A Single Case of Tourette's Syndrome Treated with Traditional Chinese

JAMS324_proof ■ 27 December 2016 ■ 1/7

+ MODEL J Acupunct Meridian Stud 2016;--(-):--e--

Available online at www.sciencedirect.com 61 62 1 63 2 Journal of Acupuncture and Meridian Studies 64 3 65 4 66 5 journal homepage: www.jams-kpi.com 67 6 68 7 69 8 70 9 CASE REPORT 71 10 72 11 73 12 74 13 75 14 76 15 A Single Case of Tourette’s Syndrome 77 16 78 17 Treated with Traditional Chinese Medicine 79 18 80 19 Q37 81 20 Min-Hwa Lee* 82 21 83 22 84 23 Q1 DAOM Program of Oregon College of Oriental Medicine, USA 85 24 --- Available online 86 25 87 26 88 27 Received: Aug 14, 2016 Abstract 89 28 Accepted: Dec 13, 2016 The objective of this case study was to investigate the effectiveness of Chinese medicine 90 29 in treating Tourette’s syndrome. Tourette’s syndrome is a childhood- onset disorder that 91 30 is characterized by sudden, involuntary movements or tics. The participant in this study 92 31 was a 33-year-old male who had been diagnosed with Tourette’s syndrome at the age of 9 93 32 years. His major complaints included facial tics, shoulder shrugging, and clearing the 94 33 throat. Using a combination of acupuncture, herbs, Gua-Sha, and lifestyle changes once 95 34 a week for 35 treatments, all the symptoms were reduced by 70%, as reported by the pa- 96 35 tient. In this case, the results indicated that Chinese medicine was able to minimize the 97 36 symptoms of Tourette’s syndrome. Further investigation is needed to support this argu- 98 37 ment. Tourette’s syndrome, which was first described in 1885 by a French physician 99 38 named Gilles de la Tourette, is characterized by facial tics, involuntary body movements 100 39 from the head to the extremities, or vocal tics, and it usually has its onset in childhood. It 101 40 is a neuropsychiatric disorder. The treatment for Tourette’s syndrome is based on phar- 102 41 macological treatment, behavior treatment, and deep brain stimulation. Unfortunately, 103 42 none of these could completely control the symptoms; furthermore, antipsychiatric drugs 104 43 might cause additional side effects, such as Parkinson symptoms, tardive dyskinesia, and 105 44 metabolic disturbances. Finding acupuncture and oriental medicine literature on treat- 106 45 ment of Tourette’s syndrome was difficult, especially that written in English. Some 107 46 research papers that have been translated into English indicated that Chinese herbs 108 47 and acupuncture could reduce the tics significantly. For example, a study by Dr Pao- 109 48 Hua Lin reported the significant effects of using acupuncture and oriental medicine in 110 49 treating 1000 Tourette’s syndrome cases. This case was treated to further investigate 111 50 Q5 the principles of Dr Lin’s study. 112 51 113 52 114 53 115 54 116 55 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// 117 56 creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any me- 118 57 dium, provided the original work is properly cited. * Corresponding author. 119 58 Q2 Q3 120 59 pISSN 2005-2901 eISSN 2093-8152 121 60 http://dx.doi.org/10.1016/j.jams.2016.12.005 Copyright ª 2016, Medical Association of Pharmacopuncture Institute. 122

Please cite this article in press as: Lee M-H, A Single Case of Tourette’s Syndrome Treated with Traditional Chinese Medicine, Journal of Acupuncture and Meridian Studies (2016), http://dx.doi.org/10.1016/j.jams.2016.12.005 JAMS324_proof ■ 27 December 2016 ■ 2/7

