Tourette's syndrome: symptoms

Symptoms of Tourette's Syndrome

Ticks include a wide repertoire of motor or vocal acts, which the patient feels as violent. Nevertheless, they can be delayed by willpower for a while. The extent to which tics can be delayed varies depending on their severity, type and timing characteristics. Many simple and fast-performing ticks (for example, quick flashing movements or twitching of one's head) can not be controlled, while other ticks that more closely resemble targeted movements, as they arise in response to an inner imperative call, can be delayed. Some patients try to disguise tics. For example, a teenager scratching the perineum can substitute socially more acceptable touches to the abdomen. Over time, the localization of tics and their severity changes - some tics can suddenly disappear or be replaced by others. Such changes sometimes cause the erroneous impression that patients are able to arbitrarily eliminate some tics and perform others. A survey of patients showed that about 90% of them have an unpleasant feeling before the teaches, which forces the patients to perform an action or produce a sound and can be designated as an imperative urge.

The intensity of ticks can be affected by a number of factors. During sleep, ticks decrease, but do not disappear completely. Tics often become more noticeable in a state of relaxation (for example, if the patient at home is watching television), as well as during stress. Ticks can significantly decrease and even disappear if the patient is concentrated on any activity. Here, for example, the description of the surgeon (before and during the operation) given by the famous English neurologist and writer Oliver Sachs (1995): "... His hands were constantly in motion. He continually touched (but never completely) his unsterilized shoulder, assistant, mirror, made sudden movements with his torso, touched his colleagues with his foot. There was a flurry of vocalizations - "Uh-uh" - as if there was a huge owl nearby. After processing the operating field, Bennett took a knife, made a neat, even cut - there was no hint of any ticotic excess movement. Hands moved strictly in accordance with the rhythm of the operation. Twenty minutes passed, fifty, seventy, one hundred. The operation was complicated: we had to bandage the vessels, find nerves - but the surgeon's actions were skillful, verified, and not the slightest hint of Tourette's syndrome ... "

Concomitant disorders

In patients with Tourette's syndrome, comorbid disorders are often detected, which are an important factor in patients' disadaptation. Nevertheless, despite numerous obstacles, many patients achieve success in life. An excellent example is Samuel Johnson, one of the most prominent personalities in English literature of the eighteenth century. He suffered from a severe Tourette syndrome with marked obsessive-compulsive symptoms. He also had autoaggressive actions and symptoms of depression.

It remains questionable whether to consider concomitant disorders as an integral part of the clinical picture of Tourette's syndrome or only as comorbid conditions. Data on the genetic association of OCD with Tourette's syndrome indicate that obsessive-compulsive symptoms are an integral component of the disease. There are reasons to believe that autoaggressive actions and some cases of DVN should also be included in the spectrum of clinical manifestations of Tourette's syndrome. In patients with Tourette's syndrome, personality disorders, affective disorders, anxiety disorders that are not related to OCD, sleep disorders, learning disabilities, phoniatric disorders are also often detected.

Recent studies using standardized assessment methods and specific diagnostic criteria have shown that approximately 40-60% of patients with Tourette's syndrome have obsessive-compulsive symptoms. According to epidemiological data, OCD is found in 2-3% of individuals in the population, so the high prevalence of these symptoms in patients with Tourette's syndrome can not be explained simply by an accidental combination of the two diseases. Studies have shown that OCD is more often detected when mothers of patients with Tourette syndrome underwent stress during pregnancy, as well as in male patients with complications in childbirth. Obsessive-compulsive symptomatology in Tourette's syndrome is an age-dependent phenomenon: symptoms intensify in adolescence and adolescence, when tics tend to weaken. The most common compulsions in patients with Tourette's syndrome include an obsessive account, putting things in order or aligning objects in a certain sequence, rubbing their hands, touching, trying to achieve absolute symmetry. Characterized by OCD fear of pollution and rituals associated with purification, are observed less often.

As already indicated, the differentiation between certain compulsions and tics can cause difficulties. It is customary to classify an action as a compulsion if it is performed in order to neutralize the discomfort caused by the preceding thought (obsession). But it must be taken into account that some patients with ticks "backdating" come up with an "obsession" to explain their uncontrollable actions. On the other hand, tick movements can later be included in the patient's repertoire of compulsions. For example, we observed a 21-year-old patient who, from the age of eight, had a tick in the form of a blink, who declared that he had to blink exactly 6 times to rid himself of the horrifying image of death. Sometimes a tick can be recognized from the context - if the motion is accompanied by other movements, belonging to the tics is not in doubt, then it itself probably has a tick character. In any case, tick-like compulsions (for example, blinking, touching, tapping) and some complex motor tics are located at the point of "intersection" of OCD and Tourette's syndrome, which makes it extremely difficult to divide them at the clinical level.

