Abstract
Psychopathology has long been described in association with a variety of movement disorders, either during the course of illness or predating the onset, including Huntington's and Sydenham's chorea and Tourette disorder (or Tourette syndrome [TS]).
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The relationship between TS and behavioral and emotional problems has received increasing attention in recent years.
12,14,16,17,18,20,21,26,27,29,30,37,44,64,69
Current conceptualizations of this disorder include presence of both multiple tics and a variety of nontic behavioral phenomena.
Georges Gilles de la Tourette published “La Maladies des Tics Convulsif,” the first paper on behavioral and emotional aspects of Tourette syndrome in 1899.
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He noted that fears and phobias frequently were found in association with tics. The early 20th century was characterized by an emphasis on psychoanalytic hypotheses about the nature of the disorder; prevailing views considered the symptomatology such as touching and utterance of obscenities as reflections of unconscious conflict regarding sexual or aggressive impulses. Single case reports filled the early scientific literature, such as Frau Emmy Von N. in Sigmund Freud's
Case Studies of Hysteria, who had facial tics and nervousness and likely suffered from unrecognized TS.
4
In
Tics and Their Treatment by Meige and Feindel (1907), a wide variety of psychiatric symptoms were described in a patient who probably had TS, including obsessions and compulsions, depression, and impulsivity.
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Beginning in the scientific dataoriented period of the 1960s, Drs. Arthur and Elaine Shapiro and colleagues noted a significant comorbidity with attention deficit disorder with hyperactivity in a large series of patients with TS.
73,74,75
According to Shapiro et al, motoric hyperactivity, impulsivity, distractibility, and attentional dysfunction commonly were present in these patients. They also reported on the frequent occurrence of repetitive, ritualistic behaviors in TS patients, such as touching, tapping, rubbing, and counting.
73,76
Investigators have subsequently described these phenomena as obsessive compulsive symptoms or disorder (OCS, OCD) and have noted a frequency ranging from 20% to 60% of patients.
30,37,64,67
Others have noted emotional features, including mood and non-OCD anxiety disorders and aggressive dyscontrol.
9,69
The natural history of Tourette disorder reveals a typical progression of increasing complexity of motor and vocal tics and an elaboration of obsessive compulsive features over time. Some authors report a reduction of tic phenomena longitudinally and a concomitant increase in the behavioral manifestations.
27,29,78
Scientific data on these long-described clinical associations between tics and emotional and behavioral symptoms has accumulated in the last decade. Recently developed neurobiologic models support theoretical relationships between movement and emotion, primarily through contiguous pathways in the basal ganglia, thalamus, and cortex.
8,11,12,28,77,79,84
Motor, vocal, behavioral, cognitive, and emotional dysfunction may represent manifestations of an underlying core disinhibition problem.
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These nontic features have an important role in the evaluation and treatment of most patients with TS. This article reviews the behavioral and emotional aspects of TS with a focus on behavioral phenomenology and psychiatric comorbidity.