+ MODEL 2 M.-H. Lee

1 1. Introduction deep brain stimulation, which is used when the conditions 63 2 are too difficult to be treated by other treatments. This 64 3 involves a surgery to install electrodes into the corre- 65 4 1.1. Biomedical perspective sponding brain areas and make a connection with a brain 66 5 pacemaker. A group of researchers from Europe conducted 67 6 Q6 Movement of tics is involuntary therefore patients are un- a long-term follow-up of patients treated with deep brain 68 7 able to control them. In addition, tics come in an urgent stimulation and monitored them for 5e6 years. They found 69 8 form. Some patients say that tics reduce the sensation of an a reduction in severity, and improvements in obsessive 70 9 urge, and they feel that the urge is relieved shortly after behaviors and depression were statistically significant [6]. 71 10 the tics. Sometimes, tics will reoccur. Felling and Singer [1] In their conclusion, they mentioned that the 2-year follow- 72 11 claimed that Tourette’s syndrome is a common and chronic up was more positive than the 5- year follow-up [8]. Third, 73 12 neuropsychiatric disorder, and the presentation of Tour- behavior therapy has been studied to reduce the severity of 74 13 ette’s syndrome includes fluctuating motor and phonic tics. tics. Wilhelm et al [9] led a randomized trial of behavior 75 14 Examples of these include eye blinking or deviation, head therapy for adults. The comprehensive behavior interven- 76 15 jerking, unusual movement of the limbs and trunk, chronic tion included a set of training: psychoeducation and 77 16 persistent cough, ocular tics, etc. [2]. In some cases, it can awareness of tics, competing response training, relational 78 17 combine with other conditions such as obsessi- training, functional analysis, etc. Another study, which 79 18 veecompulsive disorder, attention-deficit hyperactivity utilized the same comprehensive behavioral intervention 80 19 disorder, or drug-induced movements such as akathisia, and functional magnetic resonance imaging to investigate 81 20 dystonia, chorea, Parkinson’s, or antisocial behavior [2]. the behavior treatment of Tourette’s syndrome with regard 82 21 Some argued that tic disorder, another name for Tourette’s to neural change, found a significant decrease in the acti- 83 22 syndrome, and both obsessiveecompulsive disorder and vation of striatal neurons of the basal ganglia from before 84 23 attention-deficit hyperactivity disorder are oftentimes to after the treatments [10]. 85 24 associated with aggressive behavior and low impulse con- 86 25 trol [3]. 87 26 The specific causation remains unknown. However, 1.2. Acupuncture and oriental medicine 88 27 Hallett [4] suggested that Tourette’s syndrome could cause perspective 89 28 the tic sensation due to “defective sensory habituation”. 90 29 He hypothesized the habituation was caused by the tics as a In the studies of traditional Chinese medicine, there are a 91 30 Q7 reward as for urgent sensation. Hallett [4] also described few references regarding Tourette’s syndrome. One of the 92 31 Tourette’s syndrome to be often associated with an auto- authors, Dr Pao-Hua Lin [11], wrote a book, called Tour- 93 32 somal recessive inheritance. No abnormal genes have yet ette’s Syndrome Treated with Chinese Medicine. He also 94 33 been found; however, recent studies indicated that these conducted a clinical study of 1000 Tourette’s syndrome 95 34 Q8 patients showed abnormalities in GABA activities in the patients treated with acupuncture and oriental medicine 96 35 brain. Another genetic research out of the range of geno- (AOM) for his 2010 doctoral dissertation from the Liaoning 97 36 Q9 type 609 Tourette’s syndrome cases. In 2014, a signal gene, University of Chinese Medicine. He mentioned that in the Q12 98 37 Q10 rs2060546, was found near the NTN4 axon. These variants old days Tourette’s syndrome patients were treated by 99 38 are suggested to be associated with the risk of Tourette’s changing their names or the Feng shui of the patient’s 100 39 syndrome alleles [5]. Some reports suggest that it could be houses due to the evil attached to them. Even in AOM, 101 40 the result of a combination of medication, such as lamo- there is no name for Tourette’s syndrome. However, the 102 41 trigine or clomipramine, and infection from Lyme disease Huang Di Nei Jing Su Wen describes it as “.all heat 103 42 Q11 (Singer, MD). Moreover, “an imbalance of neurotransmit- madness and convulsions are fire; all that are easily star- 104 43 ters, especially dopamine and serotonin” has been hy- tled, fearful, as if they’ve lost their mind are also fire” [11]. 105 44 pothesized [6]. Lastly, some stimulants such as Qian YI (ACE 1032e1113), a famous Chinese pedestrian, Q13 Q14 106 45 methylphenidate and dextroamphetamine might trigger the wrote the first existing pedestrian book Xiao Er Zhen Zhi 107 46 syndrome as well. Hue. He summarized four conditions associated with the 108 47 There are several treatments that can control the wind to be either observed or treated. First, if the eyes look 109 48 severity of tics, but further investigation is required in upward, it means the internal heat is rushing up to the 110 49 order to control the symptoms more effectively. First, head. Second, blinking the eyes is associated with liver 111 50 pharmacological treatment is usually indicated for moder- wind, and if the eyes cannot move, then there is heat from 112 51 ate to severe tics. In clinics, nondopaminergic drugs have the eyes. Also, the twitching is due to heat in the heart. 113 52 been used for more than 30 years [7]. However, there are Third, “Ji Jing” (acute fright) is caused by Yang excess and 114 53 side effects such as parkinsonian syndromes, tardive Yin deficiency. Extreme heat induces the twitch. Fourth, 115 54 dyskinesia, and metabolic disturbances. In addition, alpha- “Ji Jing” needs to be treated by the cooling and draining 116 55 2 receptor agonists, nicotine, tetrabenazine, GABA ago- method. By contrast, “man Jing” (chronic fright) is treated 117 56 nists, botulinum toxin, cannabinoids, and immune modu- with the warming and tonification method [11]. 118 57 lators have been used and reviewed as well [7]. Hartmann Dr Pao-Hua Lin also mentioned and translated some 119 58 [7] mentioned in his article that aripiprazole and botuli- symptoms such as, “convulsion, grasping, pulling, tremors, 120 59 num toxin injection are two among the many drugs that reverse, drawing in, scurry, and sight” from Chinese med- 121 60 have been used in clinics successfully. In addition, he icine literature Yi Zong Jin Jian in regard to “ the eight 122 61 argued that it is necessary to have more controlled ran- types of wind-fright.” This can contribute to the pattern 123 62 domized studies to test these drugs. A second option is diagnosis of Tourette’s syndrome. In 2003, Simon Becker [6] 124

