David Baxter PhD
Late Founder
What Do We Know about Tourette's?
If you have the idea that every patient curses unpredictably, think again
By Scott O. Lilienfeld and Hal Arkowitz, Scientific American Mind
July 2009
On May 22, 2001, radio talk show personality Laura Schlessinger, better known as Dr. Laura, received a call from a woman who was distressed by her sister’s decision to exclude their nephew from an upcoming family wedding. When the caller mentioned that the boy suffered from Tourette’s disorder (also sometimes called Tourette syndrome), Dr. Laura berated her for even thinking that it might be appropriate to invite a child who would “scream out vulgarities in the middle of the wedding.” As we’ll soon explain, Dr. Laura’s comments embody just one of several common myths regarding Tourette’s.
Tourette’s disorder is the eponymous name for the condition first formally described in 1885 by French neurologist Georges Gilles de la Tourette, who dubbed it maladie des tics (“sickness of tics”). According to the current edition of the American Psychiatric Association’s diagnostic manual, Tourette’s disorder is marked by a history of both motor (movement) tics and phonic (sound) tics.
Motor tics include eye twitching, facial grimacing, tongue protrusion, head turning and shrugging of the shoulders, whereas phonic tics encompass grunting, coughing, throat clearing, yelling inappropriate words and even barking. Some tics are “complex,” meaning they are coordinated series of actions. For example, a Tourette’s patient might continually pick up and smell objects or repeat what someone else just said (echolalia). Often a tic is preceded by a “premonitory urge”—that is, a powerful desire to emit the tic, which some have likened to the feeling we experience immediately before sneezing. Tourette’s patients typically report short-term relief following the tic.
Tourette’s generally emerges at about age six or seven, with motor tics usually appearing before phonic tics. In rare cases, the disorder disappears by adulthood. Data suggest that it may be present in one to three out of 1,000 children; about three to four times as many males as females are affected.
Myths and Realities
As the Dr. Laura incident demonstrates, Tourette’s disorder is the subject of popular misconceptions; we’ll examine the four that are most widespread.
Misconception 1: All Tourette’s patients curse. In a survey of undergraduates by University of San Diego psychologists Annette Taylor and Patricia Kowalski, 65 percent endorsed this view. In fact, coprolalia, the use of curse words, and copropraxia, the use of obscene gestures, occur in only a minority—probably about 10 to 15 percent—of Tourette’s patients. But because these symptoms are so dramatic, they plant themselves firmly in observers’ memories. They also garner the lion’s share of media attention, as in a 2002 Curb Your Enthusiasm episode featuring a chef with Tourette’s disorder, who curses uncontrollably in front of his customers.
Misconception 2: Tourette’s symptoms are voluntary. Because Tourette’s sufferers can often suppress their tics for brief periods, some have concluded mistakenly that patients generate them of their own accord. In fact, they have little or no control over premonitory urges and can inhibit tics only for so long, just as you can only briefly avoid scratching an itch. Moreover, tic suppression typically results in a later “rebound” of tics.
Misconception 3: Tourette’s disorder is caused by underlying psychological conflict. As medical historian Howard Kushner, now at Emory University, noted, the idea that Tourette’s results from deep-seated psychological factors held sway in American psychiatry for much of the 20th century. As recently as the mid-1980s, one of us (Lilienfeld) was told by a psychologist in training that the tics of Tourette’s patients represented symbolic discharges of repressed sexual energies. Today we know that the disorder is substantially heritable. A 1985 study by R. Arlen Price, then at Yale University, and his colleagues found that in identical twins (who share virtually all of their genes) with Tourette’s, both twins had the disorder 53 percent of the time, whereas in fraternal twins (who share half their genes on average) with Tourette’s, both twins had the disorder only 8 percent of the time. Still, stress can increase tic frequency, so genes are unlikely to tell the whole story. Brain-imaging studies of Tourette’s patients reveal abnormalities in areas related to movement, such as the basal ganglia, a collection of structures buried deep in the cerebral hemispheres.
Misconception 4: People with Tourette’s are incapacitated by their *symptoms. Many individuals with Tourette’s function successfully in society. Mort Doran, a Canadian surgeon with Tourette’s, manages to suppress his tics while in the operating room; he is also an amateur pilot. Neurologist Oliver Sacks wrote of a jazz drummer who reported that his Tourette’s disorder enhanced his musical performances by imbuing them with energy. Indeed, some have argued that Tourette’s can be a blessing rather than a curse, perhaps in part because the condition forces people to learn impulse-control skills that few of us acquire. This claim is intriguing but anecdotal. Former National Basketball Association point guard Chris Jackson, who changed his name to Mahmoud Abdul-Rauf, said that his Tourette’s made him focus with laserlike precision on his shooting. He twice led the league in free-throw percentage; during one stretch of play in 1993, he made 81 consecutive free throws.
