Tourette’s Syndrome: Comorbid Disorders

Tourette Syndrome (TS) often occurs with other related conditions (also called co-occurring conditions). These conditions can include:

 attention-deficit/hyperactivity disorder (ADHD) obsessive-compulsive disorder (OCD)
, Mood disorders such as depression and Bipolar Disorder and other behavioral or conduct problems,
  and non-OCD anxiety disorders

People with TS and related conditions can be at higher risk for learning, behavioral, and social problems.

The symptoms of other disorders can complicate the diagnosis and treatment of TS and create extra challenges for people with TS and their families, educators, and health professionals.

Findings from a national Centers for Disease Control and Prevention (CDC) study1 indicated that 79% of children who had been diagnosed with TS also had been diagnosed with at least one additional mental health, behavioral, or developmental condition based on parent report.

Among children with TS:

64% had ADHD.

43% had behavioral problems, such as oppositional defiant disorder (ODD) or conduct disorder (CD).

40% had anxiety problems.

36% had depression.

28% had a developmental delay

Because co-occurring conditions are so common among people with TS, it is important for doctors to assess every child with TS for other conditions and problems.

Source:http://www.cdc.gov/ncbddd/tourette/otherconcerns.html

http://www.schoolbehavior.com/disorders/tourettes-syndrome/tourettes-syndrome-comorbid-or-associated-disorders/

Tourette Syndrome

Definition

Tourette syndrome (TS) is an inherited disorder of the nervous system, characterized by a variable expression of unwanted movements and noises (tics).

Description

The first references in the literature to what might today be classified as Tourette syndrome largely describe individuals who were wrongly believed to be possessed by the devil. In 1885 Gilles de la Tourette, a French neurologist, provided the first formal description of this syndrome, which he described as an inherited neurological condition characterized by motor and vocal tics.

Although vocal and motor tics are the hallmark of Tourette syndrome, such other symptoms as the expression of socially inappropriate comments or behaviors, obsessive compulsive disorder, attention deficit disorder, self-injuring behavior, depression, and anxiety also appear to be associated with Tourette syndrome. Most research suggests that Tourette syndrome is an autosomal dominant disorder, although a gene responsible for Tourette syndrome has not yet been discovered.

Tourette syndrome is found in all populations and all ethnic groups, but is three to four times more common in males than females and is more common in children than adults. The exact frequency of Tourette syndrome is unknown, but estimates range from 0.05% to 3%.

Causes and symptoms

The cause of Tourette syndrome is unknown, although some studies suggest that the tics in Tourette syndrome are caused by an increased amount of a neurotransmitter called dopamine. A neurotransmitter is a chemical found in the brain that helps to transmit information from one brain cell to another. Other studies suggest that the defect in Tourette syndrome involves another neurotransmitter called serotonin; or involves other chemicals required for normal functioning of the brain.

Most studies suggest that Tourette syndrome is an autosomal dominant disorder with decreased penetrance, although this hypothesis has not been proven and may not be true in all families. An autosomal dominant disorder results from a change in one copy of a pair of genes. Individuals with an autosomal dominant disorder have a 50% chance of passing on the changed gene to their children. Decreased penetrance means that not all people who inherit the changed gene will develop symptoms. There is some evidence that females who inherit the Tourette syndrome gene have a 70% chance of exhibiting symptoms and males have a 99% chance of having symptoms. It has been suggested that other genetic and environmental factors may play a role in the development of symptoms in people who inherit the changed gene, but none have been discovered. Some researchers believe that Tourette syndrome has different causes in different individuals or is caused by changes in more than one gene, although these theories are less substantiated. Further research is needed to establish the cause of Tourette syndrome.

Motor and vocal tics

The principal symptoms of Tourette syndrome include simple and complex motor and vocal tics. Simple motor tics are characterized by brief muscle contractions of one or more limited muscle groups. An eye twitch is an example of a simple motor tic. Complex motor tics tend to appear more complicated and purposeful than simple tics, and involve coordinated contractions of several muscle groups. Some examples of complex motor tics include the act of hitting oneself and jumping. Copropraxia, the involuntary display of unacceptable/obscene gestures; and echopraxia, the imitation of the movement of another individual, are other examples of complex motor tics.

