home *** CD-ROM | disk | FTP | other *** search
- Differential Diagnosis
-
- Today the full-blown case of TS is unlikely to be confused with any other disorder.
- However, only a decade ago TS was frequently misdiagnosed as schizophrenia,
- obsessive-compulsive disorder, Sydenham's chorea, epilepsy, or nervous habits. The
- differentiation of TS from other tic syndromes may be no more than semantic, especially
- since recent genetic evidence links TS with multiple tics. Transient tics of childhood are
- best defined in retrospect. At times it may be difficult to distinguish children with
- extreme attention deficit hyperactivity disorder (ADHD) from TS. Many ADHD children, on
- close examination, have a few phonic or motor tics, grimace, or produce noises similar to
- those of TS. Since at least half of the TS patients also have attention deficits and
- hyperactivity as children, a physician may well be confused. However, the treating doctor
- should be aware of the potential dangers of treating a possible case of TS with stimulant
- medication. On rare occasions the differentiation between TS and a seizure disorder may be
- problematic. The symptoms of TS sometimes occur in a rather sharply separated paroxysmal
- manner and may resemble automatisms. TS patients, however, retain a clear consciousness
- during such paroxysms. If the diagnosis is in doubt, an EEG may be useful. We have seen TS
- in association with a number of developmental and other neurological disorders. It is
- possible that central nervous system injury from trauma or disease may cause a child to be
- vulnerable to the expression of the disorder, particularly if there is a genetic
- predisposition. Autistic and retarded children may display the entire gamut of TS symptoms,
- but whether an autistic or retarded individual requires the additional diagnosis of TS may
- remain an open question until there is a biological or other diagnostic test specifically
- for TS. In older patients, conditions such as Wilson's disease, tardive dyskinesia, Meige's
- syndrome, chronic amphetamine abuse, and the stereotypic movements of schizophrenia must be
- considered in the differential diagnosis. The distinction can usually be made by taking a
- good history or by blood tests. Since more physicians are now aware of TS, there is a
- growing danger of overdiagnosis or over-treatment. Prevailing diagnostic criteria would
- require that all children with suppressible multiple motor and phonic tics, however
- minimal, of at least one year, should be diagnosed as having TS. It is up to the clinician
- to consider the effect that the symptoms have on the patient's ability to function as well
- as the severity of associated symptoms before deciding to treat with medication.
-
-
- TABLE 1. RANGE OF SYMPTOMS OF TS
-
- Motor
- Simple motor tics: fast, darting, and meaningless.
- Complex motor tics: slower, may appear purposeful
-
- Vocal
- Simple vocal tics: meaningless sounds and noises.
- Complex vocal tics: linguistically meaningful utterances such as words and
- phrases (including coprolalia, echolalia, and palilalia).
-
- Behavioral and Developmental
-
- Attention deficit hyperactivity disorder, obsessions and compulsions,
- emotional problems, irritability, impulsivity, aggressivity, and self-injurious
- behaviors; various learning disabilities
-
-
-
- Symptomatology
-
- The varied symptoms of TS can be divided into motor, vocal, and behavioral manifestations
- (Table 2). Complex motor tics can be virtually any type of movement that the body can
- produce including gyrating, hopping, clapping, tensing arm or neck muscles, touching people
- or things, and obscene gesturing. At some point in the continuum of complex motor tics, the
- term "compulsion" seems appropriate for capturing the organized, ritualistic character of
- the actions. The need to do and then redo or undo the same action a certain number of times
- (e.g., to stretch out an arm ten times bܥe><br><i>Uploader </i>: Robert Dickan
- <br><i>Email </i>: spamdude@computer.net
- <br><i>Language </i>: English
- <br><i>Subject </i>: Biology
- <br><i>Title </i>: Tourette's Syndrome
- <br><i>Grade </i>: 90
- <br><i>System </i>: High School
- <br><i>Age </i>: 18
- <br><i>Country </i>: U.S.A/
- <br><i>Comments </i>: 28 pages long
- <br><i>Where I got Evil House of Cheat Address </i>: newsgroup
- <br><i>Date </i>: may 11, 1996
-
-
-
- Tourette's Disorder
-
-
- Table of Contents
-
-
- Tourette Syndrome And Other Tic Disorders
- Definitions of Tic Disorders
- Differential Diagnosis
- Symptomatology
- Associated Behaviors and Cognitive Difficulties
- Etiology
- Stimulant Medications
- Epidemiology and Genetics
- Non-Genetic Contributions
- Clinical Assessment Of Tourette Syndrome
- Treatment Of Tourette Syndrome
- Monitoring
- Reassurance
- Pharmacological Treatment of Tourette Syndrome
- Psychodynamic Psychotherapy
- Family Treatment
- Genetic Counseling
- Academic and Occupational Interventions
- Bibliography
-
-
-
- Definitions of Tic Disorders
-
- Tics are involuntary, rapid, repetitive, and stereotyped movements of individual muscle
- groups. They are more easily recognized than precisely defined. Disorders involving tics
- generally are divided into categories according to age of onset, duration of symptoms, and
- the presence of vocal or phonic tics in addition to motor tics. Transient tic disorders
- often begin during the early school years and can occur in up to 15% of all children.
