Tourette syndrome (TS) is a neuropsychiatric disorder, notable by the uncontrollable tics it creates. These tics can cause great stress to the individual while they are also a direct result of stress and anxiety. Starting out singular and simple, tics gradually develop into ever more complex movements. There are essentially two types of tics, motor and vocal. Uncontrollable facial twitching, eye blinking, and shoulder twitching are examples of motor tics. Vocal tics could include grunting, coughing, snorting, tongue clicking, and in a small percentage coprolalia, which is uttering obscenities (Whitbourne, S. K. , & Halgin, 2013, p. 131-132).
Complex behaviors may develop into full body movements or occur when motor and vocal behaviors combine. While many people understand the amount of stress Tourette syndrome can inflict on a person, they may not be aware that it is commonly associated with other disorders. Obsessive compulsive disorder (OCD), and attention deficit/ hyperactivity disorder (ADHD) share a genetic relationship to TS. This can be seen in the significant number of diagnoses of these disorders in TS patients.
Furthermore, mood and anxiety disorders can be found in TS patients due to their genetic relationship to OCD and ADHD (Farley, 2015). The exact cause of TS is still not yet understood and there is no cure, but treatments usually combine cognitive-behavioral therapy with pharmacological therapy. This paper will focus on the relationship of TS to OCD and ADHD and how this can affect in multiple areas. Development of anxiety disorders, mood disorders, treatments, and conflicting treatments for clients will be discussed in detail as well.
To first explain the relationship of co-morbid disorders to TS, genetic factors can be addressed. TS doesn’t have many known causes, evidence has shown that is partly an inherited disorder. As mentioned before, TS, OCD, and ADHD may have a strong genetic connection. According to researchers from Massachusetts General Hospital (MGH) and UC San Francisco, seventy-two percent of TS patients received second diagnoses of ADHD or OCD. Almost one-third received diagnoses for both disorders (Farley, 2015). To be noted, these diagnoses were done in children at a very young age and are commonly noticed when treating one of the three.
In children who are diagnosed with all three psychiatric disorders, aspects of one or more are very evident among family members. The relationship could stem from a gene that involves inhibition, as lack of inhibition is seen of symptoms of each. This could be why children who are struggling to control motor tics also have trouble focusing, resulting in a diagnosis of ADHD as well. Control of the anxiety induced obsessive thoughts of OCD could also come from the same location in the brain.
This location is believed to lie in the circuitry that connects parts of the basal ganglia to the cerebral cortex (Hopkinsmedicine. rg, 2009). These disorders also tend to disappear with age, which could be a result of further development in this area of the brain. . Factors that affect neurotransmitters in the brain and specific genes could also have a relation. These three disorders have in common that they are a result of overactive neurotransmitters, specifically serotonin transport genes in ADHD and OCD (Gromisch, 2015). Levels of norepinephrine, serotonin and dopamine all have an effect on TS as well. High levels of dopamine specifically have an effect on the firing of tics.
However, finding one specific related gene would be difficult, as the exact causes to these disorders, specifically TS, is not well know yet. These correlations also do not mean that genetics are the sole cause, as there are many environmental triggers to these disorders. These environmental triggers could affect these genes in a more severe fashion which could result in the triple diagnosis. While genetics may or may not be the primary cause to these disorders, there are environmental factors that could influence development. Risk factors may vary from case to case, but some general ones stick out.
Complications during pregnancy, low birth weight, smoking during pregnancy, illness, and exposure to certain substances can be risks (NIMH. gov, 2013 and tourettesaction. org). Factors that may affect neurotransmitter levels, specifically serotonin, could lead to symptoms as well. One could then ask which disorder came first. TS, OCD, and ADHD have their similarities and differences, but one common and strong relationship is anxiety. Anxiety affects these disorders in multiple ways by being a possible cause; it makes symptoms more severe, it is a result of symptoms, and can be a symptom itself.
ADHD is known to cause significant amounts of anxiety in children who struggle with school, in work, grades, and socialization. Children may develop OCD due to extreme life stressors, and the disorder can lead to anxiety disorders. In TS patients, anxiety is experienced due to the many negative effects of TS. Tics can cause children to socialize less, struggle in school, have lower self esteem, and thus more anxiety. This can cause progress to regress, as high levels of anxiety makes controlling tics much more difficult. This shows the involvement anxiety has in these disorders, as it already does in everyone’s life.