Symptoms of DVG - hyperactivity, inattention, impulsivity - are detected in approximately 50% of patients with Tourette's syndrome and often manifest before the onset of tics. A child with a mild or severe Tourette syndrome, as a rule, gives the impression of inattentive, fussy, impulsive, so it is difficult to identify the symptoms of DVG in such a patient. Until now, it remains unclear whether DVG is one of the manifestations of Tourette's syndrome or just a comorbid disorder. Scientists have identified two types of Tourette syndrome with comorbid DVG in one of them DVG is independent of Tourette's syndrome, the other - DVG is secondary to Tourette's syndrome. Some researchers reported that the presence of DVG presages a high risk of severe tics and the presence of other comorbid disorders. Children with DVG and Tourette's syndrome often experience greater difficulties in controlling their own impulses, including aggressive ones. Aggressiveness can be accompanied by unpredictable episodes of affective relaxation, which are provoked by frustration or ridicule on the part of peers or relatives. According to one of the studies, with a combination of OCD and DVG, more frequent attacks of rage.

[1], [2], [3], [4], [5]

The course of Tourette's syndrome

The average age of the beginning of motor tics is 7 years. As the disease progresses, tics often spread in the rostrokaudal direction. The average age of the appearance of vocal tics is 11 years. Characterized by a wavy change in the type and severity of tics with a tendency to increase the severity of symptoms until the middle of the adolescent period. In adolescence, in many cases, partial remission or stabilization of symptoms is noted. In most adults with Tourette's syndrome, tics continue to affect the life of patients, and in a third of cases it is very significant.

Classification of Tourette's Syndrome

Motor and vocal tics are divided into simple and complex. Simple motor tics are fast or lightning movements involving any one muscle group. Unlike tremors, tics are irregular. An example of simple motor tics can serve as a blink, twitching the head, shrugging shoulders. Complex motor tics are slower and more coordinated movements that resemble normal, purposeful movements or gestures, but are untimely or differ in temporal pattern and amplitude. Examples are grimaces, touches, torsion of certain objects, copropraxia (indecent gestures), echopraxia (repetition of movements of other people). Motor tics most often represent clonic movements, but can also be dystonic. Clonic tics are sudden short-term and usually repetitive movements, for example, blinking or tapping. Dystonic tics also begin suddenly, but lead to a more permanent change in the posture - for example, prolonged opening of the mouth, forced torso inclination forward, accompanied by jaw clenching. Ticks often emerge as flashes, involving several different movements or sounds, quickly performed or published one after the other.

Simple vocal tics are quick, inarticulate sounds such as snorting, sniffing, coughing, which can be mistakenly regarded as a manifestation of "allergy". Complex vocal tics involve processes of higher nervous activity: they are linguistically meaningful, but inappropriate by the time utterances of interjections, words or phrases. To complex vocal tics include echolalia (repetition of someone else's speech), palalalia (repetition of one's own speech), coprolalia (shouting of obscene words or expressions). Some authors believe that vocal tics should be considered a kind of motor tics that are characterized by a contraction of the muscles of the respiratory tract.

Classification of ticks

	Motor	Vocal
Simple	Fast, lightning fast, meaningless (for example, blinking, nodding, shrugging, tongue-tugging, stomach tension, motion of toes)	Rapid, inarticulate sounds (for example, coughing, groaning, snorting, mooing, "uh, uh, uh")
Complex	Slower, seemingly appropriate (for example, gestures, dystonic postures, copropraxia, repeated touches, smoothing of hair, jumping, spinning, snapping fingers, spitting)	Linguistically meaningful speech elements (for example, coprolalia, echolalia, palalalia, "eh. Eh", "wow"),

Many doctors mistakenly believe that the presence of coprolalia is necessary to establish the diagnosis of Tourette's syndrome, but in fact, it is observed only in a small part of cases (in 2-27% of patients with Tourette's syndrome) and, as a rule, manifests only in adolescence. The heavier the disease, the higher the probability of identifying coprolalia. Some researchers consider coproparasia and coprolalia as a part of a spectrum of socially unacceptable actions or vocalizations, referred to as coprophilia. In a large series of patients with Tourette's syndrome, coprolalia was noted in 32% of cases, copropraxia in 13% of cases, and any variant of coprophilia in 38% of cases. Another study of socially unacceptable actions and expressions found that 22% of patients with Tourette's syndrome are constantly hurt by other people, 30% are tempted to hurt others, 40% are trying to suppress this desire, 24% are trying to hide their impulses, replacing an aggressive remark with something else , not offensive to another person. Seeking to hurt others, the sick most often say: "You're fat, freak, stupid ...", etc. Aggressive actions and observations are most often observed in young men with DVG, behavioral disorder, coprolathy, copropria, internal ("mental") coprolalia.

[6], [7], [8], [9], [10], [11], [12]