Tics and Tourette’s Syndrome

 Tics are repetitive, stereotyped, involuntary movements and vocalizations.  They can be classified as transient or simple, chronic, or as part of diagnosing Tourette’s syndrome (TS).  Transient/simple tics are sudden, brief, simple movements.  Common simple motor tics include eye blinking, facial grimacing, head jerking and shoulder shrugging or jerking.  Simple vocal tics can include throat clearing, sniffing, yelping, tongue clicking, or grunting sounds.  Simple tics can also change from one manifestation to another.

 Complex tics involve more muscle groups and are distinct movement patterns.  An example may be a facial expression with a head twist or shoulder jerk.  Some tics may appear voluntary or purposeful, like touching objects, hopping, twisting, or bending, and can include self-harm, such as biting oneself or punching oneself in the head.  Complex vocal tics often include words or phrases, including socially inappropriate words (coprolalia) or repeating others’ words (echolalia); however, coprolalia only occurs in 10 to 15 percent of patients with TS.

TS can only be diagnosed when:

• “Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently;
• The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than one year.  During this time, there is never a tic-free period of more than three consecutive months;
• The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning;
• The onset occurs before 18 years; and
• 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).” (Natural Treatments for Tics & Tourette’s, Sheila Rogers)

There are no blood, laboratory, or imaging tests needed for diagnosis of TS.  Imaging or blood tests may be used to rule out other conditions that might be confused with TS when the history or clinical examination is atypical.   Tics related to PANDAs are considered a separate category because they are specifically related to a streptococcal infection.

Tics are often brought on or are worse with excitement, anxiety, stress, or fatigue, and may be better during calm, focused activity.  They are also decreased during sleep but may still occur.  Overall, they can come and go over time, varying in type, frequency, location, and severity.

Environmental triggers or even tics themselves can often cause more tics to occur, and many patients report an urge prior to the tic occurring.  This urge is often only relieved after the tics occur in a certain way or after a certain number of times.  Some people can sometimes suppress or camouflage their tics in certain situations, e.g., work or school.  However, this usually leads to a substantial buildup in tension until the tic must be expressed.  Even though tics can temporarily be suppressed, it should be remembered that tics are not voluntary and the suppression is only temporary and requires a great deal of effort by the patient.

TS is usually first noticed between three and nine years old, but worst symptoms usually occur in early teen years with improvement occurring into adulthood.  It occurs in all ethnic and racial groups, and rates are three to four times higher in males than females.  Current estimates show 200,000 cases in theUSof the most severe form and possibly one in 100 people who show mild or simple tic symptoms.

There are also other neurobehavioral issues that can be associated with TS.  These include inattention, hyperactivity and impulsivity (ADHD); problems with reading, writing, and arithmetic; learning disorders; impulse control problems; sleep disorders; and obsessive-compulsive symptoms such as intrusive thoughts/worries and repetitive behaviors.  Patients may also experience depression or anxiety but it is unclear if these are related to the TS specifically or may be due to the stress that TS can cause.  Patients with TS also experience allergies at higher rates than the general population.  There are also greater numbers of other health issues, including nausea, “sick” feeling in the stomach, general aches and pains, and headaches.

Cause

The cause of TS is currently unknown.  There is evidence that TS is an inherited disorder and that some forms of ADHD and OCD are genetically related to TS.  Current research also indicates that there may be elevated levels of the NT dopamine, which would most likely create abnormal levels of other neurotransmitters (NTs), possibly serotonin and norepinephrine.  There may also be abnormal activity at the dopamine receptors.

Everything You Wanted to Know About Dopamine

Dopamine is synthesized by nerves and the adrenal glands from the amino acid L-tyrosine and is a precursor to norepinephrine (noradrenaline) and then epinephrine (adrenaline).  The production of dopamine from L-Dopa requires vitamin B6, and the conversion from dopamine to norepinephrine requires vitamin C.

Dopamine has many functions in the brain, including important roles in behavior and cognition, voluntary movement, motivation and reward, sleep, mood, attention, and learning, especially with new behaviors.  Dopamine also controls the flow of information from different areas of the brain, and dopamine disorders can cause a decline in cognitive functions, especially memory, attention, and problem-solving.