- Common tics include eye blinking, nose puckering, grimacing, and squinting. Transient
- vocalizations are less common and include various throat sounds, humming, or other noises.
- Childhood tics may be bizarre, such as licking the palm or poking and pinching the
- genitals. Transient tics last only weeks or a few months and usually are not associated
- with specific behavioral or school problems. They are especially noticeable with heightened
- excitement or fatigue. As with all tic syndromes, boys are three to four times more often
- afflicted than g! irls. While transient tics by definition do not persist for more than a
- year, it is not uncommon for a child to have series of transient tics over the course of
- several years. Chronic tic disorders are differentiated from those that are transient not
- only by their duration over many years, but by their relatively unchanging character. While
- transient tics come and go - with sniffing replaced by forehead furrowing or finger
- snapping, chronic tics - such as contorting one side of the face or blinking - may persist
- unchanged for years. Chronic multiple tics suggest that an individual has several chronic
- motor tics. It is often not an easy task to draw the lines between transient tics, chronic
- tics, and chronic multiple tics. Tourette Syndrome (TS), first described by Gilles de la
- Tourette, can be the most debilitating tic disorder, and is characterized by multiform,
- frequently changing motor and phonic tics. The prevailing diagnostic criteria include onset
- before the age of 21; recurrent, involuntary, rapid, purposeless motor movements affecting
- multiple muscle groups; one or more vocal tics; variations in the intensity of the symptoms
- over weeks to months (waxing and waning); and a duration of more than one year. While the
- criteria appear basically valid, they are not absolute. First, there have been rare cases
- of TS which have emerged later than age 21. Second, the concept of "involuntary" may be
- hard to define operationally, since some patients experience their tics as having a
- volitional component - a capitulation to an internal urge for motor discharge accompanied
- by psychological tension aefore writing, to even up, or to stand up and push a chair into
- "just the right position") is compulsive in duality and accompanied by considerable
- internal discomfort. Complex motor tics may greatly impair school work, e.g., when a child
- must stab at a workbook with a pencil or must go over the same letter so many times that
- the paper is worn thin. Self-destructive behaviors, such as head banging, eye poking, and
- lip biting, also may occur. Vocal tics extend over a similar spectrum of complexity and
- disruption as motor tics ( The most socially distressing complex vocal symptom is
- coprolalia, the explosive utterance of foul or "dirty" words or more elaborate sexual and
- aggressive statements. While coprolalia occurs in only a minority of TS patients (from
- 5-40%, depending on the clinical series), it remains the most well known symptom of TS. It
- should be emphasized that a diagnosis of TS does not require that coprolalia is present.
- Some TS patients may have a tendency to imitate what they have just seen (echopraxia),
- heard (echolalia), or said (palilalia). For example, the patient may feel an impulse to
- imitate another's body movements, to speak with an odd inflection, or to accent a syllable
- just the way it has been pronounced by another person. Such modeling or repetition may lead
- to the onset of new specific symptoms that will wax and wane in the same way as other TS
- symptoms.
-
-
- TABLE 2. EXAMPLES OF MOTOR SYMPTOMS
-
- Simple motor tics
- Eye blinking, grimacing, nose twitching, lip pouting, shoulder shrugging, arm jerking,
- abdominal tensing, kicking, finger movements, jaw snapping, tooth clicking, frowning,
- tensing parts of the body, and rapid jerking of any part of the body.
-
- Complex motor tics
- Hopping, clapping, touching objects (or others or self), throwing, arranging, gyrating,
- bending, "dystonic" postures, biting the mouth, the lip, or the arm, headbanging, arm
- thrusting, striking out, picking scabs, writhing movements, rolling eyes upwards or
- side-to-side, making funny expressions, sticking out the tongue, kissing, pinching,
- writing over-and-over the same letter or word, pulling back on a pencil while writing,
- and tearing paper or books.
