The Wrong Day to Quit Drinking 2nd Edtion (Salmon Chase, Private eye Book 1)

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And so, war was waged. Lincoln had but one reason for this war and that reason was not the abolition of slavery. I look forward to more in this series. I really like how Vidal writes. I read half of this novel before I watched the Lincoln movie not the vampire hunter one: D and I was really impressed by the amount of research that went into this book.

As someone who knows very little American history, I definitely gained a lot more knowledge after reading this book. It was a long read but worth it. View all 12 comments. Oct 16, Ned rated it really liked it. Wildly entertaining, Gore really brings to life Washington DC in , when our nation truly was on the threshold of near certain dissolution. Lincoln, the surprise victor of the presidential race faced a mostly confederate-leaning city the capitol dome was being constructed and everyone expected the raw-boned Midwesterner to fail. But he was wily and had an animal's instinct with people, keeping his veneer carefully sculpted and his ultimate strategies hidden.

The period covered is Wildly entertaining, Gore really brings to life Washington DC in , when our nation truly was on the threshold of near certain dissolution. The period covered is , and told from Lincoln and his cabinet's point of view in parallel with street-level confederate secesh conspirators who ultimately collided with the assassination of our greatest president by most polls, including mine.

It is obvious that Gore read all he could get his hands on in fact, in my youth I had often cast my eyes over the last days of Lincoln and the hanging of his assassins and conspirators so was familiar with the plot to kill him and his secretary of state. Gore has a sense of humor that appeals to me, and I found the descriptions of the deceptive generals who wouldn't fight and their put-on pomposity hilarious.

The jaundiced Seward, a most politically astute secretary of state and the ambitious and proudly upright Salmon Chase secretary of the treasury, then supreme court head are nicely contrasted as part of Lincoln's "team of rivals". The internal politics was absolutely caustic, as "the Ancient" or "the tycoon" as his secretary's dubbed him , stood between the virulently hardline republican abolitionists and the more moderate democrats. Lincoln wanted our nation to be ONE, not two colonies or countries, and this was his underlying ethos. As a lawyer he freed the slaves as a military necessity, as ownership was still constitutional, a political act among others that strained the legality of executive powers.

He knew these boundaries and, cleverly, split the parties to maintain his power base and to get elected almost regrettably, he wanted it more to complete what in his heart he knew our nation required vs the naked ambition that characterized him as a much younger man. He grew gaunt and gray in his first term, maintaining his backwoods musculature beneath somewhat disheveled clothing and haircut. Lincoln persevered with humor, and stories, almost as a solitary leader, with his odd jealous and petty wife "mother" spending like a drunken sailor on herself, and often on the edge of sanity.

His favorite son died early in office, and he knew the price of the war he was waging. He bore the awful brunt of his decisions. His secretary, John Hay, tells much of the story and finishes this book beautifully p. Lincoln had a far greater and more difficult task than Washington's. You see, the Southern states had every Constitutional right to go out of the Union. But Lincoln said, no. Lincoln said, this Union can never be broken.

Now that was a terrible responsibility for one man to take. But he took it, knowing he would be obliged to fight the greatest war in human history, which he did, and which he won. So he not only put the Union back together again, but he made an entirely new country, and all of it in his own image". Lincoln, in some mysterious fashion, had willed his own murder as a form of atonement for the great an terrible thing that he had done by giving so bloody and absolute a rebirth to his nation. Mar 30, Jude rated it it was amazing. Gore Vidal was a huge discovery for me.

But there was a lot of that going on at the time. I have always admired Abraham Lincoln as our most important president except for brief periods when I was enamored of Thomas Jefferson, Harry Truman and John Gore Vidal was a huge discovery for me. Apparently, the author read every "scrap" of information that he could find on his subject and then knitted together every true thing he found with what he could only surmise had taken place in between the facts by way of conversations which cannot be confirmed as having taken place. The book is as entertaining and enlightening a story as I have ever had the good fortune to read.

I came away with a living portrait of Lincoln, the man, and was astonished to learn of the miriad of seemingly insurmountable circumstances attendant to the ones we commonly know of his life and times. Lincoln's health was not the best and the remedy for his stomach problems a disgusting, viscous concotion called "Blue Mass" had to be endured often. His wife, though she loved him very much, was not an asset to him with her own frail mental and emotional states and some plain selfishness in the bargain. She embarrassed him publicly and politcially.

They lost children together. I hate McClellan today because I read that he organized the Army of the Potomac, but he was a tragedy as a general, to put it mildly, and got a staggering amount of Union soldiers needlessly saughtered. Well, I loved the book. Will read it again. Gore Vidal 's enjoyable and masterly fictional biography of Abraham Lincoln is, according to the author, largely based on fact. Until I read Lincoln I had a naive belief that he was a modern saint.