Dopamine is commonly associated with the pleasure system of the brain, providing feelings of enjoyment and reinforcement to motivate a person to perform certain activities. Dopamine is released by naturally rewarding experiences such as food, sex, drugs, and neutral stimuli that become associated with them. Aggression may also stimulate the release of dopamine in this way.

Sociability is also closely tied to dopamine, and low dopamine receptor-binding is found in people with social anxiety. Traits common to negative schizophrenia, such as social withdrawal and apathy, are thought to be related to a low dopamine level in certain areas of the brain. Manic episodes of bipolar disorder may also be due to an increase in dopamine, because mania can be reduced by dopamine-blocking anti-psychotics.

Dopamine has been demonstrated to play a role in pain processing in multiple levels of the central nervous system. Decreased levels of dopamine have been associated with painful symptoms that frequently occur in Parkinson’s disease. Abnormalities in dopamine neurotransmission have also been demonstrated in painful clinical conditions, including burning mouth syndrome, fibromyalgia, and restless legs syndrome.

Dopamine is eliminated from the body by either conversion to norepinephrine or final detoxification of dopamine itself via the methylation process.  It is broken down by two enzymes: catechol-O-methyl transferase (COMT) and monoamine oxidase (MAO).  COMT transfers a methyl group to the catecholamine, which is donated by S-adenosyl methionine (SAMe).  Methylation is a process that occurs as part of our natural detoxification and is the primary method the body uses to clear dopamine, norepinephrine, and epinephrine.  The methylation process requires certain nutrients, including folate, vitamin B12, methionine, choline, and betaine.  In this process, however, folate can only serve if it is in its active form, 5-methyltetrahydrofolate (5-MTHF).  Methylenetetrahydrofolate reductase (MTHFR) is an enzyme that converts folate to 5-MTHF; low levels or genetic variants of this enzyme that decrease its activity could increase levels of dopamine indirectly by reducing its detoxification.

MAO enzymes also breakdown dopamine (as well as melatonin, serotonin, norepinephrine, and epinephrine); a dysfunction in MAO enzymes (too much or too little activity) has been associated with a number of conditions, including ADD, substance abuse, migraines, and schizophrenia. This indicates that these conditions (and possibly others) may relate to increased or decreased levels of these NTs due to changes in the MAO (or other enzyme) activity.  MAOs also contain flavinoids and the bioflavinoids and polyphenols in resveratrol are being investigated in relation to MAO’s link to depression.

Pharmaceutical Treatment

Most people are not disabled by their tics and require no treatment at all.  Currently, allopathic medicine treats TS with neuroleptic medications, including haloperidol (Haldol), clonidine (Catapres), pimozide (Orap), risperidone (Risperdal), fluphenazine (Prolixin, Permitil), and clonazepam (Klonopin). Effective dosages can vary among patients and should be started at low levels and gradually increased under doctor’s supervision.  Some of the undesirable reactions to medications are weight gain, muscular rigidity, fatigue, motor restlessness, cognitive impairment, depression, and social withdrawal, most of which can be reduced with specific medications, dosage reduction, or a change of medication.  Neurological side effects such as tremor, dystonic reactions (twisting movements or postures), parkinsonian-like symptoms, and other dyskinetic (involuntary) movements are less common and are readily managed with dose reduction.  Discontinuing neuroleptics after long-term use must be done slowly to avoid rebound increases in tics and withdrawal dyskinesias. One form of dyskinesia called tardive dyskinesia is a movement disorder distinct from TS that may result from the chronic use of neuroleptics. The risk of this side effect can be reduced by using lower doses of neuroleptics for shorter periods of time. 

Additional medications with demonstrated efficacy include alpha-adrenergic agonists such as clonidine and guanfacine.  These medications are used primarily for hypertension but are also used in the treatment of tics. The most common side effects from these medications are sedation and lowering of blood pressure.  Botox has also been used in recent years in an attempt to freeze the muscles involved with the tic, but results have been mixed.  Nicotine patches may be helpful in reducing the dose of neuroleptic medication, but haven’t been shown to be helpful as single agents.  Drugs for ADHD [methylphenidate (Ritalin) and dextroamphetamine (Dexedrine)] have been described as increasing tics, but this is controversial.  For obsessive compulsive traits that interfere significantly with daily functioning, fluoxetine (Prozac), clomipramine (Anafranil), sertraline (Zoloft) and paroxetine (Paxil) may be prescribed.

