Differential Diagnosis

 Today the full-blown case of TS is unlikely to be confused with any other disorder.
 However, only a decade ago TS was frequently misdiagnosed as schizophrenia,
 obsessive-compulsive disorder, Sydenham's chorea, epilepsy, or nervous habits. The
 differentiation of TS from other tic syndromes may be no more than semantic, especially
 since recent genetic evidence links TS with multiple tics. Transient tics of childhood are
 best defined in retrospect. At times it may be difficult to distinguish children with
 extreme attention deficit hyperactivity disorder (ADHD) from TS. Many ADHD children, on
 close examination, have a few phonic or motor tics, grimace, or produce noises similar to
 those of TS. Since at least half of the TS patients also have attention deficits and
 hyperactivity as children, a physician may well be confused. However, the treating doctor
 should be aware of the potential dangers of treating a possible case of TS with stimulant
 medication. On rare occasions the differentiation between TS and a seizure disorder may be
 problematic. The symptoms of TS sometimes occur in a rather sharply separated paroxysmal
 manner and may resemble automatisms. TS patients, however, retain a clear consciousness
 during such paroxysms. If the diagnosis is in doubt, an EEG may be useful. We have seen TS
 in association with a number of developmental and other neurological disorders. It is
 possible that central nervous system injury from trauma or disease may cause a child to be
 vulnerable to the expression of the disorder, particularly if there is a genetic
 predisposition. Autistic and retarded children may display the entire gamut of TS symptoms,
 but whether an autistic or retarded individual requires the additional diagnosis of TS may
 remain an open question until there is a biological or other diagnostic test specifically
 for TS. In older patients, conditions such as Wilson's disease, tardive dyskinesia, Meige's
 syndrome, chronic amphetamine abuse, and the stereotypic movements of schizophrenia must be
 considered in the differential diagnosis. The distinction can usually be made by taking a
 good history or by blood tests. Since more physicians are now aware of TS, there is a
 growing danger of overdiagnosis or over-treatment. Prevailing diagnostic criteria would
 require that all children with suppressible multiple motor and phonic tics, however
 minimal, of at least one year, should be diagnosed as having TS. It is up to the clinician
 to consider the effect that the symptoms have on the patient's ability to function as well
 as the severity of associated symptoms before deciding to treat with medication. 


TABLE 1. RANGE OF SYMPTOMS OF TS

Motor
 Simple motor tics: fast, darting, and meaningless.
  Complex motor tics: slower, may appear purposeful 

Vocal
  Simple vocal tics: meaningless sounds and noises.
            Complex vocal tics: linguistically meaningful utterances such as words and
            phrases (including coprolalia, echolalia, and palilalia).

Behavioral and Developmental

  Attention deficit hyperactivity disorder, obsessions and compulsions, 
  emotional problems, irritability, impulsivity, aggressivity, and self-injurious
  	behaviors; various learning disabilities 



Symptomatology

 The varied symptoms of TS can be divided into motor, vocal, and behavioral manifestations
 (Table 2). Complex motor tics can be virtually any type of movement that the body can
 produce including gyrating, hopping, clapping, tensing arm or neck muscles, touching people
 or things, and obscene gesturing. At some point in the continuum of complex motor tics, the
 term "compulsion" seems appropriate for capturing the organized, ritualistic character of
 the actions. The need to do and then redo or undo the same action a certain number of times
 (e.g., to stretch out an arm ten times bܥe><br><i>Uploader </i>: Robert Dickan
<br><i>Email </i>: spamdude@computer.net
<br><i>Language </i>: English
<br><i>Subject </i>: Biology
<br><i>Title </i>: Tourette's Syndrome
<br><i>Grade </i>: 90
<br><i>System </i>: High School
<br><i>Age </i>: 18
<br><i>Country </i>: U.S.A/
<br><i>Comments </i>: 28 pages long
<br><i>Where I got Evil House of Cheat Address </i>: newsgroup 
<br><i>Date </i>: may 11, 1996



Tourette's Disorder


Table of Contents


     Tourette Syndrome And Other Tic Disorders 
          Definitions of Tic Disorders 
          Differential Diagnosis 
          Symptomatology 
          Associated Behaviors and Cognitive Difficulties 
          Etiology 
          Stimulant Medications 
          Epidemiology and Genetics 
          Non-Genetic Contributions 
     Clinical Assessment Of Tourette Syndrome 
     Treatment Of Tourette Syndrome 
          Monitoring 
          Reassurance 
          Pharmacological Treatment of Tourette Syndrome 
          Psychodynamic Psychotherapy 
          Family Treatment 
          Genetic Counseling 
          Academic and Occupational Interventions 
      Bibliography 



