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Medical Author:

Norberto Alvarez, MD

Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Tics

The leading sign of Tourette's syndrome, and the most common reason for referral for consultation, is the presence of tics. However, it is worthwhile to mention that even though tics might be disabling, they are not necessarily, as will be discussed later on, the most disabling problem in persons with Tourette's syndrome.

Tics are repetitive, involuntary or semi-voluntary, short lasting, stereotyped movements (motor tics) or vocalizations (phonic tics), of sudden presentation, usually in clusters. There are many clinical varieties of tics that can affect any part of the body, but they are more common in the face, trunk, and shoulders.

Traditionally, tics have been divided in two main groups:

1. motor tics, and
2. vocal tics.

The motor tics are described as simple motor tics when they involve a single muscle, or complex motor tics when they consists of a more coordinated movement resembling a normal function.

Similarly, the vocal tics can be simple vocal tics when they consist of simple sounds or complex when the they consist in the production of words or sentences (complex phonic tics).

The following are examples of tics commonly seen in persons with Tourette's:

• Simple motor tics include:
• eye blinking,
• shoulder rotation or elevation,
• head jerking,
• lip contractions,
• closing of the eyes,
• eyes rolling in the orbits,
• torticollis (turning the neck to one side),
• opening and closing of the mouth,
• abdominal contractions, and/or
• stretching of arms and legs.
• Complex motor tics include:
• jumping,
• kicking,
• touching objects,
• retching,
• trunk bending or rotation,
• burping,
• socially inappropriate movements,
• obscene gestures, or
• imitation of other peoples' gestures.
• Simple phonic tics include:
• grunting,
• clearing throat,
• coughing,
• meaningless sounds or utterances.
• Complex phonic tics include:
• complex and loud sounds,
• phrases out of context,
• phrases with obscenities,
• cursing,
• repetition of other person's phrases.

Tics might be transiently suppressed by the individual. Additionally, tics may also be suppressed with tasks that require concentration or by distraction. For example, when a child with tics is watching TV or playing video games, the tics maybe suppressed to a minimum. This characteristic could lead a non-informed observer to believe that the movements are fully under the child's control. However, this is not the case. Even though the patient has some control, prolonged suppression of tics is usually associated with an unpleasant sensation that is relieved only by the tic. Voluntary suppression of tics is a very taxing task for the person with Tourette's syndrome.

Most individuals with Tourette's syndrome perceive some inner body sensation before the tic occurs. For example he/she may feel a burning or an itching of the eyes that is suppressed by moving the eyes, or a tickling in the throat that is relieved only by "clearing the throat". After this subjective feeling, the patient may need to repeat the tic several times until the unpleasant sensation is gone. In some individuals a non-well defined urge precedes the tic.

Stress, anxiety, fatigue and boredom can worsen the symptoms of a person with Tourette's syndrome.

Moreover, tics have a wax and wane quality. Tics have a tendency to cluster during certain hours and under certain circumstances rather than being present evenly throughout the day. Also, tics might not be seen for hours after a severe cluster.

Additionally, the quality, frequency and type of tics change during the evolution of the disease. Tics that were once frequently seen are suppressed and exchanged for other tics.

Usually, the first signs of disease start in childhood. The tics may increase in frequency and severity in adolescence and, even though the condition is chronic, there is a tendency to improve in adulthood. By age 18, 50 % of patients with Tourette's syndrome might be symptom-free; however, some individuals might see a recurrence of the symptoms later in life. Usually, simple motor tics are seen at an early age and precede verbal tics. Also, complex tics are first seen later in life.

Other Associated Conditions

Associated conditions have been reported in almost half of the children with Tourette's syndrome. The most common are attention deficit hyperactivity disorder (ADHD) and obsessive compulsive disorder (OCD). Both of these disorders can be observed before school age. It is not clear why these conditions are so frequently present. It is probable that they share a common pathological mechanism in the brain.

In addition, individuals with Tourette's syndrome may also have depression, anxiety, and other behavioral problems. In some cases, this may be attributed to being perceived as different or being rejected by peers.

Developmental disability is not a feature of Tourette's syndrome, however the presence of ADHD may disrupt learning, resulting in poor grades.

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