Naturopathic Treatment

Like with any condition, we need to understand why a person has the symptoms that are presenting.  In Sheila Roger’s book, Natural Treatments for Tics & Tourette’s, she quotes Dr. Sidney Baker’s basic approach as “Is there something your body needs for which you have some individual, perhaps quirky, requirement that is not being met?  Or, is there something you are getting that you as an individual have some quirky, sometimes unusual, need to avoid?”  This is actually my basic philosophy in working with any patient, although I would add a third question:  “Or, is it both?”

Identifying Tic Triggers

Identifying your particular triggers may be a good start to making changes.  Some of the most common triggers include:

• Stress, overstimulation, anxiety, worry, fear, self-consciousness
• Caffeine, sugar, corn syrup, alcohol
• Noise
• Video games/TV/movies/flashing, bright, or fluorescent lights
• Infections
• Car or bus rides
• Heat or change of temperature
• Specific foods, artificial additives
• Chemical exposures, carpeting, pesticides, paint fumes, gasoline fumes
• Dust, mold, pollen
• Scented products (candles, perfume, aftershave, air-fresheners), cigarette smoke

The Association for Comprehensive Neurotherapy (CAN) has a checklist of potential triggers at www.ticsandtourettes.com that you can use as a guide; remember it is not a complete list and you may need to add to it.  You may also need to take detailed notes initially to be able to discern what part of a situation was the trigger: If you got overheated while watching a stressful movie, was it the heat, the stress, the movie, or the combination of all three?  As you are able to record and observe more situations, you may be able to discern more specific trigger patterns.

Diet

I believe diet plays a huge role in health, regardless of the symptom or diagnosis.  Many patients have reported significant changes with dietary changes, both in terms of tics reducing when certain foods were eliminated and observing tics return with the reintroduction of those foods.  Dietary changes may be beneficial because they specifically influence dopamine, reduce systemic inflammation, improve intestinal immunity, and/or provide greater nutrition.

An elimination diet is often a good place to start, although I would also recommend completing a diet diary prior to the elimination so you know which foods may be the worst culprits for you.  The most common foods reported to increase tics are gluten, dairy, egg, sugar, corn, and artificial anything (color, flavors, preservatives).  Salicylates, amines, and MSG can occur naturally in certain foods, and it may be worth investigating those specific foods.  It may also be worth investigating foods that are naturally high in dopamine, including wheat, corn, sugar, apples, bananas, and dairy.  It is interesting that patients report changes in tic behavior associated with four of the six foods on this list.  Because tyrosine is the amino acid used to synthesize dopamine, it may also be helpful to try eliminating foods naturally high in tyrosine (dairy, wild game, pork, chocolate, wheat, egg, duck, and chicken).

As with any condition, one diet does not fit all, and dietary changes may require trial and error before you find the best dietary changes for you.  Food allergy testing may be helpful, but these tests do not always provide perfectly accurate information.  Also remember to read labels carefully because of hidden additives.

Environment

Many patients report environmental triggers for their tics.  Evaluate your exposure to chemicals, cleaners, pesticides, fumes, scented home and personal products, dust, mold, pollen or other environmental allergens, and cigarette smoke at home, work, or other frequented locations.  Also consider how much screen time you have or how much time you are around electrical equipment, including TV, computer, Ipad, wireless networks, and cell phones.    Many patients with TS have sensory sensitivities (overly sensitive, under sensitive, or unusual reactions to stimuli) to heat, touch, smell, sound, light, taste, or movement.  Chapter 9 of Natural Treatments for Tics & Tourette’s has a great discussion of ways to work with different types of sensitivities to reduce their impact.  Occupational therapy may be one option to consider with sensory balancing and integration, especially for multiple sensitivities.

While you are looking at what you might need to remove from your environment, also consider how relaxing your environment is at work, school, and/or home.  While tics and TS are never simply a matter of learning how to relax, many people do report fewer or less severe tics when they are relaxed and in a relaxing environment.