-
- Copropraxia
- "Giving the finger" and other obscene gestures.
-
- Echopraxia
- Imitating gestures or movements of other people.
-
-
- TABLE 3. EXAMPLES OF VOCAL SYMPTOMS
-
- Simple vocal tics
- Coughing, spitting, screeching, barking, grunting, gurgling, clacking, whistling, hissing,
- sucking sounds, and syllable sounds such as "uh, uh," "eee," and "bu."
-
- Complex vocal tics
- "Oh boy," "you know," "shut up," "you're fat," "all right," and "what's that."
- or any other understandable word or phrase
- Rituals
- Repeating a phrase until it sounds "just right" and saying something over 3 times.
-
- Speech atypicalities
- Unusual rhythms, tone, accents, loudness, and very rapid speech.
-
- Coprolalia
- Obscene, aggressive, or otherwise socially unacceptable words or phrases.
-
- Palilalia
- Repeating one's own words or parts of words.
-
- Echolalia
- Repeating sounds, words, or parts of words of others.
-
- The symptoms of TS can be characterized as mild, moderate, or severe by their frequency,
- their complexity, and the degree to which they cause impairment or disruption of the
- patient's ongoingctivities and daily life. For example, extremely frequent tics that occur
- 20-30 times a minute, such as blinking, nodding, or arm flexion, may be less disruptive
- than an infrequent tic that occurs several times an hour, such as loud barking, coprolalic
- utterances, or touching tics. There may be tremendous variability over short and long
- periods of time in symptomatology, frequency, and severity. Patients may be able to inhibit
- or not feel a great need to emit their symptoms while at school or work. When they arrive
- home, however, the tics may erupt with violence and remain at a distressing level
- throughout the remainder of the day. It is not unusual for patients to "lose" their tics as
- they enter the doctor's office. Parents may plead with a child to "show the doctor what you
- do at home," only to be told that the youngster "just doesn't feel like doing them" or
- "can't do them" on command. Adults will say "I only wish you could see me outside of your
- office," and family members will heartily agree. A patient with minimal symptoms may
- display more usual severe tics when the examination is over. Thus, for example, the doctor
- often sees a nearly symptom-free patient leave the office who begins to hop, flail, or bark
- as soon as the street or even the bathroom is reached. In addition to the moment-to-moment
- or short-term changes in symptom intensity, many patients have oscillations in severity
- over the course of weeks and months. The waxing and waning of severity may be triggered by
- changes in the patient's life; for example, around the time of holidays, children may
- develop exacerbations that take weeks to subside. Other patients report that their symptoms
- show seasonal fluctuation. However, there are no rigorous data on whether life events,
- stresses, or seasons, in fact, do influence the onset or offset of a period of
- exacerbation. Once a patient enters a phase of waxing symptomatology, a process seems to be
- triggered that will run its course - usually within 1-3 months. In its most severe forms,
- patients may have uncountable motor and vocal tics during all their waking hours with
- paroxysms of full-body movements, shouting, or self-mutilation. Despite that, many patients
- with severe tics achieve adequate social adjustment in adult life, although usually with
- considerable emotional pain. The factors that appear to be of importance with regard to
- social adaptation include the seriousness of attentional problems, intelligence, the degree
- of family acceptance and support, and ego strength more than the severity of motor and
- vocal tics. In adolescence and early adulthood, TS patients frequently come to feel that
- their social isolation, vocational and academic failure, and painful and disfiguring
- symptoms are more than they can bear. At times, a small number may consider and attempt
- suicide. Conversely, some patients with the most bizarre and disruptive symptomatology may
- achieve excellent social, academic, and vocational adjustments.
-
- Associated Behaviors and Cognitive Difficulties
-
- As well as tics, there are a variety of behavioral and psychological difficulties that are
- experienced by many, though not all, patients with TS. Those behavioral features have
- placed TS on the border between neurology and psychiatry, and require an understanding of
- both disciplines to comprehend the complex problems faced by many TS patients. The most
- frequently reported behavioral problems are attentional deficits, obsessions, compulsions,
- impulsivity, irritability, aggressivity, immaturity, self-injurious behaviors, and
- depression. Some of the behaviors (e.g., obsessive compulsive behavior) may be an integral
- part of TS, while others may be more common in TS patients because of certain biological
- vulnerabilities (e.g., ADHD). Still others may represent responses to the social stresses
- associated with a multiple tic disorder or a combination of biological and psychological
- reactions.
