In 1885, the French physician Georges Albert Édouard Brutus Gilles de la Tourette published an account of nine patients, under the title “Study of a Nervous Affliction,” with severe tic disorders. Jean-Martin Charcot, an influential French physician and Dr. Tourette’s mentor, agreed with Tourette that a new classification for patients exhibiting such symptoms was in order and named it for his protégé whom he had assigned to study patients with such symptoms.
Thus, “Tourette Syndrome” entered the canon of medical afflictions. However, the search for the cause of the affliction proved elusive, as all sorts of fanciful theories were put forward ranging from: hereditary organic causes to repressed sexual desires of the Freudian variety; to obsessive mothers and poor parenting skills. Until the mid-sixties of the Twentieth Century, no real consensus emerged beyond that Freudian psychoanalysis was the preferred path of medical intervention.
This began to change decisively when a psychiatrist named Arthur K. Shapiro began to suspect that tic disorders were the result of organic brain abnormalities, as opposed to psychological maladjustments. His hypothesis was subsequently confirmed-at least in his estimation-when a TS patient he treated with the drug haloperidol (Haldol) showed marked improvement in regard to tics. Assisted by Elaine Shapiro, Ph.D., his wife, Dr. Shapiro wrote a forceful paper reporting his results and disparaging the then prevailing psychoanalytic paradigm. The paper was published in 1968 in the *British Journal of Psychiatry*, having been first rejected by American medical journals.
Because haloperidol, a neuroleptic (“antipsychotic”) drug, is a potent inhibitor of dopamine receptors within the brain, the “neurological disorder” classification of TS was born and gained increasing acceptance within the medical and mental health communities as advocated by the Shapiros and the Tourette Syndrome Association which they helped found along with patients’ families.
Since haloperidol, along with other neuroleptic drugs later developed, represses dopamine reception, a common theory since that time has been that dopamine plays an important role in regard to the manifestation of TS symptoms, though the exact mechanism remains unclear. (Dopamine is a hormone and neurotransmitter that, among myriad other functions, plays an important role in motor activity; thus its telling link to TS symptoms.)
Various theories concerning what exactly is the abnormality concerning dopamine (and perhaps serotonin, another neurotransmitter synthesized within the central nervous system) have been advanced, ranging from overly-sensitive dopamine receptors to an overproduction of the hormone, though nothing definitive has yet been demonstrated.
Classifying TS as an organic (or physical) illness undisputedly has economic, political and psychological benefits. But is it true? I remain skeptical for reasons I shall put forth within this essay.
The following is a quote from an article entitled “Tourette’s Syndrome and Dopamine,” published by the Society for Neuroscience:
“Other research indicates that tics are related to higher than normal levels of dopamine production and use. Perhaps there is a larger than normal number of dopamine-producing brain cells. Maybe the individual cells have an abundance of sites, or terminals, that release dopamine.” [April, 1998.]
Or perhaps the theory confuses cause with effect.
In my two previous essays regarding TS presented on *Ezine Articles*, I asserted that all mental afflictions once broadly classified as “neurotic,” including anxiety disorders, TS, OCD and ADHD, stem from the basic cause of “acute self-awareness” which engenders chronic anxiety which in turn is manifested by various symptoms in accordance with a patient’s individual pathology. An individual might exhibit symptoms of just one of these individual afflictions or any combination of them. Thus, TS is part of a broad spectrum of mental afflictions.
In the case of a person suffering from acute anxiety as exhibited by recurring panic attacks, what exactly causes his or her symptoms, such as an extremely rapid heartbeat and trembling? The answer is the neurotransmitter adrenaline (epinephrine). Can we then make the case that because adrenaline is responsible for the person’s symptoms that an elevated level of the hormone is the cause of the underlying condition per se? The answer is, of course, no. Instead, one must look for the reason why an infusion of adrenaline occurs during panic attacks.
The reason is not due to any organic abnormality that periodically and seemingly arbitrarily releases huge amounts of adrenaline. The reason for such an abnormal release of the hormone is the underlying acute anxiety that triggers the person’s panic attacks. This is clearly an act of conscious volition, but an act of volition born of habituation that renders the conscious “choice” virtually involuntary and seemingly beyond the control of the patient. This is exactly the scenario that I hold to be the case in regard to TS tics.
Here is a quote from an article entitled “Making Sense of Tourette’s,” published by the American Association for the Advancement of Science (AAAS):
“Other nonpharmaceutical interventions hold greater promise. Buoyed by the success of behavioral modification therapy in treating OCD, researchers have been examining similar approaches to Tourette syndrome. One problem with Tourette’s, says John Piacentini, a specialist on childhood and teen neuropsychiatric disorders at the University of California, Los Angeles, is that it sets up a positive feedback loop. Patients feel the need to tic and then experience relief when they do, thus reinforcing the neural circuits involved in that behavior. To break the loop, Piacentini and his colleagues have been experimenting with behavioral techniques.” [*Science*: Vol 305; 3 September, 2004]
This is, I believe, exactly correct as to the manifestation of recurring TS tics.
