor's office, so they may need to be observed while they are not aware they are being watched. ^[23] The ability to suppress tics varies among individuals, and may be more developed in adults than children.

Although there is no such thing as a "typical" case of Tourette syndrome,^[5] the condition follows a fairly reliable course in terms of the age of onset and the history of the severity of symptoms. Tics may appear up to the age of eighteen, but the most typical age of onset is from five to seven. ^[7] The ages of highest tic severity are eight to twelve (average ten), with tics steadily declining for most patients as they pass through adolescence. ^[24] The most common, first-presenting tics are eye blinking, facial movements, sniffing and throat clearing. Initial tics present most frequently in midline body regions where there are many muscles, usually the head, neck and facial region. ^[5] This can be contrasted with the stereotyped movements of other disorders (such as stims and stereotypies of the autism spectrum disorders), which typically have an earlier age of onset, are more symmetrical, rhythmical and bilateral, and involve the extremities (e. Stimming is a Jargon term for a particular form of stereotypy, a repetitive body movement (often done unconsciously that self-stimulates one or more senses in a regulated A stereotypy (ˈstɛriəˌtаɪpi (plural stereotypies) is a repetitive or ritualistic movement posture or utterance found in patients with Mental retardation, The autism spectrum, also called autism spectrum disorders (ASD or autism spectrum conditions (ASC with the word autistic sometimes replacing autism g. , flapping the hands). ^[25] Tics that appear early in the course of the condition are frequently confused with other conditions, such as allergies, asthma, and vision problems: pediatricians, allergists and ophthalmologists are typically the first to see a child with tics. Allergy is a disorder of the Immune system often also referred to as Atopy. Asthma is a chronic Condition involving the Respiratory system in which the airways occasionally constrict become inflamed, and are ^[7]

Among patients whose symptoms are severe enough to warrant referral to clinics, obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD) are often associated with Tourette's. Obsessive-compulsive disorder (OCD is a Chronic Anxiety disorder most commonly characterized by obsessive Distressing Intrusive thoughts Attention-Deficit Hyperactivity Disorder (ADHD is a neurobehavioral developmental disorder affecting about 3-5% of the world's population Not all persons with Tourette's have ADHD or OCD or other comorbid conditions (co-occurring diagnoses other than Tourette's), although in clinical populations, a high percentage of patients presenting for care do have ADHD. In Medicine, comorbidity (literally "additional Morbidity " is either * The presence of one or more disorders (or diseases in addition to ^[26] One author reports that a ten-year overview of patient records revealed about 40% of patients with Tourette's have "TS-only" or "pure TS", referring to Tourette syndrome in the absence of ADHD, OCD and other disorders. ^[27] Another author reports that 57% of 656 patients presenting with tic disorders had uncomplicated tics, while 43% had tics plus comorbid conditions. ^[13] "Full-blown Tourette's" is a term used to describe patients who have significant comorbid conditions in addition to tics. ^[13]

Causes

Main article: Causes and origins of Tourette syndrome

The exact cause of Tourette's is unknown, but it is well established that both genetic and environmental factors are involved. Causes and origins of Tourette syndrome have not been fully elucidated ^[28] Genetic studies have shown that the overwhelming majority of cases of Tourette's are inherited, although the exact mode of inheritance is not yet known,^[29] and no gene has been identified. ^[5] In some cases, tics may not be inherited; these cases are identified as "sporadic" Tourette syndrome (also known as tourettism) because a genetic link is missing. Tourettism refers to the presence of Tourette-like symptoms in the absence of Tourette syndrome, as the result of other diseases or conditions known as "secondary causes" ^[30]

Brain structures implicated in Tourette's syndrome

A person with Tourette's has about a 50% chance of passing the gene(s) to one of his or her children, but Tourette's is a condition of variable expression and incomplete penetrance. Expressivity is a term used in Genetics that refers to variations of a Phenotype in individuals carrying a particular Genotype. Penetrance is a term used in Genetics describing the proportion of individuals carrying a particular variation of a Gene (an Allele or genotype that also ^[31] Thus, not everyone who inherits the genetic vulnerability will show symptoms; even close family members may show different severities of symptoms, or no symptoms at all. The gene(s) may express as Tourette's, as a milder tic disorder (transient or chronic tics), or as obsessive compulsive symptoms without tics. Only a minority of the children who inherit the gene(s) have symptoms severe enough to require medical attention. ^[14] Gender appears to have a role in the expression of the genetic vulnerability: males are more likely than females to express tics. ^[23]

Non-genetic, environmental, infectious, or psychosocial factors—while not causing Tourette's—can influence its severity. The term psychosocial refers to one in Psychological development in and interaction with a Social environment. ^[5] Autoimmune processes may affect tic onset and exacerbation in some cases. Autoimmunity is the failure of an organism to recognize its own constituent parts as self, which results in an immune response against its own cells and tissues In 1998, a team at the National Institute of Mental Health proposed a hypothesis that both obsessive-compulsive disorder (OCD) and tic disorders may arise in a subset of children as a result of a poststreptococcal autoimmune process. The National Institute of Mental Health ( NIMH) is part of the federal government of the United States and the largest research organization in the world specializing in ^[32] Children who meet five diagnostic criteria are classified, according to the hypothesis, as having Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). PANDAS is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. ^[33] This contentious hypothesis is the focus of clinical and laboratory research, but remains unproven. ^[34][35]

