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Brief History of Tourettes
In 1825, French neurologist Jean-Marc Itard described his patient,Marquise de Dampierre, in medical literature stating the she exhibited symptoms including involuntary tics of many parts of her body and various vocalizations ranging from spontanious swearing, to demonic or strange cries. Some 50 years after Itard's report, in 1885, another French neurologist Georges Gilles de la Tourette produced a detailed account of several patients with a similar condition. Jean Martin Charcot, one of the leading European neurologists of the 19th century and Gilles de la Tourette's supervisor at the Salpetriere, attached his pupil's name to this syndrome.

General Charcteristics
Gilles de la Tourette syndrome (Often refered to as Tourettes Syndrome ot TS) is a neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics. The early symptoms of TS are typically noticed first in childhood, with the average onset between the ages of 3 and 9 years. TS occurs in people from all ethnic groups; males are affected about three to four times more often than females. It is estimated that 200,000 Americans have the most severe form of TS, and as many as one in 100 exhibit milder and less complex symptoms such as chronic motor or vocal tics. Although TS can be a chronic condition with symptoms lasting a lifetime, most people with the condition experience their worst tic symptoms in their early teens, with improvement occurring in the late teens and continuing into adulthood.

Symptoms
Simple: motor tics are sudden, brief, repetitive movements that involve a limited number of muscle groups. Some of the more common simple tics include eye blinking and other eye movements, facial grimacing, shoulder shrugging, and head or shoulder jerking. Simple vocalizations might include repetitive throat-clearing, sniffing, or grunting sounds.

Complex: tics are distinct, coordinated patterns of movements involving several muscle groups. Complex motor tics might include facial grimacing combined with a head twist and a shoulder shrug. Other complex motor tics may actually appear purposeful, including sniffing or touching objects, hopping, jumping, bending, or twisting. Complex vocal tics include words or phrases. Perhaps the most dramatic and disabling tics include motor movements that result in self-harm such as punching oneself in the face or vocal tics including coprolalia (uttering socially inappropriate words such as swearing) or echolalia (repeating the words or phrases of others). However, coprolalia is only present in a small number (10 to 15 percent) of individuals with TS. Notes: Some tics are preceded by an urge or sensation in the affected muscle group, commonly called a premonitory urge. Some with TS will describe a need to complete a tic in a certain way or a certain number of times in order to relieve the urge or decrease the sensation. Aslo, people with TS usually exhibet anger control issues, ADHD, impulsive behavior, some mood disorders, OCD, and poor social skills.

Diagnosis
TS is a diagnosis that doctors make after verifying that the patient has had both motor and vocal tics for at least 1 year. The existence of other neurological or psychiatric conditions can also help doctors arrive at a diagnosis. Common tics are not often misdiagnosed by knowledgeable clinicians. However, atypical symptoms or atypical presentations (for example, onset of symptoms in adulthood) may require specific specialty expertise for diagnosis. There are no blood, laboratory, or imaging tests needed for diagnosis. In rare cases, neuroimaging studies, such as magnetic resonance imaging or computerized tomography, electroencephalogram studies, or certain blood tests may be used to rule out other conditions that might be confused with TS when the history or clinical examination is atypical.

Treatment
Because tic symptoms often do not cause impairment, the majority of people with TS require no medication for tic suppression. However, effective medications are available for those whose symptoms interfere with functioning.There are no lab tests to diagnose Tourette syndrome. However, a health care provider should do an examination to rule out other causes of the symptoms. Neuroleptics are the most consistently useful medications for tic suppression; a number are available but some are more effective than others. Unfortunately, there is no one medication that is helpful to all people with TS, nor does any medication completely eliminate symptoms. In addition, all medications have side effects. Many neuroleptic side effects can be managed by initiating treatment slowly and reducing the dose when side effects occur. The most common side effects of neuroleptics include sedation, weight gain, and cognitive dulling. Behavioral treatments such as awareness training and competing response training can also be used to reduce tics. A recent NIH-funded, multi-center randomized control trial called Cognitive Behavioral Intervention for Tics, or CBIT, showed that training to voluntarily move in response to a premonitory urge can reduce tic symptoms. Other behavioral therapies, such as biofeedback or supportive therapy, have not been shown to reduce tic symptoms. However, supportive therapy can help a person with TS better cope with the disorder and deal with the secondary social and emotional problems that sometimes occur. Deep brain stimulation has shown promise for treating both the main symptoms of Tourette syndrome and the obsessive-compulsive behaviors.

Causes of TS
Although the cause of TS is unknown, current research points to abnormalities in certain brain regions (including the basal ganglia, frontal lobes, and cortex), the circuits that interconnect these regions, and the neurotransmitters responsible for communication among nerve cells. It may be linked to problems in certain areas of the brain. It may have to do with chemical substances (dopamine, serotonin, and norepinephrine). Given the often complex presentation of TS, the cause of the disorder is likely to be equally complex. There is strong evidence that TS is passed down through families, although the gene has not yet been found. Although early family studies suggested an autosomal dominant mode of inheritance, more recent studies suggest that the pattern of inheritance is much more complex. Although there may be a few genes with substantial effects, it is also possible that many genes with smaller effects and environmental factors may play a role in the development of TS.

Studies/Case Study
Genetic studies: Currently, NIH-funded investigators are conducting a variety of large-scale genetic studies. Rapid advances in the technology of gene discovery will allow for genome-wide screening approaches in TS, and finding a gene or genes for TS would be a major step toward understanding genetic risk factors. In addition, understanding the genetics of TS genes may strengthen clinical diagnosis, improve genetic counseling, lead to the clarification of pathophysiology, and provide clues for more effective therapies.

Neuroimaging studies: Advances in imaging technology and an increase in trained investigators have led to an increasing use of novel and powerful techniques to identify brain regions, circuitry, and neurochemical factors important in TS and related conditions.

Neuropathology: There has been an increase in the number and quality of donated postmortem brains from TS patients available for research purposes. This increase, coupled with advances in neuropathological techniques, has led to initial findings with implications for neuroimaging studies and animal models of TS.

Clinical trials: A number of clinical trials in TS have recently been completed or are currently underway. These include studies of stimulant treatment of ADHD in TS and behavioral treatments for reducing tic severity in children and adults. Smaller trials of novel approaches to treatment such as dopamine agonists and glutamatergic medications also show promise. Epidemiology and clinical science: Careful epidemiological studies now estimate the prevalence of TS to be substantially higher than previously thought with a wider range of clinical severity. Furthermore, clinical studies are providing new findings regarding TS and co-existing conditions. These include subtyping studies of TS and OCD, an examination of the link between ADHD and learning problems in children with TS, a new appreciation of sensory tics, and the role of co-existing disorders in rage attacks. One of the most important and controversial areas of TS science involves the relationship between TS and autoimmune brain injury associated with group A beta-hemolytic streptococcal infections or other infectious processes. There are a number of epidemiological and clinical investigations currently underway in this intriguing area.

Case Study Link: http://www.handle.org/validation/casestudies/CaseStudy_THI_Tourette_01.pdf

Bibliography/References/Links: http://www.cwgsy.net/community%2Ftosy/history.htm http://www.ninds.nih.gov/disorders/tourette/detail_tourette.htm http://www.nlm.nih.gov/medlineplus/ency/article/000733.htm http://www.webmd.com/mental-health/tc/tourettes-disorder-symptoms http://www.handle.org/validation/casestudies/CaseStudy_THI_Tourette_01.pdf