Prescribing tranquillizers to patients suffering from acute anxiety is beneficial to the extent that the drugs repress the brain’s ability to receive neurotransmitters and thus mitigate the symptoms of the underling mental affliction. They do not, however, address the root cause of the condition and can never constitute a cure. During a period of tremendous stress in my life, I suffered from panic attacks (and had been convinced at the time that I would not long survive due to them, despite having had no physical affliction that caused my symptoms).
During this terrible period of time, tranquilizers kept me “in the game,” so to speak, but it had only been when I had discovered the works of Dr. Claire Weekes, an Australian physician who specialized in nervous afflictions, that a cure ultimately occurred. (If one can ever in fact pronounce such a nervous sufferer “cured” in light of the genetic predisposition to anxiety.) As all terrible as my condition had seemed at the time, I have never again, after twenty-five years and through other periods of great stress, suffered a panic attack; which I attribute to the “sure and certain” knowledge concerning myself and my condition that I derived from Dr. Weekes’ behavioral analysis and remedial techniques.
In a like vein, if dopamine and/or serotonin prove the agencies that give the mechanical, metaphorical “order” for a TS sufferer to tic, then it does not necessarily follow that these hormones are doing so due to a physical abnormality within the structure of the brain. Therefore, drugs that inhibit their production or reception might be addressing the symptoms of TS and not its cause.
What is often lost sight of in such arguments concerning mental illnesses such as TS is that those who hold to the “brain = mind” theory in the brain/mind duality debate seek to position an entirely mechanical explanation for our mental existences, the same as for our physical ones. To such advocates, there is no such thing as a “controller” (mind) apart from the brain who makes decisions on an entirely volitional basis. To their way of thinking, all of our actions can be reduced to strictly physical mechanisms within the brain and central nervous system; a view that would seem to leave no real place for the field of psychology. All seemingly mental afflictions can be, at least in theory, addressed and redressed by surgery, medication or some other physical intervention.
But such a view, in my opinion, has been absolutely discredited by the success of behavioral therapies when applied to mental illnesses. My own experience as related is a testament to the potency of non-surgical, non-pharmaceutical techniques in certain instances of mental illness. Psychological afflictions do exist in fact and effective techniques to treat them are sometimes available that would have absolutely no efficacy in regard to physical illnesses.
If Tourette’s Syndrome is indeed a physical illness, then it would seem to be a most rare-perhaps an unique-example of one. What other physical illnesses would meet all of the following criteria?:
1) The disease cannot be identified and diagnosed (at least conclusively) by a blood test, X-ray or by any other physical means, but only by observation.
2) The symptoms of the disease vanish while the patient is unconscious.
3) The symptoms of the illness can be at least temporarily repressed by the sufferer, without any physical intervention, sometimes for an extended period of time. (Through “willpower,” can someone suffering with a severe toothache decide not to have it for several hours when not convenient?)
4) What exactly constitutes the disease cannot be objectively discerned, but only subjectively pronounced by “consensus.” (Such and such people have the disease because we say that they do.)
5) A significant percentage of those afflicted with the illness as children are cured, with or without medical intervention, simply by reaching adulthood.
In regard to the minority of TS sufferers afflicted with coprolalia (shouting obscene words or racial epithets), what language do they use? The one they speak, of course. If he or she does not speak French, then he or she will not shout such words in French.
Language is learned behavior that must be consciously applied; to speak a language is a volitional act, not an involuntary one. Although such sufferers feel compelled to shout such words and feel helpless to prevent themselves, it is still a conscious, volitional act that does not (generally) occur in a state of unconsciousness (when volition is not possible).
It has, however, become virtually involuntary through repetition and subsequent habituation as an attempted defense mechanism to dispel repetitive (obsessive) thought patterns that the mind finds objectionable. The same scenario is true in regard to other vocal and non-vocal tics which are either attempted defense or concentration mechanisms in accordance with obsessive-compulsive pathologies.
One phenomenon that has plagued science throughout history is that scientists at times become so enamored with their pet theories that they turn a blind eye to any indication-sometimes including glaring, common sense ones-that they might be wrong. Another is the tendency of scientific thought going from one extreme to the other. After a seemingly inevitable period of derision concerning a new theory and its formulator, sometimes both are ultimately embraced along with the wholesale discarding of what came before it as now being “nonsense.”
I am grateful to Dr. Shapiro for freeing TS sufferers and their families from the onus of Freudian psychobabble and being a pioneer in the usage of medication to improve the quality of life for those with TS. But the wholesale dismissal of the notion of TS as a psychological affliction in his wake as a medical “revolutionary” has led, in my opinion, to the misdirection of research for a cure, or at least the closest possible solution, and has left TS sufferers all too often passively waiting for the elusive physical intervention that will eradicate the affliction.
With the reported results of the Duke University behavioral therapy, as well as other encouraging signs within behavioral therapy in regard to TS, perhaps at long last the counterrevolution is gaining steam.