The exact mechanism affecting the inherited vulnerability to Tourette's has not been established, and the precise etiology is unknown. Tics are believed to result from dysfunction in cortical and subcortical regions, the thalamus, basal ganglia and frontal cortex. The thalamus (from Greek θάλαμος = room chamber, IPA= /ˈθæləməs/ is a pair and symmetric part of the brain The basal ganglia (or basal nuclei) are a group of nuclei in the Brain interconnected with the Cerebral cortex, Thalamus and The frontal lobe is an area in the Brain of Mammals It is located at the front of each Cerebral hemisphere and positioned anterior to (in front of the ^[28] Neuroanatomic models implicate failures in circuits connecting the brain's cortex and subcortex,^[5] and imaging techniques implicate the basal ganglia and frontal cortex. Neuroanatomy is the science for localizing function in the Human brain. Neuroimaging includes the use of various techniques to either directly or indirectly image the structure, function/ Pharmacology of the Brain ^[36]

Some forms of OCD may be genetically linked to Tourette's. ^[37] A subset of OCD is thought to be etiologically related to Tourette's and may be a different expression of the same factors that are important for the expression of tics. Etiology (alternatively aetiology, aitiology) is the study of causation. ^[38] The genetic relationship of ADHD to Tourette syndrome, however, has not been fully established. ^[27]

Diagnosis

According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), Tourette’s Disorder may be diagnosed when a person exhibits both multiple motor and one or more vocal tics (although these do not need to be concurrent) over the period of a year, with no more than three consecutive tic-free months. The Diagnostic and Statistical Manual of Mental Disorders' ( DSM) is published by the American Psychiatric Association The previous DSM-IV included a requirement for "marked distress or significant impairment in social, occupational or other important areas of functioning", but this requirement was removed in the most recent update of the manual, in recognition that clinicians see patients who meet all the other criteria for Tourette's, but do not have distress or impairment. ^[39] The onset must have occurred before the age of 18, and cannot be attributed to the "direct physiological effects of a substance or a general medical condition". ^[8] Hence, other medical conditions that include tics or tic-like movements—such as autism or other causes of tourettism—must be ruled out before conferring a Tourette's diagnosis. Language development. The terminology Tourettism refers to the presence of Tourette-like symptoms in the absence of Tourette syndrome, as the result of other diseases or conditions known as "secondary causes"

There are no specific medical or screening tests that can be used in diagnosing Tourette's;^[7] it is frequently misdiagnosed or underdiagnosed, partly because of the wide expression of severity, ranging from mild (the majority of cases) or moderate, to severe (the rare, but more widely-recognized and publicized cases). ^[24] The diagnosis is made based on observation of the individual's symptoms and family history, and after ruling out secondary causes of tic disorders.^[14] In patients with a typical onset and a family history of tics or obsessive–compulsive disorder, a basic physical and neurological examination may be sufficient. Tourettism refers to the presence of Tourette-like symptoms in the absence of Tourette syndrome, as the result of other diseases or conditions known as "secondary causes" ^[10]

If a physician believes that there may be another condition present that could explain tics, tests may be ordered as necessary to rule out that condition. An example of this is when diagnostic confusion between tics and seizure activity exists, which would call for an EEG, or if there are symptoms that indicate an MRI to rule out brain abnormalities. An epileptic seizure is caused by excessive and/or hypersynchronous electrical Neuronal activity and is usually self-limiting ^[40] TSH levels can be measured to rule out hypothyroidism, which can be a cause of tics. Thyroid-stimulating hormone (also known as TSH or thyrotropin) is a Peptide hormone synthesized and secreted by Thyrotrope cells in the Hypothyroidism is the disease state in humans and animals caused by insufficient production of Thyroid hormone by the Thyroid gland. Brain imaging studies are not usually warranted. Neuroimaging includes the use of various techniques to either directly or indirectly image the structure, function/ Pharmacology of the Brain ^[40] In teenagers and adults presenting with a sudden onset of tics and other behavioral symptoms, a urine drug screen for cocaine and stimulants might be necessary. For the episode of the American television series The Office, see " Drug Testing " Cocaine ( benzoylmethyl ecgonine) is a Crystalline Tropane Alkaloid that is obtained from the leaves of the Coca plant Stimulant drugs are Drugs that temporarily increase alertness and awareness If a family history of liver disease is present, serum copper and ceruloplasmin levels can rule out Wilson's disease. Liver disease is a broad term describing any number of Diseases affecting the Liver. Ceruloplasmin (or caeruloplasmin) is officially known as ferroxidase or iron(IIoxygen oxidoreductase. Wilson's disease or hepatolenticular degeneration is an Autosomal recessive Genetic disorder in which Copper accumulates in tissues ^[10] However, most cases are diagnosed by merely observing a history of tics. ^[5][14]