Chronic Infection and Dysbiosis

Many patients with TS are found to an overgrowth of yeast and an imbalance of the beneficial intestinal bacteria (dysbiosis).  I believe yeast overgrowth is an indication of some other immune imbalance, as yeast is a normal part of the intestinal flora in small amounts.  Most commonly, I see yeast overgrowth as an indication of heavy metal toxicity or other chronic infection, especially viral or bacteria.  There is even some evidence that chronic Lyme infection can cause symptoms very similar to TS and could either contribute to TS or be mistaken for it.  So while yeast overgrowth can be treated with natural or pharmaceutical anti-fungals, I believe the reason for the overgrowth must be investigated.  Dysbiosis is best treated with a high quality probiotic appropriate for the particular person both in the type and number of organisms, as well as methods to heal the intestinal lining, decrease toxicity from yeast and pathogenic bacterial toxins, and improve digestion.

Detoxification/ Methylation Support

If tics and TS are due to elevated dopamine, patients may be able to facilitate a change by optimizing detoxification through the methylation pathway.  It is interesting to note that this pathway is also the primary Phase 2 detoxification route for histamine, possibly indicating one way TS and increased allergies could be linked.  Patients do report improvement in tics and allergies with vitamin C, which is known to stabilize the mast cells, preventing histamine release.  Because histamine itself hasn’t been shown to cause tics, I wonder if the decreased load of histamine allows for greater methylation and detoxification of dopamine, thus reducing tics.  It is also interesting that the methylation pathway can be decreased by high estrogen, so balancing hormones may indirectly improve tic symptoms.

Steps to optimizing detoxification for patients with TS would include:

• identifying past and ongoing sources of toxins, including heavy metals, vaccinations, medications, chemical exposures, dental amalgams, bacterial toxins from dysbiosis, mold, and dietary toxins including gluten and casein;
• identifying and treating chronic viral, bacterial, fungal, or parasitic infections;
• identifying and eliminating exposure to allergens to decrease overall inflammation and potential nervous system reactions to allergen exposures and balance neuroimmune connections;
• identifying and treating hormonal imbalances that may affect liver detoxification, metabolism, and stress management;
• improve overall liver and kidney function, and all elimination routes; and
• specifically support the methylation pathway with appropriate doses of active folate, vitamin B12, S-adenosyl Methionine (SAMe), choline, and/or betaine.

Relaxation

Anything a patient can do to relax will be beneficial for TS symptoms and overall health.  People have reported benefit from biofeedback, acupuncture, homeopathy, massage, meditation, deep breathing, and craniosacral therapy.  Chiropractic care may also be beneficial, as structural problems will affect how the nerves function.  Exercise is a great addition, although there could be potential triggers associated with certain activities (e.g., chlorine in a swimming pool or pesticide use on a golf course).

Psychotherapy may also be helpful, especially for children when acceptance by peers is paramount for development.  Many teachers are unaware of TS and other learning tools/environments may be needed to create a supportive classroom.

Nervous System Support

The nervous system is an incredibly complex system with many interactions between NTs and connections with the immune and endocrine systems.  Because of this, I tend to focus on therapies that either provide the nervous system with basic nutrients needed for proper functioning (e.g., omega 3 essential fatty acids and magnesium) or allow the nervous system to rebalance itself (e.g., biotherapeutic drainage remedies and single homeopathics).  I am cautious using individual amino acids and NT precursors because one can easily get out of balance by oversupplementing just one amino acid or NT pathway.  There are tests that can be helpful to evaluate levels of specific NTs to get better information about possible imbalances and nutritional needs.

Individual herbs, such as St. John’sWort to increase serotonin, should also be used cautiously, as not all patients with tic or TS may have low serotonin.  Imbalances in one NT often cause, or are associated with imbalances in other levels, but the exact patterns are not always the same for all patients.  A patient who has normal serotonin may experience no benefit from taking this herb, but in a worse case, could actually creating further imbalance by elevating levels too high.  Herbs can be very powerful and can also have significant interactions with medications, so a patients’ response to herbs and drug-herb interactions should be monitored by a knowledgeable physician.  It is also important to recognize that gluten, heavy metals and other toxic exposures, and chronic infections can all have significant negative impacts on the nervous system.

Prognosis
Currently, there is no cure for TS.  However, many people improve in their late teens and adulthood.  Although TS is considered to be a chronic, life-long condition, up to a third of patients can experience a remission in adulthood.  While many people report a decrease in tics with age, other associated disorders often persist.  However, there are many individual reports of patients who have been able to make significant reductions in tics by identifying and eliminating triggers, changing their diets and environments, and supporting nervous system function.  Patients also report better outcomes when they are supported by family and friends and continue to observe and be creative with the solutions that work for them.  Let’s develop a plan that works for you.