Hope for Tourette’s Sufferers
There is no known cure for Tourette’s, but several treatment options exist. Medications such as Haldol (generic name haloperidol) and Orap (generic name pimozide), which block the action of the chemical messenger dopamine, have been found in studies to be effective in reducing the frequency and intensity of tics. Other promising medications are clonidine, which doubles as a blood pressure drug, and botulinum toxin, better known as Botox. Clonidine inhibits the chemical messenger norepinephrine, which some researchers have argued is implicated in Tourette’s. Although Botox’s mechanisms of action on Tourette’s are unknown, it appears to work by blocking body processes that are involved in facial tics or movement.
Preliminary evidence suggests that some behavioral therapies, especially habit reversal, can be helpful for Tourette’s disorder; it is not known whether combining these techniques with medication yields an additive benefit. Habit reversal teaches patients to become aware of the premonitory urges preceding tics and to learn and practice muscular actions incompatible with their tics. For example, a patient who repeatedly jerks his arm violently toward others might be taught to direct his arm slowly toward his head, culminating in touching his hair gently. This approach and others are not panaceas, but they can help some Tourette’s patients to bring their more troubling symptoms under better control.
Tourette’s through History
Some writers have argued that several famous historical figures, including Roman emperor Claudius (of I, Claudius fame) and author Samuel Johnson, may have had Tourette’s disorder. Others have speculated that composer Wolfgang Amadeus Mozart had Tourette’s, although the evidence here is more circumstantial, consisting mostly of suggestions that Mozart was prone to profanity and to hyperactivity, a symptom that commonly occurs with Tourette’s.
Psychiatrist Arthur K. Shapiro and psychologist Elaine Shapiro of Cornell University conjectured that the troubled girl who formed the basis for the 1971 book and 1973 blockbuster film The Exorcist had Tourette’s disorder. Some observers, they contend, misinterpreted her head jerking, grunting and profane language as hallmarks of demonic possession.
If you have the idea that every patient curses unpredictably, think again
By Scott O. Lilienfeld and Hal Arkowitz, Scientific American Mind
July 2009
On May 22, 2001, radio talk show personality Laura Schlessinger, better known as Dr. Laura, received a call from a woman who was distressed by her sister’s decision to exclude their nephew from an upcoming family wedding. When the caller mentioned that the boy suffered from Tourette’s disorder (also sometimes called Tourette syndrome), Dr. Laura berated her for even thinking that it might be appropriate to invite a child who would “scream out vulgarities in the middle of the wedding.” As we’ll soon explain, Dr. Laura’s comments embody just one of several common myths regarding Tourette’s.
Tourette’s disorder is the eponymous name for the condition first formally described in 1885 by French neurologist Georges Gilles de la Tourette, who dubbed it maladie des tics (“sickness of tics”). According to the current edition of the American Psychiatric Association’s diagnostic manual, Tourette’s disorder is marked by a history of both motor (movement) tics and phonic (sound) tics.
Motor tics include eye twitching, facial grimacing, tongue protrusion, head turning and shrugging of the shoulders, whereas phonic tics encompass grunting, coughing, throat clearing, yelling inappropriate words and even barking. Some tics are “complex,” meaning they are coordinated series of actions. For example, a Tourette’s patient might continually pick up and smell objects or repeat what someone else just said (echolalia). Often a tic is preceded by a “premonitory urge”—that is, a powerful desire to emit the tic, which some have likened to the feeling we experience immediately before sneezing. Tourette’s patients typically report short-term relief following the tic.
Tourette’s generally emerges at about age six or seven, with motor tics usually appearing before phonic tics. In rare cases, the disorder disappears by adulthood. Data suggest that it may be present in one to three out of 1,000 children; about three to four times as many males as females are affected.
Myths and Realities
As the Dr. Laura incident demonstrates, Tourette’s disorder is the subject of popular misconceptions; we’ll examine the four that are most widespread.