Secondary causes of tics (not related to inherited Tourette syndrome) are commonly referred to as tourettism. Tourettism refers to the presence of Tourette-like symptoms in the absence of Tourette syndrome, as the result of other diseases or conditions known as "secondary causes" ^[30] Dystonias, choreas, other genetic conditions, and secondary causes of tics should be ruled out in the differential diagnosis for Tourette syndrome. Dystonia is a neurological Movement disorder in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures A differential diagnosis (sometimes abbreviated DDx, ddx ^[10] Other conditions that may manifest tics or stereotyped movements include developmental disorders, autism spectrum disorders,^[41] and stereotypic movement disorder;^[42][43] Sydenham's chorea; idiopathic dystonia; and genetic conditions such as Huntington's disease, neuroacanthocytosis, Hallervorden-Spatz syndrome, Duchenne muscular dystrophy, Wilson's disease, and tuberous sclerosis. Developmental disorders are disorders that occur at some stage in a Child 's development often retarding the development The autism spectrum, also called autism spectrum disorders (ASD or autism spectrum conditions (ASC with the word autistic sometimes replacing autism Stereotypic movement disorder is a disorder of childhood involving repetitive nonfunctional motor behavior (e Sydenham's chorea (also known as " Saint Vitus Dance " is a disease characterized by rapid uncoordinated jerking movements affecting primarily the face feet and hands Idiopathic is an Adjective used primarily in Medicine meaning arising spontaneously or from an obscure or unknown cause. Huntington's disease, also called Huntington's chorea, chorea major, or HD, is a genetic neurological disorder characterized after Neuroacanthocytosis (also known as Levine-Critchley syndrome or chorea-acanthocytosis) is a rare movement disorder marked by progressive muscle weakness and Atrophy Pantothenate kinase-associated neurodegeneration (PKAN also known as Hallervorden-Spatz syndrome, is a Degenerative disease of the Brain, which can lead Duchenne muscular dystrophy ( DMD) is a severe recessive x-linked form of Muscular dystrophy that is characterized by rapid progression of muscle degeneration eventually Tuberous sclerosis or tuberous sclerosis complex ( TSC) is a rare multi-system genetic disease that causes benign tumours to grow in the Brain Other possibilities include chromosomal disorders such as Down syndrome, Klinefelter's syndrome, XYY syndrome and fragile X syndrome. Down syndrome, Down's syndrome, or trisomy 21 is a Chromosomal disorder caused by the presence of all or part of an extra 21st chromosome. Klinefelter's syndrome, 47XXY or XXY syndrome is a condition caused by a Chromosome Aneuploidy. XYY syndrome is an Aneuploidy of the Sex chromosomes in which a Human Male receives an extra Y chromosome, producing a 47XYY Fragile X syndrome, or Martin-Bell syndrome, is a genetic Syndrome which results in a spectrum (from none to severe of characteristic physical intellectual emotional Acquired causes of tics include drug-induced tics, head trauma, encephalitis, stroke, and carbon monoxide poisoning. Encephalitis is an acute Inflammation of the Brain, commonly caused by a viral Infection. A stroke is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain Carbon monoxide poisoning occurs after the inhalation of Carbon monoxide gas ^[10][30] The symptoms of Lesch-Nyhan syndrome may also be confused with Tourette syndrome. Lesch-Nyhan syndrome ( LNS) also known as Nyhan’s syndrome or Kelley-Seegmiller syndrome, is a rare Inherited disorder caused by a deficiency ^[25] Most of these conditions are rarer than tic disorders, and a thorough history and examination may be enough to rule them out, without medical or screening tests. ^[5]

Screening

Although not all people with Tourette's have comorbid conditions, most Tourette's patients presenting for clinical care at specialty referral centers may exhibit symptoms of other conditions along with their motor and phonic tics. ^[27] Associated conditions include attention-deficit hyperactivity disorder (ADD or ADHD), obsessive–compulsive disorder (OCD), learning disabilities and sleep disorders. In the United States and Canada, the term learning disability (LD refers to a group of disorders that affect a broad range of academic and functional skills including A sleep disorder (somnipathy is a medical disorder of the Sleep patterns of a person or animal ^[2] Disruptive behaviors, impaired functioning, or cognitive impairment in patients with comorbid Tourette's and ADHD may be accounted for by the comorbid ADHD, highlighting the importance of identifying and treating comorbid conditions. Cognition is a concept used in different ways by different disciplines but is generally accepted to mean the process of awareness or thought ^[26][44] Disruption from tics is commonly overshadowed by comorbid conditions that present greater interference to the child. ^[5] Tic disorders in the absence of ADHD do not appear to be associated with disruptive behavior or functional impairment,^[3] while impairment in school, family, or peer relations is greater in patients who have more comorbid conditions and often determines whether therapy is needed. ^[13]

Because comorbid conditions such as OCD and ADHD can be more impairing than tics, these conditions are included in an evaluation of patients presenting with tics. "It is critical to note that the comorbid conditions may determine functional status more strongly than the tic disorder," according to Samuel Zinner, MD. ^[5] The initial assessment of a patient referred for a tic disorder should include a thorough evaluation, including a family history of tics, ADHD, obsessive–compulsive symptoms, and other chronic medical, psychiatric and neurological conditions. Children and adolescents with TS who have learning difficulties are candidates for psychoeducational testing, particularly if the child also has ADHD. ^[40] Undiagnosed comorbid conditions may result in functional impairment, and it is necessary to identify and treat these conditions to improve functioning. Complications may include depression, sleep problems, social discomfort and self-injury. Major depressive disorder, also known as major depression, unipolar depression, unipolar disorder, clinical depression, or simply depression A sleep disorder (somnipathy is a medical disorder of the Sleep patterns of a person or animal Self-injury ( SI) or self-harm ( SH) is deliberate Injury inflicted by a person upon their own body without suicidal intent ^[10]

Management

Main article: Treatment of Tourette syndrome

Clonidine (or the clonidine patch) is one of the medications typically tried first when medication is needed for Tourette's. Tourette syndrome (also Tourette's syndrome or TS is an Inherited Neurological disorder with onset in childhood characterized by the presence of motor Clonidine is a direct-acting α2 Adrenergic agonist prescribed historically as an Antihypertensive agent

The treatment of Tourette's focuses on identifying and helping the individual manage the most troubling or impairing symptoms. ^[5] Most cases of Tourette's are mild, and do not require pharmacological treatment;^[11] instead, psychobehavioral therapy, education, and reassurance may be sufficient. Pharmacology (from Greek grc φάρμακον pharmakon, "drug" and grc -λογία -logia) is the study of how Drugs ^[45] Treatments, where warranted, can be divided into those that target tics and comorbid conditions, which, when present, are often a larger source of impairment than the tics themselves. ^[40] Not all people with tics have comorbid conditions,^[27] but when those conditions are present, they often take treatment priority.

