Why is Gilles de la Tourette syndrome dangerous? Symptoms, causes, methods of treatment. moderate degree

is an inflammatory process localized in the vagina. Trichomonas become a provocateur of inflammation. They are the simplest unicellular flagellar microorganisms that actively multiply in a humid environment. First, they are attached to the mucous membrane of the vagina, and then penetrate into the deeper layers of the epithelium, causing a pathological reaction. The sexual route of transmission of this pathogen prevails (up to 80% of cases of infection), but the contact-household method is not excluded.

A distinctive feature of Trichomonas is its ability to "collect" both opportunistic and pathogenic microorganisms. Therefore, monoinfection, when only Trichomonas are found in a smear, doctors rarely diagnose - only in 10.5% of cases. More often Trichomonas are a reservoir for other, smaller organisms: yeast-like fungi, microbes (gonococcus, ureaplasma, mycoplasma, chlamydia, etc.). That is why doctors so often identify a mixed infection with the leading role of Trichomonas.

The disease is widespread, and every year up to 300 million cases are registered in the world. Most often, such cases are diagnosed in women of reproductive age (from 18 to 45 years), which is due to the method of transmission of the pathogen.

Symptoms of trichomonas colpitis

Symptoms of the disease are manifested brightly, so the diagnosis of the disease is not difficult. A woman will experience the first unpleasant sensations already 3 days after infection. When signs of colpitis caused by Trichomonas appear, the patient most often goes to the doctor on her own.

The following clinical picture is characteristic of the disease:

The perineum and genital area becomes edematous, reddens and swells;

Abundant discharge appears, having a yellowish tint, foamy structure and an unpleasant odor. If, in addition to Trichomonas, another pathogenic microflora is present in the vagina, then the discharge may acquire a white or greenish tint;

Dyspareunia, that is, unpleasant, sometimes painful sensations that appear during intercourse;

Dysuria is pain during urination. In addition, the urges to him become more frequent. Women complain of a burning sensation in the urethra. This occurs when the bladder is damaged and is explained by the ability of Trichomonas to move independently with the help of special flagella;

When examining the vagina, the doctor detects multiple hemorrhages of a small size, localized along its wall. This may cause bloody blotches to be present in the discharge;

With the transition of the disease into a chronic form, menstrual irregularities are observed;

Another sign of chronic trichomonas colpitis is the appearance of pointed censers in the genital area;

Diaper rash can form on the inside of the thighs, even with sufficient hygiene. Their appearance is explained by the increased acidity of vaginal discharge during colpitis and an increase in their volume;

If the disease spreads to the uterus, appendages and ovaries, then the woman may experience pain in the lower abdomen, the temperature rises slightly. Pulling sensations may appear in the lower back.

Most often, the disease is diagnosed and treated during the acute phase, but doctors also face chronic trichomonas colpitis. It leads to the fact that the protozoa eventually form dangerous alliances with the bacteria that inhabit the vagina, and together they completely suppress the beneficial microflora, and this contributes to the further spread of inflammation in the pelvic organs.

Causes and ways of transmission of trichomonas colpitis

The penetration of Trichomonas into the vagina is the main reason for the development of colpitis. This process most often occurs during unprotected sexual contact with a male carrier of the infection.

There is another way to become infected with a dangerous microorganism - this is a household transmission route. However, it is less common than the sexual route. Mostly by contact-household way, little girls who have no idea about the rules of personal hygiene become infected. To do this, it is enough to use a washcloth or a towel on which there are Trichomonas.

Trichomonas colpitis is dangerous during pregnancy, as there is a high risk of intrauterine infection of the fetus. But even if Trichomonas has not crossed the placental barrier, there is a possibility of infection of the child during its passage through the birth canal, as well as when using instruments for obstetric care.

It is worth knowing that, being outside the body, the protozoa die, their viability is maintained for no more than 3 hours. This is due to the need of Trichomonas in a stable temperature of 37 ° C and a constantly humid environment.

In addition, there are certain risk factors that contribute to the development of the pathological process:

There is evidence that the disease can provoke premature birth, the birth of a child with low body weight and intrauterine infection of the fetus if trichomoniasis is found in a pregnant woman.

Diagnosis of trichomonas colpitis

Most often, one gynecological examination is enough for a doctor to suspect a disease. In this case, the doctor detects irritated and hyperemic vaginal mucosa, its walls are covered with serous exudate.

However, the gynecologist cannot make an accurate diagnosis only on the basis of a visual examination. To clarify the nature of the disease, laboratory tests are carried out, swabs are taken from the vagina, and sometimes from the rectum. The type of bacterial pathogen is determined by PCR, culture and cytology.

In addition, a gynecologist can send a woman for a consultation with a dermatovenereologist and a urologist.

Treatment of trichomonas colpitis

Therapy of the disease has several goals: firstly, the elimination of the acute inflammatory process, and secondly, the complete disposal of the woman from the pathogen. As a rule, the disease is treated on an outpatient basis, but in some cases hospitalization is required. These include purulent tubo-ovarian abscesses, or peritonitis, which are a complication of the disease and occur against the background of acute trichomoniasis.

Drug treatment is based on the complex prescription of systemic antibacterial drugs and local antiseptics. Control the effectiveness of therapy after the course, as well as after the next menstrual cycle. Metronidazole is considered the main antibiotic for getting rid of trichomonas colpitis. This drug has a detrimental effect not only on the main pathogen, but also on most pathogenic bacteria that often accompany trichomonas colpitis. The dosage is selected in each case individually, as well as the method of administration of the drug.

If Metronidazole cannot be used for any reason, the following alternative agents may be prescribed:

Naxojin;

Ornidazole;

As for preparations for topical use, vaginal suppositories can be shown: Trichomonacid (for 10 days), Hexicon (up to 20 days), Neo-Penotran (up to 2 weeks), Klion-D (up to 10 days), Terzhinan (up to 10 days), Meratin combi (up to 10 days). In addition, a woman will need to treat the urethra and anal area with a solution of Trichomonacid.

A woman is not released from work for the period of treatment, unless urgent hospitalization is required due to complications of the disease. The prognosis for recovery is usually favorable.

In order to verify the effectiveness of treatment, one should focus on the following criteria for recovery:

Trichomonas are not found in the smear from the vagina and rectum;

Pathogens are absent in the results of laboratory studies after 3 menstrual cycles;

There was a complete cure of the sexual partner.

After the therapeutic course, it is worth asking the doctor about the need to restore the vaginal microflora. For this, special means are used - eubiotics. They promote the growth of lactic acid bacteria, due to which the acidity of the vagina is normalized, and pathogenic microbes no longer multiply there. Among the most popular eubiotics: Lactobacterin, Bifidumbacterin, Vagilak.

As for the treatment of the chronic form of the disease, it involves the use of not only agents that affect the pathogenic microflora, but also an increase in immunity. Immunomodulators such as Immunal or Pyrogenal are prescribed. Restoration of normal microflora in chronic trichomonas colpitis is an obligatory stage of treatment. It is the chronic form of the disease that is dangerous with serious complications and mild symptoms, which contributes to the further spread of the infection.

Prevention of trichomonas colpitis

To prevent the colonization of the vagina by Trichomonas is within the power of every woman. To do this, she must follow simple rules:

Use of condoms during intercourse;

Limiting the number of sexual partners. A constant companion is the best defense against any sexually transmitted diseases;

You should not hope that local antiseptics like Miramistin are able to 100% protect a woman from the disease. However, they can be used as a preventive measure after unprotected sex;

It is important to observe the rules of personal hygiene, use only individual means, as there is a risk of household infection;

Regular washing is a guarantee of a woman's health, since Trichomonas from clothes can get into the area of ​​\u200b\u200bthe inguinal folds, and later into the vagina;

It is necessary to avoid hypothermia, to carry out activities aimed at strengthening;

All medications, especially antibiotics, should be used only on medical advice.