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That he was not. He is portrayed as being a brilliant politician: We are introduced to him as the USA was in the process of becoming disunited and was plunging into a deadly civil war. Not only was his country disunited, but also was his Republi Gore Vidal 's enjoyable and masterly fictional biography of Abraham Lincoln is, according to the author, largely based on fact. Not only was his country disunited, but also was his Republican party, many of whose senior members had little faith in his ability to win the Civil War. Yet, he pulled it off. Despite mammoth losses of life on the battlefields, incompetent military commanders, and numerous attempts to sabotage his work, Lincoln managed to defeat the Confederates and to prevent the unity of the young USA from becoming permanently disrupted.

I was surprised to learn that 'Honest Abe' was not always in favour of liberating the Black slaves and ending slavery in the USA. It was almost, it seemed to me, for pragmatic reasons that he was gradually won over to these things. The integrity of the USA was in the forefront of his mind. If allowing slavery in states that would have otherwise become disloyal to the union permitted him to keep them as allies, he allowed that even though many of his closest colleagues were in favour of abolishing slavery. The novel contains a plethora of interesting and well-portrayed characters, all of whom contribute to the suspense that is maintained throughout its more than pages of tiny font.

Dec 21, Scott W. Whatever hubris it takes to write a biography of Abraham Lincoln, it surely takes plenty to write a research-intensive page novel that covers the entire presidency. Vidal accomplishes this compression by including a pile of exposition in dialogue without it ever quite seeming like he's doing so; perhaps famous national leaders are the only characters in fiction exempt from the rule. Portraits of "minor" characters -- John Hay one of Lincoln's personal secretaries and Kate Chase daughter o Whatever hubris it takes to write a biography of Abraham Lincoln, it surely takes plenty to write a research-intensive page novel that covers the entire presidency.

Portraits of "minor" characters -- John Hay one of Lincoln's personal secretaries and Kate Chase daughter of Treasury secretary Salmon Chase in particular -- are vivid and convincing, but I loved the book most for its glimpse of Washington, D. I take both sides, really, although I lean to Vidal: Feb 21, Andrewh rated it really liked it. This was rollicking good read, and may even contain some historical truths about Abraham Lincoln and his fellow politicos duing the turbulent era of the Civil War.

Vidal draws a vivid picture of 19th century Washington - a city built on a swamp, with rudimentary facilities, but with grand aspirations. Lincoln is presented as a man of brilliant lawyerly talents, a pragmatic strategist rather than an idealistic opponent of slavery. Throughout the book, Vidal makes clear that Lincoln alternately r This was rollicking good read, and may even contain some historical truths about Abraham Lincoln and his fellow politicos duing the turbulent era of the Civil War.

Throughout the book, Vidal makes clear that Lincoln alternately referred to as the Tycoon or the Ancient was not an abolitionist in any respect, but was opposed to states leaving the union above all as un-constitutional , which led him to his famous proclamation freeing the slaves in the South, that is , as a 'military necessity'. His wife is portrayed as a slightly mad shopaholic, massively in debt, and prone to corrupt practices to raise money to do up the ramshackle White House the Mansion , while his closest advisors are all scheming behind his back the abolitionist Treasury Secretary Chase wishes to be President instead of Abe, and the Secretary of State Seward is keen on starting a war with Canada or Mexico, to replace the 'lost' secesh states.

Washington is full of spies, brothels and disease and the work presents the United States as a young country not hugely unlike Ancient Rome, corrupt yet idealistic, and destined to expand militarily - the Civil War had built the largest military force on earth, and, possibly, hints Vidal, paved the road to eventual Empire. Feb 08, Felisa Rosa rated it it was amazing Recommends it for: Once again, I am amazed by the breadth and depth of Vidal's knowledge. His seemingly encyclopedic grasp of the era is matched in equal parts by caustic wit and empathy. Vidal's Lincoln is at once human and monolithic, and the pages are imbued with his curious melancholy.

On a side note, one gets the feeling that Mark Ryden had read this book The supporting characters are equally interesting. Mary Todd is nuanced and Vidal brilliantly tracks the evolution of Lincoln's relationship with his ci Once again, I am amazed by the breadth and depth of Vidal's knowledge.

Mary Todd is nuanced and Vidal brilliantly tracks the evolution of Lincoln's relationship with his cigar chomping and ultimately lovable secretary of state, Seward. But in the end it's Vidal's one liners that I love best. Whether humorous, descriptive, or dramatic, they'll give you chills. Aug 22, Jenny Karraker rated it it was amazing. I really enjoyed this book. It is listed as fiction, because it is written in novel form, with dialogue that isn't quoted from specific historical documents.

However, the events and characters were all real. It was intriguing to read of how disrespected Lincoln was, especially by people in his own cabinet. They often thought him a naive, backwoods simpleton who knew nothing about politics and governing. But as Barbara Gannon often says in her Civil War class at University of Central Florida, you have to remember that this guy was a lawyer and knew exactly what he was doing.

