Jerry Espenson (Boston Legal) and the Co-morbidity of Asperger and Tourette Syndromes

Shashwat Goyal

Blog Post 2

Jerry Espenson is a character played by Christian Clemenson in the popular sit-com Boston Legal. He plays a gifted finance lawyer who is diagnosed with Asperger’s syndrome and possibly Tourette’s syndrome. In this post, I will comment on the possibility of him having Tourette’s syndrome as well as the problems of diagnosing these two disorders together due to their co-morbidity and status as autism-like or autism spectrum disorders(ASD).

Jerry is shown as shy and reserved, with some common tics such as keeping his hands on his thighs, making popping or purring noises, etc. While he is often quiet around people, he is a brilliant lawyer with an almost encyclopaedic knowledge of financial law and protects client from exploitative financial organizations. After being rejected from making partner due to his social awkwardness for the third time, he holds a name partner hostage with a knife and demands an immediate partnership and immunity from legal action agreement. Still sharp as ever, he orders a few junior associates to pull up precedent cases to support the legal validity of the agreement he is demanding. He is eventually calmed down and arrested, but the case against him is dropped when he is diagnosed with Asperger’s and possible Tourette’s. Asperger’s is defined as a developmental disorder that’s characterized by social awkwardness and restricted and repetitive patterns of interests (“Asperger Syndrome”, Wikipedia), like Jerry’s pre-occupation with only financial law. Tourette’s is defined as a neurological disorder characterized by involuntary motor and vocal tics (“Tourette Syndrome”, NINDS).

The possibility of Jerry having Tourette’s is supported by the often seen co-morbidity of these disorders (Berthier et al, 2003; Jacob Kerbeshian and Larry Burd, 1986; Tourette Syndrome, http://www.autism-help.org). Add to that the fact that Tourette’s is co-related with autism, at least in the similarity of symptoms (Darrow et al, 2017) and Asperger’s has been reclassified by the DSM V under PDD-NOS (Pervasive developmental disorder not otherwise specified) and mild ASD. This brings us to the problem with co-diagnosing these syndromes. While Jerry does display tics, both vocal and motor, the difficulty is differentiating whether these tics are caused by Tourette (they could be periodic or general in nature) or by social anxiety seen in Asperger and/or ASD (as also seen in Jerry). Darrow et al (2017) also commented that it’s “[difficult] to differentiate complex tics … from ASD symptoms. Careful examination of ASD-specific symptom[s]… is essential.” Even a fleeting examination clearly shows that Jerry suffers from social isolation (as he himself also says in the show). Hence, Jerry’s tics could simply be a manifestation of his social anxiety or even a coping mechanism (he changes his tics as he gets more comfortable around humans through treatment). All of this certainly points towards a more ASD-like presentation of tics rather than Tourette’s.

While we it can be said in conclusion that Jerry is likely on afflicted with Asperger/ASD and not Tourette, there could be a common neurological basis for both, leading to a kind of co-morbidity after all. Berthier et al (2003) suggested that “individuals with a genetic predisposition to Tourette may develop Asperger … after involvement of midbrain and related components of basal ganglia … normally implicated in the integration of emotional, cognitive, and motor functions.” Their patient showed both Asperger and Tourette due to a lesion in the midbrain and thalamic regions of the brain. The patient was known to be suffering from Tourette as he had a family history and showed symptoms of Tourette before developing Asperger. Hence, it can be that Asperger/ASD causes the tics through similar neural pathway as Tourette (which is intuitive as well, given our knowledge about somewhat discrete areas for motor and vocal processing in the brain), the only difference being that Tourette randomly activates that pathway (or in the presence of certain triggers) while Asperger/ASD does so due to social anxiety. Since Tourette has a genetic component and mild forms of Tourette are theorized to be extremely common (“Tourette Syndrome”, NINDS), its co-morbidity can be a case of a pre-existing Tourette being amplified by Asperger/ASD. Of course, while this certainly helps to increase our understanding of their presentation in patients and their neurological basis, it only adds to the complexity of diagnosing them together. Unless we have clear indicators of Tourette before the ASD, like in Berthier et al (2017), how can we say whether the Asperger is simply activating the same pathway or amplifying a pre-existing condition of Tourette, or even causing a new one.

References

1)     Berthier, M., Kulisevsky, J. and MD, J. (2007). Comorbid Asperger and Tourette syndromes   with localized mesencephalic, infrathalamic, thalamic, and striatal damage. Developmental Medicine & Child Neurology, 45(3), pp.207-212.

2)     Darrow, S., Grados, M., Sandor, P., Hirschtritt, M., Illmann, C., Osiecki, L., Dion, Y., King, R., Pauls, D., Budman, C., Cath, D., Greenberg, E., Lyon, G., McMahon, W., Lee, P., Delucchi, K., Scharf, J. and Mathews, C. (2017). Autism Spectrum Symptoms in a Tourette’s Disorder Sample. Journal of the American Academy of Child & Adolescent Psychiatry, 56(7), pp.610-617.e1.

3)     Kerbeshian, J. and Burd, L. (1986). Asperger's syndrome and Tourette syndrome: the case of the pinball wizard. The British Journal of Psychiatry, 148(6), pp.731-736.

4)     Ninds.nih.gov. (2019). Tourette Syndrome Fact Sheet | National Institute of Neurological Disorders and Stroke. [online] Available at: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Tourette-Syndrome-Fact-Sheet [Accessed 3 Mar. 2019].

5)     Wikipedia contributors, (2019). Asperger syndrome. [online] En.wikipedia.org. Available at: https://en.wikipedia.org/wiki/Asperger_syndrome [Accessed 3 Mar. 2019].