There is no cure for Tourette's and no medication that works universally for all individuals without significant adverse effects. Knowledge, education and understanding are uppermost in management plans for tic disorders. ^[5] The management of the symptoms of Tourette's may include pharmacological, behavioral and psychological therapies. Behavior or behaviour (see spelling differences) refers to the actions or Reactions of an object or Organism, usually Psychology (from Greek grc ψῡχή psȳkhē, "breath life soul" and grc -λογία -logia) is an Academic and While pharmacological intervention is reserved for more severe symptoms, other treatments (such as supportive psychotherapy or cognitive behavioral therapy) may help to avoid or ameliorate depression and social isolation, and to improve family support. See also Cognitive Therapy Cognitive Behavioral Therapy ( CBT) is an umbrella-term for psychotherapeutic systems that deal with cognitions interpretations In the fields of Psychology and Psychiatry, the terms depression or depressed refer to both expected and pathologically chronic or severe Educating a patient, family, and surrounding community (such as friends, school, and church) is a key treatment strategy, and may be all that is required in mild cases. ^[5][46]

Model of a haloperidol molecule. Haloperidol is a Typical antipsychotic. It is in the Butyrophenone class of Antipsychotic medications and has pharmacological effects similar Haloperidol is an antipsychotic medication sometimes used to treat severe cases of Tourette's.

Medication is available to help when symptoms interfere with functioning. ^[14] The classes of medication with the most proven efficacy in treating tics—typical and atypical neuroleptics including risperidone (trade name^[A] Risperdal), ziprasidone (Geodon), haloperidol (Haldol), pimozide (Orap) and fluphenazine (Prolixin)—can have long-term and short-term adverse effects. Typical antipsychotics (sometimes referred to as first generation antipsychotics, conventional antipsychotics, classical neuroleptics, or major tranquilizers The atypical antipsychotics (also known as second generation antipsychotics) are a group of Antipsychotic drugs used to treat psychiatric conditions Antipsychotics are a group of Psychoactive drugs commonly but not exclusively used to treat Psychosis, which is typified by Schizophrenia. Risperidone (pronounced Ris-PER-ǐ-dōn and sold under the trade name Risperdal in the Netherlands, United States, Canada, the Ziprasidone (marketed as Geodon, Zeldox) was the fifth Atypical antipsychotic to gain FDA approval (February 2001 Haloperidol is a Typical antipsychotic. It is in the Butyrophenone class of Antipsychotic medications and has pharmacological effects similar Pimozide (sold as Orap) is an Antipsychotic drug. It was discovered at Janssen Pharmaceutica in 1963. Fluphenazine (marketed as Prolixin is a Typical antipsychotic drug In Medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as Chemotherapy or Surgery. ^[40] The antihypertensive agents clonidine (trade name Catapres) and guanfacine (Tenex) are also used to treat tics; studies show variable efficacy, but a lower side effect profile than the neuroleptics. Antihypertensives are a class of drugs that are used in Medicine and Pharmacology to treat Hypertension (high blood pressure Clonidine is a direct-acting α2 Adrenergic agonist prescribed historically as an Antihypertensive agent Guanfacine (brand name Tenex, and the extended release Intuniv) is a centrally acting Antihypertensive agent ^[1] Stimulants and other medications may be useful in treating ADHD when it co-occurs with tic disorders. Drugs from several other classes of medications can be used when stimulant trials fail, including guanfacine (trade name Tenex), atomoxetine (Strattera) and tricyclics. Stimulant drugs are Drugs that temporarily increase alertness and awareness Tourette syndrome (also Tourette's syndrome or TS is an Inherited Neurological disorder with onset in childhood characterized by the presence of motor Guanfacine (brand name Tenex, and the extended release Intuniv) is a centrally acting Antihypertensive agent Atomoxetine is a non- Stimulant drug approved for the treatment of Attention-deficit hyperactivity disorder (ADHD Tricyclic antidepressants (abbreviation TCAs) are a class of Antidepressant drugs first used in the 1950s Clomipramine (Anafranil), a tricyclic antidepressant, and SSRIs—a class of antidepressants including fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox)—may be prescribed when a Tourette's patient also has symptoms of obsessive–compulsive disorder. Clomipramine (brand-name Anafranil) is a Tricyclic antidepressant. Tricyclic antidepressants (abbreviation TCAs) are a class of Antidepressant drugs first used in the 1950s Selective serotonin reuptake inhibitors ( SSRIs) are a class of Antidepressants used in the treatment of depression, Anxiety disorders An antidepressant is a Psychiatric medication used for alleviating major depression or Dysthymia ('milder' depression Fluvoxamine ( Luvox) is an Antidepressant which functions as a Selective serotonin reuptake inhibitor. ^[40]

Because children with tics often present to physicians when their tics are most severe, and because of the waxing and waning nature of tics, it is recommended that medication not be started immediately or changed often. ^[5] Frequently, the tics subside with explanation, reassurance, understanding of the condition and a supportive environment. ^[5] When medication is used, the goal is not to eliminate symptoms: it should be used at the lowest possible dose that manages symptoms without adverse effects, given that these may be more disturbing than the symptoms for which they were prescribed. ^[5]

