Chinese-Western Comprehensive Medicine Viewpoint of Tourette Syndrome

指導老師：張東迪老師
姓名：史諾亞
班級：後中三甲
學號：108030953
Preface

Background

The focus of this paper is to summarize and compare the difference between how
western and Chinese medicine view Tourette Syndrome. Tourette Syndrome is a
neurological condition usually beginning in childhood that causes involuntary movements
known as “tics”. These tics can be categorized into two groups: vocal and motor tics. For
instance, a vocal tic could cause a person uncontrollably scream like a duck loudly, while a
motor tic could cause one to uncontrollably scratch their head in a particular way. Since
there is no current consensus of a medication that is most effective for treating Tourette
Syndrome, it is therefore beneficial to determine and compare different treatment methods
and established models of the pathological mechanism of Tourette Syndrome, in order to
come to a better understanding of our current knowledge. Besides western medicine, current
research in the realm of Traditional Chinese Medicine must also be considered in this
review of medical studies in order to obtain a truly comprehensive model.

Motivation

My motivation to research Tourette Syndrome is mainly due to the fact that I was
diagnosed with a mild case of Tourette Syndrome as a child. As my case was mild, my tics
were not very apparent, and now that I am an adult I find that I am mostly in complete
control of all tics, except for a small few. However, as a child, my tics were quite
troublesome around the ages of 11-14, as I was beginning to enter puberty. At the time my
parents took me to a neurological doctor who prescribed me with Topiramate, a drug
usually used to treat epilepsy, as well as migraine headaches. At the time, the topiramate
seemingly helped with keeping tics under control, and by the time I was 15 I had stopped
taking the drug. Therefore, I am curious to learn about other current treatment models for
Tourettes. Chinese medicine was not an option when I was a child, as my parents didn’t
have access to it, nor did they understand it. The goal of this paper is to organize a better
understanding of how one can treat Tourettes, and I hope that others besides myself could
find use in this knowledge to develop their treatment plans and offer advice and help to
Tourettes patients in need.

Research Methods

A valuable search tool that was implemented for this research was Google Scholar.
Google Scholar can help one find a myriad of papers relating to Tourette Syndrome
treatment as well as theoretical studies. Though Google Scholar also has a Chinese
language search function, I chose to look for research studies conducted in English. This is
because I was curious what studies related to Chinese medicine had been done or translated
into English for the western world, as there aren’t as many Chinese medicine studies
available to English speakers. I wanted to know what people in the English speaking world
who practice Chinese medicine know on this subject. Many research articles and papers on
Google Scholar are free to use, but for the ones that are not, I used the China Medical
University library website to log in and download papers through my school account.

Research Contents and Results

1. Advances in understanding and treatment of Tourette syndrome [1]

 Tourette syndrome is a hereditary, childhood-onset neurodevelopmental disorder that was

first clearly described in 1885.
 Tourette syndrome is clinically characterized by sudden, rapid, recurrent, nonrhythmic
movements (motor tics) or sounds (vocal or phonic tics), which are often accompanied by
psychiatric comorbidities.
 The genetic basis of Tourette syndrome is not well-elucidated and, except for rare cases,
the underlying mutations remain elusive.
 The pathophysiology of Tourette syndrome remains unclear, although increasing
evidence suggests a role for alterations in basal ganglia function.
 Pharmacological treatments are available, but are often ineffective; behavioral and
surgical therapies are undergoing development and have shown promising results.
 Future research into Tourette syndrome should focus on investigating the
pathophysiology of disease, development of suitable animal models and discovery of safe
and effective therapies.

Table 1 | Differential diagnosis of tic disorders

DSM IV‐TR* classification of tic disorders
Diagnostic
features Chronic motor Tic disorder not
Tourette syndrome Transient tic disorder
or vocal tic disorder otherwise specified
Multiple motor and at least one vocal (not Single or multiple; can be either motor
Tic type Motor and/or vocal Motor and/or vocal
necessarily concurrent) or vocal, but not both
Onset Before 18 years of age Before 18 years of age Before 18 years of age After 18 years of age
<1 year from onset with <1 year from onset, but not
Duration >1 year from onset >1 year from onset
complete resolution resolved
*All disorder names and definitions are derived from the Diagnostic and Statistical Manual of Mental Disorders, edition IV–Text Revision (DSM IV-TR). 14