At the first signs of trichomonas colpitis, you must consult a doctor. This will help avoid serious complications and prevent the infection from spreading.

Education: Diploma "Obstetrics and Gynecology" received at the Russian State Medical University of the Federal Agency for Health and Social Development (2010). In 2013, she completed her postgraduate studies at the NMU. N. I. Pirogov.

Trichomonas colpitis- the most common type of lesion of Trichomonas vaginalis. The mucous membrane of the female vagina is an extremely favorable habitat for these unicellular organisms, which is the reason for the full name of the pathogen. However, due to the ignorance of the majority of the population regarding classical medical terminology (Greek κολπος - “vagina”), one can often come across assumptions about a similar diagnosis in men. Obviously, although men can become infected with Trichomonas, colpitis in men is impossible due to the lack of a vagina.

Colpitis is a female disease, but a sexual partner can also be infected with Trichomonas

However, such a diagnosis made to the partner should be a signal for an immediate visit to the doctor for preventive diagnosis. - the most common type of sexual infection, moreover, it is difficult to treat in the later stages and is prone to a recurrent course.

Infection Diagnosis

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PCR is the most accurate method for detecting Trichomonas

The main method for verifying the diagnosis when infected with Trichomonas is, the material for which is. The technology principle of this type of research is repeated copying of DNA fragments that meet specific conditions. This way it is possible to determine the presence of the causative agent of the disease with its negligible population in the body (the accuracy of the method is up to 98%).

In addition, microscopy of an unstained smear and bakposev (cultural analysis) are used. But the low information content of the study under a microscope in the absence of pronounced discharge from the urethra; the laboriousness and duration of bakposev do not contribute to their wide popularity as diagnostic tests for trichomoniasis. This is especially true of sluggish or asymptomatic infections.

Symptoms

The disease debuts in men, as a rule, with inflammation of the urethra and is called Trichomonas urethritis. It has the following clinical manifestations:

Trichomonas urethritis symptoms are not always clear

• mucous discharge from the urethra;
• itching, burning during urination;
• pain in the perineum;
• hyperemia of the sponges of the urethra and inflammation of the glans penis.

Often no symptoms are observed, the infected person feels only mild discomfort, attributing it to hypothermia or the consequences of sexual excesses, and the disease manifests itself after it has become chronic. As a rule, these are already complications:, coupled with secondary impotence and infertility.

Treatment

Do not self-medicate. Uncontrolled and inappropriately taking medications, you can get a chronic course of one of the most problematic sexual infections.

The course of treatment is prescribed only by a doctor

Antibiotics for trichomoniasis are useless; antiprotozoal agents used to treat it, on the contrary, have an antimicrobial effect, which weakens or destroys the associated pathogenic flora. These drugs have a number of side effects, they are often used in combinations when monotherapy does not work, so a doctor should prescribe treatment. This is not a discussion of additional procedures that may be required for the final destruction of pathogenic microorganisms.

For the purpose of a complete cure, both sexual partners are subject to examination and treatment, regardless of whether the infectious agent is found in the second or not. The reason for this approach in dermatovenereology is frequent carriage, when Trichomonas survives in the body for a long time, without showing itself in any way in people with strong immunity, who unwittingly become sources of re-infection.

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Gilles de la Tourette's syndrome or Tourette's disease is a disease characterized by tics of varying degrees of intensity that appear regularly and unexpectedly. The syndrome got its name from a French psychiatrist who conducted research on the disease.
Content:

Symptoms of Tourette's Syndrome

The most common symptoms of Tourette's syndrome are tics, such as frequent blinking and involuntary .

Tics mean chaotic movements (motor tics) and sounds (vocal tics), while the general motor function is not impaired. Tics occur quickly, monotonously, non-rhythmically and completely consciously.

Vocal tics can be divided into simple and complex. Simple tics include the reproduction of any sounds, for example, grunting, coughing, exclamations, whistling, even lowing. All these sound manifestations are very similar to stuttering. In the case of complex vocal tics, whole words or phrases are used.

Some people with Tourette's syndrome repeat the words of others (echolalia), while others repeat their own words repeatedly (palilalia). Often, this syndrome manifests coprolalia, when words and phrases containing profanity are spontaneously shouted out.

Motor tics can be described as compulsive movements that occur after a strong internal urge, such as sneezing or itching. Can be temporarily restrained by willpower, but only for a short time.

Patients with this syndrome may jump up and down, clap their hands unexpectedly, frown, show obscene gestures, and even inflict intentional bodily harm on themselves. Motor tics, like vocal ones, are simple (blinking, frowning) and complex (grimacing, hitting parts of the body against a wall or objects).

The severity of tics is influenced by the emotional component. Tics under stress can progress from simple to complex.
Typically, tics occur in children and adolescents as a result of a malfunctioning central system or a genetic predisposition.

Tics appear at the age of 4 years, then progress, acquiring complex forms.

The severity of tics gradually increases from light motor tics, to which vocal ones are added. This can happen over a long period, which is either several months or several years. For mild motor tics, doctors may prescribe mild sedatives, but they will not work.

The progression of the disease has a negative impact on the social life of the child, it is difficult for him to attend classes at school, sometimes parents are forced to resort to home schooling.

In adults, the symptoms are smoothed out. It is not dangerous for mental development, it has no complications. Only in some particularly severe cases, the disease remains and interferes with a full life and work.

The symptoms of Tourette syndrome are easy to recognize. To start the right treatment, you need to contact a specialist.

Causes of Tourette Syndrome

The disease is inherited in most cases, it is believed that a sick person has a special gene, which gives a predisposition to this syndrome. But the exact location of this gene has not been determined. There are cases of the disease in children with healthy parents, however, quite rarely.

Men are more often ill than women. Among the factors affecting the severity of Tourette's syndrome, there are psycho-emotional, environmental and infectious. Decreased immunity can lead to exacerbation of tics.

Poor ecology affects the health of a pregnant woman. The cause of the disease can be toxicosis, fetal hypoxia, lack of weight, difficult childbirth and birth trauma. During pregnancy, it is better not to smoke, not take, as well as medications that can provoke the development of the syndrome in a child.

There is an opinion of scientists that tics can be caused by various diseases of the brain. Tourette's syndrome can occur if the balance between the chemicals produced by the brain is disturbed, the production of dopamine having the greatest effect.

The following reasons can provoke the appearance of Tourette's syndrome:

• streptococcal
• Toxin poisoning, including alcohol
• Infections, against the background of which the temperature rises significantly
• Uncontrolled intake of psychotropic substances
• stress factor

Tourette's syndrome is not difficult to diagnose. Special examinations are not prescribed. Diagnosis is based on conversations with patients and their families.

If a person has symptoms that appeared in childhood or adolescence, last more than one year, there are phases of exacerbation and remission. The doctor may prescribe a tomography, an electroencephalogram, and blood biochemistry tests to rule out others.

Treatment of Tourette's syndrome

To treat the syndrome, you need to contact a neurologist or a psychotherapist, work with a psychologist will help to alleviate the condition and adapt in society.

A mild form of the disease does not require medical treatment. In these cases, psychotherapy, auto-training, sometimes hypnosis is used. In some cases, alternative medicine, for example, acupuncture, various types of massage, and therapeutic exercises, can give a good effect.

It is imperative to work not only with a sick child, but also with parents, explain to them how important a positive home environment is. The daily regimen must be strictly observed, to maintain the correct lifestyle.