+ MODEL

Q4 Tourette’s syndrome treated with Chinese medicine 3 Q16 Q18

1 ) 63 2 64 3 65 4 66

5 Aucklandia 67 6 68 7 Pill) 69 8 70 Plus Dragon Bone and 9 continued on next page 71 ( 10 72 11 Rehmannia 73

12 and 74 Decoction) 13 Bupleurum 75 powder to spread the liver) ( and Peony Formula) 14 Decoction) 76 15 77

16 (Sedate the Liver and Extinguish Wind 78 ( Six- Gentlemen Decoction with Buplurum (Tangkuei and Six-Yellow Decoction) Pinellia 17 (Calm the Palace Pill w/Cattle Gallstone) 79 Bupleurum (Four-Substance Decoction with Safﬂower and Phellodendron ( Gallbladder Decoction) Bupleurum ( (

18 Root Bark Decoction) 80 (Cinnamon Twig and Poria Pill) (Five Flavors Special Effect Powder) (Three-Shell Decoction to Restore the Pulse) (Eight Immortal Pill for Longevity) (Four Substance Decoction with Frankincense and (Minor Herbal formula suggestion 19 (Minor 81

20 (Six Gentlemen Decoction) 82 (Construct Roof Tiles Decoction) (Waem (Four Gentlemen Decoction) (Two Cured Decoction) (Vaporize Phlegm Pill) ) (Cool the Diaphragm) Lycium (Cinnamon Twig Decoction) ( 21 (Greatest Treasure Special Pill) 83 (Purple Snow Special Pill) 22 (Restrain the Liver Powder) 84 (Frigid Extremities Powder) 23 85