-
- Obsessions and Compulsions
-
- Although TS may present itself purely as a disorder of multiple motor and vocal tics, many
- TS patients also have obsessive-compulsive (OC) symptoms that may be as disruptive to their
- lives as the tics - sometimes even more so. There is recent evidence that
- obsessive-compulsive symptomatology may actually be another expression of the TS gene and,
- therefore, an integral part of the disorder. Whether this is true or not, it has been well
- documented that a high percentage of TS patients have OC symptoms, that those symptoms tend
- to appear somewhat later than the tics, and that they may be seriously impairing. The
- nature of OC symptoms in TS patients is quite variable. Conventionally, obsessions are
- defined as thoughts, images, or impulses that intrude on consciousness, are involuntary and
- distressful, and while perceived as silly or excessive, cannot be abolished. Compulsions
- consist of the actual behaviors carried out in response to the obsessions or in an effort
- to ward them off. Typical OC behaviors include rituals of counting, checking things over
- and over, and washing or cleaning excessively. While many TS patients do have such
- behaviors, there are other symptoms typical of TS patients that seem to straddle the border
- between tics and OC symptoms. Examples are the need to "even things up," to touch things a
- certain number of times, to perform tasks over and over until they "feel right," as well as
- self-injurious behaviors.
-
- Attention Deficit Hyperactivity Disorder (ADHD)
-
- Up to 50% of all children with TS who come to the attention of a physician also have
- attention deficit hyperactivity disorder (ADHD), which is manifested by problems with
- attention span, concentration, distractibility, impulsivity, and motoric hyperactivity.
- Attentional problems often precede the onset of TS symptoms and may worsen as the tics
- develop. The increasing difficulty with attention may reflect an underlying biological
- dysfunction involving inhibition and may be exacerbated by the strain of attending to the
- outer world while working hard to remain quiet and still. Attentional problems and
- hyperactivity can profoundly affect school achievement. At least 30-40% of TS children have
- serious school performance handicaps that require special intervention, and children with
- both TS and ADHD are especially vulnerable to serious, long term educational impairment.
- Attention deficits may persist into adulthood and together with compulsions and obsessions
- can seriously impair job performance.
-
- Emotional Lability, Impulsivity, and Aggressivity
-
- Some TS patients (percentages vary greatly in different studies) have significant problems
- with labile emotions, impulsivity, and aggression directed to others. Temper fits that
- include screaming, punching holes in walls, threatening others, hitting, biting, and
- kicking are common in such patients. Often they will be the patients who also have ADHD,
- which makes impulse control a considerable problem. At times the temper outbursts can be
- seen as reactions to the internal and external pressures of TS. A specific etiology for
- such behavioral problems is, however, not well understood. Nevertheless, they create much
- consternation in teachers and great anguish both to TS patients themselves and to their
- families. The treating physician or counselor is often asked whether those behaviors are
- involuntary, as tics are, or whether they can be controlled. Rather than trying to make
- such a distinction, it is perhaps more helpful to think of such patients as having a "thin
- barrier" between aggressive thoughts and the expression of those thoughts through actions.
- Those patients may experience themselves as being out of control, a concept that is as
- frightening to themselves as it is to others. Management of those behaviors is often
- difficult and may involve adjustment of medications, individual therapy, family therapy, or
- behavioral retraining. The intensity of those behaviors often increases as the tics wax and
- decreases as the tics wane.
-
- Etiology
-
- The most intensive research in relation to etiology has focused on neurochemical alterations
- in the brain.
- Multiple neurochemical systems have been implicated by pharmacologic and metabolic
- evidence. The most convincing evidence for dopaminergic involvement has come from the
- dramatic response to haloperidol and other neuroleptics such as pimozide, flupenazine, and
- penfluridol, as well as exacerbations produced by stimulant medications. Findings of
- reduced levels of dopamine metabolites in cerebrospinal fluid (CSF) have led investigators
- to believe that TS results from a hypersensitivity of postsynaptic dopamine receptors.
- Serotonergic mechanisms have been suggested on the basis of reduced CSF serotonin
- metabolites. Since systems relying on neurotransmitters send projections to the substantia
- nigra and the striatum, they could play an important role in the pathophysiology of TS.