• Punishment or shouting due to the manifestation of tics is unacceptable; as a result of stress, tics can only increase.
• Constant monitoring and control of the child's behavior is necessary to identify the reasons why the disease progresses.
• Assistance in replacing one tick with another - carried out together with a specialist
• The child can be distracted from the disease by involving in the creative process
• Creating a favorable atmosphere not only at home, but also at school. When no one around focuses on tics, it is easier for a child to relax.

The most important thing is to seek help in time. It is not necessary to hope that the tics will go away on their own, since the disease can progress and become complex.

In severe cases, antipsychotics are used:

• Haloperidol
• Risperidone
• Fluphenazine
• Paroxetine
• Sulperid and others.

Therapy must be regularly renewed, constantly monitor patients.

In an adult, the symptoms of Gilles de la Tourette's syndrome may disappear completely, but mental disorders often persist. These include phobias, panic attacks. Sometimes medicines have to be taken for life.

Treatment should be based on the severity of symptoms. The faster and more correctly the therapy is carried out, the better the result can be achieved.

Disease prognosis

The prognosis for this disease is quite good. If therapy is prescribed in time, then maintenance treatment is regularly carried out, then when adulthood comes, all manifestations of the syndrome disappear without a trace.

While watching the video, you will learn about Tourette's syndrome.

The manifestations of Gilles de la Tourette's syndrome are quite unpleasant. They greatly complicate the child's life, indirectly lead to a decrease in mental and physical development, since he feels inferior, and his contact with the outside world is disturbed. Therefore, it is important to recognize the onset in time and start complex treatment as soon as possible, depending on the severity of the disease.

Part three. Rehabilitation of children and adolescents with systemic neuropsychiatric disorders.

Chapter 4
Treatment of children and adolescents with Gilles de la Tourette's disease and tics.

A. D. Drobinsky and T. K. Stezhka (1980) report one case of treatment of a patient with Gilles de la Tourette's syndrome: the authors observed a teenager who was helped by a combination of melleril with seduxen. R. A. Kharitonov and V. V. Pushkov (1981) used atropine coma in the treatment of treatment-resistant forms of the disease of generalized tics, the result was contradictory.

Psychiatrists from New York (Rifkin A., Wortman R., Reardon G., Siris S. G. Psychotropic medication in adolescents: Areview. "I. clin. Psychiatry". 1986, N 8, p. 400-408) are advised to use in the treatment Tourette syndrome, haloperidol or pimozide. There is nothing original in this recommendation, unless this judgment is considered outside the general meaning of their article, imbued with the spirit of extreme caution in the use of psychotropic drugs. In fact, the authors recommend the use of psychotropic drugs only in the treatment of schizophrenia, epilepsy, and Tourette's syndrome.

Japanese psychiatrists published an article "Threatening aspects of the unconscious and sandplay psychotherapy. A case of Gilles de la Tourette syndrome" (Funai T., Inagaki T. etc. In. "Yonago Acta med". 1986, N 2, p. 91-102) . What is the course of reasoning of Japanese experts?

The syndrome of Gilles de la Tourette (we, of course, everywhere keep the terminology of the quoted authors) is the result of disunity, antagonism and expansion of consciousness and the unconscious. The latter is oversaturated with aggressive complexes, this manifests itself in coprolalia and hyperkinesis, symbolizing unreacted militancy and anger. Contact with such patients is difficult. How to restore it?

The authors propose playing in the sand - a form of non-verbal contact. An 11-year-old girl is described who was treated in a hospital for 5 months for tics and aggressive behavior. Once a week they played sandbox with the patient. After 5 months, the patient was discharged, the state of remission lasted one year, then the behavioral disorders intensified again (the tics remained unchanged).
Was there a Gilles de la Tourette syndrome here? And why, out of the many methods of psychotherapy and drug treatment, was the sand game chosen?

In 1984, a translation of a book by 13 of the most authoritative neuropathologists, living mainly on the Pacific coast of the United States, was published in Moscow. In this detailed monograph, which occupies 560 pages, two pages are devoted to the diseases of generalized tics (Ronald Kobayashi. Tourette's syndrome. In the book: Treatment of nervous diseases. M., Medicine, 1984, p. 271-272).

How does the author of these two pages imagine this disorder and what treatments does he prefer? According to the Californian professor, Tourette's syndrome begins at the age of 2-15 years, 50% of patients have vocal tics (the terminology of R. Kobayashi - however, other researchers in the USA, Japan and many European countries use the same terms), 50% - tics are expressed in violent blinking, head turning, shuddering of the shoulders or twitching of the hands. Muscular and vocal tics can be suppressed by the patient's volitional effort or, on the contrary, intensified by stress.

Boys get sick, - continues R. Kobayashi, - three times more often than girls. With the greatest frequency, the disease occurs in Ashkinazi Jews (19-62% of all patients). Approximately 35% have sick relatives. There was no association of the disease with social factors, mental illness in the family, perinatal complications, infections, trauma, or birth order in the family.

The California specialist ends his discussions about Tourette's syndrome on an optimistic note: "Patients with Tourette's syndrome do not necessarily (thank God! - M. B.) suffer from concomitant mental disorders, such as schizophrenia, hysteria or obsessive-compulsive neurosis, and may have normal intelligence ".

It is clear that R. Kobayashi expounds judgments that, for the most part, fundamentally contradict the views of the writer of these lines. I would like to draw the readers' attention to the fact that it is impossible to delay hyperkinesis and vocalization for a longer time with an effort of will, although it is necessary to strive for this, methodically and consistently develop this ability in oneself. As for R. Kobayashi's assertion that Tourette's disease mainly affects Jews originating from Europe, this is unproven. In the USSR, Jews make up 0.69% of the population. Among our patients there were only 8 Jews, that is, clearly less than 1% of all patients studied by us with the disease of generalized tics. However, it is not in the traditions of Soviet medicine to be interested in the nationality of patients, however, after reading the reasoning of R. Kobayashi, the writer of these lines became interested in them, again looked through the lists of his patients and was able to establish (or suspect) Jewish nationality in only eight patients.

In other words, R. Kobayashi's article reflects yesterday in the study of the disease of generalized tics, almost every statement of her is an anachronism or a myth. As for considerations about the treatment of such patients, here the author is closer to the truth. Without delimiting the disease into forms, the author, of course, does not assume that the approach to different patients should be different and talks about only one method of therapy - treatment with haloperidol. If, according to R. Kobayashi, an average daily dose of 9.5 mg of haloperidol is given to a patient, then 97% of patients experience improvement and it lasts for at least 4 years. The author believes that haloperidol leads to an improvement in the condition of 75% of patients, and in the remaining 25% of patients, remission occurs from other methods of treatment. R. Kobayashi is sure that neither psychotherapy, nor other methods of pharmacological treatment, except for halo-peridolotherapy, bring tangible benefits.

Well-known specialists from the USA (Weiden P., Bruun R. Worsening of Tourett "s Disorder Due to Neuroleptic - Induced Akathisia. In. "Amer. I. Psychiat.", 1987, N 4, vol. 144, p. 504-505 ) published an article "The effect of akathisia caused by the use of neuroleptics on the course of Tourette's disease". They note that the manifestations of Tourette's disease may worsen with an increase in the doses of neuroleptics used in the treatment of this disorder. The severity is associated with the appearance of neuroleptic syndrome, one of the main symptoms of which is akathisia.The authors came to a similar conclusion after studying 100 patients with Gilles de la Tourette's disease.Among these patients, only 6 patients had akathisia caused by the use of large doses of neuroleptics and leading to a deterioration in the condition of patients, an increase in the manifestations of Tourette's disease.The patients were treated with pimozide, haloperiodol or a combination of these drugs.

So, 6% of patients developed akathisia - the percentage is generally small. Judging by the data of these authors, there was rather an individual reaction to large doses of neuroleptics or insufficient intake of correctors. In our practice, we also encountered akathisia in two patients due to individual reactivity. Akathisia was eliminated by prescribing correctors in an adequate dose or by switching to another type of therapy.

In the past, akathisia was reported in another patient treated with haloperidol. He was diagnosed with a residual-organic form of Tourette's disease, treatment with Melleril was prescribed, there were no signs of akathisia; for three years, when we observed this patient, there were no manifestations of the disease.

In haloperidolotherapy of Tourette's syndrome, R. Kobayashi identifies two options: 1) with a slow increase in doses and 2) with a rapid increase in dose, without giving significant preference to any method.

It is possible to continue the list of publications, which provided the most diverse information about the treatment of patients with generalized tics. The same drugs had different effects on patients with this disorder. Why did it happen? Yes, mainly because the disease of generalized tics is heterogeneous, diverse, the three forms we have identified are the main ones, in addition to them, other forms are possible, each of which requires its own treatment. All patients with this disease (at all stages of treatment and in all forms of it) are recommended a milk diet (more calcium, which always has an anticonvulsant, antiticoid effect), daytime sleep, fluid intake restriction, "face relaxant", autogenic training, then, depending on clinical variant of Gilles de la Tourette syndrome, another treatment is added.

In the process of treating patients with generalized tic disease, special attention should be paid to the somatic condition. The fact is that recent studies have found some features of heart contractions, blood pressure, ECG, reflecting an increased neurosympathetic tone of cardiac regulation. Frequent blinking in this disease is explained by dopaminergic hyperactivity. - This was shown by Leningrad psychiatrists (E. L. Shelkunov, O. G. Kenunen, V. V. Pushkov, R. A. Kharitonov), who published the corresponding article in the Journal of the American Academy of Child Psychiatry (1986, No. 5, p. 645-652).

Before moving on from general issues of the treatment of all forms of the disease of generalized tics to considering the treatment of each form separately, we would like to draw the attention of readers to one circumstance, which has been much written about by specialists from different countries in recent years: long-term use of large doses of strong antipsychotics (such as haloperidol) supposedly can lead to asthenia and blunting of mental processes, lower academic performance and even neuroleptic encephalopathy. Of course, if the doses are excessive, if correctors are not given, the duration of sleep is insufficient, the intake of vitamins is insufficient, etc., then these phenomena are possible. The writer of these lines has never observed them either in his patients or in the patients treated by my colleagues and whom they asked me to advise.

However, it must be recognized that the use of neuroleptics such as haloperidol can sometimes lead to encephalopathy and intellectual impairment. This may be due to the imperfection of the technology for manufacturing drugs or their storage (which often occurs in conditions of carelessness and a cynical attitude of a number of workers to their duties, as our press tirelessly reports), with the individual characteristics of the patient's body, with the very action of the drug, with pathomorphism of the disease.
Any encephalopathy dramatically worsens the prognosis of any form of Gilles de la Tourette's disease - this is recognized by all authors who have published their observations on this disorder. Fortunately, among our patients there were no persons with gross encephalopathy, decreased intelligence.

Treatment of patients with residual-organic variant of the disease of generalized tics.

These persons undergo the same treatment that is given to all patients with cerebrasthenic and hyperdynamic syndromes of residual organic cerebral genesis, as well as patients with neurosis-like logosyndrome (with the exception, of course, of speech therapy). Treatment is carried out for another three years after the disappearance of the last hyperkinesis and vocalization.

After diagnosing in these individuals the disease of generalized tics as a manifestation of an early organic lesion of the central nervous system in the form of dysontogenesis and mild encephalopathy, all of them were prescribed treatment aimed at eliminating cerebrosthenia and hyperdynamia: restriction of fluid intake, afternoon sleep, education of better self-control, infusions of magnesium sulfate, glucose, ascorbic acid, etc., were combined with long-term use of melleril (sonapax), phenibut and other drugs that reduce mental and muscle excitability. In parallel with the decrease in signs of organic damage to the central nervous system, the symptoms of the underlying disease also decreased. All such patients were engaged with a speech therapist, who eliminated their dyslalia and takhilalia, and after that, vocalization and stuttering (where it was).

These patients required dosed, fractional loading. They were strictly forbidden to play football, hockey and other sports that inevitably lead to head bruises. At school, they should have been asked not at the end of the lesson, but at the beginning, not at the last lessons, but at the first - while the children were not yet tired. They were forbidden to stay in the heat, in a stuffy room, riding in transport was limited. If all these recommendations were strictly and methodically followed, cerebrosthenia, hyperdynamia and the resulting (or concomitant) signs of a neurosis-like syndrome (in particular, Gilles de la Tourette's syndrome) were gradually reduced. As soon as the patient stopped treatment, did not comply with medical and pedagogical recommendations, movement disorders and vocalization reappeared and intensified - usually this coincided with an increase in both cerebrosthenia and hyperdynamia.

Treatment of persons with a genuine variant of the disease of generalized tics.

The main drugs here are etaperazine and haloperidol. What dose will be adequate can never be predicted in advance: it may be appropriate for the age of the patient and his configuration, or may exceed it by 2-4 times (sometimes more). Having reached the optimal dose, you should stop at it, give drugs (often we combine haloperidol, etaperazine and chlorpromazine) for at least 4-5 months, and then, gradually reducing the dose, check the stability of remission. Medicines are taken until the disease is completely eliminated, that is, for years. Here we would like to dwell on some general issues of pharmacotherapy related to the drug therapy of any systemic neuropsychiatric disorders.

We divide drug treatment (of all psychoneurological and somatic disorders - not only systemic ones) into 3 types.

The first is the constant use of drugs until the disappearance or a sharp decrease in the manifestations of the disease. The doses of the drugs and the time they are taken can vary, but the drugs are given all the time.

The second is intermittent medication: the patient takes medication for 7-10 days, then they are not given to him for 1-4 days, then he takes them again at the same dose. Such intermittent treatment helps to prevent the development of addiction and side effects of certain drugs. Intermittent administration is used for long-term treatment and the use of small doses of drugs. For example, in the treatment of all dyssomnias (with or without urinary and fecal incontinence, somnostereotypes, etc.), we most often use intermittent dosing.

The third is taking large doses of drugs followed by rapid (often instantaneous) withdrawal of antipsychotics. This method is used for: 1) patient resistance to therapy; 2) ineffectiveness of high doses; 3) decrease in the reactivity of the body.

Over the course of 30-50 days, the doses of the drug are gradually increased, but if there is no expected positive effect, the patient is resistant to treatment, you need to somehow excite, excite, shake up his reactivity. By analogy with the "zigzag method" (MA Chalisov, 1953), with insulin therapy, a complete or incomplete cancellation of high doses of the drug is used. We achieve this in two main ways: 1) no medication is given at all on a given day without first reducing high doses; 2) the dose is reduced by half, after 1-2 days another half and after 3-4 days no drugs are prescribed at all or are given in very small doses.

After complete or incomplete withdrawal of antipsychotics, the patient is given more milk, vitamins, glucose, symptomatic agents (if necessary). 6-7 days after the withdrawal of drugs, they are again prescribed, but at a lower dose than before.

In the treatment of systemic neuropsychiatric disorders, we mainly used continuous and intermittent administration of drugs. As for taking large doses of neuroleptics with their subsequent rapid cancellation, we occasionally used this method only in the treatment of patients with the genuine form of generalized tics. We did not observe any complications, but we cannot widely recommend this method in outpatient practice due to the possibility of unforeseen events.

In the treatment of persons with the genuine form of the disease of generalized tics, the same question invariably arises: to what extent is it necessary to deal with neuroleptic syndrome (Delay-Deniker syndrome)?

Here is how G. G. Shanko (1979) poses the question: “Given such a high efficiency of haloperidol, one would think that the problem of treating Gilles de la Tourette’s disease has been solved. However, it turned out that when using haloperidol, pronounced side effects often occur in the form of parkinsonism , dystonic and dyskinetic disorders ... They can be observed already at the beginning of treatment, their severity does not depend on the age of the patients, the duration and severity of the disease, the presence of organic signs of brain damage (Bruun et al, 1976).Therefore, all patients receiving haloperidol over 2 mg per day, requires antiparkinsonian drugs (Woodrow, 1974) As Bruun et al (1976) write, the question arises: is it worth getting rid of the symptoms of the disease in order to suffer the side effects of haloperidol? (Shanko G. G. Generalized tic (Gilles de la Tourette's disease) in children and adolescents. Minsk, 1979, p. 110).

This argument needs a few clarifications. Firstly, the presence of an organic brain lesion sharply increases the manifestations of the neuroleptic syndrome, especially in children and adolescents. Secondly, to the question of Bruun et al. "is it worth getting rid of ...", the answer can only be unambiguously affirmative, because the suffering from the side effects of haloperidol is temporary and insignificant. After all, if peritonitis begins from an inflamed appendix, then an appendectomy is still done, not paying attention to the fact that after the operation the seam will hurt for some time.

In other words, it is necessary to prescribe haloperidol, observing, of course, a certain caution in the presence of residual or current phenomena of organic brain damage. The question remains to what extent the neuroleptic syndrome should be eliminated. We solve it in the following way.

Purely empirically, we have found that the stronger and longer the parkinsonian phenomena of haloperidol therapy for the disease of generalized tics are expressed, the faster the symptoms of Gilles de la Tourette's syndrome are stopped. Therefore, we do not always strive to completely and quickly eliminate the manifestations of the Delay-Deniker syndrome and therefore for some time we give correctors in lower doses than is customary when using haloperidol. It is clear that such treatment requires risk, understanding on the part of the patient's parents and himself, and great caution. But if you follow this principle, then success is most often guaranteed. Blood and urine tests in such cases should be done monthly. With the appearance of obvious anomalies on the part of the internal organs, it is necessary to reduce the dose of haloperidol, prescribe symptomatic treatment and correctors that completely relieve the neuroleptic syndrome.

We noticed the following pattern: after taking haloperidol (at least 10-15 days), the condition of patients with the genuine form of generalized tics most often showed significant improvement. Some symptoms of the disease (moreover, from the point of view of social adaptation and self-esteem of the patient, the most significant) quickly passed - we are talking about vocalization (including in the form of coprolalia). The patient, and especially his parents, rejoiced at this, but after a few weeks they began to sound the alarm due to the fact that hyperkinesias and tics still persisted and irritated the patient, who was already used to the fact that he was better than before.

Resistance of generalized tics to haloperidol therapy was generally widespread. In such cases, it was necessary to supplement the intake of haloperidol with the intake of melleril or etaperazine, as well as magnesium sulfate, mixtures with chloral hydrate. The effect did not always come, but a temporary, although unexpressed and inconsistent improvement, as a rule, was noted.

Highly effective in the treatment of genuine, as well as residual-organic forms of Gilles de la Tourette's disease pimozide (Orap); it is available in Hungary in tablets (per 1 mg tablet). It is similar in action to haloperidol, but causes slightly fewer side effects. We prescribed pimozide 3-4 tablets per day. To eliminate extrapyramidal disorders, half the dose was prescribed at night, and during the day the patients drank milk, took nootropil, etc. In the treatment of the residual organic form of the disease of generalized tics, pimozide was prescribed in much lower doses (up to 1-2 tablets per day), the main the same indication for treatment with this drug is the presence of a genuine form of the disease. Long-term treatment - at least 3-4 months - in combination with other drugs.

A sharp improvement occurred when the patient began to engage in psychotherapy, in particular autogenic training, and especially mastered the "face of the relaxant." Usually this was given to the patient with great difficulty, and only after many months of training did he begin to fully control his muscles. After the patient mastered autogenic training and the "face relaxer" (usually we used them in a single complex), he regularly did these exercises - until recovery. In other words, these studies often took years and years.

Psychotherapy was effective only after drug preparation and only against the background of medication. Psychotherapy thus boiled down to the ability to better self-control, to be able to suppress unexpected movements and sounds by force of will.

As for hypnotherapy, A. Shapiro and other American researchers deny its importance in the treatment of Gilles de la Tourette's disease, trying not to expand too much on this topic.

In this regard, we would like to emphasize the following: 1) all or almost all patients with any form of Gilles de la Tourette's disease that we have identified, who were treated by us, were distinguished by good suggestibility and, although not very high, but quite noticeable hypnoability - this is what they apparently , did not differ from the population; 2) in none of the patients, except for persons with a psychogenic form, the introduction into the deep degrees of the hypnotic state did not suppress hyperkinesis, tics and vocalization outside the hypnotic state, i.e. in the state of hypotaxis and somnambulism, the manifestations of Gilles de la Tourette's disease stopped, but with using post-hypnotic suggestion, this could not be induced for a long time. Most likely, those researchers are right who do not attach great importance to suggestion in the treatment, according to our classification, of the residual organic and genuine forms of the disease of generalized tics.

Treatment of patients with a psychogenic variant of the Gilles de la Tourette syndrome.

At the first stage, when neurotic disorders predominate, massive drug antineurotic therapy is needed. According to our observations, a combination of high doses of Relanium, thioridazine and radedorm at night is highly effective here. The more the patient sleeps, the more "thick-skinned" he becomes from these drugs, the faster the disease will stop. At the same time, the suggestion of a general sedative content in a state of doubt, drug hypnosis, hypnonarcosis. Usually, after 10-15 days of intensive therapy, the signs of the disease of generalized tics subside and etaperazine or haloperidol is added to the treatment, and suggestive psychotherapy is replaced by training.

Journal of neuropathology and psychiatry. S. S. Korsakova published (1991, No. 8, pp. 59-62) an article by A. Yu. Smirnov "On the differentiated therapy of Gilles de la Tourette's syndrome", which outlined the main provisions of the Ph.D. thesis of the same author "Gilles de la Tourette's syndrome in childhood "(M. 1990). The article and dissertation came from the All-Union Scientific Center for Mental Health of the USSR Academy of Medical Sciences, known for its passion for diagnosing schizophrenia. Naturally, the author considers the disease of generalized tics from a certain angle. By analogy with schizophrenia, the treatment of Gilles de la Tourette's disease is also proposed: in this sense, it is, of course, differentiated ...

Of course, among the relatives of people with Gilles de la Tourette's disease, one can meet epileptics, schizophrenics, psychopaths, and someone else. Such an environment occurs in patients with any pathology and in perfectly healthy people. It is clear that the patient is different from the patient, that all patients with the disease of generalized tics are not the same, but it is impossible to reduce everything to a schizophrenic or epileptic circle.
There are many unknown and controversial in the treatment of this disease, but this unknown or controversial will be even greater if the doctor proceeds not from clinical reality, but from far-fetched schemes.

Therapy of neurotic and neurosis-like tics.

The treatment of tics is usually complex with a different proportion of certain methods depending on the clinical picture of tics. The authors of various publications preferred different methods of treating this pathology. Some emphasized hypnotherapy (N. G. Krasnokutskaya and A. S. Bron, 1968; Yu. M. Leidman, 1971), others - on autogenic training (I. P. Sichel, R. Durand de Busingen, 1967), others considered optimal drug treatment and adherence to regime moments (N. Meige, E. Geindel, 1903). At one time, phenibut was considered a panacea, which reduces fears, tension, tics, stuttering, etc. Usually this drug is used for 4-6 weeks at 0.25-0.75 g per day. Indeed, phenibut is effective, but ... mainly in the treatment of neurotic disorders (with or without tics) and always in combination with psychotherapy and other drugs. However, we noticed that phenibut well reduces neurosis-like tics.

Tofizepam (Hungarian grandaxin, Bulgarian lonetil), which relieves anxiety, has a general calming effect, and has no contraindications, is also very effective - in this regard, tofizepam is highly effective in anxiety states of neurotic origin and therefore helps well with various systemic neurotic disorders (including tics, stuttering, dyssomnias, etc.).

All patients with tics receive the same treatment as patients with corresponding forms of stuttering and generalized tic disease. Depending on the form of tics, the following treatment is added to the indicated treatment: 1) for neurotic tics - suggestive-type psychotherapy, phenibut, mebicar, Relanium and other anti-neurotic drugs, electrosleep; 2) with neurosis-like tics - melleril, tropatsin, midokalm (for 1-2 months, 2-4 tablets per day), physiotherapy (similar to that used in the treatment of neurosis-like logosyndrome), sports: swimming, running, volleyball , basketball, skiing - in other words, any sports that exclude inevitable severe head injuries - any child with neurosis-like tics should have an outlet for the child’s natural need for movement, because physical inactivity in children and adolescents sometimes gives rise to tics (M. M. Khananashvili, 1983 ).

At the All-Union Conference on neurosis in children and adolescents, the report of the authors from Odessa (Borisova N.P., Kryzhanovskaya G.F., Levinsky M.V.) Experience in the complex use of benzodiazepines, lithium carbonate and haloperidol for the treatment of tic hyperkinesias aroused great interest. .: Neurosis in children and adolescents. M., 1986, pp. 26-28). They treated 59 children and adolescents with residual organic tics and three patients with Gilles de la Tourette's syndrome. In addition, they treated 54 patients with obsessive-compulsive disorder, etc.

All patients were treated equally: 3-5 days were given lithium carbonate (1/4-1/2 tab. 3 times a day) and phenazepam (0.4-0.75 mg per day) or diazepam (5-10 mg per day), then haloperidol was added (2-10 drops 3 times a day, i.e. 0.6-3 mg per day) and the dose was increased every 3-4 days by 1 drop at each dose until the hyperkinesis disappeared. "After the disappearance of hyperkinesis, patients continued to receive the specified combination for 7-14 days, then the doses of the drugs were gradually reduced in reverse order and completely canceled."

Speaking at the same conference, Yu. I. Malyshev (Malyshev Yu. I. Modern aspects of pharmacotherapy of tic hyperkinesis. Ibid., pp. 122-123) suggested treating children with local tics with anticonvulsants in a half dose for each age. After 3-4 days, a positive effect is already noted, in particular, phenobarbital. The duration of the course of treatment is 1 month, if necessary, such a course is repeated 2-3 times a year.

The reader has probably already paid attention to the fact that, speaking about the treatment of tics and Gilles de la Tourette's disease, we have so far mainly dealt with haloperidolotherapy and other common methods of treatment (thioridazine, phenibut). Now we would like to draw the attention of readers to some other methods of therapy that are part of the treatment complex. This is primarily about the use of etaperazine - it is given with or without haloperidol, phenibut, thioridazine, etc. We noted a very high efficiency if etaperazine was administered together with haloperidol (for the genuine form of Gilles de la Tourette's disease), thioridazine and phenibut (for the residual organic form of the disease of generalized tics and neurosis-like tics), diazepam and phenibut (for the psychogenic form of Gilles de la Tourette's disease). la Tourette and neurotic tics).

Etaperazin is given for a long time - like other drugs. Its side effect is much weaker than the side effects of haloperidol, therefore, etaperazine is especially indicated in case of diseases of the liver, kidneys, etc., which exclude long-term use of haloperidol (and even in large doses).

It helps well with neurosis-like tics and residual-organic and genuine forms of Gilles de la Tourette's disease, the French drug tiapride, produced in tablets of 100 mg. We treated several patients with this medicine at a dose of 200-300 mg per day for 3-4 months (in combination, of course, with other methods) and achieved good results.

Thus, for us, just as there is no single tic and a single disease of Gilles de la Tourette, so there is no single treatment for them. In the medical complex, the proportion of different drugs is not the same.

We do not give preference to any one method of medical therapy for tics, but we prefer a treatment complex, which necessarily includes psychotherapy. Apparently, the action of the whole complex can explain the high result of therapy: in fact, all patients who came to us about different types of tics are already healthy. Why only? From therapy or from the healing power of nature, or from a combination of these factors? However, such questions invariably arise before anyone who treats any disease of childhood and adolescence and then studies the catamnesis.

It is believed that with neurotic tics and hyperkinesis it is difficult for the patient to reproduce violent movements due to the painful struggle of motives - this is the basis for the treatment of such patients using negative practice techniques and reverse suggestion and self-hypnosis. These methods should be resorted to only after other therapies have proven ineffective.

Patients with neurosis-like tics and hyperkinesis very easily reproduce violent movements - there is no struggle of motives, you just need to have a slightly good memory in order to remember the manifestations of the disease and repeat them.

Excessive timidity, introversion, isolation and shyness, which can occur in any person (both with systemic neurotic and neurosis-like disorders, and without them), prevent such patients from easily demonstrating their unusual movements.

In childhood, these patterns persist, however, given the tendency of children to stereotypical movements, one should be wary of a prolonged and pedantic desire to duplicate violent movements. In some cases, we noted a fact that requires an explanation: if we forced patients with severe neurosis-like tics or a genuine form of generalized tics to repeat hyperkinesis and vocalization 5-6 times in a row, the latter became less frequent - more precisely, their manifestations seemed to be postponed for some time. One got the impression that each such patient should detect hyperkinesis a certain number of times a day and
vocalization. If the patient forces himself to repeat hyperkinesias and vocalizations at will, then the total number of involuntary cries and movements will decrease by approximately the same number of conscious duplications of similar symptoms.

We included such a treatment in the general complex of therapy for patients with all forms of tics and generalized tics.

Later, we found one indication that does not fit into the traditional framework of differentiation and, accordingly, the treatment of neurotic and neurosis-like disorders. Here is the idea that interested us in full.

L. P. Yatskov (Yatskov L. P. New methodological techniques of psychotherapy, definitions of suggestibility used in clinical practice. (Methodological recommendations). Vladivostok, 1979, p. 17) proposed "for the purpose of differential diagnosis of the functional and organic genesis of hyperkinesis test" arbitrary duplication", which is determined by the following method. After determining the nature and rate of hyperkinesis, the patient is given the installation to arbitrarily duplicate (cause) those movements that occur in him in the form of violent (involuntary) hyperkinesis. Our observations have shown that with functional hyperkinesis, the indicated the test is positive, i.e. the patient arbitrarily duplicates (causes) the involuntary movements observed in him. With hyperkinesis of organic genesis, the test of "arbitrary duplication" is negative, i.e. the patient fails to duplicate his involuntary hyperkinesis ".

Most likely, there was a misprint in this publication: neurotic and neurosis-like hyperkinesis should be swapped ... if only the author had in mind precisely these violations. After all, what he calls organic hyperkinesis, and what is functional, is not clear to the reader. In addition, one should not forget about the powerful suggestive influence of the doctor, especially if his communication with the patient takes place under the conditions of some unusual experiment.

As for physical therapy, there is no special physical therapy in the treatment of persons with systemic neuropsychiatric disorders (We recommend readers interested in physical therapy to refer to V. N. Moshkov's monograph "Therapeutic exercise in the clinic of nervous diseases". M., 1982). More smooth, rhythmic, varied movements (including dancing and singing), more walks, daily ordinary physical exercises, swimming, running, normal mode - all this (if carried out systematically, playfully, fun, not hysterically) helps both to prevent tics, stuttering etc., and their prompt liquidation.

After reducing tics, hyperkinesis, stuttering, etc., you need to take medications that have a beneficial effect for about 1 more month, use the “relaxant face”, autogenic training and other psychotherapy techniques that have brought tangible benefits, you need to perform about another six months all regime, general strengthening and general healing effects. All this, to one degree or another, concerns the approach to the treatment of all the disorders discussed in this book without exception.

See the continuation of the publication in the same issue of the Moscow Psychological Journal.

- a disorder that has a neuropsychic nature and manifests itself in uncontrolled motor and sound tics. The disease manifests itself in childhood, its symptoms in the form of various behavioral disorders cannot be controlled by the patient.

Other names for Tourette's syndrome are: Gilles de la Tourette's disease, generalized tic, Tourette's disease. Earlier, in the Middle Ages, Tourette's syndrome was recognized as a rare and very strange disease. He was associated exclusively with shouting obscene phrases, with offensive statements, with inappropriate expressions. Moreover, motor and vocal tics were mistaken for an obsession. That is how, for the first time in the book "Hammer of the Witches" (1489), a priest was named who suffered from this genetic disorder. The eponym of this disease was assigned in honor of the neurologist Gilles de la Tourette, on the initiative of his teacher J. M. Charcot. It was Gilles de la Tourette who, in the form of a report, described in 1885 the condition and behavior of 9 people suffering from this syndrome. Nevertheless, even before Tourette himself, such a state was described more than once by various authors.

The disease is now rare. It affects up to 0.05% of the population. The syndrome manifests for the first time in the age range between 2-5 years or between 13-18 years. At the same time, two-thirds of the patients are males, that is, boys get sick three times more often than girls. Family cases are traced in a third of patients.

In addition, most modern scientists point out that Tourette's syndrome is not a very rare disease. They note that more than 10 children out of 1000 may be affected by this anomaly, but they have a mild form and often remain undiagnosed. The level of intelligence and life expectancy of such people do not suffer.

Although scientists currently associate the development of the disease with genetic, environmental, neurological and other factors, the question of the etiology of Tourette's syndrome is still controversial, because the gene has not yet been mapped. In this regard, Tourette's syndrome, as a disease, is of interest to such sciences as: psychology, neurology, psychiatry.

Causes of Tourette Syndrome

Although the exact causes of Tourette's syndrome have not yet been established by official science, there are the following most likely hypotheses regarding the etiology of the disease:

Genetic disorders

In medicine, cases of the disease are described within the same family: brothers, sisters, fathers. In addition, hyperkinesias of varying severity are found in close relatives of children with Tourette's symptom.

Scientists suggest that Tourette's symptom is transmitted in an autosomal dominant pattern of inheritance with incomplete penetrance. However, autosomal recessive inheritance should not be excluded, as well as polygenic inheritance.

It is estimated that a person with Tourette syndrome in 50% of cases passes the genes to one of their children. However, reasons such as variable expression and incomplete penetrance explain the appearance of symptoms of varying severity in close relatives, or their complete absence. However, only a small proportion of children inherit genes that lead to serious disorders and require careful medical supervision.

Autoimmune processes in the body (PANDAS)

So, scientists from the National Institute of Mental Health in 1998 put forward the theory that tics and other behavioral disorders occur in children against the background of an autoimmune poststreptococcal process that has developed.

Experts point out that the transferred streptococcal infection and the autoimmune process that has developed against this background can even provoke tics in children in whom they have not previously been observed. However, studies in this regard have not yet been completed.

Dopaminergic hypothesis

The occurrence of Tourette's syndrome is explained by a change in the structure and functionality of the basal ganglia, neurotransmitter and neurotransmitter systems. At the same time, scientists point out that tics occur either due to an increase in the production of dopamine, or due to the fact that the receptors become more sensitive to dopamine.

At the same time, both motor and vocal tics become less pronounced when patients take dopamine receptor antagonist drugs.

In addition, scientists note a number of factors that can provoke the development of the syndrome.

Tourette, among them:

Toxicosis and stress suffered by a pregnant woman.

Reception during the bearing of a child of anabolic steroids, drugs and alcohol-containing drinks.

Intrauterine hypoxia of the fetus with impaired functioning of the central nervous system.

Prematurity of the child.

Intracranial injuries received during childbirth.

Postponed intoxication of the body.

Hyperactivity syndrome and psychostimulants taken against this background.

Increased emotional stress.

Most often, the first symptoms of Tourette's syndrome manifest in a child aged 5 to 6 years.

In general, the signs and symptoms of Tourette syndrome are as follows:

Parents begin to notice certain oddities in their behavior in their children. Children make faces, stick out their tongues, wink, blink often, clap their hands, etc.

As the disease progresses, the muscles of the trunk and legs are involved in the process. Hyperkinesis becomes more complicated and begins to manifest itself in jumping, throwing out the lower limbs, and squats.

From an early age, children are capricious, restless, inattentive, very vulnerable. Due to such a high emotionality, it is difficult for them to establish contact with their peers.

Patients are prone to depression, increased irritability. Depressive disorders are replaced by bouts of rage and aggression. After a short time, aggressive behavior is replaced by a cheerful and energetic mood. The patient becomes active and relaxed.

Echopraxia and cypropraxia are common. The former are expressed in copying the movements of other people, and the latter in offensive gestures.

Tics can pose a certain danger, since patients are able to hit their heads, put pressure on their eyes, bite their lips hard, etc. As a result, patients inflict quite serious injuries on themselves.

Voice or, as they are also called, vocal tics, are very diverse in Tourette's syndrome. They are expressed in the repetition of meaningless sounds and words, in whistles, panting, lowing, hissing, screaming. When vocal tics are introduced into the process of a person's monologue, the illusion of stuttering, hesitation and other problems with the patient's speech is created.

Sometimes patients cough non-stop, sniffle. Similar manifestations of Tourette's syndrome can be mistaken for symptoms of other diseases, for example, rhinitis, tracheitis, sinusitis, etc.

Patients are also characterized by such speech disorders as:

1. Coprolalia - the expression of obscene words (is not

   A pathognomonic symptom, as it is observed only in 10% of cases);

   Echolalia - repetitions of phrases and words uttered by the interlocutor;

   Palilalia - repeated repetitions of the same word.

   The speed of speech, its timbre, volume, tone, accents, etc. can change.

If boys are characterized by coprolalia, then girls are obsessive-compulsive traits. Coprolalia is a serious symptom of the disease, as it contributes to social maladaptation. A person pronounces curses loudly, sometimes even shouts out. Phrases are broken.

The behavior of the patient during an attack can be very eccentric. They can grunt, crackle their fingers, sway from side to side, rotate around their axis, etc.

Patients are able to anticipate the next attack, as it is accompanied by the appearance of a certain aura. Perhaps the appearance of a coma in the throat, pain in the eyes, skin itching, etc. As the patients explain, it is these subjective sensations that force them to reproduce this or that sound or phrase. The tension is released immediately after the tick is completed. The stronger the patient's emotional experiences, the more frequent and intense the tics will be, both vocal and motor.

Intellectual development of patients does not suffer. But motor and speech tics have an impact on his learning and behavior.

Other symptoms of Tourette's syndrome are behavioral reactions expressed in excessive impulsivity, aggression, emotional instability.

The disease reaches its peak by adolescence, and as maturity approaches, it declines or disappears altogether. However, the persistence of symptoms of the disease throughout a person's life is not ruled out. In 25% of cases, the disease is latent and worsens after a few years. Complete remission is rare.

Depending on how severe the symptoms of the disease are in the patient, there are several degrees of Tourette's syndrome:

Easy degree. The patient is able to control all vocal and motor deviations without problems. Sometimes these disorders remain unrecognized by the people around them. In addition, asymptomatic periods are possible, although they are quite short-lived.

Moderate degree. The patient is able to control the existing violations, but it is not possible to hide them from the environment. In this case, there are no asymptomatic periods at all.

pronounced degree. A person is not able to control the symptoms of the disease, or does it with great difficulty. Signs of illness are obvious to everyone around.

Severe degree. Vocal tics and motor tics are pronounced. The muscles of the trunk and limbs are involved in the process. A person is unable to control the symptoms of the disease.

Features of tics in Tourette's syndrome

Tics in Tourette's syndrome have characteristic features. So, motor disturbances are always monotonous, for a while the patient can suppress them. There is no rhythm.

Another distinguishing feature of tics is that they are preceded by an impulse that the person is unable to overcome. It occurs just before the start of the tick. Patients describe it as an increase in tension, an increase in feelings of pressure, or an increase in energy that needs to be released. This must be done in order to normalize your condition, to return the former “good” state of health.

Patients indicate that they feel a lump in the throat, discomfort in the shoulder girdle. This prompts them to shrug or cough. In order to get rid of the unpleasant sensation in the eyes, people begin to blink frequently. Prodromal sensory phenomena, or prodromal urges - this is how these impulses are called, which patients experience before tics.

At the same time, not every patient, especially in childhood, is able to appreciate this foreshadowing urge. Sometimes children do not even notice that they have tics and are surprised if they are asked a question about this or that condition.

There are certain criteria by which the diagnosis of Tourette's syndrome becomes possible:

The debut of tics before the age of 18 (in some cases up to 20) years.

The movements of the patient are involuntary, repeated according to a certain stereotype. Multiple muscle groups are involved in the process.

The patient has at least one vocal tic.

Having multiple motor tics.

The duration of the course of the disease is more than a year.

The disease has an undulating character.

Tics are not caused by other conditions, such as medications.

It is mandatory to carry out a differentiated diagnosis and distinguish Tourette's syndrome from the following diseases:

Chorea minor (movements are slow, worm-like, most often only hands and fingers are involved in the process);

Huntington's chorea (tics are irregular, spasmodic, involving the limbs and face);

Parkinson's disease (elderly people are susceptible, characterized by gait disturbance, rest tremor, mask-like face);

Taking medications (neuroleptics) against which neuroleptic tics may occur (these drugs are used to treat Tourette's syndrome, therefore, before starting therapy, all tics in the patient should be thoroughly studied);

Wilson's disease;

Post-infectious encephalitis;

The child must be examined not only by a neurologist, but also by a psychiatrist. Equally important is the dynamic observation of the patient, the collection of a family history.

Examinations that allow you to clarify the diagnosis and distinguish Tourette's syndrome from other pathologies: MRI or CT of the brain, EEG, electromyography, electroneurography. It is also possible to take urine to determine the level of catecholamines and metabolites in it. An increase in the content of dopamine in the urine, homovanillic acid, and excretion of noradrenaline will indicate the disease.

Treatment of Tourette's syndrome

Treatment of Tourette syndrome is an individual process. A specific scheme is selected based on the patient's condition, and also largely depends on the severity of pathological manifestations. Mild and moderate degree of the disease lends itself well to correction using such psychological techniques as art therapy, music therapy, animal therapy. For a child, psychological support, a favorable emotional background in which he exists is extremely important.

Therapy can be optimal only if it is selected for a particular child:

With a mild degree of Tourette's syndrome, only additional support provided to the child is enough. It is possible to adapt his environment, changes in the school process (for example, allowing a child with Tourette's syndrome to perform control work not in the general class, but in a separate room and not limiting it in time). Often this is enough to reduce the symptoms of the disease. It's good when the teacher goes to meet the parents. So, in the classroom, you can show children a scientific film about people with this disease.

If tics affect the quality of life of the patient, then he is shown medication, which will minimize the manifestations of the disease. The main drugs used in this case are neuroleptics (Pimozide, Haloperidol, Fluorphenazine, Penfluridol, Risperidone), adronomimetics (Clonidine, Catapress), benzodiazepines (Diazepam, Phenozepam, Lorazepam). Drugs are used only in extreme cases, since their administration threatens the development of various side effects. A positive effect from the use of antipsychotics can be expected in about 25% of cases.

There is evidence that forms of Tourette's syndrome that are resistant to conservative therapy are amenable to surgical correction using deep brain stimulation (DBS). However, at this point in time, this technique is at the testing stage, therefore, it is forbidden to use it for the treatment of children. The method boils down to the fact that with the help of surgical manipulations, electrodes are introduced into certain parts of the brain. The apparatus with which the electrodes are connected is placed in the chest. He, at the right time, transmits a signal through the electrodes to the brain, preventing or preventing the development of the next tick.

Non-drug methods are also widely used, such as segmental reflex massage, exercise therapy, acupuncture, laser reflexology, etc.

In the future, the treatment of Tourette's syndrome includes such methods as biofeedback therapy, injection of botulinum toxin to rid the patient of vocal tics. Treatment with Cerucal showed positive effects, however, in order to be able to use the drug in pediatric practice, it is necessary to conduct additional, larger trials.

Currently, Haloperidol remains the drug of choice. Its action is aimed at blocking dopamine receptors in the area of ​​the basal ganglia. Children are advised to start with a dose of 0.25 mg per day with a weekly increase of 0.25 mg. In 24 hours, a child can receive from 1.5 to 5 mg of the drug, depending on his age and body weight. A drug such as Pimozite has fewer side effects compared to Gadloperidol, however, it is forbidden to use it for violations in the functioning of the heart.

The doctor to contact if you have symptoms of Tourette's syndrome is a psychiatrist.

Against the background of ongoing treatment, improvement in well-being can be achieved in 50% of patients after they enter adolescence or adulthood. If tics cannot be completely eliminated, then lifelong therapy is possible.

Although the disease does not affect a person's life expectancy, it can disrupt its quality, and sometimes quite strongly. Patients are prone to depression, panic attacks and need constant psychological support from the people around them.

Self-enlightenment and enlightenment of the environment. Understanding what constitutes Tourette's syndrome makes it possible to delve deeper into the problems of the child. The source of knowledge should be the attending physician, as well as information resources such as medical textbooks, journals and articles on this topic.

It is important to understand the mechanism that triggers the next tick. Recording what preceded the next vocal and behavioral disorder will help to build a logical chain and establish a push factor.

Making adjustments. If you make appropriate changes in the environment of a sick child, in the routine of his life, then you can reduce the number of tics. Often, breaks in homework, the possibility of additional rest at school, etc., help.

Rebuilding an existing skill. The child should be taught to control the tics. This must be done by a qualified person. To rebuild the skill, the child will need to have a clear understanding of tic behavior in order to learn how to correct it later.

Regular meetings with the treating doctor. A qualified psychiatrist is obliged to conduct conversations and classes with the child, which aim not only to provide psychological support, but also to help him cope with his thoughts, behavior, feelings. Members of the family where a child with this problem is growing up can also take part in consultations.

Sometimes a child with motor tics should be allowed more time to type on the keyboard than to write by hand. School teachers should be made aware of this. Also, do not forbid the child to move or leave the class if he needs it. Sometimes these children should be given privacy.

If necessary, you can practice classes with a tutor or switch to home schooling.

Education: In 2005, she completed an internship at the First Moscow State Medical University named after I.M. Sechenov and received a diploma in Neurology. In 2009, she completed her postgraduate studies in the specialty "Nervous Diseases".