Symptom Domains of Tourette syndrome

Symptom Domains of Tourette syndrome:

Current therapeutic approaches: 

Ph - Pharmacology

Su - Surgical (DBS)

Bh - Behavioural (CBT, CBIT/HRT)

LR - Possible learning-related difficulties may be associated: should be assessed and accomodated

Symptom Domain		Ph	Bh	LR
Tics	Motor and vocal tic behaviours. Complex and simple tics	* (+Su)	*	*
Attention Deficit	Impaired attention and concentration	*	*	*
	Can appear as one of the earliest symptoms of TS in young children before tics
Hyperactivity	Hyperkinesis/high level of activity	*		*
	Rapid speech		*	*
	Verbosity/poor turn-taking in conversation (reciprocity)		*	*
	Can appear as one of the earliest symptoms of TS in young children before tics
Depression	Low mood	*	*
	Reduced concentration			*
	Common in a high percentage of individuals with TS
Social Impairments:	Theory of Mind difficulties			*
	Literal thinking/understanding		*	*
	Impaired attribution of intention/use of touching		*	*
	Increased/disproportionate emotional responses
	Speech difficulties		*	*
	Auditory processing dysfunction (can involve more reading of lips and other expressive cues)			*
	Distraction due to tics			*
Sensory Integration	SPD symptomatology			*
	Sensory hypersensitivity: Can involve any modality (tactile, auditory, visual, olfactory, vibration sense, temperature sense, taste)			*
	Many children find certain clothing uncomfortable
	Preference for or avoidance of specific textures/materials
	Different modalities may interfere with others (may not be able to discern speech when watching visual images or reading or not be able to read, write or listen effectively if accompanied by excessive visual stimuli or additional environmental noise)			*
	Poor volume awareness when speaking			*
Non-verbal Learning Difficulties	Slow reading and writing speed (typing and reading screens may be similarly affected)		*	*
	Sensory integration difficulties (can affect visual and auditory modalities)			*
	Tics, obsessions and compulsions may interfere with studying/carrying out assignments			*
	May take on too many simultaneous tasks			*
	May have difficulty in completing assignments or personal projects		*	*
	Individuals may compensate for NLDs with enhanced verbal abilities
Learning Difficulties	As with all children, those with TS may also have any category of LDs including dyslexia/dyspraxia/dysgraphia/dyscalcula etc.		*	*
	The majority of individuals with TS fall into the average to high range of IQ. TS itself does not appear to impair intelligence (or focused motor skills in most) and evidence suggests that compensatory changes may occur over time which can lead to enhancement of some cognitive and motor functions. However some do have motor skills deficits. Handwriting quality and drawing accuracy is sometimes affected. Some have gait abnormalities.
Obsessive-Compulsive Behaviours	Ritualised activities/complex tic behaviours	*	*	*
	Unwanted or unsettling thoughts (may be contrary to the individual's personality/feelings)			*
	Obsessive thinking/thought tics (looping)			*
	Anxiety about other people/family/upcoming events/changes. Heightened empathic response			*
	Concerns about symmetry and evening-up, numerical ordering/preferencing (OCBs relating to washing/cleaning appear to be less common)			*
	Perfectionism (may lead to prolonged time spent on activities/tasks)			*
Anxiety	Considered to be one of the most disabling symptom domains of TS	*	*	*
	Panic attacks		*	*
	Social anxiety and low self-esteem		*	*
Neuro-endocrine	Heightened stress response (evidence for increased cortisol concentrations)
	Polyuria (increased diuresis/urine flow)			*
	Increased thirst response
	Evidence for hypothalamic involvement including temperature dysregulation
	A number of hormones/neurotransmitter substances show altered CNS or systemic concentrations (including dopamine, serotonin, histamine, nor-epinephrine, GABA, cortisol, dynorphin-A/beta-endorphin, gonadotrophin, lutenising hormone release-factor, opioid receptor responsivity and increased urinary amines)
Sleep Dysfunction	Poor quality sleep	*	*	*
	Reduced sleep time
	Increased sleep disturbance/awakening and less REM sleep
Immunological	Some evidence for increased susceptibility to some infections (possible immunoglobulin deficiencies)
	Enhanced inflammatory responsiveness
	Allergies must be considered and ruled out
	Many report an increase in other symptoms during illness e.g tics			*

Tourette syndrome does not have one 'specific' symptom profile that is represented in all individuals although the presence of motor tics for twelve months or more accompanied by 'vocal' tics is the defining feature in diagnosis. Some domains may be more represented in some or be of minimal significance in others. Evidence suggests that there may be several different 'phenotypes' of Tourette syndrome although these have proved difficult to define. One of the most significant axes is the relationship between tic behaviours and obsessive-compulsive behaviours (OCB). Much debate continues with respect to TS-related OCB/OCD and OCD. There are several perspectives. One is that TS and OCD are manifestations of a spectrum disorder with a common neuro-pathological/genetic origin. Another is that TS-related OCB is possibly intrinsic to TS itself but shares an area of over-lapping neuro-pathology, and thus symptomatology, with OCD. It is also becoming more apparent that a possible relationship with autistic specrum disorder may exist. Although some people with TS also receive a diagnosis of ASD it is known that a high proportion of those with a primary diagnosis of TS have some symptoms that are shared with ASD and once thought to be characteristic only of ASD. These include 'Theory of mind' and social difficulties. However it should be noted that these neuro-developmental 'disorders' are mostly defined only by observed signs and symptom sets and their underlying physiological/anatomical cause is unknown and thus no investigative tests are available. Sometimes responsiveness to specific drug therapies may help increase the strength of a diagnosis. Many neurological (and especially psychiatric) disorders are diagnosed using numerical scoring algorithms based on a relatively subjective 'grouping' of symptoms. Much current work focuses on determining the actual aetiology of neuro-developmental conditions such as TS, autism (ASD), ADD/ADHD and SPD in order to establish better diagnostic definition and reduce the ambiguities of subjective/intuitive assessment.