Table 2 | Pharmacological therapies for Tourette syndrome

Agent Mode of action Indication
Guanfacine and clonidine α-Adrenergic agonists
Typical antipsychotic drugs Dopamine D2 receptor
(haloperidol, pimozide and
antagonists
fluphenazine)
Atypical antipsychotic drugs Dopamine D2 receptor
(risperidone and ziprasidone) antagonists and 5-HT2
serotonin receptor
Usage Adverse effects
First-line treatment for moderate tics Sedation, dizziness, fatigue,
Tics (moderate),
Guanfacine is a second-line treatment hypotension, irritability, rebound
ADHD
for ADHD hypertension
Sedation, weight gain, muscle
Second-line treatment in patients who
stiffness, dystonia, tremor, akathisia,
Tics (moderate to do not respond to α-adrenergic agonists
parkinsonism, cognitive impairment,
severe) Haloperidol and pimozide are both
school phobia, cardiac conduction
FDA-approved for Tourette syndrome
problems (most likely with pimozide)
Tics (moderate to Second-line treatment in patients who Sedation, weight gain, akathisia,
severe) do not respond to α-adrenergic agonists; school phobia
preferred over typical antipsychotics
owing to a reduced risk of neurological

Atypical antipsychotic drugs
(aripiprazole)
Anticonvulsant drugs
(topiramate)
Tetrabenazine
Botulinium toxin
Atomoxetine
Benzodiazepines (clonazepam)
Stimulant drugs (methylphenidate
and dextroamphetamine)
Antidepressant agents (fluoxetine,
sertraline, citalopram,
escitalopram, fluvoxamine and
paroxetine)
antagonists adverse effects
Dopamine D2 receptor
Tics (moderate to Third-line treatment
and 5-HT2 serotonin Sedation, akathisia, weight gain
severe) Not well-studied in Tourette syndrome
receptor partial agonists
Reduced propensity for adverse effects
Cognitive and/or language problems,
NR Tics (moderate) Not well-studied, but available data are
sedation
promising
Dopamine-depleting Tics (moderate to Third-line treatment Sedation, depression parkinsonism and
agent severe) Not well studied in Tourette syndrome akathisia
Tics (disabling and/or Weakness, motor restlessness, blurry
Blocks acetylcholine
bothersome motor or vision, hypophonia, hoarseness,
release at neuromuscular Localized injections into muscles
vocal tics, especially of dysphagia
junctions
the eyelids and neck) and aspiration
Norepinephrine reuptake Sedation, irritability, and abdominal
Tics and ADHD Third-line treatment for ADHD
inhibitors discomfort
GABAA receptor Fatigue, irritability, dizziness; abrupt
Useful for anxiety and can help to treat
Anxiety withdrawal can lead to increased
modulators tics in patients with coexisting anxiety
anxiety
Dopamine and Effective for ADHD Methylphenidate
Decreased appetite, insomnia,
norepinephrine reuptake ADHD has been studied in combination with
irritability and increased tics
inhibitors either clonidine or guanfacine
First-line treatment; only approved for
Selective serotonin OCD, anxiety and Behavioral activation, insomnia and
use in children with depression
reuptake inhibitors depression risk of interactions with other drugs
Varying levels of positive effects

2. Relaxation Therapy in Tourette Syndrome: A Pilot Study [2]

“To evaluate the feasibility and efficacy of behavioral relaxation therapy as treatment for
Tourette syndrome, 23 patients were recruited from a university-based pediatric Tourette
syndrome referral clinic. Individuals were randomized and stratified according to initial tic
severity and the presence of attention-deficit hyperactivity disorder into either relaxation therapy
or a minimal therapy (control) group. Sixteen patients, mean age 11.8 years (S.D. 2.8 years),
completed the 3-month study, which included weekly, hour-long, individual training sessions for
6 weeks.”
 3. A Chinese Herbal Formulation, Xiao- Er-An-Shen Decoction, Attenuates
Tourette Syndrome, Possibly by Reversing Abnormal Changes in
Neurotransmitter Levels and Enhancing Antioxidant Status in Mouse Brain [3]

“Within the framework of TCM theory, Tourette Syndrome is considered to be closely

associated with a syndrome arising from the propulsion of Liver Wind and an increase in phlegm
formation, which are caused by excessive Liver Yang and Spleen deficiency, respectively (Lee,
2017). The agitated Liver Wind and increased phlegm formation by the Spleen act together to
obstruct the transportation of Qi and thus harass Shen (which is closely related to brain function),
resulting in the manifestation of symptoms of head jerking, shoulder shrugging, blinking eyes,
winking eyebrows, pointing lips, yelling, kicking legs, irritability, and so on.”