24 Amomum 86 25 87 Di Gu Pi Yin Ba Xian Chang Wan San Jia Fu Mai Tang Si Ni San Jia Wei Xiao Yao San Chai Hu Shu Gan Tang Wen Dan Tang Er Chen Tang Dang Gui Liu Huang Tang Ru Mo SiMyrrh) Wu Tang Tao Hong SiPeach Wu Pit) Tang Gui Zhi Fu Ling Wan Zi Xue Dan An Gong Niu HuangZhi Wan Bao Dan Oyster Shell Decoction) Liang Ge San Yi Gan San Si Jun Zi Tang Liu Jun Zi Tang Gui Zhi Tang Decoction) Zhi Bai Di Huang Wan Zhen Gan Xi Feng Tang Chai Hu Jia Long Gu Mu LI Tang Xiao Chai Hu Tang Gun Tan Wan Jian Ling Tang Xiao Ban Xia Tang 26 Wu Wei Yi GongXiang San Sha Liu Junand Zi Tang 88 27 89 28 90 29 91 30 92 31 93 32 94 33 95 34 96 35 97 36 98 37 99 38 100 39 101 40 102 41 103 42 104 43 105 44 106 45 107 46 108 47 109 48 110 49 111 50 112 Blinking eyes; winking eyebrows; shoulderextremities shrugging; tremor along of with dizziness;weakness thin of and vitality; pallid five palm in heat;thirsty; body sweating; red type; dryness lips; in stool; soundscoating in but the dry throat; and mirror-like thin; tongue rapid and slightly wiry pulse Head jerking, shoulder shrugging,extremities, vigorous hypochondria twitching pain, of low the attitude, appetite, greasy stubborn white tongue coating, wiry pulse Headache like being stabbed,tightness, pain irritable, in unable fix to locations, concentrate,bruising chest purple spots, tongue bruising with spots in the eyes Cold extremities, tiredness, diarrhea, swollen palescanty tongue coating with Head jerking, shoulder shrugging,eyebrows, blinking pointing eyes, lips, winking yelling,headache, kicking dizziness, legs, red irritability, faceurination, and red eyes, tongue constipation, with darker wiry, white and or big yellow or coating, flooding fullness; pulse Urgent onset; irritable; face,twitching; trunk, swearing; and phlegmy extremity sound muscle insomnia; in red the tongue throat; with thirsty; slippery, greasy and and big yellow pulse coating; wiry, 51 113 )

52 ) 114 53 115 54 116 Gan Qi Yu

55 ) 117 56 118 ) Gan Feng Nei

57 Pi Xu Zhi Leng 119 Yin Xu Feng Dong 58 120 59 121

60 ) 122 ) Qi Zhi Xie Yu 61 Tan Huo Rao Shen 123 Spleen deficiency cold extremities ( Liver Qi stagnation ( Jie Qi stagnation and blood( stasis Wind moving caused bydeficiency Yin ( Liver wind not causedexterior by evil ( Dong Table 1 Pattern Symptom 62 Phlegm fire harassing the( mind 124 Q17 Please cite this article in press as: Lee M-H, A Single Case of Tourette’s Syndrome Treated with Traditional Chinese Medicine, Journal of Acupuncture and Meridian Studies (2016), http://dx.doi.org/10.1016/j.jams.2016.12.005 JAMS324_proof ■ 27 December 2016 ■ 4/7

+ MODEL 4 M.-H. Lee

1 also wrote the article, “Tourette’s syndrome and Chinese 63 2 medicine: treatment possibilities” in the Journal of Chinese 64 3 Medicine in October 2003. It stated that children’s tetanic 65 4 condition was often called “fright wind” or “child fright 66 5 wind” in AOM [12]. 67 6 According to Dr Lin’s book [1], the Chinese medicine 68

7 Pill) scholars have categorized the possible reasons for Tour- 69 8 ette’s syndrome into three types. First, Qi stagnation pro- 70 9 duces a stubborn personality [13]. In AOM, a stubborn 71 10 personality can result in liver Qi stagnation and disturb the 72 11 Qi circulation. Long-term Qi stagnation causes further ﬁre 73 to Restore Five Decoction) 12 Eupolyphaga that turns into the wind. Convulsion of the extremities in 74 and Betel Nut Pill)

13 and AOM is a syndrome of wind. Second, the wind evil con- 75 Yang 14 tributes to the symptom of nonrhythmic motor tics. In AOM, 76 15 the wind, cold, summer heat, dampness, dryness, and ﬁre 77 Decoction)

16 Rhubarb are the major external factors to cause diseases. Third, 78 ( Aucklandia 17 ( phlegm ﬁre disturbs upward and harasses the clear brain Q15 79 (Tonify the 18 creating a tremor in the extremities. Finally, prenatal 80

19 Herbal formula suggestion factors can be the reason. For example, during pregnancy, 81 Quisqualis (Dissolve Parasites Pill) 20 ( the mother may become frightened, have emotional stress, 82

21 (Mume Pill) or experience trauma during the delivery. 83 22 One study has been conducted with the clinical obser- 84 23 vation of 62 Tourette’s syndrome cases using scalp 85 24 acupuncture. They compared 2-hour versus 30-minute 86 25 needle retention at several locations on the scalp; the 87 Shi Jun Zi Tang Da Huang Zhe ChongBu Wan Yang Huan Wu Tang Wu Mei Wan Mu Xiang Bing Lang Wan 26 Hua Chong Wan Raw dragon bone Raw oyster shell, seaPig food brain, pig liver result was similar. Both significantly reduced the symptoms 88 27 [14]. Then, Dr Pao-Hua Lin, a famous Taiwanese AOM doctor 89 28 who treated over 1000 Tourette’s syndrome cases, sum- 90 29 marized four treating principles in his book. The four 91 30 principles are clearing heat and draining downward, 92 31 warming the center, calming the liver and extinguishing 93 32 wind, and harmonizing. Not only acupuncture and herbs 94 33 were used, but also lifestyle and dietary suggestions were 95 34 included in the treatment. He used DU 20, GB20, GV14, 96 35 TW23, LI4, ST36, SP6, HT7, PC6, BL60, and GB41 for 97 36 everyone consistently. In addition, ear points or ear seeds 98 37 were considered. If Yin deficiency causes Yang rising on the 99 38 Du meridian, CV2 can be used. However, if the Yang rising is 100 39 on the Shaoyang meridian, needle LV3 can be used. 101 40 Later in his book, he categorized Tourette’s syndrome 102 41 into eight AOM patterns with its recommended formula. 103 42 The patterns, symptoms, and corresponding formula are 104 43 summarized in Table 1 [11]. 105 44 Besides the formulas that Dr Lin suggested, two formulas 106 45 have been studied in an animal model. They are Jian Pi Zhi 107 46 Dong Decoction and Ningdong granule [12]. In Dr Becker’s 108 47 [6] article, he mentioned Pei Xue-yi’s experience regarding 109 48 the treatment of Tourette’s syndrome. Thirty cases were 110 49 divided into two AOM patterns, internal stirring of liver 111 50 wind and windephlegm harassing above. 112 Biting nails; craving tosymptoms eat of dirt, parasites charcoal, in and the tea digestion leaves; system any Insufficiency of any mineral through a blood test 51 The first group with the “internal stirring of the liver” 113 52 pattern had the following symptoms: head shaking, blinking 114 53 of the eyes, twisted head, and shoulder shrugging. All 20 115 54 ) cases in this group had emotional stress and irritability. 116

55 ) Their tongues were red with a thin yellow coating, and 117 56 pulses were wiry and rapid. No acupuncture points were 118 Kuang Wu Zhi Que 57 ) mentioned, but they were treated with a herbal formula. 119 58 The ingredients in the herbal formula were Jian Can 120 continued 59 ( (Bombyx batryticatus) 10 g, Gou Teng (Ramulus Uncariae 121 60 cum Uncis) 10 g, Quan Xie (Buthus martensi) 6 g, Shi Jue 122 Ming (Concha Haliotidis) 30 g, Bai Ji Li (Fructus Tribuli 61 Cong Zheng 123 According to the symptoms ( Mineral deﬁciency, imbalance of nutrient ( Fu, Ying Yang Shi Tiao 62 Table 1 Pattern Symptom Terrestris) 10 g, and Lian Xin (Plumula Nelumbinis 124 Q17 Please cite this article in press as: Lee M-H, A Single Case of Tourette’s Syndrome Treated with Traditional Chinese Medicine, Journal of Acupuncture and Meridian Studies (2016), http://dx.doi.org/10.1016/j.jams.2016.12.005 JAMS324_proof ■ 27 December 2016 ■ 5/7

