eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Tourette Syndrome: Follow-up

Author: Jason S Hawley, MD, Chief of Neurology, Carl R Darnall Army Medical Center
Coauthor(s): Sharette K Gray, MD, Chief of Outpatient Psychiatry, Carl R Darnall Army Medical Center
Contributor Information and Disclosures

Updated: Jun 23, 2008

Follow-up

Further Inpatient Care

  • Only rarely do patients with Tourette syndrome (TS) need hospitalization. Most of the patients who do require hospitalization have comorbid conditions and are a threat to themselves or to others.
  • Patients with the complex tics of coprolalia or copropraxia might need a brief hospitalization if their families have difficulty controlling them.

Further Outpatient Care

  • Psychotherapeutic counseling and support  
    • Other measures should be taken to nurture self-esteem and self-correction. Individual counseling, cognitive and behavioral therapies, and group therapy should be considered.
    • Areas of strength should be emphasized, such as talents and skills, interests, any family or peer supports, and psychological resilience.
    • Social skills training can help develop and reinforce more effective methods of confident and prosocial communication.
    • Parents or other guardians may benefit from parent behavior management and discipline training, recognizing that the underlying purpose of discipline is to instill a sense of self-control and responsibility for one's behavior.
    • Allowances must be made for the child's uncontrollable behaviors that result from processes of the disorder, but some behaviors, such as spitting at others or obscene gestures, have negative social connotations and require special guidance. Methods to help the child manage these behaviors include nonjudgmental acceptance of the child regardless of the nature of the behaviors and working with the child to adapt or substitute alternative, more appropriate behaviors that satisfy premonitory urges, such as spitting into a handkerchief instead of spitting openly.
    • Parenting skills books, workshops, and trained specialists are widely available and emphasize practical methods in positive reinforcement of desirable behaviors through giving praise or rewards, modeling appropriate behaviors, and administering "time-outs" from rewards or attention for inappropriate or uncontrolled behaviors.
    • Parents also may benefit from group support and education or other topical groups and from individual supportive counseling to cope with accompanying stress.
    • Information is available through school counselors, psychologists, representatives of local chapters of the Tourette Syndrome Association, Inc, or related topical organizations.

Prognosis

  • For most patients, symptoms reach their fullest expression some time during adolescence, roughly a decade after onset. At some time, symptoms become more unpredictable, sometimes changing markedly from day to day or week to week. Despite this, the later teenage years are often a time when the severity of tics levels off and remission begins. Several retrospective studies indicate that many patients, even those with severe tics during childhood, improve considerably during the late teenage to early adult years. Approximately one third of patients experience complete remissions of tics during this period, whereas another one third of patients improve to the point that their tics are relatively mild and do not cause impairment. Some evidence shows that adolescent tic severity may be of more prognostic value.
  • Two thirds of children with TS can anticipate a significant amelioration of their tics or almost complete remission. Life-long remissions are rare.
  • The continued presence of such tics is often denied or minimized by these parents but is reported by other family members. At times, tics do not occur in a physician's office, and assessment of these very mild, but persistent tic disorders is difficult.
  • Approximately one third of patients with TS do not experience a significant amelioration of symptoms as adults. For these patients, little data are available on which percentages become worse, remain much the same, or improve to some degree. A fair number of patients present in their third, fourth, and fifth decades for treatment after self-diagnosis. Elderly patients who have never been diagnosed are far more rare but also do present for diagnosis.

Patient Education

  • The Tourette Syndrome Association is an excellent tool for patient education.
  • One of the most important aspects of treating TS is educating the patient and family members about tic disorders and associated behavioral disturbances. In addition to lengthy discussions with the patient and family at the time of diagnosis, a packet of educational brochures prepared by the Tourette Syndrome Association is helpful.
  • A local TS support group may be of great benefit to patients and family members.
  • Individual, group, or family counseling may help in facilitating a healthy adaptation to the illness.
  • Several relaxation or stress management treatment approaches reportedly improve the tics. For example, tics are known to worsen from stress and to improve during periods of relaxation. Whether such therapies have a direct effect on the tics or exert an indirect influence by allowing patients to deal more productively with life stresses is unclear.