“Xiao- Er-An-Shen Decoction (XEASD), a Chinese herbal formulation consisting of nine

individual herbs—namely, Polygalae Radix (the root of Polygala tenuifolia), Astragali Radix
(the root of Astragalus membranaceus), Acori tatarinowii Rhizoma (rhizome of Acorus
tatarinowii Schott), Citri reticulatae pericarpium (Citrus reticulata Blanco), Alpiniae oxyphyllae
Fructus (fruits of A. oxyphyllae), Aurantii Fructus (fruits of Citrus aurantium L)., Pinelliae
Rhizoma (rhizome of Pinellia ternata (Thunb)., Notopterygii Rhizoma et Radix (radix of
Notopterygium incisum Ting ex H. T. Chang), and Glycyrrhizae Radix et Rhizoma (radix and
rhizome of Glycyrrhiza uralensis Fisch) (Li et al., 2018)—has been clinically prescribed for the
treatment of TS and other excitatory movement disorders in children for more than 20 years in
mainland China. It is effectively used to provide nutrients to the brain and tranquillize and dispel
phlegm to reduce fright in the practice of traditional Chinese medicine (TCM).”

“The biochemical mechanism(s) underlying the beneficial effects of XEASD in TS remained

largely unknown. In the present study, we investigated the effects of XEASD in a mouse model
of TS induced by 3,3’-iminodipropionitrile (IDPN) by assessing the grades of stereotypy and
locomotor activities. The levels of several neurotransmitters as well as antioxidant status in brain
tissues were also measured to explore the possible biochemical mechanism(s) underlying the
beneficial effect of XEASD in TS.”

FIGURE 3 | Effects of XEASD treatment on glutamate and aspartate levels in brain tissue of IDPN-induced TS mice. (A) Biochemical assay of glutamate levels was
performed as described in Materials and Methods. (B) Levels of aspartate in brain tissues were measured as described in Materials and Methods. Control 1 represents
normal control mice; control 2 represents IDPN-challenged control mice. Data are expressed as the percentage of non-challenged control 1 values. *P < 0.05,
significantly different from the control 1; #P < 0.05, significantly different from the IDPN control 2. The value of the glutamate levels of control 1 (mean ± S.E.M.)
and aspartate level of control 1 (mean ± S.E.M.) were 2953 ± 440 (nmol/mg protein) and 0.73 ± 0.06 (nmol/mg protein), respectively.

4. Clinical Study on Treatment of Tourette's Syndrome with Acupuncture-

Chinese Herbs Combination [4]

“As one of the intractable children's diseases, Tourette's syndrome is a kind of chronic
mental disease characterized by multiple convulsions with involuntary vocalization.We
have treated it with the combination of acupuncture and Chinese.”
Treatment Methods

1. Group A:

(1) Acupuncture

Major acupoints: Baihui (GV 20), Wudaozhenchanqu

(Chorea tremor area), Fengchi (GB 20), Hegu (LI 4) and Neiguan (PC 6).
Adjunct points: For frequent wink, add Yintang (Ex-HN 3) and Yaiyang (Ex-HN 5); for shoulder
shrugging, add Yingxiang (LI 20); for mouth convulsion, add Dicang (ST 4) and Jiache (ST 6);
for abnormal vocalization, add Lianquan (CV 23); for poor sleep, add Shenmen (HT 7).

Methods: After routine sterilization, stainless filifonn needles of 40 mm were used to puncture
Baihui (GV 20) and Wudaozhenchanqu fast and subcutaneously to reach subgaleal region, and
then followed by 2-ruinute rapid twirling manipulation 200 times per ruinutes. The rest points
were punctnred perpendicularly with even manipulations, once every ten minutes during the 30
minutes needle retaining. The cases were treated once daily and one course contains 20 times.

