Yale University Bullettin 2011- Carlotta Zanaboni

In the Loop 2011 VOLUME 9

The Yale Child Study Center Tourette Syndrome and

Obsessive-Compulsive Disorder Research Team Newsletter


This issue of In the Loop features studies to confirm and expand treatment options for children with Obsessive Compulsive Disorder (OCD) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep (PANDAS) (Williams, Swedo interview), others that provide practical guidance for parents dealing with children with OCD (Lebowitz), and an exciting new look at the relationship between OCD and attachment (Gordon). Next, we consider the lifetime arc of Tourette Syndrome (TS) symptomatology with a look at tic severity issues in early childhood that may be predictive of future outcome (Bloch), and further explore the relationship between TS and ADHD (Sukhodolsky). We also present novel and engaging treatment possibilities for TS (Hampson, Kobets) as well as a fascinating study that is underway to assess the creativity of children and adolescents with TS (Zanaboni).

TS/OCD Research Highlights - 2011


Did you know Tourette syndrome has a link with creativity?


Well, it seems to be affirmative! At least if you consider Mozart, Molière and Johnson as artists! They actually had Tourette.



Undoubtedly, Tourette syndrome has a neurophysiologic origin in at least the five following interdependent frontal cortico-subcortical circuits: dorsolateral prefrontal circuit, lateral orbitofrontal circuit, anterior cingulate circuit, oculomotor circuit, and motor circuit. They program and structure movements and are involved in the reception, interpretation and elaboration of sensorial-sensitive input and in the elaboration of motor output, too.

Surprisingly, creativity and divergent thinking also activate dorsolateral prefrontal circuit and anterior cingulate circuit of frontal cortex. (O. Beversdorf, 2003; A.W. Flaherty, 2005; A. Dietrich, 2010; R. Kawashima, 2010). In particular, frontal lobe is linked with idea generation; this phenomenon is clearest in verbal creativity, but it also shapes non-linguistic creativity.



The assumption that TS is linked with creativity first comes from a professor of Clinical Neurology of the Albert Einstein College of Medicine in New York, Oliver Sacks (1992). The following describes his distinctionbetween the stereotypic form and the phantasmagoric form of TS:

“At one extreme is the stereotypic form with its simple motor tics, iterations, perseverations, and brief,

explosive vocalisations. At the other extreme is an elaborate, innovatory, phantasmagoric form which is especially remarkable for its mimicry, antics, playfulness, extravagance, impudence,audacity, inventions, dramatisations, unexpected and sometimes surreal associations, intense and uninhibited affects, speed, "go," vivid imagery and memory, hunger for stimuli and incontinent reactivity, and constant reaching into

inner and outer worlds for new material to Tourettise, to permute and transform. “

He also emphasizes the possibility of patients leveraging TS into an orderly flow, producing artistry with extraordinarily creative features. For instance, this is how a famous jazz musician found out a way to treasure his disease and discovered the inseparability between his Tourettes and creativity.

"Rhythm and Tourette Syndrome have been intertwined from the first day I found that drumming on a table could mask my jerky hand, leg and neck movements . . . could harness my unbounding [Tourettic] energy, directing it into an orderly flow."(T. Aldridge,1980)



Starting with the hypothesis that those with TS are more creative than those without, I conducted a study in Italy (Porta&Zanaboni, 2010)at IRCSS Galeazzi of Milan involving 23 TS children/adolescents (6-18 years olds), their teachers, and parents, and a control group using Williams’(2004)“Divergent Thinking

Test”, “Creative Personality Test” and “Williams Rating Scale”.

According to Poincaré, creativity is “the union of pre-existing elements that produce new and useful combinations”. Williams’ model (see Guilford, 1954; Torrance, 1959; Williams, 1966) states that the main features of creativity are thinking-cognitive-divergent factors (fluidity, flexibility, originality, elaboration) and personality-emotional-divergent factors (curiosity, imagination, complexity, risk taking).