There was a method in his madness that eventually astounds those who earlier opposed him. When you read of the pressure he was under from the casualties of the war and its seeming no end in sight, you are reminded of his strength of character, the compassion he had for people on both sides of the war, and his determination and stamina to persevere amidst the opposition from both the South and North, bickering within his own party, and the tremendous slaughter on the battlefields.

This book also portrayed a more compassionate view of Mary Todd Lincoln. She has often been portrayed as an emotionally unstable woman though perhaps today she would have been diagnosed with bipolar disorder. Yet here she is described as being very knowledgeable about the politics of the day and seemed to be a good companion for Lincoln. In visiting Japan 25 years ago, I learned that they call Washington the father of the United States and Lincoln the mother. He certainly displayed a great loyalty and sacrificial lifestyle for this country.

It is so shocking that he is assassinated at the end of the war; but on a philosophical view, perhaps his role was to get us through this great conflagration and unite us into a country that more accurately reflects the Declaration of Independence that all men are created equal. In light of recent events over the past year, we certainly need to visit those racial issues again and work toward the things Mr Lincoln strove for so courageously.

May 27, Louise rated it really liked it Shelves: I'd like to give this book 5 stars for the extraordinary undertaking of thought and research that it represents, but the book, while very good, is weakened by its ambition and its reliance on dialog. This detracted from his most interesting portrait, that of Lincoln. The characters are developed primarily th I'd like to give this book 5 stars for the extraordinary undertaking of thought and research that it represents, but the book, while very good, is weakened by its ambition and its reliance on dialog. The characters are developed primarily through conversation, so much that it reads more like a script than a novel.

Even as a script, it's in need of an edit. Some of the conversation has tremendous impact, such as Lincoln at cabinet meetings, exchanges with Mary, meeting with free Blacks, Lincoln on his own political situation, Mary talking with relatives, David and Booth, and Hay in Paris. At other times, the dialog seems to be there because it's just too clever to leave out.

A Novel" is a far better book. Feb 25, Rob Anderson rated it it was amazing. Conceptually, I have an issue with historical fiction, but it's so damn entertaining! Gore Vidal does it better than anybody. I've read Burr and Lincoln and both are excellent. In Lincoln, Vidal doesn't deviate from the historical facts at least per my wikopedia spot checks , but through dialogue he builds out the characters of Lincoln, Seward, Chase, and Grant in a manner that is completely believable, insightful, and, yeah, entertaining. I won't be citing "Lincoln" as a source document, but a Conceptually, I have an issue with historical fiction, but it's so damn entertaining!

I won't be citing "Lincoln" as a source document, but after reading it, I feel like I have greater insight into Lincoln and the civil war. On to , next in the Narratives of Empire series. Sep 08, Lindz rated it really liked it Shelves: This is not the easiest book to read.

It is dense, large, and dense. But very much worth the read if you have any interest in the American Civil War or President Lincoln. Like any good Historical novel worth it's salt, it's brilliantly researched. A lot of the things said by Lincoln in the novel were in fact recorded speech from the great President. What I love about this novel though is that you never quite know what is going through Lincoln's head. All the point of views are from his wife, his This is not the easiest book to read. All the point of views are from his wife, his secretary, his minister of treasury and his minister of war.

You will feel smarter after reading this novel. Oct 08, Amy rated it it was amazing. I became obsessed with this book! Wierd parallels with current happenings This is the first book I've read by Gore Vidal, and now I want to read more. He really brought this period to life and made it interesting and understandable. It was nothing like what I would have thought, had I thought more about it.

The White House was a rat-infested dump with smelly swamps and garbage all around, where people were often sick or died, and inhabited by mostly confederate sympathizers. It was not the best place to be a Yankee. Lincoln was always interesting. He and his family didn't really fit in well with the existing society. He seemed to be odd and not too bright, and people thought he was not in control. But somehow, he was always able to arrange things to turn out the way he wanted, often without people realizing he was doing it - probably due to his homey way of talking, injecting stories, etc.

I thought he was pretty entertaining. His wife, on the other hand, was a handful and somewhat, if not completely, crazy, especially later in the book. Much of the time, she could not stop spending money on both herself and the Capitol, which neither could really afford. She then had to do whatever she could to stave off the debtors, much of which was illegal or immoral. Even though I of course knew what was going to happen to him, view spoiler [He was assassinated, hide spoiler ] there was still an air of suspense as the time approached, and a sense of the sadness and anger after the event.

This book took me longer to finish than normal, but I think it was worth it. Fortunately, I had audiobooks to listen to at the same time. What is it about Abraham Lincoln that so attracts authors and readers? Why have there been 15, books written about him -- reportedly more than have been written about any other person in world history, with the exception of Jesus Christ? And what was it about Gore Vidal, the famously acerbic author who died on July 31, , that brought out so much intensity in the obituary columns?

Gore Vidal's Lincoln is a good place to start looking for answers. While Vidal wrote mysteries, plays, and tele What is it about Abraham Lincoln that so attracts authors and readers? While Vidal wrote mysteries, plays, and television scripts over a career that spanned six decades, he became best known for a series of historical novels about American history.