(2) Chinese herbs

Modified Tranquilizing Liver-wind Decoction was used for different conditions.

2. Group B

“Take holoperidol orally. For 4-year-old children, the initial dose was 0.5mg/day, for 5-year-
old children, the initial dose was lmg/day, twice one day. Later the dose can be gradually
increased according to the condition, the total dose was supposed to be 1.5 rag-8 rag. They took
artane of the same dose to decrease the side effects.”

“Combination of acupuncture and Chinese herbs had better treatment effect than holoperidol,
and it doesn't have the side effects as holoperidol. Furthermore, it has practical value with its
easy operation and less cost. This therapy can broaden the treatment means of Tourette's
syndrome and perfect its treatment mechanism from the clinical view, and thus can make the
treatment more systematic and integrative.”
 5. Traditional Chinese Medicine Ningdong Granule: the Beneficial Effects in
Tourette’s Disorder [5]

“This 8-week, randomized, placebo- controlled, double-blind clinical study investigated the
short-term effectiveness and safety of the traditional Chinese medicine, Ningdong (ND) granule
in pediatric subjects (aged 7 – 18 years) with Tourette’s disorder (TD). Subjects received either 1
g/kg per day ND granule (n = 33) or placebo (n = 31) and tics were measured at baseline and
after 4 and 8 weeks of treatment. Body mass index, electrocardiogram and laboratory measures
were recorded at baseline and at week 8. After 8 weeks of treatment with ND granule, subjects
exhibited a 41.39% reduction in the total tic score while the placebo group showed a 10.79%
decrease. Regarding side-effects, two subjects reported loss of appetite and one experienced
constipation in the ND granule group. There were no significant changes in laboratory and
physical examinations. These results suggest that ND granule is both effective and safe, and may
be a good candidate for the treatment of patients with TD.”

Analysis and Discussion

1. Advances in understanding and treatment of Tourette syndrome [1]

This is an especially important review study that can help one to come up with a
clearer picture of the current state of Tourette Syndrome research. It is especially beneficial
for those looking to have an overview of the different theories for the mechanism of
Tourette’s, treatment protocols and what to expect when treating Tourette’s patients, as well
as describing the differential diagnosis of Tourette Syndrome. Perhaps the most important
contribution from this study is a comprehensive table describing in detail the currently
accepted treatment methods of Tourette’s, as well as descriptions of the different
pathological mechanisms that these treatments intend to correct. The review suggests that
Tourette Syndrome may have to do with alterations in basal-ganglia function within
different pathways in the body, including the dopaminergic nigrostriatal pathway, which
could possibly explain the reason why dopamine D2 receptor antagonists, as well as
dopamine depleting agents might have a roll in helping alleviate Tourette Syndrome tic
symptoms. Interestingly, the article also mentions how drugs that increase dopamine
function in the brain such as levodopa could also increase the frequency of tics. This
personally makes me wonder what this could mean for Parkinson’s patients with Tourette
Syndrome considering levodopa treatment. Table 2 above shows the many different
pharmaceutical treatments of Tourette’s used today, and it is clear that while these drugs
have a positive effect on Tourette’s, they have many adverse effects as well, which is why it
will be important to compare this current western medical research with other types of
alternative therapy, including the role of Chinese medicine in treatment.

