Severity of Tourette Syndrome and comorbidities, by age. Lancet 2002;360(9345)1577-86.


A great overview of tic disorders can be found in the review article J Neurol (2006) 253:1-15.

This article focuses on clinically relevant aspects of tic disorders.

What are "Tics"Edit

Hallmark of tic disorders are involuntary/semivoluntary, sudden, rapid, recurrent, unpredicatable, non-rhythmic movements (motor tics) and sounds (vocal tics)

Distinguishing tics from other hyperkinetic movement phenomena can be tricky; the following characteristics of tics are useful in making accurate diagnosis:

  • Motor and vocal tics are often preceded by premonitory urges
  • Patients are generally able to briefly suppress onset of tics, but the premonitory tension or discomfort/anxiety rises
  • Once an episode of tics occur, there is a brief feeling of relief
  • Stress, fatigue, and even excitement can exacerbate tics
  • Consider in the differential diagnosis: stereotypies of autism spectrum disorders, chorea, athetosis, myoclonus, dystonia, paroxysmal dyskinesias, compulsions of OCD, seizures, and, of course, “pseudoseizures”

Tics can be simple or complex:Edit

Simple Tics Complex Tics
Motor Tics Eye blinking, sticking tongue out, head jeking

Coordinated patterns of sequential movements: touching the nose, echopraxia, copropraxia, smelling objects, kissing self, others, arm flapping

Vocal Tics Barking, yelling, throat clearing Coprolalia, echolalia, palilalia

DSM-IV-TR diagnosisEdit

While tics can be primary (idiopathic or inherited) or secondary (due to drugs, infection, or developmental disorders), the DSM-IV classifies tics by other characteristics:

  • Tourette Syndrome involves frequent motor AND vocal tics (must have both, but not necessarily concurrently), starting before age of 18 and lasting for 1 year
  • If the above tics had been observed for more than 4 weeks, but less than 1 year, the diagnosis is Transient Tic Disorder
  • If frequent vocal OR motor tics start before 18 and last for a year, the diagnosis is Chronic Motor or Vocal Tic Disorder
  • All other possibilities (onset >18yo, duration <4w) fit under Tic Disorder NOS

Diagnostic PearlsEdit

  • Document family history of tics when evaluating a child
  • Order TSH: this is a frequent comoridity
  • Sudden onset or worsening of symptoms: obtain Group A beta-hemolytic strep swab, ASO titer, and anti-DNAse B leves (think PANDAS)
  • Rule out other secondary causes: head trauma, stroke, autism, CO poisoning, hypoglycemia
  • Rule out drugs and intoxication as potential causes: antidepressants, anticholinergics, antihistamines, levodopa, antiepileptics

Treatment PearlsEdit

  • Behavioral and supportive treatments
sleep hygeine, physical exercise, emotional support
habit reversal is a behavioral therapy centered on rinterruption of stimulus-response sequences, shown effective in RCTs
  • Pharmocological treatments
Dopamine-R antagonists: pimozide (most effective, but requires EKG monitoring for arrhythmias), chlorpromazine, haloperidol, fluphenazine, risperdone (may be best tolerated)
Alpha-adrenergics can ameliorate both tics and comorbid ADHD with milder side effects: clonidine, guanfacine are safe and effective
Dopamine-R agonists, at low doses (pergolide), benzodiazepines (clonazepam), and calcium-channel blockers (not diltiazem) may have a role;
SSRIs are used for comorbid OCD

High-yield factsEdit


  • Coprolalia/copropraxia = obscene words and gestures are complex vocal and motor tics
  • Echolalia/echopraxia = mimicking other’s sounds and gestures are complex tics as well
  • Jerks that last less than 200ms are most likely myoclonus (not tics)
  • Cannabis, alcohol, and nicotine may decrease tics
  • Stimulants, stress, fatigue, heat exposure, caffeine, dopamine agonists, and beta-hemolytic strep infection can exacerbate tics

Tourette syndromeEdit

  • to diagnose TS, need 2 or more motor tics and at least 1 vocal tic at some time during the illness
  • onset typically before age of 7
  • symptoms typically peak around 9-11 years of age, and subside in adolescence
  • less than 10% fully recover
  • Common comorbidities include OCD and ADHD
  • M:F ratio is 5:1

Further ReadingEdit

Facts for Families from AACAP website. Updated in 2004; 1 page pdf

Prescribing Psychotropic Medications to Children Practice parameters from AACAP. Updated 2009

Tourette Syndrome Association has medical articles, family information, and videos on TS


Article Progress

Write Edit Finalize


Completeness Grammar Fact And Reference Check High-Yield Check Index Links Trial Release Final Check


Ad blocker interference detected!

Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers

Wikia is not accessible if you’ve made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected.