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Tourette Syndrome
Yeditepe Üniversitesi Hastanesi Çocuk
ve Ergen Psikiyatrisi
Anabilim Dalı
Tourette Syndrome
an inherited neuropsychiatric disorder with onset in
childhood, characterized by the presence of
multiple physical (motor) tics and at least one
vocal (phonic) tic
Genetic studies have shown that the overwhelming
majority of cases of Tourette's are inherited,
although the exact mode of inheritance is not yet
known, and no gene has been identified.
Gender appears to have a role in the expression of
the genetic vulnerability: males are more likely
than females to express tics.
Tourette Syndrome
Non-genetic, environmental, infectious, or psychosocial factors—while
not causing Tourette's—can influence its severity.
In 1998, a team at the US National Institude of Mental Health proposed
a hypothesis that both obsessive–compulsive disorder (OCD) and tic
disorders may arise in a subset of children as a result of a
poststreptocoocal autoimmune process
Children who meet five diagnostic criteria are classified, according to
the hypothesis, as having Pediatric Autoimmune Neuropsychiatric
Disorders Associated with Streptococcal infections (PANDAS).
Tics are believed to result from dysfunction in cortical and subcortical
regions, the thalamus,basal ganglia and frontal cortex.
Tourette Syndrome
Diagnostic Criteria
A) Both multiple motor and one or more vocal tics have been
present at some time during the illness, although not necessarily
B) The tics occur many times a day (usually in bouts) nearly every
day or intermittently throughout a period of more than 1 year, and
during this period there was never a tic-free period of more than 3
consecutive months.
C) The onset is before age 18.
D) The disturbance is not due to the direct physiological effects of a
substance (e.g. stimulants) or a general medical condition (e.g.
Huntington's disease or post-viral encephalitis).
Tourette Syndrome
Although the word "involuntary" is used to describe the nature of the tics, this is
not entirely accurate.
People with TS feel an irresistable urge to perform their tics, much like the need to
scratch a mosquito bite.
Some people with TS are able to hold back their tics for up to hours at a time, but
this only leads to a stronger outburst of tics once they are finally allowed to be
coprolalia has been sensationalized by the media, it is actually rare, occuring in
less than 30% of people who have a severe case.
Coprolalia does not have to be exclusively swear words. Many times coprolalia
manifests itself as socially inappropriate or unacceptable words or phrases
Tourette Syndrome
it is believed that an abnormal metabolism of the neurotransmitters dopamine
and serotonin are involved with the disorder.
It is genetically transmitted; parents having a 50% chance of passing the gene
on to their children.
Girls with the gene have a 70% chance of displaying symptoms, boys with the
gene have a 99% chance of displaying symptoms.
Between 1 and 10 children per 1,000 have Tourette's
People with Tourette's have normal life expectancy and intelligence.
The severity of the tics decreases for most children as they
pass through adolescence, and extreme Tourette's in
adulthood is a rarity.
There is no effective medication for every case of tics, but
there are medications and therapies that can help when
their use is warranted.
Explanation and reassurance alone are often sufficient
treatment; education is an important part of any
treatment plan
A. Repeated voiding of urine into bed or clothes (whether
involuntary or intentional).
B. The behavior is clinically significant as manifested by
either a frequency of twice a week for at least 3
consecutive months or the presence of clinically
significant distress or impairment in social, academic
(occupational), or other important areas of functioning.
C. Chronological age is at least 5 years (or equivalent
developmental level).
D. The behavior is not due exclusively to the direct
physiological effect of a substance (e.g., a diuretic) or a
general medical condition ( e.g., diabetes, spina bifida, a
seizure disorder).
Two physical functions prevent bedwetting.
1)The first is a hormone that reduces urine production at night.
2)The second is the ability to wake up when the bladder is full.
Children usually achieve nighttime dryness by developing one or both of these
There appear to be some hereditary factors in how and when these develop.
At about sunset each day, the body releases a minute burst of antidiuretic
hormone(also known as arginine vasopressin or AVP).
This hormone cycle is not present at birth. Many children develop it between
the ages of two and six years old, others between six and the end of
puberty, and some not at all.
The second ability that helps people stay dry is waking when the bladder is full.
This ability develops in the same age range as the vasopressin hormone,
but is separate from that hormone cycle.
Most bedwetting is a developmental delay, not an emotional problem or physical illness.
Only a small percentage (5% to 10%) of bedwetting cases are caused by specific
medical situations.
Bedwetting is frequently associated with a family history of the condition.
Bedwetting children can suffer emotional stress or psychological injury if they feel
shamed by the condition.
most treatment plans aim to protect or improve self esteem
Treatment guidelines recommend that the physician counsel the parents, warning about
psychological damage caused by pressure, shaming, or punishment for a condition
children cannot control.
Age 5: 20%
Age 6: 10 to 15%
Age 7: 7%
Age 10: 5%
Age 15: 1-2%
Males make up 60% of bedwetters overall and make up more than 90%
of those who wet nightly
Medical definitions: primary vs. secondary
Primary nocturnal enuresis (PNE) is the most common form of bedwetting.
Secondary nocturnal enuresis occurs after a patient goes through an extended
period of dryness at night (roughly 6 months or more) and then reverts to nighttime
wetting. Secondary enuresis can be caused by emotional stress or a medical
condition, such as a bladder infection.
Psychological issues (e.g., death in the family, sexual abuse, extreme bullying) are established as a
cause of secondary nocturnal enuresis (a return to bedwetting),
Psychological-social impact
a bedwetting child is not at fault for the situation.
Many medical studies state that the psychological impacts of
bedwetting are more important than the physical considerations. “It
is often the child's and family member's reaction to bedwetting that
determines whether it is a problem or not
Whether bedwetting causes low self-esteem remains a subject of
debate, but several studies have found that self-esteem improved
with management of the condition.
Children questioned in one study ranked bedwetting as the third most
stressful life event, after parental divorce and parental fighting.
delaying treatment until the child is at least six or seven years old.
Bedwetting alarms
DDAVP (Desmopressin)
a synthetic replacement for antidiuretic hormone
Tricyclic antidepressants
with anti-muscarinic properties have been proven successful in treating
A. Repeated passage of feces into inappropriate
places (e.g., clothing or floor) whether involuntary or
B. At least one such event a month for at least 3
C. Chronological age is at least 4 years (or equivalent
developmental level).
D. The behavior is not due exclusively to the direct
physiological effects of a substance (e.g., laxatives)
or a general medical condition except through a
mechanism involving constipation.
in 5-year-olds is ~1-3%.
The disorder is thought to be more common in males than females, by
a factor of 6 to 1.
In the type without constipation, the feces are usually well-formed,
soiling is intermittent, and feces are usually deposited in a prominent
location. This form may be associated with oppositional defiant
disorder or conduct disorder