Vocal tics are actually manifestations of motor tics that involve the muscles required for vocalization. Simple vocal tics include stuttering, stammering, abnormal emphasis of part of a word or phrase, and inarticulate noises such as throat clearing, grunts, and high-pitched sounds. Complex vocal tics typically involve the involuntary expression of words. Perhaps the most striking example of this is coprolalia, the involuntary expression of obscene words or phrases, which occurs in fewer than one-third of people with Tourette syndrome. The involuntary echoing of the last word, phrase, sentence or sound vocalized by oneself (phalilalia) or of another person or sound in the environment (echolalia) are also classified as complex tics.

The type, frequency, and severity of tics exhibited varies tremendously between individuals with Tourette syndrome. Tourette syndrome has a variable age of onset and tics can start anytime between infancy and age 18. Initial symptoms usually occur before the early teens; the mean age of onset for both males and females is approximately seven years of age. Most individuals with symptoms initially experience simple muscle tics involving the eyes and the head. These symptoms can progress to tics involving the upper torso, neck, arms, hands, and occasionally the legs and feet. Complex motor tics are usually the latest-onset muscle tics. Vocal tics usually have a later onset then motor tics. In some rare cases, people with Tourette syndrome suddenly present with multiple, severe, or bizarre symptoms.

Not only is there extreme variability in clinical symptoms between individuals with Tourette syndrome, but individuals commonly experience a variability in type, frequency, and severity of symptoms over the course of their lifetime. Adolescents with Tourette syndrome often experience unpredictable and variable symptoms, which may be related to fluctuating hormone levels and decreased compliance in taking medications. Adults often experience a decrease in symptoms or a complete end to symptoms.

A number of factors appear to affect the severity and frequency of tics. Stress appears to increase the frequency and severity of tics, while concentration on another part of the body that is not involved in a tic can result in the temporary alleviation of symptoms. Relaxation, following attempts to suppress the occurrence of tics, may result in an increased frequency of tics. An increased frequency and severity of tics can also result from exposure to such drugs as steroids, cocaine, amphetamines, and caffeine. Hormonal changes such as those that occur prior to the menstrual cycle can also increase the severity of symptoms.

Other associated symptoms

People with Tourette syndrome are more likely to exhibit non-obscene, socially inappropriate behaviors such as expressing insulting or socially unacceptable comments or socially unacceptable actions. It is not known whether these symptoms stem from a more general dysfunction of impulse control that might be part of Tourette syndrome.

Tourette syndrome appears to also be associated with attention deficit disorder (ADD). ADD is a disorder characterized by a short attention span and impulsivity, and in some cases hyperactivity. Researchers have found that 21-90% of individuals with Tourette syndrome also exhibit symptoms of ADD, whereas 2-15% of the general population exhibit symptoms of ADD.

People with Tourette syndrome are also at higher risk for having symptoms of obsessive-compulsive disorder (OCD). OCD is a disorder characterized by persistent, intrusive, and senseless thoughts (obsessions) or compulsions to perform repetitive behaviors that interfere with normal functioning. A person with OCD, for example, may be obsessed with germs and may counteract this obsession with continual hand washing. Symptoms of OCD are present in 1.9-3% of the general population, whereas 28-50% of people with Tourette syndrome have symptoms of OCD.

Self-injurious behavior (SIB) is also seen more frequently in those with Tourette syndrome. Approximately 34-53% of individuals with Tourette syndrome exhibit some form of self-injuring behavior. The SIB is often related to OCD but can also occur in those with Tourette syndrome who do not have OCD.

Symptoms of anxiety and depression are also found more commonly in people with Tourette syndrome. It is not clear, however, whether these symptoms are symptoms of Tourette syndrome or occur as a result of having to deal with the symptoms of moderate to severe Tourette syndrome.

People with Tourette syndrome may also be at increased risk for having learning disabilities and personality disorders; and may be more predisposed to such behaviors as aggression, antisocial behaviors, severe temper outbursts, and inappropriate sexual behavior. Further controlled studies need to be performed, however, to ascertain whether these behaviors are symptoms of Tourette syndrome.