+ MODEL Tourette’s syndrome treated with Chinese medicine 5

1 Nuciferae) 4 g. Slight modifications were made accordingly He said if he did not take it, the headache would get worse 63 2 during the period of treatment. For example, if phlegm was and he did not want that to happen. He also took vitamin B 64 3 present, they added Ban Xia (Rhizoma Pinelliae Ternatae), and fish oil once a day. For the Tourette’s syndrome, he had 65 4 Ju Hong (Pars Rubra Epicarpii Citri Eryhtrocarpae), and Tian no medication for 1 year prior to starting the AOM treatment. 66 5 Zhu Huang (Concretio Silicea Bambusae Textilis). 67 The second group with the “wind and phlegm harassing 6 2.1. Diagnosis 68 7 above” pattern had the following symptoms: head nodding, 69 8 eye blinking, lip pointing, shoulder shrugging, and making 70 According to the patient’s report, he was diagnosed with Q20 9 “hey and ha” sounds. The tongue presentation was red with 71 Tourette’s syndrome when he was 9 years old. The AOM 10 a white, thick coating, and the pulse was slippery, as that 72 diagnosis was liver Yang rising with wind due to liver and 11 of the first group, but not rapid. Their treatment principle 73 kidney Yin deficiency. Based on his facial tics and involun- 12 was to transform the phlegm and settle the wind. Similar to 74 tary head and shoulder movements, internal wind was 13 the first group, this group was treated only with an herbal 75 indicated. Maciocia [13] stated that the main manifesta- 14 formula. The formula included Ban Xia (Rhizoma Pinelliae 76 tions of internal wind included tremors, tics, vertigo, and 15 Ternatae) 6 g, Ju Hong (Pars Rubra Epicarpii Citri Eryh- 77 severe dizziness. Furthermore, he explained that liver Yang 16 trocarpae) 6 g, Dan Na Xing (Rhizoma Arisaematis cum Felle 78 rising could give rise to internal wind in chronic patients. Q21 17 Bovis) 4 g, Fu Ling (Sclerotium Poriae Cocos) 10 g, Tian Zhu 79 The patient’s pulse was wiry and thin in all positions. Ac- 18 Huang (Concretio Silicea Bambusae Textilis) 10 g, Gou Teng 80 cording to pulse diagnosis in Maciocia’s [13] book, a wiry 19 (Ramulus Uncaretio cum Uncis) 10 g, Shi Chang Pu (Rhizoma 81 pulse could be clinically significant for liver disharmony, 20 Acori Graminei) 10 g, and Yu Jin (Tuber Curcumae) 10 g. Bai 82 pain, or phlegm. In addition, a thin pulse indicated Yin Xu. 21 Ji Li (Fructus Tribuli Terrestris) and Shi Jue Ming (Concha 83 The red tip of the tongue indicated heat in the heart and 22 Haliotidis) were added if the jerking of the limbs was 84 absence of tongue coating indicated stomach or kidney Yin 23 severe. 85 deficiency [11]. Since a headache was located in the vertex 24 The results for the treatment were as follows: 20% were 86 area, which usually occurred around 11 AM, it was identified 25 cured, 20% showed marked improvement, 33% experienced 87 as either heart fire or liver Yang rising based on the Chinese Q22 26 some improvement, and 27% reported no improvement at 88 clock and the location of a headache. Maciocia [13] in his 27 all [12]. 89 book The Practice of Chinese Medicine hypothesized that 28 90 the head is the area where all Yang energy accumulates. 