In cases of multiple disorders, it could be possible that one can trigger the development of the other. For example, the significant stress and anxiety from ADHD could have lead to the development of OCD, and the stress from both disorders resulted in TS. Perhaps the order could be rearranged, but the point lies in the fact that each symptom causes multiple stressors that can lead to other severe disorders. People with TS may be able to handle their symptoms very well, until ADHD and/or OCD symptoms take control and make life more difficult.
If these disorders become unmanageable, more severe complications can possibly develop. According to multiple sources, each of these disorders has the possibility to cause anxiety disorders as mentioned, mood disorders, suicidal thoughts or behavior, substance abuse, sleep disorders, and disconnections with family. All of these disorders are associated with TS in one way or another, and their likeliness will increase in those with multiple diagnoses. Suicidal thoughts or behavior along with mood disorders, particularly depression, are the most serious (mayoclinic. rg).
The combined stress and anxiety that rises from coping with these disorders can drive an individual to experience those symptoms. Like how TS, ADHD, and OCD share a co-morbid relationship, these complications have their own level of co-morbidity as well. Anxiety disorders can be a precursor to depression or substance abuse, and sleep disorders such as insomnia are found among people with depression. The potentiality of these complications developing makes proper treatments imperative for these individuals.
When the root cause of the disorder from person to person isn’t properly understood, therapy can be extremely difficult and can sometimes aggravate other symptoms. Cognitive behavioral therapy can become complex for the therapist and frustrating for the client. Pharmaceutical therapy is an area in which the psychiatrist must be careful when treating cases with these multiple disorders. For example, the drug Ritalin that is used to treat ADHD increases levels of dopamine and norepinephrine in the brain (Nevid, Rathus, Greene, 2014).
For someone who also has TS, the high levels of dopamine would aggravate tics and make them far more difficult to control. The individual would need to be assessed to decide which disorder is more prevalent, and for which medication the benefits would outweigh the risks. The drug clonidine has been shown to have the best results when treating both ADHD and TS. This could be the primary medication used in individuals who are not experiencing more prevalent symptoms of OCD (Robertson Jr. MD, 2015). Issues could also arise due to conflicting diagnoses from different clinicians.
Symptoms could be more prevalent at certain periods, and this can make things more confusing for the individual. Consistency, communication, and patience are vital for proper diagnosis and treatment for these co-morbid disorders. As Dr. Marco Grados stated, “we should think of this triple disorder as a single new one,” and maybe this should be done (hopkinsmedicine. org). Children with TS, ADHD, and OCD require more attentive therapy to ensure complications don’t develop. Depression has been diagnosed in children under 12 years old and while rare, this is extremely unfortunate.
One positive facet to these disorders is that they are indeed manageable with therapy and for many people clear up by adulthood. Educating parents on how teach their children and notice warning signs of complications is just as important. The stress of these disorders has impacts on the family and friends of the individual as well. Support systems are vital to anyone living with a mental disorder. There are still people who had lifelong TS who went on to live fulfilling, successful lives. One example is Ray, or “Witty Ticcy Ray,” from Oliver Sacks book The Man Who Mistook His Wife For A Hat: And Other Clinical Tales.
Ray dealt with TS for the majority of his life, especially when it came to holding a steady job, but was still loved by friends and his wife. However, like some other people with TS, he had a musical ability. Ray would spend his weekends as jazz drummer. According to Sacks, Ray’s drumming ability came from, in a way, from his Tourette’s. When he prescribed Ray Haldol, Ray seemed to slow down, lose his drumming ability, and couldn’t function. TS isn’t a disorder that can be “fixed” by medication. It requires intensive therapy with the client’s full participation as well.
Ray eventually found balance through therapy and medication, as he would take his medication for work and stop taking it on the weekends for music (Sacks, 1985). Many more people around the world have a daily mental battle with Tourette’s just to hold back the tics. For the time being, therapy and medication will have to suffice. Hopefully with future research to identify the exact causes, conditions for those with Tourette’s syndrome and co-morbid disorders could continue to improve more and more.