Diagnosis

Tourette syndrome cannot be diagnosed through a blood test. The diagnosis is made through observation and interview of the patient and discussions with other family members. The diagnosis, of Tourette syndrome is complicated by a variety of factors. The extreme range of symptoms of this disorder makes it difficult to differentiate Tourette syndrome from other disorders with similar symptoms. Diagnosis is further complicated by the fact that some tics appear to be within the range of normal behavior. For example an individual who only exhibits such tics as throat clearing and sniffing may be misdiagnosed with a medical problem such as allergies. In addition, such bizarre and complex tics as coprolalia may be mistaken for psychotic or "bad" behavior. Diagnosis is also confounded by individuals who attempt to control tics in public and in front of health care professionals and deny the existence of symptoms. Although there is disagreement over what criteria should be used to diagnosis Tourette syndrome, one aid in the diagnosis is the DSMMD (DSM-IV). The DSM-IV outlines suggested diagnostic criteria for a variety of conditions including Tourette syndrome.

DSM-IV criteria

• presence of both motor and vocal tics at some time during the course of the illness
• the occurrence of multiple tics nearly every day through a period of more than one year, without a remission of tics for a period of greater than three consecutive months
• the symptoms cause distress or impairment in functioning
• age of onset of prior to 18 years of age
• the symptoms are not due to medications or drugs and are not related to another medical condition

Some physicians critique the DSM-IV criteria, arguing that they do not include the full range of behaviors and symptoms seen in Tourette syndrome. Others criticize the criteria since they limit the diagnosis to those who experience a significant impairment, which may not be true for individuals with milder symptoms. For this reason many physicians use their clinical judgment as well as the DSM-IV criteria as a guide to diagnosing Tourette syndrome.

Treatment

There is no cure for Tourette syndrome. Treatment involves the control of symptoms through educational and psychological interventions and/or medications. The treatment and management of Tourette syndrome varies from patient to patient and should focus on the alleviation of the symptoms that are most bothersome to the patient or that cause the most interference with daily functioning.

Psychological and educational interventions

Psychological treatments such as counseling are not generally useful for the treatment of tics but can be beneficial in the treatment of such associated symptoms as obsessive-compulsive behavior and attention deficit disorder. Counseling may also help individuals to cope better with the symptoms of this disorder and to have more positive social interactions. Psychological interventions may also help people cope better with stressors that can normally be triggers for tics and negative behaviors. Relaxation therapies may, however, increase the occurrence of tics. The education of family members, teachers, and peers about Tourette syndrome can be helpful and may help to foster acceptance and prevent social isolation.

Medications

Many people with mild symptoms of Tourette syndrome never require medications. Those with severe symptoms may require medications for all or part of their lifetime. The most effective treatment of tics associated with Tourette syndrome involves the use of drugs such as haloperidol, pimozide, sulpiride, and tiapride, which decrease the amount of dopamine in the body. Unfortunately, the incidence of side effects, even at low dosages, is quite high. The short-term side effects can include sedation, dysphoria, weight gain, movement abnormalities, depression, and poor school performance. Long-term side effects can include phobias, memory difficulties, and personality changes. These drugs are therefore better candidates for short-term rather than long-term therapy.

Tourette syndrome can also be treated with such other drugs as clonidine, clonazepam, and risperidone, but the efficacy of these treatments is unknown. In many cases, treatment of such as associated conditions such as ADD and OCD is often more of a concern than the tics themselves. Clonidine used in conjunction with such stimulants as Ritalin may be useful for treating people with Tourette syndrome who also have symptoms of ADD. Stimulants should be used with caution in individuals with Tourette syndrome since they can sometimes increase the frequency and severity of tics. OCD symptoms in those with Tourette syndrome are often treated with such drugs as Prozac, Luvox, Paxil, and Zoloft.

In many cases the treatment of Tourette syndrome with medications can be discontinued after adolescence. Trials should be performed through the gradual tapering off of medications and should always be done under a doctor's supervision.

Prognosis

The prognosis for Tourette syndrome in individuals without associated psychological conditions is often quite good, and only approximately 10% of Tourette syndrome individuals experience severe tic symptoms. Approximately 30% of people with Tourette syndrome will experience a decrease in the frequency and severity of tics, and another 30-40% will experience a complete end of symptoms by late adolescence. The other 30-40% will continue to exhibit moderate to severe symptoms in adulthood. There does not appear to be a definite correlation between the type, frequency, and severity of symptoms and the eventual prognosis. Patients with severe tics may experience social difficulties and may isolate themselves from others in fear of shocking and embarrassing them. People with Tourette syndrome who have such other symptoms as obsessive compulsive disorder, attention deficit disorder, and self-injurious behavior usually have a poorer prognosis.