2. Relaxation Therapy in Tourette Syndrome: A Pilot Study [2]

This is a study of “relaxation therapy”, a method of training the body and mind to
relax and become more aware of tension through muscle relaxation and breathing methods,
as well as potentially guided meditation. In this particular study, many different relaxation
methods were used, such as diaphragmatic breathing, awareness training, and
electromyographic feedback. There was also a type of body behaviour training that helped
train the body to become more relaxed and aware by using 10 different postures. Patients
were expected to invest about 25 minutes daily to work on these techniques. This makes me
wonder, would east Asian traditional methods such as yoga, meditation, and qigong/taichi
also be useful for this type of patient? I believe that could be a potential focus of future
research concerning how relaxation and stress reduction could help Tourette Syndrome
patients, especially those with more severe presentations.
16 patients participated in this study, and five different standardizations for tic
severity were used to measure. In the group that partook in the relaxation therapy, most
patients had improvement over the first six weeks, even though these improvements were
small. However, the improvement was still greater than the control group, which focused
only did a minimal version of relaxation therapy. The most interesting note in my opinion,
is that after three months there was a plateau effect, and the patients began to see less
improvement from the relaxation methods. There were different explanations for this effect.
For instance, it was suggested that the patients might have been less compliant with
following the relaxation protocol as time went on. Another explanation was that tics “wax
and wane” like the moon, and it is hard to predict when they will appear. Even though this
is an older study, it is especially important as a foundation for any future studies to be done
concerning the role of stress reduction and relaxation in healing illness. Hopefully more
studies can be done to help those with Tourette’s syndrome become more mindful and
relaxed in their body, so they won’t be as dependent on pharmaceutical drugs that can cause
serious side effects in certain situations.
 3. A Chinese Herbal Formulation, Xiao- Er-An-Shen Decoction, Attenuates
Tourette Syndrome, Possibly by Reversing Abnormal Changes in
Neurotransmitter Levels and Enhancing Antioxidant Status in Mouse Brain
[3]

This particular study focused on the formula Xiao-Er-An-Shen Decoction (XEAS)

as a potential treatment for Tourette Syndrome. A unique aspect of this study is that it not
only explains the Chinese medicine mechanism of the formula, but also describes a
potential mechanism that can be explained by modern medical theory, which ended up
being the main focus of the study. The explanation for Tourette’s, according to the
researchers, is related to a rising of liver wind and an increase of phlegm formation, which
itself is caused by excessive liver yang and a spleen deficiency. This inhibits the proper
movement of qi, causing the shen to be harassed, which would cause the typical motor and
vocal tic presentation of these patients (the shen is related to brain function). As the
researchers had recently discovered that XEAS decoction had an effect potentially stronger
than haloperidol for Tourette’s treatment, they decided to learn more about the biochemical
mechanism for XEAS decoction, by measuring its effect on mice. A significant discovery
from this study was that XEAS decoction significantly reduced the amount of GABA in the
mouse brain, as opposed to the control group. This is especially important, as it has been
discovered that Tourette’s patients usually have an increase of GABA in the brain. This
shows that this formula may have potential to help this particular type of Tourette’s patient.
However, I personally wonder if this formula would still have a positive effect for a
Tourette’s patient who doesn’t exhibit the pattern of liver wind rising/phlegm. In Chinese
medicine there are still many different patterns that could present in this type of patient.
Therefore, more research and studies are necessary, especially with humans, as opposed to
mice.

4. Clinical Study on Treatment of Tourette's Syndrome with Acupuncture-

Chinese Herbs Combination [4]

The purpose of this study was to research how a combination of acupuncture and
herbal medicine compared to haloperidol for the treatment of Tourette Syndrome. The
acupuncture points used were GV20, GB20, LI4, PC6. Other points were also added
depending on symptoms. For instance, HT7 would be added if the patient has poor sleep.
The herbal medicine used was called “Modified Tranquilizing Liver-Wind Decoction”. The
“control” group took haloperidol daily, with dose changing dependent on age. Artane was
also taken to decrease side effects. According to the study, the Chinese herbs and
acupuncture group were able to treat Tourette’s, and didn’t have the same side effects that
haloperidol would.
I added this study to this review paper for one reason: because it is terrible. This is
without a doubt one of the worst research studies I have ever had the pleasure of reading,
and it shows the danger of blindly trusting whatever scientists produce. Therefore, I added
this study here in order to show the differences between good and bad research. Why is it so
bad? First of all, this study doesn’t even define what Tourette’s syndrome is. Which
framework are they using to classify severity of Tourette’s symptoms? If you don’t follow a
framework of any kind, then how can you know that symptoms were decreased? This study
uses no framework, therefore they just expect you to believe that symptoms were decreased,
without sharing any specific details to compare before and after. Next, what is this formula
“Modified Tranquilizing Liver-Wind Decoction”? Is there are a Chinese name for it? What
are the ingredients? Why did they determine to use this formula? If you don’t take the time
to explain the details of this formula, then it suddenly becomes dangerous, as the reader has
no idea the specifics of what constitutes it. I was astounded when I read this article, as I
would have expected a TCM research university in China to not have allowed this low
standard to be published, as it is unhelpful for the future of Chinese medicine. This is just
another reason why CMU and Taiwan are better pioneers for this type of research.

