Tourette’s Syndrome—Tics, Obsessions, Compulsions: Developmental Psychopathology and Clinical Care

Tourette’s syndrome and obsessive-compulsive disorder (OCD) have caught the imagination of the public. The movie As Good As It Gets and David Sedaris’s chapter “A Plague of Tics” in Naked(1) portray likable and engaging people struggling to overcome the challenges posed by these disorders. Both disorders present psychiatrists and neurologists with a fascinating array of phenomena that pose biological, psychological, developmental, and philosophical challenges. What is the pathophysiology that accounts for childhood onset, waxing course, and remission in adulthood? Why is Tourette’s syndrome so often comorbid with OCD and attention deficit hyperactivity disorder (ADHD)? How do unwanted movements, thoughts, and behaviors affect the developing sense of self? What accounts for the widely different outcomes, ranging from severe disability to heroic mastery of Tourette’s syndrome/OCD symptoms? What can neuroimaging and genetic studies of Tourette’s syndrome contribute to the philosophical understanding of the mind/brain question? This volume offers much both to veteran Tourette’s syndrome clinicians and to those interested in understanding the advances in neuropsychiatric disorders.

The Yale Child Study Center has played a leading role in the clinical and research understanding of Tourette’s syndrome and OCD for three decades. This book provides a current summary of Tourette’s syndrome and OCD, edited by Drs. James Leckman and Donald Cohen of the Child Study Center, and establishes an important benchmark in the synthesis of clinical practice and science focused on Tourette’s syndrome. In 21 chapters and two appendixes, the editors portray Tourette’s syndrome in meticulous scientific detail made human with fascinating case material. Most chapters have multiple authors, among them such international experts as David Pauls, Robert King, Robert Schultz, John Walkup, George Anderson, Alice Carter, Bradley Peterson, Lawrence Scahill, Ada Zohar, and Alan Apter.

The chapter authors and editors deserve credit for crafting a cohesive and comprehensive book that includes multiple perspectives and is dense with information. Topics are grouped in related sections, and chapters are written to complement each other. Individual chapters begin with brief previews and end with summaries of the most important concepts. This volume should be considered as a standard reference for Tourette’s syndrome and related conditions.

Leckman and Cohen begin the book by describing the historical conflict between two perspectives on Tourette’s syndrome: neurobiology and depth psychology. Involuntary actions, unwanted thoughts, and forbidden impulses may undermine a child’s quest for autonomy, but the pathophysiological explanation varies between the language of neuroscience and that of depth psychology. Following the introductory chapter, the book is articulated in three sections.

Section 1, Individuals, Symptoms, and Diagnoses, summarizes what is known about tics, comorbid disorders, neuropsychological and social function, differential diagnosis, and the Darwinian perspective. Chapters on “Tics and Tic Disorders” and “Obsessive-Compulsive Disorder, Anxiety, and Depression” survey the clinical phenomenology using extensive data as well as concise but lively clinical anecdotes. For example, forbidden urges are typified by the story of a high-energy physicist who had to give up his job because he felt the urge to disobey the “Danger: High Voltage” warning by touching the forbidden apparatus (p. 30). New concepts explaining known clinical phenomena add interest, even for readers with extensive experience with these disorders. For example, the temporal course of Tourette’s syndrome is described on the basis of the mathematical concept of a fractal, a term borrowed from the language of chaos theory. A fractal is a repeated pattern that can be observed across different scales of time or space. For tics, it has long been known that individual tics come in bursts of multiple tics. What is new is the perspective that these bursts also come in clusters of bursts and that the clusters of bursts occur within clusters themselves. This fractal pattern is better communicated graphically as a distribution of events over time than by text, and a series of scatter plots does that well graphically (p. 38). The first section of the book also includes chapters on comorbid ADHD and learning disabilities, neuropsychological aspects, peer acceptance, differential diagnosis, and Tourette’s syndrome from the Darwinian perspective on adaptation.

Section 2, Causes and Determinants, presents a comprehensive review of the etiology of Tourette’s syndrome and OCD. After an introductory chapter by the editors, chapter authors provide excellent summaries of the epidemiology, genetics, environmental risk and protective factors, neuroanatomy, and neurochemistry of Tourette’s syndrome and OCD.

The final section, Partnerships for Making the Best of Tourette’s, gives recommendations for the clinical management of the disorder. Diagnosis, rating scales, psychological assessment, psychosocial treatments, advice for teachers, psychopharmacology, and the role of volunteer organizations are all addressed in separate chapters. Although each chapter deserves mention, the most interesting may be that on volunteer organizations. Kathryn Taubert, a retired executive with experience in both the insurance industry and the March of Dimes, surveys the role of volunteerism in America. She focuses on the Tourette Syndrome Association to illustrate the functions of personal support, education, research, and advocacy. Ms. Taubert integrates her professional view of the business of volunteerism with her life experience with Tourette’s syndrome symptoms. Psychiatrists, psychologists, and allied mental health professionals will find valuable insight regarding advocacy for many disorders in this chapter. Ms. Taubert breathes the fire of personal passion into the abstract topics of collaboration, barriers to collaboration, and future prospects. For example, she takes issue with the biological view of the behavioral problems seen in schoolchildren with Tourette’s syndrome:

In conclusion, this book is an important, comprehensive, and well-written summary of the state of the clinical and research work on Tourette’s syndrome, OCD, and developmental psychopathology.