Grow Cannabis Indoors

Tourette's Syndrome: Gecko Guy's Story

This video is of a 19 year old guy with tourette syndrome.He goes by the name of GeckoGuy31127 on youtube.

Dating with Tourette Syndrome

Get it “Out of the Way” Early

You don’t need the added pressure of concealment--plus the more you try to hide tics, the worse they can get. Although you probably shouldn’t introduce yourself with , “Hi, my name’s Joel, and I have Tourette’s,” it’s a good idea to clear the air early on.  Suggestion: Take the opportunity offered the next time you tic. You can be sure he or she noticed, so you might say, “you know that twitchy thing I do? It’s because I have Tourette Syndrome.” After that you can provide as much or as little information as the person’s reaction seems to require. A joke or two can come in handy as well.

Blurting

That very tic-like occurrence that happens when you feel compelled to say something completely inappropriate—is one of the most frequent worries that people with TS have on a date.  It’s a concern because it does happen sometimes.  If this is one of your fears, it’s a lot easier to explain before it actually happens than afterwards.

Symptom Substitution

is one strategy you can use if you currently have a tic that you fear might offend your date. Talk to a doctor or therapist who knows TS well about how to do this (basically, it involves finding an alternative behavior that satisfies the same urge).  For example:  say you have a nose-picking tic—there might be something else you could do with your finger when that urge comes on. With a bit of practice, you can avoid causing offense, even though it might not be possible to stop ticcing altogether.

Talk About It, Role Play

Many people with TS, especially those whose symptoms are more severe, worry about finding a partner to discuss these things with. The issue may be what you think about yourself, not how others see you. Childhood and adolescent experiences of being teased and bullied, can lower self-esteem. In one Canadian study1, 40 percent of adults with TS reported problems in dating or making friends. For some, seeing a counsellor can help talk through your experiences, and perhaps help you role-play the things you worry about, like introducing yourself to someone new or telling a date about your TS.

Lower the Stress Level

Meeting new people is stressful for everyone, .but  the same things that work for others can work for you too.  Find ways to be in low-stress situations with lots of potential partners. Instead of the high-anxiety bar and club scene, for example, you might try joining a martial arts class or taking a night class in a foreign language. Meeting someone with a shared interest reduces the stress level because you aren’t literally “on the prowl,” so there’s less pressure to perform. Others swear by speed dating events, organised singles parties that include icebreaker games and such. And of course, going out with a group of friends means you can check out the local venues but still have a great time if your pick up lines fall flat. Online dating is a possibility as well.

Play Your StrengthsMany people with TS have some advantages over others when it comes to dating – good verbal skills, quick minds and quick wit.  You can probably charm anyone—just give yourself the chance.  Try honing your “charm” skills with relatives, neighbors, barristas, even pets.

Source:http://tsa-usa.org/aPeople/LivingWithTS/dating.htm

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Clara Faile

Clara Faile has Tourette syndrome. But when she's acting — she's playing the starring role in Greendale High's production of "Peter Pan" — the nervous tics and the anxiety disappear.Video by Mike De Sisti

Tourette's Uncovered Part 1 and 2

Tourette Syndrome: Handbook for Patient and Family (Google Affiliate Ad)

Transient tic disorder also known as benign tic disorder of childhood

Transient tic disorder is a temporary condition in which a person makes one or many brief, repeated, difficult to control movements or noises (tics)

Tics are a type of dyskinesia, which is the general medical term given to impairments or distortions of voluntary movements. Although tics vary considerably in severity, they are associated with several neuropsychiatric disorders in children and adolescents

A tic is a nonvoluntary body movement or vocal sound that is commonly made repeatedly, rapidly, and suddenly. It has a stereotyped but nonrhythmic character. The child or adolescent with a tic experiences it as irresistible urge or feeling similar to sneezing but can suppress the movement or noise for a period of time. Tics are categorized as motor or vocal, and as simple or complex. The word "tic" itself is French.

The cause of transient tic disorder can be physical or mental (psychological). It may be a mild form of Tourette syndrome.

The child may have facial tics or tics involving movement of the arms, legs, or other areas.

Tics may involve:

Movements that occur again and again and don't have a rhythm
An overwhelming urge to make the movement
Brief and jerky movements that include the following:

Blinking,Clenching the fists,Curling the toes,Flaring the nostrils,Grimacing Jerking the arms,Kicking Opening the mouth,Raising the eyebrows,Shrugging the shoulders,Sticking out the tongue

The tics often look like nervous behavior. Tics appear to get worse with stress and do not occur during sleep.

