Correspondence

Tourette's Syndrome

N Engl J Med 2002; 346:710February 28, 2002

Article

To the Editor:

The review of Tourette's syndrome by Jankovic (Oct. 18 issue)1 contains a Venn diagram (Figure 1 of the article) that may be misleading. The figure suggests that Tourette's syndrome lies at the intersection of tics, attention-deficit–hyperactivity disorder, obsessive–compulsive disorder, and other behavioral disorders. Although these disorders often coexist with Tourette's syndrome and even with each other, they are not necessary for the diagnosis of Tourette's syndrome. The presence of tics alone, not caused by other conditions, is sufficient for the diagnosis.2

Joseph DeVeaugh-Geiss, M.D.
Duke University Medical Center, Durham, NC 27705

2 References

1. 1

   Jankovic J. Tourette's syndrome. N Engl J Med 2001;345:1184-1192
   Full Text | Web of Science | Medline

2. 2

   Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:101-3.
   

To the Editor:

Two additional diseases to consider in the differential diagnosis of Tourette's syndrome are allergic rhinoconjunctivitis and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Failure to discriminate allergic rhinoconjunctivitis from Tourette's syndrome or PANDAS can lead to misdiagnosis and inappropriate treatment.1,2

Anita Gewurz, M.D.
Rush Medical College, Chicago, IL 60612-3828
agewurz@rush.edu

2 References

1. 1

   Finegold I. Allergy and Tourette's syndrome. Ann Allergy 1985;55:119-121
   Medline

2. 2

   DeVera M, Gewurz AT. PANDAS or PARC: a pediatric puzzle. Pediatr Asthma Allergy Immunol 2000;14:137-140
   CrossRef | Web of Science

Author/Editor Response

Dr. Jankovic replies:

To the Editor: I agree with Dr. DeVeaugh-Geiss that motor and phonic tics without coexisting disorders are sufficient for a diagnosis of Tourette's syndrome. On the basis of the personal evaluation of well over 1000 patients with Tourette's syndrome, however, I believe that Tourette's syndrome consisting of tics alone occurs in only a minority of the patients who present to our Movement Disorders Clinic — admittedly, a biased sample of patients. According to a survey of 3500 patients with a diagnosis of Tourette's syndrome, only 12 percent had tics alone as the manifestation of the disorder.1 Thus, the Venn diagram was designed to draw attention to the frequent association of other disorders with tics and to highlight the importance of focusing on the whole person, rather than one particular symptom, such as tics.

Dr. DeVeaugh-Geiss refers to the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV),2 which include a requirement that the tics “cause marked distress or significant impairment in social, occupational, or other important areas of functioning.” Because of this vague language, milder cases of Tourette's syndrome would be difficult to classify, and the criteria do not take into account the frequently associated behavioral disorders that may be more distressing than the tics. Because of these and other matters of concern (e.g., the onset of tics is defined in DSM-IV as occurring before 18 years of age, rather than 21 years of age), the criteria will be modified in subsequent editions. Until then, I and others who engage in research on Tourette's syndrome prefer to use the classification developed by the Tourette Syndrome Classification Study Group.3

Dr. Gewurz comments on allergic rhinoconjunctivitis and PANDAS. Because of the controversy about their relation to Tourette's syndrome, I did not specifically mention PANDAS, but in the section on immunology I briefly discussed the overlap between poststreptococcal syndromes and Tourette's syndrome. I recognize that this topic requires further discussion, but because of space limitations I only briefly summarized the evidence for and against immunologic and other causes of tics.4

Joseph Jankovic, M.D.
Baylor College of Medicine, Houston, TX 77030
josephj@bcm.tmc.edu

4 References

1. 1

   Freeman RD, Fast DK, Burd L, Kerbeshian J, Robertson MM, Sandor P. An international perspective on Tourette syndrome: selected findings from 3,500 individuals in 22 countries. Dev Med Child Neurol 2000;42:436-447
   CrossRef | Web of Science | Medline

2. 2

   Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington, D.C.: American Psychiatric Association, 1994.
   

3. 3

   The Tourette Syndrome Classification Study Group. Definitions and classification of tic disorders. Arch Neurol 1993;50:1013-1016
   Web of Science | Medline

4. 4

   Jankovic J. Differential diagnosis and etiology of tics. In: Cohen DJ, Jankovic J, Goetz CG, eds. Tourette syndrome. Vol. 85 of Advances in neurology. Philadelphia: Lippincott Williams & Wilkins, 2001:15-29.