Definitions of Tic Disorders

 Tics are involuntary, rapid, repetitive, and stereotyped movements of individual muscle
 groups. They are more easily recognized than precisely defined. Disorders involving tics
 generally are divided into categories according to age of onset, duration of symptoms, and
 the presence of vocal or phonic tics in addition to motor tics. Transient tic disorders
 often begin during the early school years and can occur in up to 15% of all children.
 Common tics include eye blinking, nose puckering, grimacing, and squinting. Transient
 vocalizations are less common and include various throat sounds, humming, or other noises.
 Childhood tics may be bizarre, such as licking the palm or poking and pinching the
 genitals. Transient tics last only weeks or a few months and usually are not associated
 with specific behavioral or school problems. They are especially noticeable with heightened
 excitement or fatigue. As with all tic syndromes, boys are three to four times more often
 afflicted than g! irls. While transient tics by definition do not persist for more than a
 year, it is not uncommon for a child to have series of transient tics over the course of
 several years. Chronic tic disorders are differentiated from those that are transient not
 only by their duration over many years, but by their relatively unchanging character. While
 transient tics come and go - with sniffing replaced by forehead furrowing or finger
 snapping, chronic tics - such as contorting one side of the face or blinking - may persist
 unchanged for years. Chronic multiple tics suggest that an individual has several chronic
 motor tics. It is often not an easy task to draw the lines between transient tics, chronic
 tics, and chronic multiple tics. Tourette Syndrome (TS), first described by Gilles de la
 Tourette, can be the most debilitating tic disorder, and is characterized by multiform,
 frequently changing motor and phonic tics. The prevailing diagnostic criteria include onset
 before the age of 21; recurrent, involuntary, rapid, purposeless motor movements affecting
 multiple muscle groups; one or more vocal tics; variations in the intensity of the symptoms
 over weeks to months (waxing and waning); and a duration of more than one year. While the
 criteria appear basically valid, they are not absolute. First, there have been rare cases
 of TS which have emerged later than age 21. Second, the concept of "involuntary" may be
 hard to define operationally, since some patients experience their tics as having a
 volitional component - a capitulation to an internal urge for motor discharge accompanied
 by psychological tension aefore writing, to even up, or to stand up and push a chair into
 "just the right position") is compulsive in duality and accompanied by considerable
 internal discomfort. Complex motor tics may greatly impair school work, e.g., when a child
 must stab at a workbook with a pencil or must go over the same letter so many times that
 the paper is worn thin. Self-destructive behaviors, such as head banging, eye poking, and
 lip biting, also may occur. Vocal tics extend over a similar spectrum of complexity and
 disruption as motor tics ( The most socially distressing complex vocal symptom is
 coprolalia, the explosive utterance of foul or "dirty" words or more elaborate sexual and
 aggressive statements. While coprolalia occurs in only a minority of TS patients (from
 5-40%, depending on the clinical series), it remains the most well known symptom of TS. It
 should be emphasized that a diagnosis of TS does not require that coprolalia is present.
 Some TS patients may have a tendency to imitate what they have just seen (echopraxia),
 heard (echolalia), or said (palilalia). For example, the patient may feel an impulse to
 imitate another's body movements, to speak with an odd inflection, or to accent a syllable
 just the way it has been pronounced by another person. Such modeling or repetition may lead
 to the onset of new specific symptoms that will wax and wane in the same way as other TS
 symptoms. 


TABLE 2. EXAMPLES OF MOTOR SYMPTOMS

Simple motor tics
 Eye blinking, grimacing, nose twitching, lip pouting, shoulder shrugging, arm 	jerking,
 abdominal tensing, kicking, finger movements, jaw snapping, tooth 	clicking, frowning,
 tensing parts of the body, and rapid jerking of any part of the 	body. 

Complex motor tics
  Hopping, clapping, touching objects (or others or self), throwing, arranging, 	gyrating,
  bending, "dystonic" postures, biting the mouth, the lip, or the arm, 	headbanging, arm
  thrusting, striking out, picking scabs, writhing movements, 	rolling eyes upwards or
  side-to-side, making funny expressions, sticking out the 	tongue, kissing, pinching,
  writing over-and-over the same letter or word, pulling 	back on a pencil while writing,
  and tearing paper or books. 