5. Traditional Chinese Medicine Ningdong Granule: the Beneficial Effects in

Tourette’s Disorder [5]

This study was to test a formula known as “Ningdong Granule” with an eight week
study, to test its efficacy for Tourette Syndrome. This was a placebo controlled double-blind
trial, with a control group that took plain starch, as opposed to the actual formula. 68
Tourette’s patients aged 7-18 years old participated in this trial. This particular study is
much more professional than the above, and explains in detail how the “Ningdong Granule”
was procured, as well as the herbal contents and processing methods used to formulate it.

“Water-extraction and alcohol-precipitation was used to produce Ningdong granule

(lot No. 20051017) by the Pharmaceutical Department of the Provincial Hospital Affiliated
to Shandong University.21 The eight main components of ND granule were:
(i) Rhizoma Gastrodiae, Gastrodia elata B1 (rhizome); (ii) Codonopsis pilosula,
Codonopsis pilosula (Franch) Nannf. (root); (iii) dwarf lilyturf tuber, Ophiopogon
japonicus (L.f.) Ker-Gawl. (root tuber); (iv) White Peony Alba, Paeonia lactiflora Pall.
(root); (v) keel, Rhinocerotidae, Hipparion spp. Cervidae, Bovidae and Proboscidae (fossil
of bone or tooth); (vi) oyster shell, Ostrea gigas Thunb. (shell); (vii) Pheretima asiatica,
Pheretima aspergillum (whole polypide); and (viii) liquorice, Glycyrrhiza uralensis Fisch.
(root). The proportions of these eight components in ND granule were 2:3:2:4:5:5:2:2,
respectively. Each 1 g of ND granule was produced from 2.35 g of dry crude components.
The proportions of the eight components were measured by the Pharmacognostic
Department of the Chinese Medicine Academy in Shandong Province according to the
criteria of the Pharmacopoeia of China”

The result of this study was that a significantly greater number of tic symptoms were
reduced in the group receiving “Ningdong Granule”, as opposed to the group receiving the
starch. The explanation from the researchers is that this particular formula can help treat yin
deficiency in the heart and liver to relieve spasms and convulsions. Therefore, I wonder if
this formula might be better for motor tics as opposed to vocal tics. Hopefully more
research can be conducted on this topic in the future.

Conclusion
 Many conclusions may be drawn from this review of Tourette Syndrome research.
Perhaps the most important insight is the fact that there are many different pathological
mechanisms that may cause this condition, and we still don’t have a clear picture of exactly
what is happening to the brain to cause Tourette’s. Because of this however, there are
numerous treatment methods available with proven efficacy, and more and more research is
being done. Besides western medicine, Chinese medicine is also a promising treatment
protocol. Chinese medicine can prevent some of the typical side-effects related to Tourette’s
treatment, and we are still just at the beginning of our understanding of how it can help.
There is so much more research to be done, and as that research progresses, I imagine that
our understanding and ability to treat this illness will increase tenfold. Also, relaxation
therapy may play an important role in treatment, which could help Tourette’s patients
become less dependent on pharmaceuticals.

Gained Knowledge

I learned a great deal about Tourette Syndrome from compiling this review. As I
also have Tourette Syndrome, I was aware of much of this information, but I still learned a
lot. For instance, now I have a greater understanding and appreciation for the role that
Chinese medicine can play in treatment, and it is especially interesting to relate this
knowledge to my current studies at school. In the future I would like to take the time to
compile and compare more research based on the pattern diagnosis on Chinese medicine, as
there are many different ways to analyze this syndrome. I also see now that there are many
different pharmaceuticals that can be used to treat it, besides the anticonvulsant drug
Topamax that I took as a child. This type of review compilation assignment makes me even
more excited to continue my studies of Chinese and Western medicine, as well as hopefully
participate in the research and dialogue of Tourette Syndrome treatment in the future.

References

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1998, Pages 136-142, ISSN 0887-8994, https://doi.org/10.1016/S0887-8994(97)00200-2.

3. Chen Jihang, Leong Pou Kuan, Leung Hoi Yan, Chan Wing Man, Li Zhonggui, Qiu Jingyu,
Ko Kam Ming, Chen Jianping, A Chinese Herbal Formulation, Xiao-Er-An-Shen Decoction,
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