Cognitive behavioral therapy (CBT) is a useful treatment when OCD is present,^[47] and there is increasing evidence supporting the use of habit reversal in the treatment of tics. See also Cognitive Therapy Cognitive Behavioral Therapy ( CBT) is an umbrella-term for psychotherapeutic systems that deal with cognitions interpretations Habit reversal training (HRT is a "multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders" ^[48] Relaxation techniques, such as exercise, yoga or meditation, may be useful in relieving the stress that may aggravate tics, but the majority of behavioral interventions (such as relaxation training and biofeedback, with the exception of habit reversal) have not been systematically evaluated and are not empirically supported therapies for Tourette's. A Relaxation technique (also known as Relaxation training) is any method process procedure or activity that helps a person to relax to attain a state of increased calmness Biofeedback is a form of Alternative medicine that involves measuring a subject's quantifiable bodily functions such as Blood pressure, Heart rate, ^[49]

Prognosis

André Malraux (1901–1976) was a French author, adventurer and statesman who had Tourette syndrome. André Malraux (3 November 1901 – 23 November 1976 was a French Author, adventurer and Statesman, and a dominant figure in French politics and culture This article is about the country For a topic outline on this subject see List of basic France topics. An author is defined both as "the person who originates or gives existence to anything" and that authorship determines responsibility for what is created A statesman or stateswoman or statesperson is usually a Politician or other notable figure of State who has had a long and respected career in ^[50][51] President Kennedy, Mme Malraux, French Minister of Culture André Malraux, Jackie Kennedy and Vice President Johnson were photographed at the unveiling of the Mona Lisa at the National Gallery of Art, Washington DC, in 1963. John Fitzgerald "Jack" Kennedy (May 29 1917&ndashNovember 22 1963 often referred to by his initials JFK, was the thirty-fifth President of Mona Lisa (also known as La Gioconda) is a 16th century portrait painted in oil on a Poplar panel by This article is about the National Gallery of the United States for other National Galleries see National Gallery. ^[52]

Tourette syndrome is a spectrum disorder—its severity ranges over a spectrum from mild to severe. The majority of cases are mild and require no treatment. ^[11] In these cases, the impact of symptoms on the individual may be mild, to the extent that casual observers might not know of their condition. The overall prognosis is positive, but a minority of children with Tourette syndrome have severe symptoms that persist into adulthood. ^[28] A study of 46 subjects at 19 years of age found that the symptoms of 80% had minimum to mild impact on their overall functioning, and that the other 20% experienced at least a moderate impact on their overall functioning. ^[7] The rare minority of severe cases can inhibit or prevent individuals from holding a job or having a fulfilling social life. In a follow-up study of thirty-one adults with Tourette's, all patients completed high school, 52% finished at least two years of college, and 71% were full-time employed or were pursuing higher education. ^[53]

Regardless of symptom severity, individuals with Tourette's can expect to live a normal life span. Life expectancy is the average number of years of life remaining at a given age Although the symptoms may be lifelong and chronic for some, the condition is not degenerative or life-threatening. Degeneration is Deterioration in the Medical Sense. Generally it is the change from a higher to a lower form Intelligence is normal in those with Tourette's, although there may be learning disabilities. Intelligence (also called intellect) is an Umbrella term used to describe a property of the Mind that encompasses many related abilities such as the capacities ^[14] There is no reliable means of predicting the outcome for a particular individual. The gene or genes associated with Tourette's have not been identified, and there is no potential "cure". ^[14]

Several studies have demonstrated that the condition in most children improves with maturity. Tics may be at their highest severity at the time that they are diagnosed, and often improve with understanding of the condition by individuals and their families and friends. The statistical age of highest tic severity is typically between eight and twelve, with most individuals experiencing steadily declining tic severity as they pass through adolescence. One study showed no correlation with tic severity and the onset of puberty, in contrast with the popular belief that tics increase at puberty. In many cases, a complete remission of tic symptoms occurs after adolescence. ^[24][54] However, a study using videotape to record tics in adults found that, although tics diminished in comparison with childhood, and all measures of tic severity improved by adulthood, 90% of adults still had tics. Half of the adults who considered themselves tic-free still displayed evidence of tics. ^[53]

It is not uncommon for the parents of affected children to be unaware that they, too, may have had tics as children. Because Tourette's tends to subside with maturity, and because milder cases of Tourette's are now more likely to be recognized, the first realization that a parent had tics as a child may not come until their offspring is diagnosed. It is not uncommon for several members of a family to be diagnosed together, as parents bringing children to a physician for an evaluation of tics become aware that they, too, had tics as a child.

Children with Tourette's may suffer socially if their tics are viewed as "bizarre". If a child has disabling tics, or tics that interfere with social or academic functioning, supportive psychotherapy or school accommodations can be helpful. Psychotherapy is an Interpersonal, relational intervention used by trained psychotherapists to aid clients in problems of living ^[14] Because comorbid conditions (such as ADHD or OCD) can cause greater impact on overall functioning than tics, a thorough evaluation for comorbidity is called for when symptoms and impairment warrant. In Medicine, comorbidity (literally "additional Morbidity " is either * The presence of one or more disorders (or diseases in addition to ^[10]

Tim Howard, goalkeeper for Everton F.C., says, "Tourette's Syndrome is not a problem. Timothy Matthew "Tim" Howard (born March 6, 1979, in North Brunswick, New Jersey, United States) is a Football (soccer In many team Sports a goalkeeper (termed goaltender netminder, goalie, or keeper in some sports Everton Football Club is an English football club located in the city of Liverpool. It is part of my life. It doesn't affect me one way or another on or off the field. "^[55]

