Gilles de la Tourette (second from left, top row)
and colleagues in the field of neurology at a Paris hospital.
TOURETTE'S SYNDROME
Potential Treatments with Chinese Medicine
Tourette's syndrome is named for Gilles de la Tourette (1857-1904), the physician who defined it in an 1885 publication (1). Tourette was from a medical family in France and became a neurologist in Paris, specializing in hysteria and its treatment. He noted an unusual syndrome in several young children (7-10 years of age) that had been brought to him for unusual behavior. They suffered from a type of tic disorder, which was understood to be a form of convulsion. At the time, these tics were described as follows:
Contractions-instantaneous, fast, involuntary-generally limited to a small number of muscles, usually with the muscles of the face, but also being able to affect others, that of the neck, trunk, or limbs....At one time it may be a flickering of the eyelids, a convulsive tugging of the cheek, wrinkling of the nose, twisting of the lips, which give to the face a grimacing air; at another time, it is a shaking of the head, an abrupt and momentary distortion of the neck repeated several times; at a third time, it is a rising of a shoulder, a convulsive agitation of the abdominal muscles or diaphragm. It is, in a word, an infinite variety of odd movements which escape any single description....These tics are in some cases accompanied by a cry, of a shout more or less noisy, very characteristic….there is a singular tendency to always repeat the same word, same exclamation, and the individual even utters aloud words which he would like to restrain that are more severe.
In ancient cultures, convulsions, tics, and strange exclamations were attributed to the influence of demons; in China they were understood to come from a kind of "wind." But, in the late 19th century, when this particular disorder was described as Tourette's syndrome, it was recognized and is still known to be a brain disorder. Many people come to be aware of it today via one of its peculiar manifestations, called coprolalia, which involves sudden, uncontrolled uttering of foul language, a phenomenon readily portrayed in movies. However, the disorder is primarily a physical tic disorder, and the coprolalia is just one manifestation of vocal tics that occur in people with this disorder.
Unlike epilepsy, to which it is sometimes compared, the sudden physical or vocal activity of Tourette's syndrome is frequently associated with certain other mental disorders, particularly attention deficit hyperactivity disorder (ADHD) and obsessive/compulsive disorder; in addition, emotional lability, irritability, impulsiveness, aggressiveness, self-injurious behaviors, and varied learning disabilities may also be present. Tourette's syndrome is observed in young children and mostly affects boys, which is a situation similar to that for ADHD, but characterized by more activity and aggressive behavior. Still, Tourette's syndrome, which is estimated to affect about 0.05% of the population (but nearly 0.1% of the male population), can manifest in a range of intensities from minor tics (with no evident mental impairment) and little interference with daily activities, to considerable mental and behavioral disability.
Although the basic cause of Tourette's syndrome is unknown, current research suggests that there is an abnormality in the genes affecting the brain's metabolism of neurotransmitters such as dopamine, serotonin, and norepinephrine. Therefore, for the more severe cases, there are some drugs that are given to manipulate levels of these neurotransmitters, including clonidine (Catapres), pimozide (Orap), haloperidol (Haldol), fluphenazine (Prolixin), and sulpiride (not licensed in the U.S.). Some newer drugs have been introduced for this application, including risperidone (Risperdal), olanzapine (Zyprexa), thiothixene (Navane), and clozapine (Clozaril). Clinical trials are also underway for quetiapine (Seroquel) and ziprasidone (Zeldox). Other drugs are used or being studied for disorders that accompany Tourette's syndrome. Since many children with Tourette's also present with ADHD, a concern has arisen about use of Ritalin (methylphenidate). It was feared that the stimulant Ritalin might exacerbate the tic disorder. However, a trial has shown that Ritalin is well-tolerated and may actually reduce the tic incidence in children with Tourette's (2). Still, all these drugs have limited effects, and can produce undesired side effects, so alternatives may be sought.
Traditional Chinese medicine can not differentiate as finely among the specific manifestations of neurological disorders as is done with modern medical analysis. Tourette's syndrome definitely has features in common with both ADHD and epilepsy. Epilepsy and other convulsive disorders (including those due to infections such as encephalitis, meningitis, tetanus, etc.) are much better known to Chinese physicians than the tic disorders or ADHD, and there are many traditional formulas and modern clinical trials for treatment of the seizure disorders. Some work has been done with Chinese therapies for ADHD, but much less with Tourette's syndrome, so the Chinese approach to the other diseases must remain the primary source of suggestions for treatment of Tourette's syndrome.
The diseases that arise in childhood and involve involuntary movements are considered to be based primarily on an essence deficiency with emphasis on yin deficiency. The deficiency of essence (sometimes referred to as marrow essence) adversely affects brain development. The yin deficiency aspect reduces control over physical movements and mental focus; the body and mind become dominated by both yang that is uncontrolled by adequate yin and by wind generated by the liver that is insufficiently nourished with essential fluids. These problems may be reinforced by other disorders, such as fire syndrome of the stomach worsened by dietary factors, and fire syndrome of the heart, which might be initiated by or worsened by situations in which the child becomes frightened. Fire syndromes also include infections that cause fevers and have secondary manifestations in convulsions.
In addition to the syndromes defined here-deficiencies, heat, yang agitation, and internal wind-there also may be "phlegm mist" of the orifices, explaining some of the effects on the brain and the persistence of the disorder. Such phlegm-mist conditions may be especially diagnosed where there is an obsessive-compulsive disorder or inability to concentrate. In the analysis of another brain disorder, autism, which also mainly affects boys and is usually noted very early in childhood, a distinction is made between the relative lack of expressiveness in that brain disorder in contrast to the uncontrolled yang nature of ADHD or Tourette's. In Tourette's syndrome, the yang agitation either may be depicted as a particularly strong yang (excess fire syndrome) or as a weak yang (imbalance due to deficiency of yin), but both of these exist within the context of essence deficiency. It has recently been noted that children with Tourette's syndrome tend to be shorter than others (3), and this is consistent with the Chinese concept of essence deficiency and yin deficiency leading to developmental disorders.
From the theoretical standpoint, traditional Chinese medicine therapies would be aimed at nourishing the essence, with focus on supplementing the yin of the kidney and liver, settling yang and wind, and opening the orifices. Effectiveness of Chinese herbal medicine remains unknown. A discussion of herbs and formulations that may be relevant to treating Tourette's is presented in a separate section, below.
There is one widely circulated report on acupuncture therapy for Tourette's syndrome involving 156 patients, which was published several years ago in the English language Journal of Traditional Chinese Medicine (4). The children treated were ages 6-15, and were seen relatively soon after the diagnosis was made (within one year). The doctors divided the patients into two subtypes using Chinese medical principles:
Yangming stagnant heat (heat in the stomach channel), characterized by robust, plump physical form, ruddy complexion, high levels of tic activity (with more vigorous expression), and often accompanied by constipation. Typical yangming heat indicators were suggested to be present in the pulse (strong, rapid, slippery) and tongue appearance (red tongue, yellow coating). For treatment, the points neiting (ST-44), quchi (LI-11), pianli (LI-6), and sibai (ST-2) were needled. The first three points were needled by using thrusting and lifting technique and sibai was treated by the bird-pecking reduction method, with the needle sensation propagating downward.
Insufficient essence (essence that nourishes brain development and also affects overall physical well-being), characterized by having a weak constitution and thin physical form, pallor, milder and slower expression of tics, and frequent urination. Typical indictors of deficiency were noted for the pulse (weak and thready) and tongue appearance (swollen and pale). For treatment, the points yamen (GV-15), lianquan (CV-23), shenmen (HT-7), and fuliu (KI-7) were needled. yamen was needled deeply (1.5-2.0 cun), and the needle was withdrawn immediately when an electric shock like sensation was felt in the upper limbs. lianquan was needled by the bird pecking method until a local sensation of distention was felt. The other two points were treated with the reinforcement method of twisting and rotation of the needle.
In the group of patients evaluated and treated, 66 were of the yangming stagnant heat type and 90 of the essence deficiency type. Acupuncture was administered daily with needling time of 30 minutes, using the specified maneuvers at the beginning, and after 10, 20, and 30 minutes. A course of treatment was two weeks. These courses of therapy were continued until the person displayed a cure of the disease or ceased showing improvement. If a patient did not show improvement within three courses, it was considered a failure of treatment.
The doctors claimed a "cure" rate of 73%, meaning that the symptoms went away with the therapy and did not come back for some time (unspecified), even with drug therapy discontinued. Further, only 12 of the 156 children treated failed to show some significant improvement. The authors noted that in 84 patients who had shown EEG abnormalities at the outset, 72 of those cases became normal after the treatment course. They did not attempt to explain how a congenital condition such as this might be improved so dramatically without reverting soon after therapy had ceased, and they did not specify how many courses of therapy were needed for the successful cases. However, one course of treatment is usually defined as a period that demonstrates clear effects in some patients and three courses of treatment were considered necessary to determine if acupuncture was not working, so some effects would be expected in the range of 2-6 weeks of daily therapy, with longer duration potentially needed to get optimal results.
The lead author of the study, Wu Lianzhong, works at the acupuncture department of the No.1 Hospital affiliated with the Tianjin College of Traditional Chinese Medicine. He specializes in neurological disorders and has reported also on treatment of hysteria and stroke with acupuncture.
Although a specific set of acupuncture points was given in this article, one cannot conclude that these points are necessarily better than others than might be chosen. In a review of therapies for epilepsy (5), both herb therapies and acupuncture therapies varied considerably from one clinic to the next. Therefore, the points listed above can be used as a guide to therapy, but each patient would be treated according to their specific constitution and presentation of symptoms.
From the herbal perspective, gastrodia (tianma) is an interesting potential therapeutic agent. It is used traditionally to treat convulsions and tics in children and its active ingredients have structural similarities to dopamine, a neurotransmitter that is blocked by some of the drug therapies for Tourette's, and which might be regulated by molecules that mimic it. Gastrodia and its active constituents, including vanillin and gastrodin, have been reported helpful in treating epilepsy in China. In the historical records of use of gastrodia, it is noted that for both acute and chronic convulsive disorders (6):
Gastrodia is associated with the liver meridian, frequently used to treat the syndromes of excess heat generating wind, with the liver wind stirring up. It has been praised as "the miraculous wind-relieving drug." For instance, Gouteng Yin, a decoction first listed in the Xiaoer Yaozhen Zhijue (Key to therapeutics of Children's Diseases by Qianyi, 1119 A.D.), is a prescription of gastrodia with some wind-extinguishing and convulsion-relieving materials (uncaria, antelope horn, scorpion). For the treatment of chronic infant convulsion, it can be used with ginseng, atractylodes, and scorpion together, which will have the function on tonifying the spleen and relieving convulsion. These herbs are in Xingpi San (spleen-activating powder), used for those of weak constitution having convulsions.
Xingpi San is derived from Gouteng Yin by the addition of spleen tonifying herbs. Below is a presentation of key ingredients for five formulas mentioned in the Chinese medicine texts as suited to treating children with convulsions (7). Overlapping ingredients are noted in the table layout of the formula ingredients (the last two formulas have most of their ingredients in common and are displayed in the right hand column together; ingredients unique to the formulas are listed in the bottom row):
| Gouteng Yin | Xingpi San | Zhanghuan Wushe San | Niuhuang Zhenjing Wan & Jingfeng Baolong Wan |
| Gastrodia Scorpion Ginseng Licorice | Gastrodia Scorpion Ginseng Licorice Typhonium | Scorpion Ginseng Typhonium | Gastrodia Scorpion Licorice Typhonium |
| Antelope horn Uncaria | Acorus Lotus seed Hoelen Saussurea Atractylodes | Acorus Silkworm Zaocys Pinellia Chiang-huo Cimicifuga | Arisaema Silkworm Ox gallstone Pinellia Amber Siler Uncaria Bamboo sap Others |
The consistently used item is scorpion. This animal drug, used as a single ingredient or with only one or two other herbs by some doctors, is frequently mentioned as a useful therapy for epilepsy (5). In a recent review of clinical applications of insect drugs (8), it was said that:
Scorpion is pungent, neutral, and toxic in nature, and has the same action as centipede (i.e., tranquilizing the internal wind for arresting convulsion, removing toxic substances and hard masses so as to stop pain by clearing away obstruction from the channels and collaterals). Being good at entering the liver channel to expel wind and induce diaphoresis, scorpion has a strong power in tranquilizing the endogenous wind for arresting convulsion.
According to the famous 20th Century physician Jiao Shude (9): "Scorpion extinguishes wind and settles tetany, effectively treating frequent jerking, tremors of the arms and legs, and shaking of the head." Researchers examining the effects of scorpion toxin (which causes severe reactions when injected into the bloodstream via a bite) showed that it stimulates dopamine levels.
The use of ginseng and licorice in the formulas is common practice in pediatric medicine when children are thought to suffer from a deficiency syndrome (epilepsy, as many other brain-centered disorders, is thought to involve superficial excess that arises from internal deficiency). A condition called "chronic spleen wind" is an example of something to be treated with such spleen tonics and with wind-inhibiting agents, like scorpion (spleen wind, is a type of "fright wind," a severe disease involving tightening of muscles; in the spleen wind type, the child shows symptoms of gastric disturbance, such as vomiting or diarrhea). Typhonium, acorus, arisaema, and pinellia, which appear in three of the four formulas, are all botanically related and used for alleviating phlegm obstruction associated with convulsions, tics, and mental disorders (bamboo sap is an unrelated medicinal material with similar use). Gastrodia, silkworm, antelope horn, zaocys, and uncaria are classified as wind-inhibiting agents.
Some of the items listed in the formulas are not available for use. Scorpion is not suitable for routine use in Western practice because of its classification as toxic. Antelope horn is not used due to concerns about the endangered status of the antelope; and ox gallstone is extremely expensive (often substituted by an imitation product of ox bile salts). However, all the other ingredients listed are readily obtained and considered safe.
 Silkworm larvae on the vine. |  Harvested silkworm larvae. |  Beauveri fungus spores. |
Silkworm refers to the larvae of the silkworm that have become infiltrated by the fungus Beauveria bassiana. When collected, the entire bodies of the larvae are full of this fungus, so that it provides the active ingredients sought for medicinal use. This Chinese medicine material is similar in nature to cordyceps, which is a different larvae infiltrated by another fungus, Cordyceps sinensis; the active constituents also differ. Further, gastrodia, a commonly used herb in the anticonvulsive formulas, is a plant that grows in the presence of another fungus that turns out to be the source of its medicinal ingredients.
Beauveri is a soil fungus that affects insects. The silkworms get the fungal disease and die, becoming stiffened from the growth of the fungus. Traditionally, these are collected for use as medicine in China, but the fungus is to be avoided as much as possible in silk production. However, it is now the practice to purposefully raise silkworms where this fungus is present to get a large supply of the medicine. Little is known about the active constituents of silkworm fungus; an ingredient of the fungus, beauvericin, is known to be toxic to the insects, and it is possible that it affects their nervous system. This ingredient may have a calming effect on the human nervous system. As to its traditional use, according to the review of insect drugs:
Silkworm, salty, pungent and mild in nature, is indicated for disorders of the liver and lung channels, has the effects of tranquilizing endogenous wind and arresting convulsion, dispelling wind to remove heat, and relieve itching and pain, reducing phlegm, and resolving masses.
In the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine volume on pediatrics (11), there is a section on epilepsy. One type includes restlessness, sudden crying, and screaming with wagging tongue-a form more similar to the manifestation of some cases of Tourette's. The recommended formula is comprised of codonopsis (a replacement for ginseng in modern TCM practice), licorice, hoelen, acorus, polygala, gastrodia, zizyphus, scorpion, amber, asparagus, and cinnabar. Acorus and polygala are a common pair used for resolving phlegm mist and opening the orifices, gastrodia, silkworm, and scorpion are used to settle wind, codonopsis, licorice and hoelen tonify the spleen, while zizyphus and asparagus nourish the blood and yin to calm the heart; cinnabar and amber are counted as "heavy" natured sedatives. These herbs are of the type that might be used to treat Tourette's syndrome based on theoretical principles. Cinnabar can not be used in Western practice (due to its content of mercury), and scorpion is usually avoided (as previously mentioned), but all the other ingredients are available.
As a neurological disease, Tourette's syndrome, would seem a reasonable target for therapy by acupuncture, a treatment method that appears to have a significant influence on the brain and nervous system. In addition, certain Chinese herbs are often employed in China with claimed success in treating disorders of the brain and, in particular, those that manifest as convulsions or repeated movements. The therapies aim to calm the nervous system, but do not induce drowsiness, and may reduce the frequency and severity of the tics.
January 2004