Of these, Lincoln may have been his most successful. The book focuses almost exclusively on the sixteenth American presidency itself, beginning shortly before Lincoln's inauguration and ending at his assassination four years later. Though it was clearly well researched, Vidal was not writing a scholarly history. Rather, he was a storyteller, with a focus on gossip and personality quirks that gives the reader immediate access to some of the most dramatic scenes in our country's history. Lincoln himself is not portrayed as a monolithic leader carved out of granite; he is shown as a shrewd political operator who still sometimes bumbles from one crisis to the next, deeply conflicted about slavery and a lightning rod for abuse.

Then again, given our current political polarization, Vidal suggested, it is useful to consider what disunity really looks like. Historical novels work best when they go beyond chronicling what happened to show us how people really lived. Vidal gives us what we want: While there are some fictional characters, most of the characters are based on real people. While we can never know the truth about any historical event, Vidal clearly had a lot of fun speculating about the origins and growth of our American empire.

In real life, Gore Vidal was complex, never shying from controversy or attention.

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He famously battled with people like William Buckley, Norman Mailer, Truman Capote and, for that matter, anyone else who crossed him. He saw himself as a character, which may be why his Lincoln is so full of great characters.

However many red-state-blue-state buffoons we now have on our political stage, he seemed to be telling us, it's a safe bet that things were once worse. Aug 19, Ashley rated it liked it. After reading Team of Rivals, I have become obsessed with all things Lincoln Administration, and I began reading Vidal's novel the day before the great literary icon passed away.

I found this an engrossing read, despite the Vidal-isms and some forgivable tics that were admittedly annoying the overuse of the word "mischieviously" and some of the more obvious add-ons to scenes where subtlety would have worked better for me. I loved his Chase murmuring hymns to himself, his slightly debauched Joh After reading Team of Rivals, I have become obsessed with all things Lincoln Administration, and I began reading Vidal's novel the day before the great literary icon passed away.

I loved his Chase murmuring hymns to himself, his slightly debauched John Hay, and wish he had done more with Stanton. For example, I hungered for the true-life scene of Stanton weeping in his office after Lincoln's death. He sat up all night with the president, serving as the rock everyone needed. Vidal makes him seem coldly efficient; reality is that once Lincoln actually passed, his Secretary of War was absolutely inconsolable.

I also found the ending of the book disappointing; I really didn't need John Hay in Paris speculating about plots involving Congress and Stanton and others. I think there would have been a more graceful way to end the book. But man, it was extremely engaging and I am very sorry that it's over, seven hundred plus pages later. Feb 06, Julie rated it really liked it Shelves: First, I just read through many reviews here on Goodreads where the comment was made over and over again , what an amazing work of non-fiction this is.

I don't want to burst anyone's bubble, but this book is entitled "Lincoln: This is a novel, y'all, and it's important to know the difference. The author himself, in an afterword, makes it known that, while he stayed true to historical pieces of information as much as possibl First, I just read through many reviews here on Goodreads where the comment was made over and over again , what an amazing work of non-fiction this is.

The author himself, in an afterword, makes it known that, while he stayed true to historical pieces of information as much as possible, he has taken liberties as well. Presidents, this book is probably going to sit on your nightstand, unfinished, for the rest of your life. President, and he's one of my favorite human beings of all time. I am also a great reader. But, this book was heavy in my hands and it was hard to crack open once I had put it down. Nov 15, Robin Friedman rated it it was amazing.

Lengthy though the book is, the writing is crisp and eloquent. It held my attention throughout. The book is part of a series of novels by Vidal exploring the history of the United States. In writing historical novels, it is difficult to tell where fact ends and fiction begins. This is particularly th A Novel Of Abraham Lincoln In his historical novel "Lincoln", Gore Vidal has written with great insight about our sixteenth president, his cabinet, his family, his enemies, and the Civil War Era.

This is particularly the case in dealing with a complex figure such as Lincoln whose life and political legacy remain controversial and subject to many interpretations. Controversial matters that Vidal addresses in his novel include Lincoln's attitude towards African-Americans and the Reconstruction policy that Lincoln might have pursued if he had lived. Vidal's book shows careful study of Lincoln's life and the Civil War era.

He uses the resources uniquely available to the novelist to good advantage by probing the thought processes and feelings of his characters where historical evidence is lacking. I found the portrait of Lincoln compelling, but it is important to remember that Vidal is writing a novel.

Vidal's book begins as the President-elect arrives secretly in Washington, D. In the course of the novel, passages of recollection by various characters, reliable and unreliable, cast some light on Lincoln's earlier life. The book moves carefully and slowly, with a great deal of attention given, and properly so, to the earlier period of Lincoln's presidency. Much attention is given to Washington, D.

