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New Literary History 32.3 (2001) 519-536



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The Voice in Tourette Syndrome

James Miller

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Tourette syndrome is an unusual chronic medical condition characterized by the childhood onset of multifocal motor and vocal tics, which may include phonation, vocalization, or the articulation of formed words, including obscenities or profanities. 1 Some of the tics relieve an inner urge or compulsion. Persons with Tourette Syndrome frequently also have obsessive-compulsive disorder and attention deficit disorder, and there is an increased incidence of both these behavioral conditions in their families.

The causes of Tourette Syndrome are currently unknown although recent years have seen a gratifying increase in knowledge of the pathophysiologic basis for this truly neuropsychologic phenomenon, and Tourette Syndrome currently holds a high place in the interests of students of human neurobiology. It is no longer confined to the black box of undecipherable psychiatric anomolies, for much is now known of its etiology, neuroanatomic localization within the central nervous system, concurrent neuropsychiatric conditions, and the pharmacologic means to beneficially alter its course. Intriguing information points toward functional abnormalities in specific areas of the brain in persons with Tourette Syndrome, and there is growing evidence that an infection with beta hemolytic streptococcus may be one trigger of Tourette Syndrome and other involuntary movement disorders in genetically susceptible persons.

Despite the accumulation of all this information, the causes of the phonatory and other tics in Tourette Syndrome remain unknown as do the nature of the relationships to obsessive-compulsive disorder and attention deficit-hyperactivity disorder. In like fashion, although inappropriate phonation remains the sine qua non of Tourette Syndrome, and essentially establishes the diagnosis in appropriate persons when present, it remains unclear why some Tourette persons make no abnormal sounds, whereas unwanted phonation can severely complicate the lives of others.

Although the tics of Tourette Syndrome occur without premonition in many instances, some patients experience a subjective discomfort which is then relieved by the tic, a phenomenon begging the question whether [End Page 519] the tics are willful or involuntary. Current imaging and neurobiological studies shed some light on the brain mechanisms involved, thereby holding out the prospect that, once Tourette becomes a tale well told, there may be important new insights into a very basic question of human behavior: what goes on in the brain when a person decides to do something?

The Nature of Tics

A tic is difficult accurately to describe. It is a relatively brief, episodic, muscle contraction, whose frequency and severity waxes and wanes, and which can be mimicked. J. Jankovic provides a useful five part classification, dividing tics into simple and complex motor tics, simple and complex phonic tics, and, finally, compulsive tics. 2

  • A simple motor tic is a sudden, brief, contraction of a localized muscle group, such as to cause the face to twitch or shoulder to jerk.

  • A complex motor tic involves many groups of muscles and mimics a gesture inappropriate to the circumstance. Examples are forward bending of the trunk, facial grimacing, touching, or hand wringing.

  • A simple phonic tic is a noise without meaning such as a grunt, bark, or squeak.

  • A complex phonic tic is the articulation of meaningful words and includes coprolalia, echolalia, and palilalia.

  • A compulsive tic is a response to an inner urge and may manifest as any of the above.

The term phonic tic is preferable to vocal tic since it encompasses all noises emitted from all phonatory structures, including sounds which may not strictly originate from the vocal cords. Phonic tics are seldom the initial presentation of Tourette Syndrome, and the majority are sounds made by a simple motor tic of phonatory muscles. Although the presence of phonic tics is the single best identifier of Tourette Syndrome, only a minority of patients ever exhibit this feature, and of these persons only a small portion suffer embarrassment or social stigmatization because of uncontrollable sounds or disruptive language. For the majority of sufferers, both the motor and phonic tics can be minimized by using appropriate neuroleptic medication (dopamine-blocking), thereby providing a means both to benefit the quality of the patient...

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