Misconception 1: All Tourette’s patients curse. In a survey of undergraduates by University of San Diego psychologists Annette Taylor and Patricia Kowalski, 65 percent endorsed this view. In fact, coprolalia, the use of curse words, and copropraxia, the use of obscene gestures, occur in only a minority—probably about 10 to 15 percent—of Tourette’s patients. But because these symptoms are so dramatic, they plant themselves firmly in observers’ memories. They also garner the lion’s share of media attention, as in a 2002 Curb Your Enthusiasm episode featuring a chef with Tourette’s disorder, who curses uncontrollably in front of his customers.
Misconception 2: Tourette’s symptoms are voluntary. Because Tourette’s sufferers can often suppress their tics for brief periods, some have concluded mistakenly that patients generate them of their own accord. In fact, they have little or no control over premonitory urges and can inhibit tics only for so long, just as you can only briefly avoid scratching an itch. Moreover, tic suppression typically results in a later “rebound” of tics.
Misconception 3: Tourette’s disorder is caused by underlying psychological conflict. As medical historian Howard Kushner, now at Emory University, noted, the idea that Tourette’s results from deep-seated psychological factors held sway in American psychiatry for much of the 20th century. As recently as the mid-1980s, one of us (Lilienfeld) was told by a psychologist in training that the tics of Tourette’s patients represented symbolic discharges of repressed sexual energies. Today we know that the disorder is substantially heritable. A 1985 study by R. Arlen Price, then at Yale University, and his colleagues found that in identical twins (who share virtually all of their genes) with Tourette’s, both twins had the disorder 53 percent of the time, whereas in fraternal twins (who share half their genes on average) with Tourette’s, both twins had the disorder only 8 percent of the time. Still, stress can increase tic frequency, so genes are unlikely to tell the whole story. Brain-imaging studies of Tourette’s patients reveal abnormalities in areas related to movement, such as the basal ganglia, a collection of structures buried deep in the cerebral hemispheres.
Misconception 4: People with Tourette’s are incapacitated by their *symptoms. Many individuals with Tourette’s function successfully in society. Mort Doran, a Canadian surgeon with Tourette’s, manages to suppress his tics while in the operating room; he is also an amateur pilot. Neurologist Oliver Sacks wrote of a jazz drummer who reported that his Tourette’s disorder enhanced his musical performances by imbuing them with energy. Indeed, some have argued that Tourette’s can be a blessing rather than a curse, perhaps in part because the condition forces people to learn impulse-control skills that few of us acquire. This claim is intriguing but anecdotal. Former National Basketball Association point guard Chris Jackson, who changed his name to Mahmoud Abdul-Rauf, said that his Tourette’s made him focus with laserlike precision on his shooting. He twice led the league in free-throw percentage; during one stretch of play in 1993, he made 81 consecutive free throws.
Hope for Tourette’s Sufferers
There is no known cure for Tourette’s, but several treatment options exist. Medications such as Haldol (generic name haloperidol) and Orap (generic name pimozide), which block the action of the chemical messenger dopamine, have been found in studies to be effective in reducing the frequency and intensity of tics. Other promising medications are clonidine, which doubles as a blood pressure drug, and botulinum toxin, better known as Botox. Clonidine inhibits the chemical messenger norepinephrine, which some researchers have argued is implicated in Tourette’s. Although Botox’s mechanisms of action on Tourette’s are unknown, it appears to work by blocking body processes that are involved in facial tics or movement.
Preliminary evidence suggests that some behavioral therapies, especially habit reversal, can be helpful for Tourette’s disorder; it is not known whether combining these techniques with medication yields an additive benefit. Habit reversal teaches patients to become aware of the premonitory urges preceding tics and to learn and practice muscular actions incompatible with their tics. For example, a patient who repeatedly jerks his arm violently toward others might be taught to direct his arm slowly toward his head, culminating in touching his hair gently. This approach and others are not panaceas, but they can help some Tourette’s patients to bring their more troubling symptoms under better control.
Tourette’s through History
Some writers have argued that several famous historical figures, including Roman emperor Claudius (of I, Claudius fame) and author Samuel Johnson, may have had Tourette’s disorder. Others have speculated that composer Wolfgang Amadeus Mozart had Tourette’s, although the evidence here is more circumstantial, consisting mostly of suggestions that Mozart was prone to profanity and to hyperactivity, a symptom that commonly occurs with Tourette’s.
Psychiatrist Arthur K. Shapiro and psychologist Elaine Shapiro of Cornell University conjectured that the troubled girl who formed the basis for the 1971 book and 1973 blockbuster film The Exorcist had Tourette’s disorder. Some observers, they contend, misinterpreted her head jerking, grunting and profane language as hallmarks of demonic possession.