Copropraxia
  "Giving the finger" and other obscene gestures. 

Echopraxia
 Imitating gestures or movements of other people. 


TABLE 3. EXAMPLES OF VOCAL SYMPTOMS

Simple vocal tics
 Coughing, spitting, screeching, barking, grunting, gurgling, clacking, whistling, 	hissing,
 sucking sounds, and syllable sounds such as "uh, uh," "eee," and "bu." 

Complex vocal tics
  "Oh boy," "you know," "shut up," "you're fat," "all right," and "what's that." 
 or any other understandable word or phrase
Rituals
 Repeating a phrase until it sounds "just right" and saying something over 3 times. 

Speech atypicalities
 Unusual rhythms, tone, accents, loudness, and very rapid speech. 

Coprolalia
 Obscene, aggressive, or otherwise socially unacceptable words or phrases. 

Palilalia
 Repeating one's own words or parts of words. 

Echolalia
 Repeating sounds, words, or parts of words of others. 

 The symptoms of TS can be characterized as mild, moderate, or severe by their frequency,
 their complexity, and the degree to which they cause impairment or disruption of the
 patient's ongoingctivities and daily life. For example, extremely frequent tics that occur
 20-30 times a minute, such as blinking, nodding, or arm flexion, may be less disruptive
 than an infrequent tic that occurs several times an hour, such as loud barking, coprolalic
 utterances, or touching tics. There may be tremendous variability over short and long
 periods of time in symptomatology, frequency, and severity. Patients may be able to inhibit
 or not feel a great need to emit their symptoms while at school or work. When they arrive
 home, however, the tics may erupt with violence and remain at a distressing level
 throughout the remainder of the day. It is not unusual for patients to "lose" their tics as
 they enter the doctor's office. Parents may plead with a child to "show the doctor what you
 do at home," only to be told that the youngster "just doesn't feel like doing them" or
 "can't do them" on command. Adults will say "I only wish you could see me outside of your
 office," and family members will heartily agree. A patient with minimal symptoms may
 display more usual severe tics when the examination is over. Thus, for example, the doctor
 often sees a nearly symptom-free patient leave the office who begins to hop, flail, or bark
 as soon as the street or even the bathroom is reached. In addition to the moment-to-moment
 or short-term changes in symptom intensity, many patients have oscillations in severity
 over the course of weeks and months. The waxing and waning of severity may be triggered by
 changes in the patient's life; for example, around the time of holidays, children may
 develop exacerbations that take weeks to subside. Other patients report that their symptoms
 show seasonal fluctuation. However, there are no rigorous data on whether life events,
 stresses, or seasons, in fact, do influence the onset or offset of a period of
 exacerbation. Once a patient enters a phase of waxing symptomatology, a process seems to be
 triggered that will run its course - usually within 1-3 months. In its most severe forms,
 patients may have uncountable motor and vocal tics during all their waking hours with
 paroxysms of full-body movements, shouting, or self-mutilation. Despite that, many patients
 with severe tics achieve adequate social adjustment in adult life, although usually with
 considerable emotional pain. The factors that appear to be of importance with regard to
 social adaptation include the seriousness of attentional problems, intelligence, the degree
 of family acceptance and support, and ego strength more than the severity of motor and
 vocal tics. In adolescence and early adulthood, TS patients frequently come to feel that
 their social isolation, vocational and academic failure, and painful and disfiguring
 symptoms are more than they can bear. At times, a small number may consider and attempt
 suicide. Conversely, some patients with the most bizarre and disruptive symptomatology may
 achieve excellent social, academic, and vocational adjustments. 

Associated Behaviors and Cognitive Difficulties

 As well as tics, there are a variety of behavioral and psychological difficulties that are
 experienced by many, though not all, patients with TS. Those behavioral features have
 placed TS on the border between neurology and psychiatry, and require an understanding of
 both disciplines to comprehend the complex problems faced by many TS patients. The most
 frequently reported behavioral problems are attentional deficits, obsessions, compulsions,
 impulsivity, irritability, aggressivity, immaturity, self-injurious behaviors, and
 depression. Some of the behaviors (e.g., obsessive compulsive behavior) may be an integral
 part of TS, while others may be more common in TS patients because of certain biological
 vulnerabilities (e.g., ADHD). Still others may represent responses to the social stresses
 associated with a multiple tic disorder or a combination of biological and psychological
 reactions. 