Miscellaneous

Medicolegal Pitfalls

  • Patients with Tourette syndrome (TS) may go undiagnosed. The excessive movements are implicated as twitchiness or anxiety and not necessarily considered a disease. Patients and families may not necessarily alert the practitioner regarding the symptoms.
  • The practitioner could potentially diagnose tics as chorea or myoclonus, and initiate an unnecessary work up to evaluate these conditions.
  • Improper diagnosis of  phonic tics, such as throat clearing, sniffing or cough, as allergies or asthma.
 
Acknowledgments

I would like to acknowledge the help and support of Dr. Mark Landau, Staff Neurologist at Walter Reed Army Medical Center. His advise and review of this article and topic was greatly appreciated and necessary for the submission of the updated eMedicine review of Tourette Syndrome.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Emad Soliman, MD, to the development and writing of this article.



More on Tourette Syndrome

Overview: Tourette Syndrome
Differential Diagnoses & Workup: Tourette Syndrome
Treatment & Medication: Tourette Syndrome
Follow-up: Tourette Syndrome
References
[ CLOSE WINDOW ]

References

  1. Jankovic J. Tourette's syndrome. N Engl J Med. Oct 18 2001;345(16):1184-92. [Medline].

  2. Bohlhalter S, Goldfine A, Matteson S, Garraux G, Hanakawa T, Kansaku K, et al. Neural correlates of tic generation in Tourette syndrome: an event-related functional MRI study. Brain. Aug 2006;129:2029-37. [Medline].

  3. Comella CL. Gilles de la Tourette's syndrome and other tic disorders. CONTINUUM: Lifelong Learning in Neurology. June 2004;10 (3):128-41.

  4. Alsobrook JP 2nd, Pauls DL. The genetics of Tourette syndrome. Neurol Clin. May 1997;15(2):381-93. [Medline].

  5. Singer HS, Hong JJ, Yoon DY, Williams PN. Serum autoantibodies do not differentiate PANDAS and Tourette syndrome from controls. Neurology. Dec 13 2005;65(11):1701-7. [Medline].

  6. Tanner CM, Goldman SM. Epidemiology of Tourette syndrome. Neurol Clin. May 1997;15(2):395-402. [Medline].

  7. Kadesjo B, Gillberg C. Tourette's disorder: epidemiology and comorbidity in primary school children. J Am Acad Child Adolesc Psychiatry. May 2000;39(5):548-55. [Medline].

  8. Cheung MY, Shahed J, Jankovic J. Malignant Tourette syndrome. Mov Disord. Sep 15 2007;22(12):1743-50. [Medline].

  9. Simonic I, Nyholt DR, Gericke GS, Gordon D, Matsumoto N, Ledbetter DH, et al. Further evidence for linkage of Gilles de la Tourette syndrome (GTS) susceptibility loci on chromosomes 2p11, 8q22 and 11q23-24 in South African Afrikaners. Am J Med Genet. Mar 8 2001;105(2):163-7. [Medline].

  10. A complete genome screen in sib pairs affected by Gilles de la Tourette syndrome. The Tourette Syndrome Association International Consortium for Genetics. Am J Hum Genet. Nov 1999;65(5):1428-36. [Medline].

  11. Anca MH, Giladi N, Korczyn AD. Ropinirole in Gilles de la Tourette syndrome. Neurology. May 11 2004;62(9):1626-7. [Medline].

  12. Bloch MH, Leckman JF, Zhu H, Peterson BS. Caudate volumes in childhood predict symptom severity in adults with Tourette syndrome. Neurology. Oct 25 2005;65(8):1253-8. [Medline].

  13. Bruun RD, Budman CL. The course and prognosis of Tourette syndrome. Neurol Clin. May 1997;15(2):291-8. [Medline].

  14. Chappell PB, Scahill LD, Leckman JF. Future therapies of Tourette syndrome. Neurol Clin. May 1997;15(2):429-50. [Medline].