Sounds may also occur, such as:
Clicking Grunting Hissing Moaning Sniffing Snorting Squealing Throat clearing


The criteria for transient tic disorder specify that the onset must occur before the age of 18 years; the tics must occur many times a day almost every day for at least four weeks but not longer than 12 months

Simple childhood tics usually disappear over a period of months.There are usually no complications tho a chronic motor or vocal tic disorder can develop.

Talk to your health care provider if you are concerned about a transient tic disorder, especially if it continues or disrupts your child's life.

Movement Disorders

Movement Disorders are a group of neurological diseases which is thought to be caused by defects in the basal ganglia, clusters of nerve cells in the brain that control muscular activity.
Injury to these regions ultimately affects the motion of muscles in the face, limbs, and trunk. The movement disorders most often discussed as candidates for marijuana based therapies are dystonias, Huntington's disease, Parkinson's disease and Tourette's syndrome. As a general consideration, it is important to note that stress and anxiety tend to worsen the symptoms of movement disorders. Thus, marijuana's calming effect could be a primary reason why some patients claim that it brings them relief.

Dystonias are a subgroup of movement disorders that share similar symptoms: slow, sustained, involuntary muscle contractions that often cause sufferers to hold their limbs, trunks, or necks in odd positions. They may be confined to one part of the body; for example, spasmodic torticollis affects only the neck, while Meige's syndrome distorts the face. These chronic, slowly progressive disorders are often painful and can cause mild to severe disability. Some dystonias are inherited, while others occur as side effects of certain drugs. Scientists have yet to discover the specific neurological malfunctions that cause dystonias.

Several different drugs are used to treat various forms of dystonia. The most commonly prescribed drugs—benzodiazepines, baclofen, Botulinum toxin, anticholinergic agents, and tetrabenazine—merely relieve the symptoms of dystonia rather than resolving the condition itself. In many cases the relief they provide is incomplete. Baclofen (Lioresal) and benzodiazepines, including diazepam (Valium) and clonazepam (Klonopin, Rivotril), act by reducing the nervous system's ability to stimulate muscle contractions. Both drugs usually make patients drowsy and may also cause a range of additional side effects, including muscle weakness and behavioral problems. Botulinum toxin—a bacterial compound that also causes food poisoning—also blocks muscle stimulation; it produces few side effects but must be injected directly into the affected muscles. Anticholinergic drugs such as trihexyphenidyl (Artane) and diphenhydramine (Benadryl) deactivate muscle contractions; they, too, cause drowsiness and other side effects that can become severe at high doses. Tetrabenazine, although not available in the United States, is a dopaminedepleting compound available in Canada and Europe that is often prescribed for the relief certain types of dystonia.

No controlled study of marijuana in patients with dystonia has yet been published. Cannabidiol, a chemical component of marijuana (see Chapter 2), was tested in a preliminary open trial in which patients knew they were receiving the experimental drug. The five participants showed only modest improvements, which increased with the amount of drug they received.1 Better results occurred in a study of an animal model for dystonia —a mutant strain of hamsters—in which researchers tested a synthetic cannabinoid that activates the same cellular receptors as THC. The hamsters exhibited a type of dystonia that produces either sudden spasms of rapid, jerky motions or slow, repetitive writhing movements, both of which decreased under the influence of the cannabinoid.2

Besides being a diagnosis in its own right, dystonia is also a symptom of other major movement disorders, including Huntington's disease. This inherited disorder usually manifests itself in middle age, continues to worsen, and ultimately leads to death within 15 years of its appearance. Symptoms include rapid, uncontrolled muscle movements (called “chorea, ” from the Greek word for dance), emotional disturbance and eventually dementia. Patients may take drugs, including reserpine or haloperidol, mainly to control their psychological symptoms. All of these medicines produce adverse side effects, so physicians often wait to prescribe them until a patient's symptoms become severe.