Obsessions and Compulsions

 Although TS may present itself purely as a disorder of multiple motor and vocal tics, many
 TS patients also have obsessive-compulsive (OC) symptoms that may be as disruptive to their
 lives as the tics - sometimes even more so. There is recent evidence that
 obsessive-compulsive symptomatology may actually be another expression of the TS gene and,
 therefore, an integral part of the disorder. Whether this is true or not, it has been well
 documented that a high percentage of TS patients have OC symptoms, that those symptoms tend
 to appear somewhat later than the tics, and that they may be seriously impairing. The
 nature of OC symptoms in TS patients is quite variable. Conventionally, obsessions are
 defined as thoughts, images, or impulses that intrude on consciousness, are involuntary and
 distressful, and while perceived as silly or excessive, cannot be abolished. Compulsions
 consist of the actual behaviors carried out in response to the obsessions or in an effort
 to ward them off. Typical OC behaviors include rituals of counting, checking things over
 and over, and washing or cleaning excessively. While many TS patients do have such
 behaviors, there are other symptoms typical of TS patients that seem to straddle the border
 between tics and OC symptoms. Examples are the need to "even things up," to touch things a
 certain number of times, to perform tasks over and over until they "feel right," as well as
 self-injurious behaviors. 

Attention Deficit Hyperactivity Disorder (ADHD)

 Up to 50% of all children with TS who come to the attention of a physician also have
 attention deficit hyperactivity disorder (ADHD), which is manifested by problems with
 attention span, concentration, distractibility, impulsivity, and motoric hyperactivity.
 Attentional problems often precede the onset of TS symptoms and may worsen as the tics
 develop. The increasing difficulty with attention may reflect an underlying biological
 dysfunction involving inhibition and may be exacerbated by the strain of attending to the
 outer world while working hard to remain quiet and still. Attentional problems and
 hyperactivity can profoundly affect school achievement. At least 30-40% of TS children have
 serious school performance handicaps that require special intervention, and children with
 both TS and ADHD are especially vulnerable to serious, long term educational impairment.
 Attention deficits may persist into adulthood and together with compulsions and obsessions
 can seriously impair job performance. 

Emotional Lability, Impulsivity, and Aggressivity

 Some TS patients (percentages vary greatly in different studies) have significant problems
 with labile emotions, impulsivity, and aggression directed to others. Temper fits that
 include screaming, punching holes in walls, threatening others, hitting, biting, and
 kicking are common in such patients. Often they will be the patients who also have ADHD,
 which makes impulse control a considerable problem. At times the temper outbursts can be
 seen as reactions to the internal and external pressures of TS. A specific etiology for
 such behavioral problems is, however, not well understood. Nevertheless, they create much
 consternation in teachers and great anguish both to TS patients themselves and to their
 families. The treating physician or counselor is often asked whether those behaviors are
 involuntary, as tics are, or whether they can be controlled. Rather than trying to make
 such a distinction, it is perhaps more helpful to think of such patients as having a "thin
 barrier" between aggressive thoughts and the expression of those thoughts through actions.
 Those patients may experience themselves as being out of control, a concept that is as
 frightening to themselves as it is to others. Management of those behaviors is often
 difficult and may involve adjustment of medications, individual therapy, family therapy, or
 behavioral retraining. The intensity of those behaviors often increases as the tics wax and
 decreases as the tics wane. 

Etiology

The most intensive research in relation to etiology has focused on neurochemical alterations
in the brain. 
 Multiple neurochemical systems have been implicated by pharmacologic and metabolic
 evidence. The most convincing evidence for dopaminergic involvement has come from the
 dramatic response to haloperidol and other neuroleptics such as pimozide, flupenazine, and
 penfluridol, as well as exacerbations produced by stimulant medications. Findings of
 reduced levels of dopamine metabolites in cerebrospinal fluid (CSF) have led investigators
 to believe that TS results from a hypersensitivity of postsynaptic dopamine receptors.
 Serotonergic mechanisms have been suggested on the basis of reduced CSF serotonin
 metabolites. Since systems relying on neurotransmitters send projections to the substantia
 nigra and the striatum, they could play an important role in the pathophysiology of TS.
 Medications affecting that system seem somewhat effective for obsessions but have
 inconsistent effects on tics. The role of the cholinergic system is clouded by
 contradictory reports. Enhancing cholinergic function by use of physostigmine has been
 associated both with the improvement and the worsening of TS. Elevated levels of red blood
 cell choline have been found in TS patients and their relatives, but the significance is
 unclear. Investigation of the GABAergic system suggests that it may be implicated. The
 proximity and connections between the GABA and dopamine systems support the possibility of
 an interrelationship. Response to clonazepam (a GABAergic agent) has been positive in some
 cases. Yet other GABAergic drugs such as diazepam do not have such positive effects.
 Noradrenergic mechanisms have been most persuasively implicated by observations that
 clonidine, a drug that inhibits noradrenergic functioning by the stimulation of an
 autoreceptor, may improve motor and phonic symptoms. Noradrenergic involvement has also
 been suggested by the exacerbation of the syndrome by stress and anxiety. The use of
 functional neuroimaging techniques such as positron emission tomography may help clarify
 many physiologic relationships and identify important anatomical areas in the near future. 