- Medications affecting that system seem somewhat effective for obsessions but have
- inconsistent effects on tics. The role of the cholinergic system is clouded by
- contradictory reports. Enhancing cholinergic function by use of physostigmine has been
- associated both with the improvement and the worsening of TS. Elevated levels of red blood
- cell choline have been found in TS patients and their relatives, but the significance is
- unclear. Investigation of the GABAergic system suggests that it may be implicated. The
- proximity and connections between the GABA and dopamine systems support the possibility of
- an interrelationship. Response to clonazepam (a GABAergic agent) has been positive in some
- cases. Yet other GABAergic drugs such as diazepam do not have such positive effects.
- Noradrenergic mechanisms have been most persuasively implicated by observations that
- clonidine, a drug that inhibits noradrenergic functioning by the stimulation of an
- autoreceptor, may improve motor and phonic symptoms. Noradrenergic involvement has also
- been suggested by the exacerbation of the syndrome by stress and anxiety. The use of
- functional neuroimaging techniques such as positron emission tomography may help clarify
- many physiologic relationships and identify important anatomical areas in the near future.
-
- Stimulant Medications
-
- A particularly important risk factor in tics and TS is the use of stimulant medication.
- Over 25% of all TS patients in some cohorts have had a course of stimulation medication
- early in the emergence of their behavioral or tic symptoms because they have been diagnosed
- as having ADHD. Over the last several years, series of cases have been reported in which
- the use of stimulants (methylphenidate, dextroamphetamine, and pemoline) has been
- correlated with the onset of motor and phonic tics. There is also chemical evidence to
- support the observation that stimulants will increase the severity of tics in 25-50% of TS
- patients. In many cases, the tics associated with stimulant medication will disappear with
- the reduction or termination of the medication. It is more controversial whether stimulants
- can actually trigger or produce prolonged chronic multiple tics or TS that will persist
- following their termination. However, cases have been reported in which that seems to have
- occurred. Available information thus indicates that stimulants should be used cautiously
- with ADHD children who have a close relative with tics, should generally be avoided with
- ADHD children with a first-degree relative with TS, and should be terminated with the onset
- of tics in children who previously were tic-free. Children and parents should be educated
- concerning the risks versus benefits in each case prior to being treated with stimulants.
- Alternatives such as behavioral management, environmental manipulation, and/or other types
- of medication should be considered carefully.
-
- Epidemiology and Genetics
-
- While once thought to be rare, TS is now seen as a relatively common disorder affecting up
- to one person in every 2,500 in its complete form and three times that number in its
- partial expressions that include chronic motor tics and some forms of obsessive-compulsive
- disorder. The question of the familial transmission of TS was first raised in the original
- 19th century descriptions of the disorder, but a genetic basis for TS was not considered
- seriously until recently. Several genetic studies have now been reported and other rigorous
- studies are now well enough along to draw several important conclusions. Those studies have
- investigated many families in which TS and other tic disorders have been transmitted over
- several generations. Based on available information, it is now clear that TS is a genetic
- disorder. The vulnerability to TS is transmitted from one generation to another. When we
- speak of "vulnerability," we imply that the child receives the genetic or constitutional
- basis for developing a tic disorder; the precise type of disorder or severity may be
- different from one generation to another. That vulnerability is transmitted by either
- mothers or fathers and can be passed on to either sons or daughters. When one parent is a
- carrier or has TS, it appears that there is about a 50-50 chance that a child will receive
- the genetic vulnerability from that parent. That pattern of inheritance is described as
- autosomal dominant. However, not everyone who inherits the genetic vulnerability will
- express any of the symptoms of TS. There is a 70% chance that female gene carriers will
- express any of the symptoms of TS. For a male gene carrier, there is a 99% chance of
- showing some clinical expression of the gene. The degree of expression is described as
- penetrance. In males, the penetrance is higher than in females; thus, males are more likely
- to have some form of expression of the genetic vulnerability. There is a full 30% chance of
- female gene carriers showing no symptoms at all. For males, the figure is 1%. There is a
- range of forms in which the vulnerability may be expressed that includes full-blown TS,
- chronic multiple tics, and, as most recently recognized, obsessive-compulsive disorder.
- Some individuals have TS (or chronic tics) and obsessive-compulsive disorder together;
- others may have the conditions singly. There are also differences between the sexes in the
- form of expression of the TS gene. Males are more likely to have TS or tics; females are
- more likely to have obsessive-compulsive disorder; however, both males and females may have
- any combination or severity. The severity of the disorder is also highly variable. Most
- individuals who inherit the TS genetic vulnerability have very mild conditions for which
- they do not seek medical attention. Researchers are actively engaged in searching for the
- chromosomal location of the TS gene of affected individuals. At present, there is no
- genetic or biochemical test to determine if a person with TS or an unaffected individual
- carries the gene. There is no prenatal test for the vulnerability to TS. When scientists
- succeed in locating the gene, such tests may become available.