The pace of the book picks up as it proceeds through Lincoln's first term and reelection, the end of the Civil War, and the assassination. The picture of Abraham Lincoln that emerges from Vidal is of a man of great intellect, ambition and will, determined to save the Union at all costs. Vidal portrays Lincoln's overriding dedication to the Union. In order to preserve the Union, Lincoln uses extraordinary and even ruthless political skills. Thus, Vidal's novel considers extensively Lincoln's relationship with his cabinet. This necessitated discontinuation in only one case.

Dexamphetamine tended to produce more compulsive behaviours, which were also more likely to resemble clinical OCD, than did methylphenidate. Abnormal movements and compulsive behaviours tended to co-occur on methylphenidate only Borcherding et al. Gadow and colleagues studied 11 prepubertal hyperactive boys with tic disorder who received placebo and three doses of methylphenidate 0.

Methylphenidate also reduced the occurrence of vocal tics in two settings. None of the motor tic measures revealed drug effects. On an operationally defined minimal effective dose, only one boy experienced motor tic exacerbation Gadow et al. Gadow and colleagues also studied 34 prepubertal children with ADHD and tic disorder who received placebo and three doses of methylphenidate twice daily for 2 weeks, each under double-blind conditions.

However, these changes in motor tic frequency were not perceived by care providers as a worsening in the severity of the child's tic disorder. Most dose—response relationships were linear, but the mean minimal effective dose was 0. Castellanos and colleagues conducted a 9-week placebo-controlled crossover DBT in 20 subjects in three cohorts, evaluating the effect of methylphenidate and dexamphetamine on tic severity in boys with ADHD and TS.

Fairly high doses of methylphenidate and dexamphetamine in the first cohort resulted in significant increases in tic severity which were sustained on higher doses of dexamphetamine, but which attenuated on methylphenidate. Fourteen of 20 subjects continued stimulant treatment for 1—3 years, generally in combination with other psychotropics.

Stimulant-associated adverse effects, including tic exacerbations, were reversible in all cases Castellanos et al. It has been suggested that when treating ADHD with stimulants, controlled release preparations and the adjunctive use of clonidine are helpful to extend stimulant effects and control the adverse effects Carrey et al.

Clinicians have been successfully using a combination of clonidine and stimulants safely, for many years, to treat children with ADHD; it has been suggested that clonidine both works synergistically with stimulants to reduce behavioural symptoms, and helps with the initiation of sleep Popper, Consequent on three deaths reported in children receiving the combination, Popper carefully goes through all the evidence, and ends by suggesting that the deaths were probably not in fact due to the combination Popper, He very carefully thereafter considers the safety and sense of the combination, providing valuable guidelines for the clinician.

In the UK pemoline has been withdrawn from the market. Side-effects of the stimulant include dependence, psychotic states and growth retardation British National Formulary, Several markers for ADHD were shown to improve significantly after treatment with desipramine, and desipramine was always superior to clonidine. On measures of tic severity, neither drug made tics worse. Desipramine showed a statistically significant improvement on a global linear analogue scale, but not with standardized tic severity ratings.

Clonidine did not significantly alter tic severity with any measure Singer et al. Problems such as acute collapse and sudden death have, however, been reported with the use of desipramine in children Riddle et al. The main problem with the drug, however, is the side-effect profile e. In the author's experience, it is therefore not first choice.

OCD is generally now thought to be unresponsive to psychodynamic psychotherapies, but it does respond to behaviour therapy, especially exposure and response prevention, and to medications such as clomipramine and the SSRIs Greist et al. By and large, the doses given for depression are lower e. Fluoxetine and fluvoxamine have been documented most frequently in TS. Delgado and colleagues described a year-old man with TS who presented for treatment of OCD symptoms. Fluvoxamine worsened tics, led to coprolalia and did not help the OCD.

Double-blind sequential discontinuation of fluvoxamine and pimozide confirmed that pimozide alone reduced only tics and the combination of fluvoxamine and pimozide was required for the improvement in OCD Delgado et al. Five of the 10 patients were responders. Fluoxetine was well tolerated, with adverse effects including behavioural agitation or activation in four patients and mild gastrointestinal symptoms in two Riddle et al.

Data were therefore analysed on 26 patients 13 children, 13 adults who were treated for 3—8 months. Fluoxetine therapy, however, was associated with a trend towards some improvement in tic severity, attentional abilities and social functioning Kurlan et al. McDougle and colleagues conducted a retrospective case-controlled analysis and evaluated fluvoxamine in 33 patients with OCD and a comorbid tic disorder, and 33 patients also with OCD but without a comorbid tic disorder. McDougle and colleagues then undertook a study involving 62 patients with a principle DSM diagnosis of OCD and gave placebo for a week followed by 8 weeks of fluvoxamine in identical capsules.

There had been no 1-week placebo responders. Thirty-four patients were refractory to fluvoxamine and were then entered into a 4-week double-blind placebo-controlled 2 mg haloperidol addition phase. Haloperidol was not useful in treating OCD symptoms in the absence of tics. Fluvoxamine blood levels were not related to treatment response McDougle et al. Fluvoxamine George et al. Side-effects of the SSRIs include gastrointestinal side-effects diarrhoea, nausea and vomiting, which are dose related , headache, restlessness and anxiety; they do not cause weight gain British National Formulary, A DBT of diazepam a benzodiazepine versus placebo at 2 mg t.