Stimulant Medications

 A particularly important risk factor in tics and TS is the use of stimulant medication.
 Over 25% of all TS patients in some cohorts have had a course of stimulation medication
 early in the emergence of their behavioral or tic symptoms because they have been diagnosed
 as having ADHD. Over the last several years, series of cases have been reported in which
 the use of stimulants (methylphenidate, dextroamphetamine, and pemoline) has been
 correlated with the onset of motor and phonic tics. There is also chemical evidence to
 support the observation that stimulants will increase the severity of tics in 25-50% of TS
 patients. In many cases, the tics associated with stimulant medication will disappear with
 the reduction or termination of the medication. It is more controversial whether stimulants
 can actually trigger or produce prolonged chronic multiple tics or TS that will persist
 following their termination. However, cases have been reported in which that seems to have
 occurred. Available information thus indicates that stimulants should be used cautiously
 with ADHD children who have a close relative with tics, should generally be avoided with
 ADHD children with a first-degree relative with TS, and should be terminated with the onset
 of tics in children who previously were tic-free. Children and parents should be educated
 concerning the risks versus benefits in each case prior to being treated with stimulants.
 Alternatives such as behavioral management, environmental manipulation, and/or other types
 of medication should be considered carefully. 

Epidemiology and Genetics

 While once thought to be rare, TS is now seen as a relatively common disorder affecting up
 to one person in every 2,500 in its complete form and three times that number in its
 partial expressions that include chronic motor tics and some forms of obsessive-compulsive
 disorder. The question of the familial transmission of TS was first raised in the original
 19th century descriptions of the disorder, but a genetic basis for TS was not considered
 seriously until recently. Several genetic studies have now been reported and other rigorous
 studies are now well enough along to draw several important conclusions. Those studies have
 investigated many families in which TS and other tic disorders have been transmitted over
 several generations. Based on available information, it is now clear that TS is a genetic
 disorder. The vulnerability to TS is transmitted from one generation to another. When we
 speak of "vulnerability," we imply that the child receives the genetic or constitutional
 basis for developing a tic disorder; the precise type of disorder or severity may be
 different from one generation to another. That vulnerability is transmitted by either
 mothers or fathers and can be passed on to either sons or daughters. When one parent is a
 carrier or has TS, it appears that there is about a 50-50 chance that a child will receive
 the genetic vulnerability from that parent. That pattern of inheritance is described as
 autosomal dominant. However, not everyone who inherits the genetic vulnerability will
 express any of the symptoms of TS. There is a 70% chance that female gene carriers will
 express any of the symptoms of TS. For a male gene carrier, there is a 99% chance of
 showing some clinical expression of the gene. The degree of expression is described as
 penetrance. In males, the penetrance is higher than in females; thus, males are more likely
 to have some form of expression of the genetic vulnerability. There is a full 30% chance of
 female gene carriers showing no symptoms at all. For males, the figure is 1%. There is a
 range of forms in which the vulnerability may be expressed that includes full-blown TS,
 chronic multiple tics, and, as most recently recognized, obsessive-compulsive disorder.
 Some individuals have TS (or chronic tics) and obsessive-compulsive disorder together;
 others may have the conditions singly. There are also differences between the sexes in the
 form of expression of the TS gene. Males are more likely to have TS or tics; females are
 more likely to have obsessive-compulsive disorder; however, both males and females may have
 any combination or severity. The severity of the disorder is also highly variable. Most
 individuals who inherit the TS genetic vulnerability have very mild conditions for which
 they do not seek medical attention. Researchers are actively engaged in searching for the
 chromosomal location of the TS gene of affected individuals. At present, there is no
 genetic or biochemical test to determine if a person with TS or an unaffected individual
 carries the gene. There is no prenatal test for the vulnerability to TS. When scientists
 succeed in locating the gene, such tests may become available. 

