Tics and Tourette Syndrome
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Direct answer
Tourette syndrome is a neurodevelopmental disorder with multiple motor tics and at least one vocal tic, present for more than one year with onset before the age of 18. Tics are sudden, brief, repetitive movements or sounds, often preceded by a premonitory urge that is relieved by performing the tic. Comorbid ADHD and obsessive-compulsive disorder are common, and haloperidol or aripiprazole are reserved for tics that are disabling despite behavioural treatment.
What you must remember
- Tic: a sudden, brief, repetitive movement or vocalisation, often with a premonitory urge that is relieved by performing the tic.
- Duration criteria: Tourette syndrome needs multiple motor tics and at least one vocal tic for more than one year, with onset before 18 years; tics lasting under a year suggest transient tic disorder.
- Course: onset typically around 5 to 7 years, peak severity around 10 to 12 years, and frequent improvement by late adolescence or adulthood.
- Coprolalia and echolalia: involuntary swearing and echoing of words are recognised features, but they occur in only a minority of patients.
- Comorbidity: ADHD, obsessive-compulsive disorder and anxiety are common and often cause more impairment than the tics themselves.
- Behavioural therapy: comprehensive behavioural intervention for tics, with habit reversal training, is first-line for bothersome tics.
- Drug treatment: alpha-2 agonists such as clonidine or guanfacine for milder disease, and haloperidol, aripiprazole or risperidone for severe tics, with monitoring for extrapyramidal effects and raised prolactin.
A pathway from tics to treatment
A 10-year-old boy with eye blinking and throat clearing since the age of seven, plus inattention at school, comes for review. The steps below follow the order in which the features are assessed and treated.
- Confirm the tic history: sudden, brief, stereotyped movements or sounds with a premonitory urge separate tics from dystonia or chorea.
- Apply duration criteria: more than one year of multiple motor and at least one vocal tic points to Tourette syndrome.
- Screen for comorbidity: ADHD, obsessive-compulsive disorder and anxiety are often more disabling than the tics and need their own plan.
- Start psychoeducation: explain the natural course to the family, since many tics improve in adolescence.
- Offer behavioural therapy: comprehensive behavioural intervention for tics is first-line when tics cause bother.
- Use drugs for disabling tics: clonidine or guanfacine when ADHD coexists, and a dopamine receptor antagonist or partial agonist for severe tics.
- Monitor side effects: extrapyramidal symptoms, sedation, weight gain and hyperprolactinaemia need regular review.
Where the stem misleads on tics
Most errors come from applying the Tourette label too early or prescribing without considering comorbidity.
- Trap: diagnosing Tourette syndrome after a single tic lasting a few months Correct: tics under one year suggest transient tic disorder, while Tourette needs more than a year of motor and vocal tics.
- Trap: treating tics with methylphenidate as first choice Correct: stimulants can worsen tics, so an alpha-2 agonist is preferred when ADHD coexists.
- Trap: assuming coprolalia is present in every patient Correct: it occurs in only a minority, so its absence does not exclude Tourette syndrome.
- Trap: starting haloperidol without planned monitoring Correct: dopamine blockers cause extrapyramidal effects and hyperprolactinaemia, which need scheduled review.
Frequently asked questions
What is the duration criterion for Tourette syndrome?
Tourette syndrome requires multiple motor tics and at least one vocal tic, present for more than one year, with onset before the age of 18 years. Tics lasting less than a year suggest a transient tic disorder instead.
Which drug is preferred for tics when ADHD coexists?
Alpha-2 agonists such as clonidine or guanfacine are preferred for tics when ADHD coexists, because stimulants such as methylphenidate can worsen tics in some patients. Behavioural therapy remains the first-line approach for tics that cause bother.
What is comprehensive behavioural intervention for tics?
Comprehensive behavioural intervention for tics, known as CBIT, combines habit reversal training with psychoeducation and relaxation techniques. It is a first-line, non-drug treatment that reduces tic severity in children and adults with Tourette syndrome.
Why are haloperidol and aripiprazole used in Tourette syndrome?
Haloperidol and aripiprazole act on dopamine receptors and are used for severe or disabling tics that do not respond to behavioural therapy or alpha-2 agonists. They are chosen with monitoring for extrapyramidal effects, sedation and raised prolactin.
How is obsessive-compulsive disorder related to Tourette syndrome?
Obsessive-compulsive disorder occurs more often in people with Tourette syndrome than in the general population, and it often causes more impairment than the tics. Assessment for OCD and ADHD is therefore part of the routine evaluation.