CASE STUDY |
(The client's name has been changed to honor the family's request for confidentiality. All other details of the case are factual.)
Gretchen
Miller
A 21 Year-old
Woman with Tourette's Syndrome
Gretchen, a twenty-one year old woman, had been referred to HANDLE by her sister, who had learned of the Institute's services through a speech and language therapist in Oregon. Initially, Gretchen decided not to follow up on this referral, since she had been coping well with her Tourette's Syndrome most of her life. (She was only formally diagnosed with Tourette's at the age of twenty.) In fact, Gretchen waited until the pressure and stress of working two jobs intensified her outward manifestations of Tourette's. She felt she had to do something. Within a week of this decision she had scheduled and made plans to fly from the mid-west to Seattle for her HANDLE evaluation.
During the evaluation Gretchen relayed that she felt her head tics were disrupting her social life. Not, as she explained, that her friends felt differently about her, but that it interfered with her concentration and that she had a hard time organizing her thoughts. She was quite concerned about planning her future. One area of grave concern was making career choices. For example, she wanted to become a cosmetologist and was concerned that her hands' twitching would interfere. She felt for the first time the effects of her condition on her future life options.
Gretchen's mother reported that heavy bleeding during the pregnancy might have been a miscarried twin. Gretchen was born prematurely, weighing 4lb 12oz. She remained in the hospital for two weeks. She was not a cuddly child and threw impressive temper tantrums. Her developmental milestones (crawling, walking, etc.) were normal. As a child she began to exhibit tics gradually. At first her fingers would stiffen up while playing piano. She would try to play as fast as she could to finish the piece before her fingers stiffened and she had to stop to stretch them. Also when playing she had a hard time coordinating her left and right hands, and she could not get them to perform different movements, one from the other. She also found it difficult to control her rhythm and keep to the beat.
As a child Gretchen remembered hating wearing her Sunday shoes because she could not move her toes and her stockings would get bunched up in the shoes. In third grade face and neck tics began to bother her, as her jaw would involuntarily jerk down to her chest, or she would squeeze her mouth or suck her lip up to her nose. In high school the tics in her hands and wrists became very prevalent. Her mother was so concerned that Gretchen would break her wrists that a doctor was consulted who reluctantly put on casts saying: if we stop the movement here it will go somewhere else. The casts were short lived.
Gretchen was an awkward child and very accident prone. Not a meal went by when she did not knock over her beverage (her mother quickly learned to give her only water). In one clumsy instance, Gretchen burned her eye lid with a curling iron.
Gretchen experienced some ear infections, but more often she just had ear aches. She still gets car sick on long trips. She always avoided amusement park loop rides.
It is very hard for Gretchen to fall asleep. She always waits until she is completely exhausted before going to bed. If she is not completely exhausted she will wake up again. Her mother described her as "fidgety" while trying to fall asleep, but, that once asleep, the fidgeting stopped.
During the evaluation Gretchen completed every task successfully. Yet she clearly had to use all of her energy and control for some of them. When specific systems were being taxed, her involuntary tics reached a frequency of seven per minute. The involuntary tics that she exhibited included head shaking, mouth opening, eye and cheek twitching, hand stretching, and vocal tics and grunts.
In her pencil grasp she avoided contact between the tip of her thumb and the writing implement. She occasionally picked up the pencil with her left hand and transferred it to her right hand before writing. She said that she preferred to write in cursive. When she was asked to write with her eyes closed she said she felt like she was out of control and as if she were writing unusually large.
When she tried to tap individual fingers without moving the fingers on her opposite hand, she had a very hard time. She admitted as a child when she wrote reports, the corners of her pages always got crumpled by the extraneous movements of her non-writing hand, and she erased so often that she wore holes in the paper.
By far the most challenging subtests for Gretchen were those of visual functions. At this time her tics were most frequent, and of the greatest variety within a very short time period. When trying to track a pencil point her eyes blinked, and her face twitched and grimaced constantly. She said that her eyes felt "buggy" when she tried to maintain focus on a moving object. Even a stationary object proved to be difficult, as a single bead suddenly became two in her sight, while the string through the bead disappeared altogether. When asked, Gretchen supported the clinician's observation that she was hypersensitive to light. She said that she prefers indirect lighting and overcast skies, and that sunlight hurt her eyes. She also reported that her eyes hold an after-image for a while after completing one visual activity, and that this obviously interferes with the next.
Gretchen demonstrated and reported numerous indicators of hypersensitivity to touch: her mother's describing her as not being cuddly, her hating stiff shoes with bunched stockings, and her unusual pencil grasp were some of the indicators.
That Gretchen had numerous ear aches, gets car sick, hates spinning rides, as well as her particular problematic sleep patterns, all indicate that her vestibular system is weak. It is not able to support the higher systems, especially visual tracking and steady muscle tone.
For the visual system to function correctly it relies upon many factors including: tracking and muscle tone for teaming (both reliant on the vestibular system), ability to work separately from her head and neck (reliant on reflex inhibition) and ability of the pupils to constrict and dilate according to the light conditions of the target and the surrounding (a sphincter muscle issue, as well as one of irregular binocular control). Each of these systems were weak or irregular, not just in relation to her eyes. Visual functions, clearly, were the most stressed functions for Gretchen for these reasons.
Gretchen demonstrated and reported numerous areas of immature reflex inhibition, such as crumpling the corners of her papers when she wrote, being unable to have each hand move through independent finger patterns when playing piano, and being unsuccessful in keeping unwanted finger movements quiet during the finger tapping subtest.
Gretchen also presented with unusual rhythmic patterns, and recalls having had difficulty with rhythm throughout her life.
Thus, Gretchen's profile is completely harmonious with the major issues HANDLE identifies with Tourette's Syndrome: (1) light sensitivity, (2) immaturity in reflex inhibition and differentiation of movement/response, and (3) irregular rhythm. Of course when light is too bright for one's eyes, the individual will squint and their eyes will twitch momentarily. Imagine that most light is too bright, and that once a movement begins in one area, the nervous system is not mature enough to keep that movement from traveling to other nerves and muscle groups. You would then experience head tics, and vocal tics, and arm tics, as Gretchen does. With the irregularities in muscle tone and rhythm, these tics take on a life of their own. However, since the tics require the neurotransmitter dopamine to support their movement, and the movement stimulates the brain to produce more dopamine, thus creating a viscous cycle. First the eyes twitch in reaction to being over stressed by the light. The twitch is in reaction to the stress that has been placed on the cranial nerve which serves the eye. This nerve is called the trigeminal nerve. Branches (or roots) of the trigeminal nerve extend into the eye, forehead, nose, cheeks, mouth, tongue, and jaws. For Gretchen, the stress to the trigeminal nerve originated in her eyes but, as she experienced in third grade, it was first through her mouth and jaw that she relieved the stress by involuntarily movements of her jaw.
Gretchen was given a series of individualized exercises that were designed to strengthen her weakened systems, especially her visual systems and her reflex inhibition. She was given customized activities to strengthen her vestibular system, since it is needed to support the visual system and muscle tone. She also was given activities to increase her sense of rhythm and her ability to perform tasks of interhemispheric integration, since differentiation without reintegration is not beneficial. The exact activities and means of implementation for Gretchen would not be applicable to everyone with Tourette's Syndrome, since Gretchen presented with additional and individual deficits and strengths.
In addition to specific exercises, Gretchen received recommendations on compensatory techniques to employ while the exercises were strengthening her weak systems. She was also given some broad nutritional recommendations to support the overall program.
Gretchen began her exercises right away. When she came back for her exercise check two weeks later, she could already feel a difference. Her tics were already reduced to a maximum of two tics per minute. She said it was hard at first to get herself to do the exercises every day for the twenty minutes they required. It was her amazement at how much the HANDLE clinicians had learned by observing her that gave her the ability to stick with the program, feeling that if the diagnostic work had been so expansive and specific, then the recommendations must also be right for her. Before she reached a feeling that she had in fact achieved her goal of being tic-free, Gretchen had performed the exercises for twelve weeks. Her roommates in the apartment she shared, helped her with some of them, and supported her trough the process, giving her feedback on her improvement. She said within that time there were very frustrating moments when her tics would return, and she would call HANDLE for more suggestions. Each time the HANDLE clinicians had been able to identify the factor causing the return of the tics (which never returned to their former intensity, even during these instances). Usually the offending element was something simple like the weather suddenly becoming very sunny. Gretchen was amazed at how simple and easy the answers were and how tangible and easy the suggestions were: were sunglasses, chew gum, get photogrey lenses, drink more water through the crazy straw. She was equally amazed at what a difference she felt in just a few days after following the new suggestions.
Not quite a year after her evaluation, Gretchen sent HANDLE a tape describing her experience and how her life was changed by the HANDLE program. She said that she is very happy where she is now, she has learned to identify momentary offenders herself and knows what to do when a few tics return. She said: "when I take care of myself, the tics are completely gone." When she was diagnosed with Tourette's she felt it was like a revelation to know that there was something behind her fidgeting and extraneous movements.
Her mother had always prayed faithfully for healing but Gretchen did not believe that it would ever happen. "Now" Gretchen said, " I can sit still and know that I am still and not move, and I feel at peace. I am thankful to God. My mother's prayer was answered through HANDLE. My life will never be the same."