Whether or not this is due to a direct action on TS symptoms or is merely an anxiolytic effect is not clear. There are, however, problems with long-term prescription of benzodiazepines including addiction and tolerance.

Gonce and Barbeau first reported the successful use of clonazepam in seven TS patients Gonce and Barbeau, , followed by Dion and Chouinard Dion and Chouinard, , In general, it was felt that clonazepam was well tolerated and produced no TD. Drtilkova and colleagues compared clonazepam and clonidine in 20 children mean age 11 years , 14 with chronic tic disorder and six with TS. Clonazepam was significantly superior to clonidine and produced fewer side-effects Drtilkova et al. Merikangas and colleagues conducted a single-blind investigation of 20 TS patients.

As TS patients had previously been reported to have high red blood cell choline levels, red blood cell choline was measured. Patients with high red blood cell to plasma choline ratios responded significantly better to clonazepam than to haloperidol, and the clonazepam responders were significantly more likely to have a family history of TS or tics Merikangas et al. Jankovic and Rohaidy reported that TS patients with mild symptoms improved with clonidine or clonazepam, whereas those with more severe symptomatology required fluphenazine, pimozide, haloperidol or tetrabenazine Jankovic and Rohaidy, On the other hand, clonazepam-induced TS symptoms in a year-old subject with hyperexplexia or abnormal startle response have been described Gillman and Sandyk, Clonazepam has also been used to treat tardive Tourette-like syndrome Kuniyoshi et al.

Side-effects of clonazepam important in TS include drowsiness, fatigue, dizziness, paradoxical aggression, irritability and mental changes British National Formulary, Mondrup and colleagues evaluated progabide a GABA receptor agonist in 17 patients with hyperkinetic movement disorders, including four with TS.

Others have also suggested its use Fog and Regeur, It has been suggested that the pathophysiology of TS may be linked to a relative imbalance between cholinergic and dopaminergic activity within the striatum and that nicotine may alter this imbalance Dursun and Reveley, Animal experiments in the late s and early s demonstrated that nicotine potentiated haloperidol-induced catalepsy and reduced locomotor activity Manderscheid et al. At around the same time, there was a case report that chewing nicotine gum reduces tics Brill, Devor and Isenberg reported a male TS patient whose symptoms reduced markedly when he smoked cigarettes Devor and Isenberg, In open studies involving small numbers of TS patients who were being treated with haloperidol, the frequency of tics was reduced significantly during a min nicotine gum Nicorette chewing period and the hour afterwards, suggesting once again that nicotine appears to potentiate the effects of haloperidol Sanberg et al.

In addition, many discontinued the gum because of side-effects, especially nausea and a bitter taste in the mouth Sanberg et al. Subsequent DBTs suggested that nicotine markedly potentiated haloperidol effects in treating TS and showed lesser effects on symptoms when used alone; placebo gum had no effect McConville et al. Mainly because of the unacceptable side-effects of gum, transdermal nicotine patches TNP were subsequently used Silver and Sanberg, ; Dursun et al.

Other side-effects of TNPs include headache, light-headedness, sweating, tremor and sleep disturbances Davila et al. Nicotine is also available as a nasal spray and an inhaler is under development Benowitz, ; to the best of the author's knowledge, neither of these applications has been used in TS. A nicotine antagonist, mecamyline marketed as an antihypertensive agent in the USA , was prescribed in 13 TS patients. Improvements were noted in tics, mood, irritability and aggression Sanberg et al.

It does appear that agents acting on the nicotine receptors may well be useful in the treatment of TS, especially when used as an augmenting agent to neuroleptics. More research, however, is needed in the area. Walsh and colleagues reported tic, irritability and compulsive symptom reduction with Verapamil Cordilox, Securon, Univer, Verapress; 20 mg t. After a suggestion that nifedipine augments haloperidol in the treatment of TS, the successful combination of nifedipine and haloperidol in treating a patient with TS was reported Alessi et al.

Micheli and colleagues evaluated seven TS patients aged 12—31 years, before treatment, after 1 month on placebo, after a single 10 mg nifedipine dose three subjects and monthly while on flunarizine 10—15 mg mean dose 13 mg. None of the patients receiving nifedipine improved, but treatment with flunarizine significantly decreased both motor and phonic tic severity and frequency in all but one patient. Adverse effects occurred in four patients and included mild transient headaches, depression and bradykinesia Micheli et al. As there is some evidence that tic-like movements in animals such as head shakes and wet dog shakes are blocked by buspirone Handley and Dursun, , buspirone was tried and found to be useful in a patient who was refractory to other treatment Dursun et al.

