BLOG No. FORTY NINE

Welcome back to my blog on anxiety and depression. Today I want to talk about Tourette’s syndrome (TS). TS is a neuropsychiatric disease that usually has an onset in childhood. TS contains both motor (muscle movement) tics and phonic (vocal) tics. Usually, these tics are involuntary, such as deep, guttural (low pitch) grunts and motor tics, like frequent blinking.

TS has been strongly tied to obsessive-compulsive disease and usually has a family history associated with tics, OCD, ADD, mood disorders, and other psychiatric conditions. Parents frequently flip out when their kids, usually the preschool variety, begin having vocal tics. Children can be cruel (as well as adults) and parents worry that their beloved child may grow up and become shunned.

But vocal tics are common in kids and usually go away within a few months. However, if they become associated with motor tics and last for more than a year, that patient would be diagnosed with TS.

A man goes into a job interview. The interviewer says, “What is your full, legal name?”

“Peter F---ing B---stard Michael Jones,” he replies.

“Peter, do you have Tourette’s Syndrome?’

“No, but the priest who did my baptism did.”

As PET scanning (positive emission tomography) is becoming more utilized, scientists are finding more about the neurotransmitters involved with various psychiatric illnesses. This includes TS. Both serotonin deficiencies and elevated D2 dopamine in the ventral striatum (think deep brain) are found when scanning the patients with TS as compared to patients without it.

One author, that I will not mention, in his article on TS, mentioned that perhaps the serotonin issues of TS are similar to the serotonin issues of OCD. But then, he goes on to say that while Prozac, a serotonin drug, does help some of the symptoms of TS, patients typically do much better with medications that directly lower D2 dopamine. Is my belief that D2 dopamine excess drives both OCD and TS, with a much minor component of low serotonin. Why providers continue to start their treatment of these diseases with serotonin drugs amazes me. Serotonin drugs have been reported, in numerous cases, to worsen TS.

So, brainiacs, what are you thinking about out there? Yeah, I thought so! So what about the GABA-Glutamate balancing medications like Lamictal and Trileptal. Do they help control TS? It would certainly be reasonable to think so.

But oddly enough we don’t find it to be helpful in TS. In fact, there have been numerous reports of Lamictal triggering a new onset of TS in patients that don’t have it and have no family history of it. How could that be?

No one really knows why that happens, but it may be that TS is triggered by elevated D2 that just happens not to be caused by the GABA-Glutamate imbalance. D2 must go up on its own, without a known cause. This is probably why Haldol and Orep—old D2 suppressors, and Abilify, a second-generation D2 suppressor, are the only medications approved by the FDA to treat TS.

Well, a fast summer storm has quickly blown in and the rain has diluted my Chardonnay. But it has not diluted my resolve to drink it anyway! Until next time when we talk about the future of psychiatry, this is Dr. G saying keep the faith!