What is Tourette syndrome?

 

Tourette syndrome (TS) is a neuropsychiatric disorder which occurs due to the chronic occurrence of multiple motor tics and at least one vocal or phonic tic, with symptom onset typically during childhood. These tics are often characterised by fluctuations in tic frequency and severity, including periods of remission and exacerbation. 

A hallmark feature of most affected individuals is uncomfortable somatic sensations, called sensory phenomena or premonitory urges. These sensations often precede tic expression and are integral to the condition's pathophysiology (1). 

While the exact cause of TS remains unclear, potential contributors include neurochemical imbalances and comorbid conditions such as attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive behaviours. Nevertheless, understanding Tourette syndrome means looking beyond its visible motor and vocal tics to identify the sensory phenomena that often drive them. 

Let’s explore how hidden emotional triggers, stress, and repressed memories can shape tic behaviour. 

The Neuropsychology of Tourette syndrome 

Everyday behaviours such as swallowing, coughing, and yawning have been observed to be accompanied by bodily sensations that we interpret as urges to act. These experiences exhibit key subjective similarities with the premonitory urges linked to tics in TS and certain repetitive behaviours associated with other neuropsychiatric disorders such as; OCD, autism, and addiction. 

Although there are different theories about the underlying causes of tics, in terms of their triggers and general mechanisms, the precise reasons remain a subject of ongoing debate. Tourette syndrome is a complex condition likely resulting from a combination of genetic and environmental factors. Neurotransmitters in the brain, such as dopamine and serotonin nerve signals may contribute to its development. 

In light of this, researchers argued two key brain systems control behavior one drives motivational urges (the desire to act) and the other controls intentional action (planned goal-directed movement). The intentional action system involves parts of the brain that help with motor control and our sense of will when we act. 

This distinction allows us to understand movements better; voluntary actions are flexible and controlled, while involuntary actions are automatic and rigid. Tics fall somewhere in between. They're often triggered by a premonitory urge, a feeling that builds up before the tic happens. 

Research on tics has shown mixed results. Some studies suggest tics are preceded by brain activity similar to voluntary actions, while others found no consistent pattern. Tics are less common during sleep but can still occur, suggesting they may sometimes be involuntary (2). 

The subconscious mind and Tourette syndrome 

The subconscious regulates our automatic behaviours, emotional responses, and physiological functions. It stores memories, emotions, and past experiences that we may not be fully aware of influencing our reactions to stress and external triggers. In an individual with TS, the subconscious mind may influence the onset or severity of tics, often triggering them in response to unresolved emotional conflicts or psychological stress. 

Stress and anxiety trigger the subconscious mind and can influence the severity of Tourette syndrome symptoms. When an individual experiences stress, the body may unconsciously increase the frequency or intensity of tics. Emotional discomfort or anxiety is processed in the brain and may manifest physically as a tic. This creates a feedback loop whereby stress leads to more tics, which in turn triggers greater anxiety about the tics making it harder to break the cycle (3).

Tics can also function as a form of emotional release or expression. In some cases, individuals with Tourette syndrome may observe that their tics are triggered by underlying repressed emotions or subconscious thoughts. A sudden motor movement or vocalisation may represent the mind’s way of externalising internal emotional tension or conflict. This phenomenon underscores the relationship between emotional dysregulation and physical tics, suggesting that addressing emotional factors could be an important aspect of managing the condition (4). 

How to Treat Tourette Syndrome 

There is no cure for Tourette syndrome. Treatment focuses on managing tics that interfere with daily activities and functioning. If tics are not severe, treatment may not be required. 

Medication
Medications to help control tics or reduce symptoms of related conditions include:

1. Medications that block or lessen dopamine: Fluphenazine, haloperidol, risperidone, and pimozide can help control tics, Possible side effects include weight gain and involuntary movements 
2. Botulinum (Botox) injections: An injection into the affected muscle might help relieve a simple or vocal tic. 
3. ADHD medications: Stimulants such as methylphenidate (Metadate CD, Ritalin LA, etc.) and dextroamphetamine (Adderall XR, Dexedrine, others) can help increase attention and concentration. However, for some people with Tourette syndrome, medications for ADHD can exacerbate tics. 
4. Central adrenergic inhibitors: Medications such as clonidine and guanfacine typically prescribed for high blood pressure might help control behavioral symptoms such as impulse control problems and rage attacks. Side effects may include sleepiness.
5. Antidepressants: Fluoxetine might help control symptoms of sadness, anxiety and OCD
6. Antiseizure medications: Recent studies suggest that some people with Tourette syndrome respond to topiramate (Topamax), which is used to treat epilepsy (5).

Non-pharmacological treatments 

Behavior therapy 

Tics are undeniably neurological, they are also sensitive to the environment in which they occur. Cognitive behavioural intervention for tic (CBIT) is a non-medication-based treatment that recognises the premonitory urges and teaches to perform a movement that contradicts the tic and the urges and learn to perform a movement that contradicts the tic intentionally. 

It focuses on three key components; First, it helps patients become more aware of their tics and the urges that precede them. Second, it trains patients to perform a competing behavior when they feel the urge to tics which can help reduce the frequency or intensity of tics. Finally, CBIT involves adjusting to daily routines and activities that support tic reduction and improve the overall management of the condition (6).

Hypnosis therapy 

Hypnosis therapy is emerging as a non-invasive approach to managing tics by using stress reduction, positive reinforcement, and visualisation techniques. While hypnosis therapy is not a cure, it is a promising complementary treatment for conditions such as Tourette syndrome or stress-induced tics. These techniques are most effective when guided by a trained hypnotherapist and practised consistently. 

Research suggests these methods can significantly reduce tic frequently, and give patients greater control. Hypnotic methods for relaxation focus on calming the mind and body which can help minimise tics. Key techniques include:

• Visualisation of Relaxing Environments: to reduce stress levels, patients imagine themselves in a serene setting, such as a quiet beach or forest.
• Progressive Muscle Relaxation: during hypnosis, individuals are guided to release tension from head to toe, promoting deep relaxation.
• Controlled Breathing: practising slow, deep breaths inhaling through the nose and exhaling through the mouth can reduce physical tension that may trigger tics (7).

Alternative therapies can also play an essential role in managing Tourette syndrome by providing more options alongside behavioural intervention; methods like neurofeedback, a bio-feedback where individuals learn to regulate brain activity. However, due to mixed evidence, they may not be considered first-line treatments but may benefit some. 

Creating supportive environments at school or work can reduce triggers and improve daily functioning. A healthy lifestyle including a balanced diet, good sleep hygiene, and regular physical exercise, contributes to overall well-being and can positively impact tic severity. 

While these approaches may not replace evidence-based therapies like CBIT, they offer holistic options to complement a comprehensive treatment plan for individuals with Tourette syndrome.

 

By: Bamlak Agegnehu RN/BMgt

Edited by: Damilola Elewa