Botulinum toxin injections were pioneered by Scott and colleagues Scott, ; Scott et al. They have been used for some time in focal dystonia Jankovic and Brin, and oral—lingual dyskinesia Ludlow et al. More recently they have proved useful in TS, targeting the symptoms of blepharospasm, neck and facial muscles Jankovic, ; Jankovic and Hallett, ; Poungvarin et al. Scott and colleagues reported on a year-old boy with severe coprolalia, OCD and ADHD who was considerably improved by unilateral vocal cord injections of botulinum toxin; not only was his coprolalia improved, but also the premonitory sensations that were associated with the vocal tics and coprolalia Scott et al.

He was injected with 3. His therapeutic response was excellent and not only reduced coprolalia, but also aided the general symptoms Trimble et al. On the other hand, Chappell and colleagues treated two males with botulinum toxin, both of whom had frequent and forceful tics involving a specific body area shoulder in one patient, lower thigh in the other ; an injection of botulinum toxin was given into these areas. Neither patient had a reduction of tics or premonitory urges Chappell et al. Early work by Sandyk reported the successful use of naltrexone, naloxone and oxycodone on TS symptoms Sandyk, a , b ; Sandyk et al.

Using a self-report scale, subjects reported a significant reduction of tics after treatment with naltrexone when compared with placebo. An improvement in the Trail Making B test, which is a measure of attention and visuomotor sequencing and planning, occurred after receiving naltrexone when compared with placebo or propoxyphene Kurlan et al. Pentazocine has also been reported as a useful drug Bazire, Meuldijk and Colon reported the case of a man whose TS symptoms responded to methadone after he had not responded to many traditional drugs Meuldijk and Colon, McConville and colleagues reported two TS patients who responded to the sequential use of opioid agonists and antagonists.

Risks with opioids are the addiction potential and the risk of tic exacerbation after sudden withdrawal McConville et al. The use of lithium in TS is not common. Few have documented the usefulness of lithium in a small number of TS patients Erickson et al. Kerbeshian and Burd described 13 boys with TS some of whom also had bipolar disorder; interestingly, when they were treated with lithium, the tic symptomatology improved in seven; blood levels ranged between 0. The use of lithium, however, was not useful in controlling tic symptomatology in other cases Borison et al.

Cholinergic modulating drugs such as physostigmine Stahl and Berger, , have proved useful, while others such as dimethylaminoethanol Deanol; Finney et al. On the other hand, cases have been reported where carbamazepine has reduced the TS symptoms Lutz and Feldman, An early study by Consroe and colleagues suggested that cannabidiol may be useful in dystonic movement disorders Consroe et al. Sandyk and Awerbach then described three TS patients who had incomplete responses to conventional anti-TS medications and who then reported a significant reduction in both motor and vocal tics following recreational use of marijuana; the authors, however, note that the patients may have used marijuana to reduce the stress and anxiety that occurred secondary to TS, as all three reported reduced anxiety when using marijuana Sandyk and Awerbach, Moss and colleagues then suggested that cannabinoids may increase the effectiveness of neuroleptics in TS Moss et al.

Hemming and Yellowlees reported a year-old man who failed to respond to either haloperidol or pimozide, but who, several years later, found that his nightly intake of marijuana rendered him absolutely symptom free Hemming and Yellowlees, In the author's clinical experience several patients have reported a reduction in symptoms with the recreational use of marijuana. It has also been documented, however, that cannabis has no effect on tics and increases the individuals inner tension Meuldijk and Colon, Certain drugs may be helpful in reducing the next-day effects of sleep deprivation such as melatonin.

A preliminary study using melatonin in multidisabled children and early results in TS and ADHD are promising, with no significant side-effects Freeman, Several combination strategies have been used in TS including nicotine and haloperidol Silver and Sanberg, , and nicotine and sulpiride Dursun and Reveley, ; recently, the safe use of pergolide and both stimulants and clonidine has been reported Lipinski et al.

Kurlan, however, cautions that an acute parkinsonistic syndrome may be induced by the combination of a SSRI and a neuroleptic in adult TS patients Kurlan, Budman and colleagues have reported the successful use of the antiviral agent acyclovir Budman et al. These suggested medications have only been used in a small number of patients with very specific indications; results are still to be replicated in other laboratories and the treatments assessed in controlled studies in larger samples of patients.

Based on evidence implicating abnormal gonadotrophic functioning in TS, Sandyk and colleagues studied luteinizing hormone, follicle stimulating hormone, luteinizing hormone releasing hormone and testosterone; abnormalities suggested a hypothalamic-mediated luteinizing hormone releasing hormone deficiency. The antioestrogenic agent clomiphene citrate Clomid was successful in treating TS symptoms Sandyk et al. Peterson and colleagues reported the first use in TS of the non-steroidal androgen receptor blocking agent flutamide Eulexin, Fugerel. One male and one female underwent open trials of the drug and a second male participated in a placebo-controlled crossover DBT.