  15. Como PG. Tourette syndrome. Neuropsychological tests for obsessive-compulsive disorder and attention deficit hyperactivity disorder. Neurol Clin. May 1997;15(2):255-65. [Medline].

  16. Freeman RD. Attention deficit hyperactivity disorder in the presence of Tourette syndrome. Neurol Clin. May 1997;15(2):411-20. [Medline].

  17. Kompoliti K, Goetz CG. Tourette syndrome. Clinical rating and quantitative assessment of tics. Neurol Clin. May 1997;15(2):239-54. [Medline].

  18. Kumar R, Lang AE. Tourette syndrome. Secondary tic disorders. Neurol Clin. May 1997;15(2):309-31. [Medline].

  19. Kurlan R. Future direction of research in Tourette syndrome. Neurol Clin. May 1997;15(2):451-6. [Medline].

  20. Kurlan R. Tourette syndrome. Treatment of tics. Neurol Clin. May 1997;15(2):403-9. [Medline].

  21. Kurlan R. Tourette's syndrome. In: Movement Disorders, Neurologic Principles and Practice. 2nd edition. New York: The McGraw-Hill Companies, Inc.; 2004:659-692.

  22. Kurlan R, Como PG, Miller B, Palumbo D, Deeley C, Andresen EM, et al. The behavioral spectrum of tic disorders: a community-based study. Neurology. Aug 13 2002;59(3):414-20. [Medline].

  23. Leckman JF, Peterson BS, Pauls DL. Tic disorders. Psychiatr Clin North Am. Dec 1997;20(4):839-61. [Medline].

  24. Marcus D, Kurlan R. Tics and its disorders. Neurol Clin. Aug 2001;19(3):735-58, viii. [Medline].

  25. Marras C, Andrews D, Sime E, Lang AE. Botulinum toxin for simple motor tics: a randomized, double-blind, controlled clinical trial. Neurology. Mar 13 2001;56(5):605-10. [Medline].

  26. Miguel EC, Rauch SL, Jenike MA. Obsessive-compulsive disorder. Psychiatr Clin North Am. Dec 1997;20(4):863-83. [Medline].

  27. Packer LE. Social and educational resources for patients with Tourette syndrome. Neurol Clin. May 1997;15(2):457-73. [Medline].

  28. Pranzatelli MR. Movement disorders in childhood. Pediatr Rev. Nov 1996;17(11):388-94. [Medline].

  29. Robertson MM, Banerjee S, Kurlan R, Cohen DJ, Leckman JF, McMahon W, et al. The Tourette syndrome diagnostic confidence index: development and clinical associations. Neurology. Dec 10 1999;53(9):2108-12. [Medline].

  30. Shavitt RG, Hounie AG, Rosario Campos MC, Miguel EC. Tourette's Syndrome. Psychiatr Clin North Am. Jun 2006;29(2):471-86. [Medline].

  31. Singer HS. Tourette's syndrome: from behaviour to biology. Lancet Neurol. Mar 2005;4(3):149-59. [Medline].

  32. Visser-Vandewalle V, Ackermans L, van der Linden C, Temel Y, Tijssen MA, Schruers KR, et al. Deep brain stimulation in Gilles de la Tourette's syndrome. Neurosurgery. Mar 2006;58(3):E590. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

Tourette syndrome, tic, motor tic, phonic tic, vocal tic, Tourette, obsessive-compulsive disorder, OCD, attention deficit hyperactivity disorder, ADHD, TS psychopathology, large dorsolateral prefrontal region, increased cortical white matter in the right frontal lobe, dopamine supersensitivity

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Jason S Hawley, MD, Chief of Neurology, Carl R Darnall Army Medical Center
Jason S Hawley, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

Sharette K Gray, MD, Chief of Outpatient Psychiatry, Carl R Darnall Army Medical Center
Sharette K Gray, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Jennifer S Morse, MD, Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego
Jennifer S Morse, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Aerospace Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eduardo Dunayevich, MD, Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories
Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.