Tourette Tics Seen as ‘Bad Habits’ in Latin America

Letting out the snorts, barks, obscene words, or other vocal or motor tics of Tourette syndrome isn’t exactly the way to make a positive impression in any society. And that includes the Central American country of Costa Rica.

Not long ago in Costa Rica, for instance, a teen received death threats from classmates because he couldn’t halt his Tourette-provoked motor tics, and another was hit and injured by a priest because his Tourette syndrome prompted him to swear obscenely in church.

Yet even with such hostile reactions to their disease-induced tics, Costa Rican Tourette patients often seem to keep their cool about them, a study published in the April Journal of the American Academy of Child and Adolescent Psychiatry suggests. How do they do it? Essentially by playing down or even denying the problem.

The study was headed by Carol Mathews, M.D., a psychiatrist at the University of California at San Francisco, and involved the collaboration of other researchers, including Luis Diego Herrera Amighetti, M.D., of the University of Costa Rica School of Medicine at San José.

Mathews and her colleagues focused on 85 Costa Rican subjects aged 5 to 29 years who had been diagnosed with Tourette syndrome as part of a larger study they were doing on the genetics of Tourette. They found that the disease profiles of their subjects were similar to those of Tourette patients in other countries. For instance, the male-female ratio for Tourette is 5 to 1, the average age of onset was about 6 years, and about one-fifth of patients tended to swear because of their disease. In contrast, their subjects seemed to have tics that were at least as bad as those of patients in other countries—perhaps worse.

Yet, despite the severity of their tics, most of the subjects did not consider them to be any big deal, Mathews and her team discovered. Sixty percent denied any impairment whatsoever; 13 percent admitted to only infrequent problems, such as occasional mild teasing by peers or scolding by parents. Or as Mathews and her team write, “Symptoms that would typically be reported as causing significant impairment in the United States were often reported as having little or no impact. . . .”

For instance, one patient with severe Tourette tics reported being expelled from school because of them. Yet he did not view expulsion as a major problem. As he saw it, school attendance beyond a certain age in his community was not regarded as essential in the first place, so having to leave school a few years earlier than planned was only a minor inconvenience.

One reason Tourette patients in Costa Rica do not view tics as problematic, Mathews and her coworkers determined, is because Costa Ricans tend to view tics as “mañas,” that is, as bad habits. Or as Mathews told Psychiatric News, “Tics are seen as being primarily behavioral in nature, rather than having a biological basis. This is true throughout much of Latin America, as far as we can tell.”

There is one positive side to the belief that tics are bad habits, Mathews and her colleagues pointed out—it spares patients the stigma of having a neuropsychiatric illness. “In Costa Rica,” they wrote, “symptoms that are thought to be psychogenic in nature seem in general to carry less stigma than those thought to be neuropsychiatric, such as autism, perhaps because they are considered to be transient and easily treatable.”

There is another possibly positive side as well, the authors inferred: When tics are viewed as bad habits, patients are sometimes offered psychotherapy or behavioral modification to get rid of them.

Nonetheless, Mathews told Psychiatric News, “These treatments are somewhat controversial” and the belief that tics are bad habits is definitely negative when it leads to psychological or physical abuse of Tourette patients, as the two anecdotes above illustrate. But perhaps the most negative fallout from the belief that tics are bad habits is that patients do not seek medical treatment that might help them. Mathews explained to Psychiatric News, “There are several different forms of treatment available, most of which are neuroleptics. Haloperidol and pimozide have been used for years, and risperidol is now in common use; the alpha adrenergic agents clonidine and guanfacine are also commonly used. These agents do not work for everyone, but can be very effective for some. For most people they reduce the severity of the tics, but do not eliminate them. Of course, all medications have side effects, which must be balanced with the benefits gained by using them.”

An abstract of the study, “Cultural Influences on Diagnoses and Perception of Tourette Syndrome in Costa Rica,” is posted on the Web at www.jaacap.com under “Contents” and then “April 2001.” ▪