-
- Non-Genetic Contributions
-
- The individual variations in character, course, and degree of severity by which TS is
- manifested cannot be explained by genetic hypotheses alone. Furthermore, it appears that
- about 10-15% of TS patients do not acquire the disorder genetically. Thus, non-genetic
- factors are also responsible, both as causes and as modifiers of TS. Non-genetic factors
- that have been implicated include such stressful processes or events during the prenatal,
- perinatal, or early life periods as fetal compromise and exposure to drugs or other toxins.
- Findings from one study in which decreased birth weights were observed in the affected
- co-twins of discordant monozygotic pairs lend further support to the influence of
- environmental factors.
-
-
-
- Clinical Assessment Of Tourette Syndrome
-
- Assessment of a case of TS involves far more than simple diagnosis. Since symptoms may
- fluctuate in severity and character from hour to hour, a thorough understanding of the
- patient may take a considerable amount of time. As the patient becomes more comfortable
- with the doctor, there will be less likelihood of symptom suppression or inhibition. Only
- when there is confidence in the physician is the patient likely to acknowledge the most
- frightening or bizarre symptoms. The nature, severity, frequency, and degree of disruption
- produced by the motor and vocal tics need to be carefully assessed from the time of their
- emergence until the present. Inquiries should be made about factors that may have worsened
- or ameliorated their severity. A critical question concerns the degree to which the tics
- have interfered with the patient's social, familial, and school or work experiences. In
- those respects interviews with families may be revealing and informative. During the
- evaluation of a patient with TS, the clinician must assess all areas of functioning to
- fully understand both difficulties and strengths. It is important to explore the presence
- of attentional and learning disabilities, a history of school and/or work performance, and
- relationships with family and peers. Before receiving the diagnosis, the patient and/or
- family may have thought he or she "was going crazy." The patient may have become extremely
- distressed by his or her own experiences and by the often negative responses evoked.
- Parents may have scolded, cajoled, ridiculed, threatened, and perhaps beaten the child to
- stop the "weird" and embarrassing behavior, and the emotional sequelae may affect the
- patient far beyond the period of childhood. During the evaluation of a child, therefore,
- family issues including parental guilt need to be addressed. Relevant factors elicited
- through careful diagnostic evaluation can be approached through clarification, education,
- and therapeutic discussion with the youngster and the family. Careful assessment of
- cognitive functioning and school achievement is indicated for children who have school
- problems. TS children with school performance difficulties often do not have clearly
- delineated learning disorders, and the average IQ of TS patients is normal. Rather, their
- problems tend to lie in the areas of attentional deployment, perseverance, and the ability
- to keep themselves and their work organized. Many have difficulties with penmanship
- (graphomotor skills) and compulsions that interfere with writing. Determining specific
- problem areas will help in the recommendation of alternatives (e.g., extended periods of
- time for tests, the use of a typewriter or the emphasis on oral rathe! r than written
- reports). The neurological examination should include documentation of neuromaturational
- difficulties and other neurological findings. About half of TS patients have
- non-localizing, so called "soft," neurological findings suggesting disturbances in the body
- scheme and integration of motor control. While such findings have no specific therapeutic
- implications, they are worth noting as "baseline" data since the use of medications such as
- haloperidol may cloud the neurological picture. The EEG is often abnormal in TS, but the
- EEG findings are nonspecific. Computed tomography of the brain produces normal results in
- people with TS. Thus, unless there is some doubt about the diagnosis or some complicating
- neurological factors, an EEG and a computed tomography are not necessary parts of the
- clinical evaluation. Additional studies that may be considered in the biological work-up
- include serum electrolytes, calcium, phosphorous, copper, ceruloplasmin, and liver function
- tests - all related to movement disorders of various types. In practice, however, they are
- rarely needed for the diagnosis. A behavioral pedigree of the extended family, including
- tics, compulsions, attentional problems and the like is useful. Previous medications must
- be reviewed in detail during assessment. If a child has received stimulant medications, it
- is important to determine what the indications for the medications were, whether there were
- any pre-existing tics or compulsions, and the temporal relation between the stimulants and
- the new symptoms. Catecholaminergic agonists are contained in other drugs, such as in
- decongestant combinations used in treating allergies and in medications used for asthma. If
- a patient with TS is on a stimulant or a drug containing an ephedrine like agent,
- discontinuation should be strongly considered. If the physician examines a previously
-