Results confirm the initial hypothesis for Flexibility subtest of “Divergent Thinking Test”, regardless of the typical OCD rigidity of TS patients. Flexibility is the skill to change approach towards the stimulus, the capability to pass from one category to another, and change your mindset to avoid obstacles.



I repeated the study with a sample of 18 Tourette patients of Dr. Leckman, Dr. King, Dr.Sukhodolsky, Dr. King, Dr. Bloch, Dr. Lombroso, Dr. Vitulano and Dr. Scahill at the YCSC, and the main results confirm Flexibility is more likely to be developed in Tourette patients (α=0.003, sign level=.05). Additionally, the findings of this second study found Fluidity to be more developed in the clinical sample(α=0.005, sign level=.05). Fluidity is the ability to quickly consider a huge quantity of ideas and then generate a large number of valid answers.



Medications: the role of dopamine

Tourette syndrome presents an altered dopaminergic synaptogenesis, which sometimes has to be managed with medications in addition to a psychological support.  At the same time, creative personality is influenced by mesolimbic dopamine, especially when measured by Novelty Seeking and Creative Drive. Even if Creative Drive is not identical to Creative Skill-the latter depends more on neocortical association area- Creative Drive correlates better with successful creative outputs than Creative Skill does.

Furthermore, while creativity  and medications used to treat TS are both linked to the same dopaminergic, serotoninergic and noradrenergic systems, these treatments can only produce an intensification of preexisting personality traits and aesthetic subjective skills and do not cause a genuine improvement in artistic-creative skills. Thus it is possible to assume that creative-divergent skills truly belong to patients and they are not merely borne by a psychotropic effect.

Creativity-based interventions

As additional treatment to medications and/or other psychological techniques (e.g. Habit Reversal Training), Tourette patients have a variety of choices between visual art, music, acting and dancing therapeutic programs to engage with.

For example, consider the school environment, which is usually an obstacle for Tourette patients. By implementing psychoeducational classes for teachers, parents and students  and a re-creational lab for classmates of Tourette students, an otherwise stressful context can become a supportive or even therapeutic setting. Generally, TS students are ignored, misunderstood and discriminated against in school; instead they need their classmates and teachers to learn and use appropriate conduct with them. A TS creative school lab should first take in account motor and linguistic diseases in choosing themes and activities, then include simple tasks to avoid feelings of failure on the part of the patients, as well as exclude tasks that may highlight symptomatology or induce a forced control (e.g. singing is not suitable for kids with severe vocal tics) to prevent embarrassment or tiredness. Rules are stated to the children but not rigidly enforced, taking into account their behavioral ADHD-OCB/OCD patterns.

For instance, therapeutic acting or role play can incorporate body activity to deal with ADHD and the practice of new cognitive-behavioral and interactive-relationships styles to soften OCB/OCD traits. Potentially it can also improve these patients’ social skills (empathy) and self- efficacy, bolstered by public approval from the final performance. This causes a shift away from the immediate satisfaction given by impulsive pleasure of tic manifestation and towards a more gradual and controlled one given by the creative product and by extension of learned cognitive-behavioral patterns outside the therapeutic context.



The general correlation between psychopathology and creativity has already been explained by Evolution theories(Huxley, 1964). According to Huxley, because psychopathology has a genetic component, it must show some positive aspects, creativity is one of them. Actually, creativity is one’s ability to use cognitive and aesthetic skills and empathy towards cultural evolution(Csikzentmihaly, 1998).

The link between TS and creativity has been verified empirically. Moreover, TS patients have a strong expressive-creative predisposition that the psychologist can use to channel their energy in interventions which lead these patients to be aware of their TS features on one hand and of their mental aptitude on the other.

To conclude I’d like to thank Yale Child Study Center and in particular Prof. James Leckman and Prof. Denis Sukhodolsky, Prof. Mauro Porta (IRCSS Galeazzi, Milan).

Dr. Carlotta Zanaboni, Prof.Mauro Porta, Prof. James Leckman