Since anxiety and stress appear to worsen involuntary movements in many patients with Huntington's disease and since marijuana reduces those feelings in most users, some have proposed it as an alternative to existing medications. Animal studies suggest that cannabinoids might suppress choreic movements, presumably by stimulating receptors in the basal ganglia (see Chapter 2). In a preliminary study of four people with Huntington's disease, one patient showed improvement under the influence of cannabidiol.3 Based on this limited success, researchers attempted a double-blind crossover study (see Introduction to Part II for a discussion of clinical study design) on 15 patients who were not taking medications to inhibit chorea but found that participants ' symptoms neither improved nor worsened after treatment with cannabidiol. 4 These results are perhaps to be expected, though, since cannabidiol does not bind to the predominant type of cannabinoid receptor (CB1) on neurons affected by Huntington's dis-ease. THC or other cannabinoids that readily bind CB1 receptors seem likelier candidates as medications for Huntington 's disease, but their effects on patients with the disorder remain unknown.

One of the most devastating movement disorders, Parkinson's disease, affects approximately 1 million Americans age 50 and older. Symptoms include tremor, muscular rigidity, instability, and impeded motion (both slowed movement and abrupt stopping in midmovement). The single most effective drug to treat Parkinson's disease, levodopa (L-Dopa, Larodopa, Dopar), has many drawbacks, so physicians tend to reserve it for functionally impaired patients. After several years of use, levodopa tends to wear off quickly after each dose, so patients constantly cycle through phases of mobility and disability. Additional side effects include nausea, hallucination, and confusion. Researchers also suspect that, while levodopa dramatically improves all of the signs and symptoms of Parkinson's disease, its use may accelerate the disease's progress; no clinical evidence confirms this concern.

Because they act on the same neurological pathways that Parkinson 's disease disrupts, cannabinoids could in theory be useful in treating the disorder (see Chapter 2). The IOM team found only one published account of a clinical trial of marijuana for Parkinson's disease. The study was prompted by a patient's report that smoking marijuana reduced tremor, but when researchers tested the drug on five additional patients with tremor, they found no evidence of improvement. On the other hand, conventional medications, including levodopa, successfully reduced tremor in all five patients.5

Unlike Huntington's and Parkinson's diseases, Tourette's syndrome typically appears during childhood. Patients exhibit a variety of rapid, involuntary, repetitive movements and vocalizations, collectively called tics. The causes of Tourette's syndrome are largely unknown but are thought to impair brain areas that convert a person's intent to move into actual movements. Damage to these same areas produces involuntary movement in Huntington's disease and restricts voluntary movement in Parkinson's disease.

Two widely used medications for Tourette's syndrome, pimozide (Orap) and haloperidol (Haldol) inhibit the effects ofthe neurotransmitter dopamine. Cannabinoids, by contrast, increase dopamine release, so one might predict that cannabinoids would actually exacerbate the symptoms of Tourette's syndrome. Yet four clinical case histories indicate that marijuana use can reduce tics in Tourette 's patients. In three of the four cases, however, the investigators suggest that marijuana's anxiety-reducing properties—rather than any specific effect on the neural pathway that produces tics—caused the patients' symptoms to improve.6

In summary, while persuasive basic evidence exists for the role of cannabinoids in movement, clinical evidence for their usefulness in relieving the symptoms of movement disorders is lacking. The few existing studies were performed on small numbers of patients and without consideration that marijuana's antianxiety effects might reduce the symptoms in question. Moreover, while there are a few isolated anecdotal reports that marijuana helps patients with these disorders, there are no surveys to suggest that these patients' experiences are at all representative.

Thus, with the possible exception of spasticity in multiple sclerosis, there is little reason to recommend additional clinical trials of marijuana or cannabinoids for movement disorders, the IOM study team concluded. That is not to say that more extensive animal studies will never provide stronger evidence in favor of human trials. But until reliable animal models exist for most movement disorders, such evidence is unlikely to be forthcoming. In the meantime the IOM team recommends conducting double-blind, placebo-controlled clinical trials of individual cannabinoids such as THC—but not smoked marijuana—for the treatment of movement disorders.

The IOM team further specified that these trials should test the effects of cannabinoids on movement alone—that is, the experiments should distinguish cannabinoids' effects on movement from their effects on anxiety or mood. For if cannabinoids merely provide a psychological boost to people with multiple sclerosis, their use would probably not warrant the risk of short-term memory loss, cognitive impairment, and other known side effects. But if cannabinoids directly improve spasticity and other movement-related symptoms, as well as mood, they would offer a uniquely useful treatment. Cannabinoids therefore represent an