Non-Genetic Contributions

 The individual variations in character, course, and degree of severity by which TS is
 manifested cannot be explained by genetic hypotheses alone. Furthermore, it appears that
 about 10-15% of TS patients do not acquire the disorder genetically. Thus, non-genetic
 factors are also responsible, both as causes and as modifiers of TS. Non-genetic factors
 that have been implicated include such stressful processes or events during the prenatal,
 perinatal, or early life periods as fetal compromise and exposure to drugs or other toxins.
 Findings from one study in which decreased birth weights were observed in the affected
 co-twins of discordant monozygotic pairs lend further support to the influence of
 environmental factors. 



Clinical Assessment Of Tourette Syndrome

 Assessment of a case of TS involves far more than simple diagnosis. Since symptoms may
 fluctuate in severity and character from hour to hour, a thorough understanding of the
 patient may take a considerable amount of time. As the patient becomes more comfortable
 with the doctor, there will be less likelihood of symptom suppression or inhibition. Only
 when there is confidence in the physician is the patient likely to acknowledge the most
 frightening or bizarre symptoms. The nature, severity, frequency, and degree of disruption
 produced by the motor and vocal tics need to be carefully assessed from the time of their
 emergence until the present. Inquiries should be made about factors that may have worsened
 or ameliorated their severity. A critical question concerns the degree to which the tics
 have interfered with the patient's social, familial, and school or work experiences. In
 those respects interviews with families may be revealing and informative. During the
 evaluation of a patient with TS, the clinician must assess all areas of functioning to
 fully understand both difficulties and strengths. It is important to explore the presence
 of attentional and learning disabilities, a history of school and/or work performance, and
 relationships with family and peers. Before receiving the diagnosis, the patient and/or
 family may have thought he or she "was going crazy." The patient may have become extremely
 distressed by his or her own experiences and by the often negative responses evoked.
 Parents may have scolded, cajoled, ridiculed, threatened, and perhaps beaten the child to
 stop the "weird" and embarrassing behavior, and the emotional sequelae may affect the
 patient far beyond the period of childhood. During the evaluation of a child, therefore,
 family issues including parental guilt need to be addressed. Relevant factors elicited
 through careful diagnostic evaluation can be approached through clarification, education,
 and therapeutic discussion with the youngster and the family. Careful assessment of
 cognitive functioning and school achievement is indicated for children who have school
 problems. TS children with school performance difficulties often do not have clearly
 delineated learning disorders, and the average IQ of TS patients is normal. Rather, their
 problems tend to lie in the areas of attentional deployment, perseverance, and the ability
 to keep themselves and their work organized. Many have difficulties with penmanship
 (graphomotor skills) and compulsions that interfere with writing. Determining specific
 problem areas will help in the recommendation of alternatives (e.g., extended periods of
 time for tests, the use of a typewriter or the emphasis on oral rathe! r than written
 reports). The neurological examination should include documentation of neuromaturational
 difficulties and other neurological findings. About half of TS patients have
 non-localizing, so called "soft," neurological findings suggesting disturbances in the body
 scheme and integration of motor control. While such findings have no specific therapeutic
 implications, they are worth noting as "baseline" data since the use of medications such as
 haloperidol may cloud the neurological picture. The EEG is often abnormal in TS, but the
 EEG findings are nonspecific. Computed tomography of the brain produces normal results in
 people with TS. Thus, unless there is some doubt about the diagnosis or some complicating
 neurological factors, an EEG and a computed tomography are not necessary parts of the
 clinical evaluation. Additional studies that may be considered in the biological work-up
 include serum electrolytes, calcium, phosphorous, copper, ceruloplasmin, and liver function
 tests - all related to movement disorders of various types. In practice, however, they are
 rarely needed for the diagnosis. A behavioral pedigree of the extended family, including
 tics, compulsions, attentional problems and the like is useful. Previous medications must
 be reviewed in detail during assessment. If a child has received stimulant medications, it
 is important to determine what the indications for the medications were, whether there were
 any pre-existing tics or compulsions, and the temporal relation between the stimulants and
 the new symptoms. Catecholaminergic agonists are contained in other drugs, such as in
 decongestant combinations used in treating allergies and in medications used for asthma. If
 a patient with TS is on a stimulant or a drug containing an ephedrine like agent,
 discontinuation should be strongly considered. If the physician examines a previously
