Home About Dr. What is Tourette Syndrome? Shawn Ewbank, Psy. The most common course of TS begins with initial tics being noticed at ages Sometimes it takes much longer before a TS diagnosis is given or suspected because many parents, and even a lot of doctors, are not experts at recognizing tics. A momentary sense of relief typically follows the completion of a tic.
Over the course of hours, tics occur in bouts, with a regular intertic interval. Tics increase during periods of emotional excitement and fatigue. Tics can become "complex" in nature and appear to be purposeful. Tics can be willfully suppressed for brief intervals and can be evoked by the mere mention of them. Management of Tourette's syndrome should include timely and accurate diagnosis, education, and behavior or pharmacologic interventions.
Use of neuroleptic medications and dopamine D 2 antagonist drugs can be effective but may be associated with significant side effects. Primary care physicians are often the first physicians to be consulted about tics. Tics are defined as sudden, rapid, purposeless, repetitive, nonrhythmic, stereotyped movements or vocalizations. Common simple tics are eye blinking, shoulder jerking, picking movements, grunting, sniffing and barking. Table 1 lists some common motor and vocal tics.
Complex tics. Tourette's syndrome is a chronic tic disorder that is characterized by both motor and vocal tics, with onset in childhood. Table 2 lists current diagnostic criteria for Tourette's syndrome. Coprolalia was originally described as a pathognomonic symptom by Gilles de la Tourette, but it occurs in only 8 to 39 percent of patients, mostly males, and is not required for a diagnosis.
Tourette's syndrome has a waxing and waning course, with one tic appearing and typically being replaced by another, although in most cases multiple tics are present concomitantly.
Tics are often temporarily suppressible, sometimes for minutes, occasionally for hours. Some patients can suppress their tics during the school day or work day. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently.
The tics occur many times a day usually in bouts nearly every day or intermittently throughout a period of more than one year, and during this period there was never a tic-free period of more than three consecutive months. The disturbance causes marked distress or significant impairment in social, occupational or other important areas of functioning.
The disturbance is not due to the direct physiologic effects of a substance e. Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders.
Washington, D. Copyright Tics have come to be recognized as a common component of development. It has been estimated that as many as one in five children has had a tic at some point in the first 10 years of life, 6 — 8 although accurate epidemiologic data are limited. These tics typically are transient, lasting less than one year.
Some patients acquire longstanding chronic tics, usually motor tics, that may persist for years. Motor tics are more common than vocal tics. The prevalence of Tourette's syndrome is one to 10 cases per 10, In most children, Tourette's syndrome has a fluctuating course. Anxiety, stress and fatigue often intensify tics. Tics are usually significantly reduced during sleep or when the patient is focused on an activity.
Psychoactive drugs, particularly cocaine and stimulants, have a tendency to worsen tics. In most cases, tics peak in severity between nine and 11 years of age. In one study, 10 73 percent of patients median age of 18 years reported that their tics had disappeared or considerably decreased at follow-up.
In another follow-up study, 11 only 9 percent of study subjects had severe symptoms after five to 15 years. In our experience, about 85 percent of patients have remission or improve considerably as adults Figure 1. The clinical course of Tourette's syndrome.
Onset typically occurs before seven years of age and the disorder is usually recognized two to three years after onset. In most children, the severity peaks at nine to 11 years of age.
About 5 to 10 percent of patients have an intensifying course with little or no improvement. In about 85 percent of patients, symptoms diminish during and after adolescence. Between 5 and 10 percent of patients continue to have unchanged or worsening symptoms into adolescence and adulthood.
In this population, the likelihood of tics continuing for decades is substantial. Patients in their seventh, eighth and ninth decades of life may have tics that have been present since childhood. In most older patients, the tics tend to become quite stable over time, although occasionally new tics will be acquired. There is no reliable way to predict which children will have a poorer prognosis. The precise etiology of Tourette's syndrome is unknown.
Tics are believed to result from a tripartite dysfunction in the central nervous system. Imaging techniques have implicated the basal ganglia and frontal cortex in the pathogenesis of Tourette's syndrome. As a result, the tic-related neural circuits for throat clearing, sniffing, eye squinting or facial grimacing may run too frequently and out of synchrony with those for other motor movements.
Stress and anxiety may neurochemically intensify this inhibitory deficit. Tic disorders and Tourette's syndrome are frequently accompanied by other conditions.
Precise arrangement of objects Touching things Rechecking Smelling Licking Erasing Writing and rewriting of letters until perfect Washing hands repeatedly. Mental echolalia words, phrases Obscene thoughts Counting or grouping Sexual thoughts Thinking about forbidden actions standing on desk in school, kissing teacher, touching others sexually Thinking about exposing oneself. Holding groin Obscene gestures Touching others sexually Placing head on another's breast Picking at buttocks.
Echolalia repeating others' words or statements Echopraxia imitating others' actions Palilalia repeating one's own statements, words or parts of words. Quick temper Mood swings Overreaction Exhibitionism Negativism. Repeated requests for family members to repeat strange phrases or repeatedly asking the same question. An extremely important concept in the evaluation and development of treatment programs for patients with tic disorders is the recognition that multiple undiagnosed comorbid conditions may result in a moderate to severe level of functional impairment.
Under such circumstances, it is necessary to identify each of these conditions, since it may be necessary to treat one, two or even three of the conditions in order to improve functioning. Other complications include depression, sleep problems, social discomfort and self-injurious behavior.
Tics are classified as either primary idiopathic or secondary. Table 5 lists secondary causes of tics. Idiopathic tic disorders and Tourette's syndrome are multifactorial in etiology. Genetic predisposition is important, but environmental factors influence the risk, the severity and the course of the disorder. Studies show a concordance rate of about 60 percent for Tourette's syndrome in monozygotic twins and 10 percent in dizygotic twins.
Head trauma. Sydenham's chorea. Carbon monoxide poisoning. Creutzfeldt-Jakob disease. Huntington's disease. Hallervorden-Spatz disease. Was this article helpful? Explore Popular Topics. Behavior Problems. Learning Disorders. View More Topics. Sign Up for Our Newsletters.
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