The improvement was sustained in the woman during daily flutamide ingestion and in one of the men during intermittent use. The symptoms of one of the men became refractory to treatment after 5 weeks of flutamide and the woman became depressed and had protracted diarrhoea during her treatment Peterson et al. One of the most novel recent treatments of TS has been laser therapy in Russia. Bondarenko and colleagues reported successful low-intensity infrared laser irradiation of blood, used to correct the antioxidative system in TS.

Index patients receiving laser therapy received lower doses of neuroleptics in contrast to controls no laser therapy who required higher neuroleptic doses Bondarenko et al. This of course is interesting, but must be viewed as experimental at this stage and is not used or advocated by experts, including the author.

Wu and colleagues treated TS patients with acupuncture in China. The success rate was The cure rate in children aged 11—15 years was markedly higher than in children aged 6—10 years. Although fascinating, once again this is a single report and experts in the field, including the author, do not use this method. Jankovic and Rohaidy documented their experience with TS patients. Most patients required a trial of more than one medication before a satisfactory improvement was reached.

In summary, clonazepam and clonidine were tolerated relatively well, but only one-third had an excellent response. Pimozide, fluphenazine and tetrabenazine seemed most effective but were associated with more adverse reactions. Haloperidol had the highest incidence of side-effects. Fulton and colleagues surveyed TS subjects who replied to a mailed questionnaire. The most commonly prescribed medications were reported to be haloperidol, pimozide, clonidine and benztropine Cogentin which was taken in conjunction with other medications.

See a Problem?

TS is probably a heterogeneous condition, from an aetiopathological, genetic, clinical phenomenological and psychopathological point of view. To summarize, and in the author's opinion taking into account the literature and personal experience , there is no doubt that ADHD is very common in TS, even in mild cases. It is thought that, in time, it will be clear that there is a specific type of ADHD which is peculiar to TS, which is phenomenologically different from that in pure ADHD, but it is unclear as to whether or not this has treatment implications.

In the author's opinion, the depression in TS is highly likely to be multifactorial in aetiology, highlighting the importance of a full psychiatric history and mental state examination in each patient. The anxiety, personality disorders and other behavioural problems are often seen in TS clinics and may be due either to the comorbidity with ADHD or to referral bias. Certainly, the majority of the patients in the author's clinic usually have multiple pathology, although it is recognized that as it is a specialist clinic, it probably attracts patients who are more difficult to manage.

Many neurotransmitters have been implicated as malfunctioning in TS. As can be seen, the medications used to treat the various TS symptoms differ in their receptor affinity profile and indeed their efficacy. The most tried and tested medications for the motor and vocal tics remain the dopamine antagonists, with haloperidol, pimozide, sulpiride and tiapride receiving most attention.

The new atypical neuroleptics such as risperidone and olanzapine have appeal and deserve further research; more DBTs are certainly needed. Clonidine which affects the noradrenergic system is also used widely and has been noted to improve tics, ADHD symptoms and behaviour problems. New and novel treatments as diverse as immunomodulatory therapy, plasmapheresis, antiobiotics, antiviral agents, melatonin, psychosurgery and even laser therapy and acupuncture, have all been reported to be successful in treating TS.

These, however, have only been tried on a few patients and must be given only with the strictest of indications e. The author has no personal experience with any of these and would not recommend anyone other than experienced clinicians very well acqainted with TS to use them. In the author's clinic, the most commonly prescribed medications to adults are sulpiride in approximately one-third of patients, followed by fluoxetine and haloperidol, and then pimozide.

The most commonly prescribed medications to children and adolescents are clonidine in around one-third, followed by sulpiride, haloperidol and fluoxetine. Many patients with milder symptoms require no medication, but reassurance and psycho-education M. Many patients require polytherapy and thus the author prefers not to use agents such as pimozide in these instances.

In addition, the author is somewhat cautious, as in the UK at least, most of the agents are neither recommended for children, nor licensed for use in TS. TS is a truly fascinating disorder. Each patient presents the clinician with something well known and well recognized, as well as something new or unusual, which stimulates further research. Only when the putative gene s or genetic mechanisms are well defined, will some of these issues be resolved, such as the precise phenotype s.

Further medication trials in better defined subgroups may then lead to improved treatments. The author wishes to thank Dr Jeremy Stern for his thoughtful comments, Dr Joe Black for helping obtain original articles, the pharmaceutical companies for supplying articles and Mr John Ludgate for his comments and support. The basis of the treatment section of this article was first presented at the International Canadian Tourette Syndrome meeting in Quebec City, November ; thanks are given to the Canadian Tourette Syndrome Foundation for stimulating the research.

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Close mobile search navigation Article navigation. History, prevalence and epidemiology. Clinical characteristics and complexities. Tourette syndrome, associated conditions and the complexities of treatment Mary M. Brain , Volume , Issue 3, 1 March , Pages —, https: Abstract Tourette syndrome TS is characterized by multiple motor tics plus one or more vocal phonic tics, which characteristically wax and wane.

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Through Her Eyes

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Introduction

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