29 91 This confirmed the diagnosis as liver Yang rising due to the 30 2. Case Presentation 92 symptoms in the head. 31 93 32 A 33-year-old male had been diagnosed with Tourette’s 94 33 syndrome at the age of 9 years. He was medicated with 2.2. Treatment 95 34 sedation drugs for 25 years after the diagnosis. As the 96 35 treatment was noneffective in controlling any of his 97 2.2.1. Acupuncture 36 symptoms, he stopped taking the medication 1 year before 98 The acupuncture points were as follows: Zhu’s scalp point 37 Q19 coming to the clinic. His main symptoms include tics on the 99 for tremor, Yin Tan, Bai Hui (Du 20), Si Zhu Kong (Tw 23), 38 face, clearing the throat, and involuntary head and shoul- 100 Jia Che (St 6). Xia Guan (St 7), Nei Guan (Pc 6), Shen Men 39 der movements. Besides Tourette’s syndrome, he also 101 (Ht 7), San Yin Jiao (Sp 6), Jue Yin Shu (Bl 14), Feng Shi (Gb 40 complained of headaches. The severity of headaches was 102 31), Yang Ling Quan (Gb 34), Tai Chong (Lv 3), He Gu (Li 4), 41 6/10. It is mainly located at the front of the head and 103 Zu San Li (St 36). 42 vertex area. His third complaint was social anxiety. He 104 All the points were treated once a week for 35 treat- 43 stated that he had limited social activity. Usually, his daily 105 ments. Besides scalp points and Yin Tang, all points were 44 activities are working and walking his dog. He works at a 106 needled bilaterally. SL type of needles were used; 0.22 mm 45 place where he does not see the customer in person. He 107 of 15-mm needles were used for the Zhu’s tremor scalp 46 explained that he seldom socialized with friends. Occa- 108 points, and 0.32 mm of 30-mm needles were used for all the 47 sionally, he would go out with coworkers to drink beer. 109 body points. There was no stimulation for all the needles, 48 When he needed to make a public speech or met with other 110 but GB 31 and GB 34 needed to have a Qi sensation. The Q23 49 coworkers, he had excessive worry and anxiety. This made 111 needles were retained for 20 minutes in each treatment. 50 his tic symptoms worse. He had a car accident in 2001, 112 51 resulting in broken ribs and lacerated spleen. The spleen 113 52 was not removed after the accident; later, it recovered 2.2.2. Herb formula 114 53 fully. The formula Zhen Gan Xi Fan Tang with raw herbs was used 115 54 He was single and biked to work from Monday to Friday. He for the first 12 treatments. The ingredients were Huai Niu 116 55 preferred spicy food and tried to avoid gluten. He had no Xi (Archyanthis Bidentatae Radix) 18 g, Dai Zhe Shi (Hae- 117 56 complaints concerning his digestive system. His bowel matitum) 30 g, Long Gu (Os Draconis) 15 g, Sheng Mu Li 118 57 movement was once a day, and he had neither constipation (Concha Ostrae) 15 g, Gui Ban (Testudinid Plastrum) 15 g, 119 58 nor soft stool. He felt thirsty most of the time, although he Xuan Shen (Radix Scrophulariae Ningpoensis) 15 g, Tian Men 120 59 thought he was hydrated enough. He felt cold most of the Dong (Asparagi Radix) 15 g, Yin Chen Hao (Herba Arteme- 121 60 time, but his face and eyes were red. He took one Excedrin siae Yinchenhao) 6 g, Chuan Lian Zi (Meliae Toosendan 122 61 tablet and several pills of Aspirin a day for headaches if Fructus) 6 g, Mai Ya (Hordel Fructus germinates) 6 g, and Q24 123 62 needed. Usually, he took three to four pills of Aspirin a day. Gan Cao (Radix Glycyrrhizae) 6 g. 124

