Due to low reading and writing speed & concentration difficulties, school children with Tourette Syndrome may need more time in order to do their best in tests and are often better located in a separate room if they have difficulty suppressing tics or in maintaining attention when surrounded by other students.

Obsessive-compulsive behaviour (OCB)

A large proportion of people with Tourette Syndrome have obsessive and compulsive behaviours (OCB). Indeed, obsessive behaviours were considered, in the earliest descriptions of the disorder, to be an integral part of TS. Evidence from clinical research suggests a wide variance in the prevalence of OCB in cohorts of individuals studied. Although there has been a recent tendency to give a diagnosis of OCD alongside a separate diagnosis of TS, it is becoming clear that specific differences characterise Tourettic-OCD and classic OCD [<R>] and that OCB in TS has a very intrinsic involvement in many other symptoms of TS and is frequently very resistant to the drugs that are used to treat OCD (such as SSRIs). 


In TS, obssessive and compulsive behaviours tend more to focus on 'evening things up', symmetry, counting, numerical balance, perfectionism and 'getting to the root of things'. Obsessive thought patterns may be a significant difficulty and be a source of distraction and anxiety. Enshrinement of fragments of sensory input (words, sounds, music, incidents etc.), thoughts and memories, may result in endless reiteration. In classic OCD, concerns about contamination and 'germs' often predominate and may give rise to obssessive behaviours relating to cleaning, ordering their living environment meticulously and washing or protecting the body from dirt and infection. They may develop elaborate rituals to ensure they or their family are not exposed to potential contamination. People with TS frequently have strong 'intentions' to impose organisational order and neatness on their 'environment but in actuality may tend towards a state of seeming disorder. There are however many similarities but distinction must be acknowledged as it implies differring origins for behaviours and the consideration of different approaches to diagnosis and subsequent management.


In OCB and OCD there is always an awareness that behaviour or thoughts may be irrational but often require 'expression' in order to a feeling of things being 'just right'. Obsessions and compulsions appear to have an intricate relationship with complex tic behaviours. Tics (simple and complex), in Tourette Syndrome, may often include a compulsive (conscious) aspect or premonitory 'urge'.

Tourette Syndrome and autism: room for diagnostic confusion

It is a concern that existing qualitative 'psychological' and checksheet-driven protocols that are used for diagnosing autism often produce false positive results for people who have Tourette Syndrome but are not on the autistic spectrum. There can be significant apparent symptom cross-over between the two conditions. Autism is a differential diagnosis for TS but rarely is TS regarded as a differential for autism, yet mistakes have occurred. Confusion is inevitable although can be limited by stricter interpretation of diagnostic characteristics. Although many with TS have social and sensory difficulties as well as obsessive thinking etc., that are shared with ASD (including Asperger Syndrome), there are several areas that are markedly different and are considered defining in ASD. These include an apparent reduced concern for other's feelings (although in Asperger's, empathy may be clear), a lack of awareness of the isolation and autonomy of the individual mind, less need to develop friendships, dislike of touching or being touched (but this may not be a true reflection of inner wants) and a seeming lack of imaginative play/behaviour. 


Although 'theory of mind' difficulties do occur in TS, many of these 'classic' ASD deficits are, conversely, strongly developed 'attributes' in TS. E.g: Expansive and highly-developed imaginative life, gregariousness, need for tactile contact, emotional hyper-responsivity and sometimes very overt concern and empathy for others and a need to express their 'feelings'. It also appears that some of the shared symptoms and 'characteristics' between the two disorders may have a very different origin and have their roots in differing neurological and psychological aetiologies. However an awareness that the two disorders may co-occur should always be considered. An often overlooked component that can play a central role in both TS and ASD is sensory hyper-sensitivity. Patients with either condition will often emphasise that such sensory problems cause some of their most significant difficulties.

Dr Oliver Sacks (neurologist) series, 'The Mind's Eye' features a documentary about Shane an artist with #Tourette Syndrome. Insightful video: http://www.youtube.com/watch?v=ljX1rsMNA34

Tourette Syndrome is much, much more than just tics. Tics are just the 'tip of the iceberg' but the part that gets all the attention

"I want to tell you something which may not make any sense"

Extract from the movie 'Phoebe in Wonderland' © Silverwood Films/Phoebe in Wonderland, LLC

Phoebe is a young girl with Tourette Syndrome, who has strong obsessive and compulsive behaviours. She is performing the part of Alice in 'Alice in Wonderland' in the school stage production and has been going through a very difficult time at school and in living with her condition. She is sitting on the catwalk above the stage with her very tolerant and understanding drama teacher, Miss Dodger, who says to Phoebe:

"I want to tell you something which may not make any sense.

But I should say it just so that one day, you might remember it,

and maybe it will make you feel better.

At a certain point in your life, probably when too much of it

has gone by...

you will open your eyes

and see yourself for who you are...

especially for everything that made you so different

from all the awful normals.

And you will say to yourself...

"But I am this person."

And in that statement, that correction,

there will be a kind of love."

  

Phoebe: "I'm so scared."

Miss Dodger: "We all are."

In the UK, www.tourettes-action.org.uk are able to provide a list of approved doctors (consultants) who are specialists in #Tourette Syndrome

There are many successful people with Tourette Syndrome: teachers, athletes, artists, writers, musicians, actors, doctors & scientists. It is notable that in the United States, where advocacy and strong anti-discrimination legislation is in place has a much greater representation of individuals with TS in fulltime employment and in the professions, art and pubic life than many other societies. In many countries people with TS are often restricted by prejudice not ability.

Increased stress may result in an increase in the severity of tics & other symptoms in #Tourette Syndrome

Waxing and waning

A characteristic of Tourette Syndrome is that symptoms may vary with time (waxing and waning) sometimes from day-to-day and may change with age although no characteristic progression/remission pattern exists. Some individuals are better able to manage or suppress tic behaviours as they grow older (the reverse is true in some) and evidence suggests that, in some, tics may become almost non-existent. However tics are not always the most challenging aspect of TS and other more troublesome aspects can persist or dominate.

Dopamine in the basal ganglia of the brain may be involved in movement control. In #Tourette Syndrome drugs that inhibit dopamine may help

Evidence suggests that some of the principle chemical messengers (neurotransmitters) involved in #Tourette Syndrome, are dopamine, nor-adrenaline & serotonin

Evidence suggests that #Tourette Syndrome involves an altered balance of chemical messengers as well as structural differences in the brain