A supportive environment and family generally gives those with Tourette's the skills to manage the disorder. ^[56][57] People with Tourette's may learn to camouflage socially inappropriate tics or to channel the energy of their tics into a functional endeavor. Accomplished musicians, athletes, public speakers, and professionals from all walks of life are found among people with Tourette's. There are sociological and cultural aspects of living with Tourette syndrome (also Tourette's syndrome Tourette's or TS including legal advocacy and health insurance issues Outcomes in adulthood are associated more with the perceived significance of having severe tics as a child than with the actual severity of the tics. A person who was misunderstood, punished, or teased at home or at school will fare worse than children who enjoyed an understanding and supportive environment. ^[7]

A controlled study on a small group of individuals with Tourette's found that young people with the syndrome have greater cognitive control over movements than their age-matched controls, possibly because the need to suppress tics results in a more efficient control over inhibitory movements, a skill that confers an advantage when switching between tasks. The executive system is a theorized Cognitive system in Psychology that controls and manages other cognitive processes Children with Tourette's (in the absence of comorbid ADHD) performed more accurately on a goal-oriented eye-movement task, requiring active inhibition of automatic eye movements, and they made fewer errors than their unaffected peers, suggesting compensatory changes in the brain resulting in greater cognitive control. ^[58] A subsequent study confirmed and extended the paradoxical result that individuals with Tourette's exhibit greater levels of cognitive control than age-matched healthy peers. ^[59] A study of eight children, age 8–17, found that children with Tourette syndrome were quicker at processing certain mental grammar skills than are children without the condition. The abnormalities that lead to tics may also lead to "other rapid behaviors, including the cognitive processing of rule-governed forms in language and other types of procedural knowledge". ^[60]

Epidemiology

Tourette syndrome is found among all social, racial and ethnic groups,^[2][61] has been reported in all parts of the world,^[62] and is three to four times more frequent among males than among females. ^[63] The tics of Tourette syndrome begin in childhood and tend to remit or subside with maturity; thus, a diagnosis may no longer be warranted for many adults, and prevalence is much higher among children than adults. In Epidemiology, the prevalence of a Disease in a Statistical population is defined as the total number of cases of the disease in the population at a given ^[24] Children are five to twelve times more likely than adults to be identified as having tic disorders;^[64] as many as 1 in 100 people experience tic disorders, including chronic tics and transient tics in childhood. Tic disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM based on type (motor or phonic and duration of Tics (sudden rapid nonrhythmic ^[2]

Discrepancies across current and prior prevalence estimates come from several factors: ascertainment bias in earlier samples drawn from clinically referred cases, assessment methods that may fail to detect milder cases, and differences in diagnostic criteria and thresholds. In scientific research ascertainment bias occurs when false results are produced by non-random sampling and conclusions made about an entire group are based on a distorted or Sampling is that part of Statistical practice concerned with the selection of individual observations intended to yield some knowledge about a population of concern ^[65] There were few broad-based community studies published before 2000 and until the 1980s, most epidemiological studies of Tourette syndrome were based on individuals referred to tertiary care or specialty clinics. An Epidemiological study is a statistical study on human populations which attempts to link human health effects to a specified cause In Medicine, tertiary healthcare is specialized consultative care usually on referral from primary or secondary medical care personnel by specialists ^[1][66] Children with milder symptoms are unlikely to be referred to specialty clinics, so these studies have an inherent bias towards more severe cases. A biased sample is a statistical sample of a population in which some members of the population are less likely to be included than others ^[1][67] Studies of Tourette syndrome are vulnerable to error because tics vary in intensity and expression, are often intermittent, and are not always recognized by clinicians, patients, family members, friends or teachers;^[5][68] approximately 20% of persons with Tourette syndrome do not recognize that they have tics. Penetrance is a term used in Genetics describing the proportion of individuals carrying a particular variation of a Gene (an Allele or genotype that also ^[5] Recent studies—recognizing that tics may often be undiagnosed and hard to detect—use direct classroom observation and multiple informants (parent, teacher, and trained observers), and therefore record more cases than older studies relying on referrals. ^[69][46] As the diagnostic threshold and assessment methodology have moved towards recognition of milder cases, the result is an increase in estimated prevalence. ^[65]

Tourette syndrome was once thought to be rare: in 1972, the US National Institutes of Health (NIH) believed there were fewer than 100 cases in the United States,^[70] and a 1973 registry reported only 485 cases worldwide. "NIH" redirects here For other meanings of NIH see NIH (disambiguation. ^[71] However, multiple studies published since 2000 have consistently demonstrated that the prevalence is much higher than previously thought. ^[72] The emerging consensus is that 1–11 children per 1,000 have Tourette's, with several studies supporting a tighter range of 6–8 children per 1,000. ^[3] Using year 2000 census data, a prevalence range of 1–10 per 1,000 yields an estimate of 53,000–530,000 school-age children with Tourette's in the US^[3] and a prevalence range of 6–10 per 1,000 means that 64,000–106,000 children aged 5–18 years may have Tourette's in the UK. ^[46] Most of these children are undiagnosed and have mild symptoms without distress or impairment. ^[62][69]

History and research directions

Main article: History of Tourette syndrome

Jean-Martin Charcot (1825–1893) was a French neurologist and professor who bestowed the eponym for Tourette syndrome on behalf of his resident, Georges Albert Édouard Brutus Gilles de la Tourette. Tourette syndrome is an inherited Neurological disorder with onset in childhood characterized by the presence of multiple physical (motor Tics and at least This article is about the country For a topic outline on this subject see List of basic France topics. Charcot is shown here during a lesson with a "hysterical" woman patient at the Salpêtrière hospital. Pitié-Salpêtrière Hospital ( Groupe hospitalier de la Pitié-Salpétrière) is a world-renowned Teaching hospital located in Paris, France.