+ MODEL 6 M.-H. Lee

1 The patient cooked the raw herbs himself using four week treatment, for more than 35 treatments, with 63 2 Q25 cups of water until the solution was reduced to two cups. acupuncture and herbs, the outcome still remained some 64 3 He drank one cup of solution after breakfast and the other degree of improvement. Other modalities might need to be 65 4 Q26 cup after dinner. The raw herb decoction needed to be considered besides acupuncture and herbs. In addition, 66 5 drunk warm. After the 13th treatment, the granule Zhen more cases are needed to be studied in order to compare 67 6 Gan Xi Fan Tang formula continued to be used until the 35th the outcomes. 68 7 treatment. The dosage remained the same, but the patient 69 8 took 6 g three times a day before meal. 3.1. Conclusion 70 9 71 10 2.2.3. Another modality The effectiveness of AOM to treat Tourette’s syndrome in 72 th th 11 Gua-Sha was used after the 12 treatment until the 35 this study was fair due to lack of scientific outcome mea- 73 12 treatment. Ceramic Chinese spoons were used for Gua-Sha. surement and limited case number. If the outcome was Q33 74 13 The Alba Hawaiian body oil was used as a lubricant for Gua- based on the patients’ self-report, then the effectiveness 75 14 Q27 Sha. would have been 70%. In conclusion, AOM could be a sup- 76 15 plement treatment for Tourette’s syndrome. Further 77 16 2.3. Outcome investigation and more modality besides acupuncture, 78 17 herb, and Gua- Sha can be used in order to improve the 79 18 His fifth treatment follow-up form showed his symptoms of quality of life of Tourette’s syndrome patients. 80 19 Tourette’s syndrome were unchanged. In addition, the 81 20 82 headache symptoms were the same, but his social anxiety Disclosure statement 21 improved. He started to meet people and hiked with friends 83 22 every weekend. 84 23 The author declares no conflicts of interest and no financial 85 According to clinician’s observation, his tics and other interest related to the material of this manuscript. 24 signs of Tourette’s syndrome decreased. According to the 86 25 87 Q28 patient’s self-rating on a scale of servility (5/5 indicating 26 the most severe symptom and 0/5 no symptom at all), his Acknowledgments 88 27 89 Q29 Tourette’s syndrome symptoms decreased. He reached the 28 servility of 2/5 from 5/5. He had a headache only for a This study is supported financially by the author. 90 29 week compared with having a headache every day. After 91 30 th 92 the 35 treatment, the patient presented no tics during the References 31 25-minute interview, and he also reported that his tics were 93 32 reduced by 70% during his daily activities. 94 33 [1] Felling RJ, Singer HS. Neurobiology of Tourette’s syndrome: 95 34 current status and need for further investigation. J Neurosci. 96 e 35 3. Discussion 2011;31:12387 12395. 97 36 [2] Singer HS. Current issues in Tourette’s syndrome. Mov Disord. 98 2000;15:1051e1063. 37 Tourette’s syndrome is in the second category that was 99 [3] Banaschewski T, Siniatchkin M, Uebel H, Rothenberger A. Q30 38 reviewed by the World Health Organization in 1996. It has Compulsive phenomena in children with tic disorder and 100 39 been proved to have improved with the treatment of attention deficit-hyperactive disorder. Z Kinder Jugend- 101 40 traditional Chinese medicine [14]. Based on the YineYang psychiatr Psychother. 2003;31:203e211 [In German]. 102 41 of traditional Chinese medicine, if the Yin blood or circu- [4] Hallett M. Tourette’s syndrome: update. Brain Dev. 2015;37: 103 42 lation is impaired, then the Yang’s nervous function would 651e655. Q34 104 43 be affected [14]. In Chang’s [14] comparative review of the [5] Paschou P, Yu D, Gerber G, Evans P, Tsetsos F, Davis LK, et al. 105 44 meridian system and the mechanism of acupuncture, he Genetic association signal near NTN4 in Tourette’s syndrome. 106 e 45 proposed that if acupuncture increased blood flow, then Ann Neurol. 2014;76:310 315. 107 46 the electromagnetic field that was generated was too weak [6] Becker S. Tourette’s syndrome and Chinese medicine: treat- 108 ment possibilities. J Chin Med. 2003. Q35 47 Q31 to change the circuit in the neurovascular bundles. 109 [7] Hartmann A. Clinical pharmacology of nondopaminergic drugs 48 The AOM’s diagnosis was liver Yang rising due to kidney in Tourette’s syndrome [review]. Int Rev Neurobiol. 2013;112: 110 49 and liver Yin deficiency. If we applied Chang’s [14] com- 351e372. 111 50 parison, the liver and kidney Yin blood would cause [8] Porta M, Servello D, Zanaboni C, Anasetti F, Menghetti C, 112 51 tremors, tics, and body movement due to the close circuit Sassi M, et al. Deep brain stimulation for treatment of re- 113 52 system of nerve. After the acupuncture treatment to focus fractory Tourette’s syndrome: long-term follow-up. Acta 114 53 on the increasing liver and kidney’s blood, the movement Neurochir (Wien). 2012;154:2029e2041. 115 54 Q32 has significant change. [9] Wilhelm S, Peterson AL, Piacentini J, Woods DW, 116 55 This study’s outcome was based on observation and the Deckersbach T, Sukhodolsky DG, et al. Randomized trial of 117 56 patient’s report. In addition, social activities of this case behavior therapy for adults with Tourette’s syndrome. Arch 118 Gen Psychiatry. 2012;69:795e803. 57 were based on the patient’s report. Owing to the limitation 119 [10] Deckersbach T, Chou T, Britton JC, Carlson LE, Reese HE, 58 of outcome measurement for Tourette’s syndrome, this Siev J, et al. Neural correlates of behavior therapy for Tour- 120 59 study would be more significant if a self-report dairy was ette’s disorder. Psychiatry Res. 2014;224:269e274. 121 60 used. Furthermore, some herbal formulas have been stud- [11] Lin P-H. Tourette’s Syndrome Treated with Chinese Medicine. 122 61 ied only in the animal trials, and some case studies re- 2nd ed. Taipei, Taiwan: Su Quan (Book Spring) Publishing 123 62 ported some degree of improvement. Even after once-a- House; 2011. 124

+ MODEL Tourette’s syndrome treated with Chinese medicine 7

1 [12] Lv H, Li A, Ma H, Liu F, Xu H. Effects of Ningdong granule on [14] Chang S. The meridian system and mechanism of acupunctureda 5 2 the dopamine system of Tourette’s syndrome rat models. J comparative review. Part 1: the meridian system. Taiwan J 6 e e 3 Ethnopharmacol. 2009;124:488 492. Obstet Gynecol. 2012;51:506 514. 7 4 [13] Maciocia G. The Practice of Chinese Medicine. 2nd ed. United 8 Q36 Kingdom: Churchill Livingstone; 2008:8e9.