A French doctor, Jean Marc Gaspard Itard, reported the first case of Tourette syndrome in 1825,^[73] describing Marquise de Dampierre, an important woman of nobility in her time. Jean Marc Gaspard Itard ( April 24 1774 – July 5, 1838) was a French Physician born in Provence. ^[11] Jean-Martin Charcot, an influential French physician, assigned his resident Georges Albert Édouard Brutus Gilles de la Tourette, a French physician and neurologist, to study patients at the Salpêtrière Hospital, with the goal of defining an illness distinct from hysteria and from chorea. Pitié-Salpêtrière Hospital ( Groupe hospitalier de la Pitié-Salpétrière) is a world-renowned Teaching hospital located in Paris, France. Hysteria in its colloquial use describes a state of Mind, one of unmanageable Fear or Emotional excesses Chorea sancti viti (Latin for " St Vitus' dance " is an abnormal involuntary movement disorder one of a group of neurological disorders called Dyskinesias ^[23]

In 1885, Gilles de la Tourette published an account of nine patients, Study of a Nervous Affliction, concluding that a new clinical category should be defined. ^[74] The eponym was later bestowed by Charcot after and on behalf of Gilles de la Tourette. ^[23][75]

Little progress was made over the next century in explaining or treating tics, and a psychogenic view prevailed well into the 20th century. ^[23] The possibility that movement disorders, including Tourette syndrome, might have an organic origin was raised when an encephalitis epidemic from 1918–1926 led to a subsequent epidemic of tic disorders. An organic disease is one which involves or affects Physiology or bodily organs. Encephalitis is an acute Inflammation of the Brain, commonly caused by a viral Infection. In Epidemiology, an epidemic (from Greek epi- upon + demos people is a classification of a disease that appears as new cases in a ^[76]

During the 1960s and 1970s, as the beneficial effects of haloperidol (Haldol) on tics became known, the psychoanalytic approach to Tourette syndrome was questioned. Haloperidol is a Typical antipsychotic. It is in the Butyrophenone class of Antipsychotic medications and has pharmacological effects similar ^[77] The turning point came in 1965, when Arthur K. Shapiro—described as "the father of modern tic disorder research"^[78]—treated a Tourette’s patient with haloperidol, and published a paper criticizing the psychoanalytic approach. Arthur K Shapiro (1923–1995 was a Psychiatrist and expert on Tourette syndrome. ^[76]

Since the 1990s, a more neutral view of Tourette's has emerged, in which biological vulnerability and adverse environmental events are seen to interact. ^[5][23] In 2000, the American Psychiatric Association published the DSM-IV-TR, revising the text of DSM-IV to no longer require that symptoms of tic disorders cause distress or impair functioning. The American Psychiatric Association (APA is the main Professional organization of Psychiatrists and trainee psychiatrists in the United States, and the ^[79]

Findings since 1999 have advanced TS science in the areas of genetics, neuroimaging, neurophysiology, and neuropathology. Neuroimaging includes the use of various techniques to either directly or indirectly image the structure, function/ Pharmacology of the Brain Neurophysiology (from Greek grc νεῦρον neuron, "nerve" grc φύσις physis, "nature origin" and grc -λογία Neuropathology is the study of Disease of nervous system tissue usually in the form of either small surgical biopsies or whole autopsy brains Questions remain regarding how best to classify Tourette syndrome, and how closely Tourette's is related to other movement disorders or psychiatric disorders. Psychiatry is a medical specialty which exists to study, prevent, and treat Mental disorders in Humans Psychiatric Good epidemiologic data is still lacking, and available treatments are not risk free and not always well tolerated. Epidemiology is the study of factors affecting the Health and Illness of populations and serves as the foundation and Logic of interventions made in the Tourette syndrome (also Tourette's syndrome or TS is an Inherited Neurological disorder with onset in childhood characterized by the presence of motor ^[80] High-profile media coverage focuses on treatments that do not have established safety or efficacy, such as deep brain stimulation, and alternative therapies involving unstudied efficacy and side effects are pursued by many parents. In Neurotechnology, deep brain stimulation ( DBS) is a surgical treatment involving the implantation of a medical device called a Brain pacemaker ^[34]

Society and culture

Main article: Sociological and cultural aspects of Tourette syndrome

Samuel Johnson (1709–1784) circa 1772. There are sociological and cultural aspects of living with Tourette syndrome (also Tourette's syndrome Tourette's or TS including legal advocacy and health insurance issues Samuel Johnson (often referred to as Dr Johnson) (18 September Johnson had Tourette syndrome.

Not everyone with Tourette's wants treatment or a "cure", especially if that means they may "lose" something else in the process. ^[81][82] Some people believe that there may be latent advantages associated with genetic vulnerability to the syndrome. ^[82] Cognitive control may be enhanced in young people with Tourette's because the need to suppress tics results in a more efficient control of inhibitions. ^[58] There is evidence to support the clinical lore that children with "TS-only" (Tourette's in the absence of comorbid conditions) are unusually gifted: neuropsychological studies have identified advantages in children with TS-only. In Medicine, comorbidity (literally "additional Morbidity " is either * The presence of one or more disorders (or diseases in addition to ^[27][83] One study found that children with TS-only are faster than the average for their age group on timed motor coordination. Gross motor coordination addresses the Gross motor skills walking running climbing jumping crawling lifting one's head sitting up etc ^[84]

Notable individuals with Tourette syndrome are found in all walks of life, including musicians, athletes and authors. There are sociological and cultural aspects of living with Tourette syndrome (also Tourette's syndrome Tourette's or TS including legal advocacy and health insurance issues The best-known example of a person who may have used obsessive–compulsive traits to advantage is Dr Samuel Johnson, the 18th-century English man of letters, who had Tourette syndrome as clearly evidenced by the writings of James Boswell. Samuel Johnson (often referred to as Dr Johnson) (18 September James Boswell 9th Laird of Auchinleck ( October 29, 1740 - May 19, 1795) was a lawyer diarist and Author born in Edinburgh ^[85] Johnson wrote A Dictionary of the English Language in 1747, and was a prolific writer, poet, and critic. Published on 15 April 1755 and written by Samuel Johnson, A Dictionary of the English Language, sometimes published as Johnson's Dictionary, is among

Although it has been speculated that Mozart had Tourette's,^[86][87] no Tourette's expert or organization has presented credible evidence to show that this was the case,^[87] and there are problems with the available data. There are sociological and cultural aspects of living with Tourette syndrome (also Tourette's syndrome Tourette's or TS including legal advocacy and health insurance issues ^[88]

The entertainment industry often depicts those with Tourette syndrome as social misfits whose only tic is coprolalia, which has furthered stigmatization and the public's misunderstanding of those with Tourette's. There are sociological and cultural aspects of living with Tourette syndrome (also Tourette's syndrome Tourette's or TS including legal advocacy and health insurance issues ^[89] The coprolalic symptoms of Tourette's are also fodder for radio and television talk shows in the US^[90] and in the British media. ^[91]

Notes

References

Sources

• Bagheri MM, Kerbeshian J, Burd L. "Recognition and management of Tourette's syndrome and tic disorders". American Family Physician. 1999; 59:2263–74. PMID 10221310 Retrieved on 28 October 2006. Events 306 - Maxentius is proclaimed Roman Emperor. 312 - Battle of Milvian Bridge: Constantine Year 2006 ( MMVI) was a Common year starting on Sunday of the Gregorian calendar.
• Leckman JF, Cohen DJ. Tourette's Syndrome—Tics, Obsessions, Compulsions: Developmental Psychopathology and Clinical Care. John Wiley & Sons, Inc. , New York, 1999. ISBN 0-471-16037-7 Outline. Retrieved on 28 October 2006. Events 306 - Maxentius is proclaimed Roman Emperor. 312 - Battle of Milvian Bridge: Constantine Year 2006 ( MMVI) was a Common year starting on Sunday of the Gregorian calendar.
• Robertson MM. "Tourette syndrome, associated conditions and the complexities of treatment" (PDF). Brain. 2000;123 Pt 3:425–62. PMID 10686169 Retrieved on 25 January 2007
• Tourette Syndrome: Frequently Asked Questions. Tourette Syndrome Association. Events 41 - After a night of negotiation Claudius is accepted as Roman Emperor by the Senate Year 2007 ( MMVII) was a Common year starting on Monday of the Gregorian calendar in the 21st century. The Tourette Syndrome Association ( TSA) based in Bayside New York United States is a Non-profit voluntary organization and the only national health-related organization Retrieved on January 6, 2006. Events 1066 - Harold Godwinson is crowned King of England. 1205 - Philip of Swabia becomes King Year 2006 ( MMVI) was a Common year starting on Sunday of the Gregorian calendar.
• What is Tourette syndrome? Tourette Syndrome Association. Archived May 24, 2006. Events 1218 - The Fifth Crusade leaves Acre for Egypt. 1276 - Magnus Ladulås is crowned Year 2006 ( MMVI) was a Common year starting on Sunday of the Gregorian calendar.
• The Tourette Syndrome Classification Study Group. "Definitions and classification of tic disorders". Arch Neurol. 1993 Oct;50(10):1013–16. PMID 8215958 Archived April 26, 2006. Events 1467 - The miraculous image in Our Lady of Good Counsel appear in Genazzano, Italy. Year 2006 ( MMVI) was a Common year starting on Sunday of the Gregorian calendar.
• Walkup, JT, Mink, JW, Hollenback, PJ, (eds). Advances in neurology, Vol. 99, Tourette syndrome. Lippincott, Williams & Wilkins, Philadelphia, PA, 2006. ISBN 0-7817-9970-8
• Zinner SH. "Tourette disorder". Pediatr Rev. 2000;21(11):372–83. PMID 11077021

Further reading

• Kushner, HI. A cursing brain?: The histories of Tourette syndrome. Harvard University Press, 2000. ISBN 0-674-00386-1.
• Olson, S. "Making Sense of Tourette's" (PDF). Science. 2004 Sep 3;305(5689):1390–92. PMID 15353772

External links

• Tourette syndrome at the Open Directory Project—Organizations
• Tourette syndrome at the Open Directory Project
• Tourette's Syndrome: minimizing confusion—a blog by Roger Freeman, MD, clinical head of the Neuropsychiatry Clinic, British Columbia's Children's Hospital, professional advisory board member of the Tourette Syndrome Foundation of Canada, and former member of the Tourette Syndrome Association Medical Advisory Board. The Open Directory Project ( ODP) also known as dmoz (from directory The Open Directory Project ( ODP) also known as dmoz (from directory BC Children's Hospital is a medical facility located in Vancouver, British Columbia. The Tourette Syndrome Foundation of Canada (or TSFC) is a Canadian voluntary organization based in Toronto Ontario. The Tourette Syndrome Association ( TSA) based in Bayside New York United States is a Non-profit voluntary organization and the only national health-related organization Dr. Freeman has over 180 journal-published articles on PubMed.
• Tourette syndrome: Newly diagnosed—a 3-hour video/slide presentation by John Walkup, MD, deputy director of the Division of Child and Adolescent Psychiatry, Johns Hopkins Hospital and 2007 Chair of the Tourette Syndrome Association Medical Advisory Board