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The essential features of this disorder are multiple motor and one or more vocal tics. These may appear simultaneously, or at different periods during the illness. The tics occur many times a day, nearly every day or intermittently throughtout a period of more than one year. The anatomic location, number, frequency, complexity, and severity of the tics change over time.

The tics typically involve the head and, frequently, other parts of the body, such as the torso and upper and lower limbs. The vocal tics include various sounds such as clicks, grunts, yelps, barks, sniffs, and coughs, or words. Coprolalia, a camplex vocal tic involving the uttering of obscentities, is present in up to a third of cases. Complex motor tics involve touching, squatting, deep knee bends, retracing steps, and twirling when walking are often present.

In approximately half the cases, the first symptoms to appear are bouts of a single tic, most frequently eye-blinking, less frequently tics involving another part of the face or the body. Initial symptoms can also include tongue protrusion, squatting, sniffing, hopping, skipping, throat-clearing, stuttering, uttering sounds or words, and coprolalia. Other cases begin with multiple symptoms, which may include any combination of the previously described tics, and various noises such as barks, grunts, screams, yelps, or snorts.

Associated features. There may be other symptoms, such as mental coprolalia (sudden, intrusive, senseless thoughts of socially unacceptable or obscene words, phrases, or sentences that differ from true obsessions in that no attempt is made to ignore, suppress, or neutralize the thoughts), obsessions, and compulsions.

In clinical samples, other mental disorders are frequently associated with Tourette's Disorder, particularly Attention-deficit Hyperactivity Disorder and Obsessive Compulsive Disorder. It is not clear if this co-morbidity also exists in representative community samples.

Age at onset. The median age at onset is 7 years, and the great majority have an onset before age 14. This disorder may appear as early as one year of age.

Course. The disorder is usually lifelong, though periods of remission lasting from weeks to years may occur. In some cases, the severity and frequency of the symptoms diminish during adolescence and adulthood, and the symptoms do no vary in severity over time as much as before. In other cases, the symptoms of the disorder disappear entirely, usually by early adulthood.

Complications. Complications include physical injury, such as blindness due to retinal detachment (from head-banging or striking oneself), orthopedic problems (from knee-bending, neck-turning), skin problems (from picking), and, in rare cases, self-mutilation (from head-banging).

Prevalence. The estimated lifetime prevalence rate is at least 0.5 per thousand.

Sex ratio. The disorder is at least three times more common in males than in females.

Familial pattern. Tic Disorders are more common among first-degree biologic relatives of people with Tourette's Disorder than among the general population. Evidence suggests that Tourette's Disorder and Chronic Motor or Vocal Tic Disorder may be inherited as a single autosomal disorder.

In addition, there is some evidence that Obsessive Compulsive Disorder is more common in first-degree biologic relatives of people with Tourette's Disorder than in the general population and is another expression of the same underlying disorder.

Differential diagnosis. See differential diagnosis of tics, page 79. Amphetamine Intoxication, many neurologic disorders (such as cerebrovascular accidents, Lesch-Nyhan syndrome, Wilson's disease, Sydenham's chorea, Huntington's chorea, and multiple sclerosis), Organic Mental Disorders, and Schizophrenia may present with abnormal motor movements. These disorders can readily be differentiated from Tourette's Disorder because they have distinguishing symptoms, signs, clinical course, and physiologic abnormalities as revealed by laboratory tests; and none of them involve vocalizations similar to the clicks, grunts, yelps, barks, sniffs, coughs, and words of Tourette's Disorder.

Diagnostic criteria for 307.23 Tourette's Disorder

A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently.

B. The tics occur many times a day (usually in bouts), nearly every day or intermittently thoughtout a period of more than one year.

C. The anatomic location, number, frequency, complexity, and severity of the tics change over time.

D. Onset before age 21.

E. Occurrence not exclusively during Psychoactive Substance Intoxication or known central nervous system disease, such as Huntington's chorea and postviral encephalitis.

Taken from Diagnostic and Statistical Manual of Mental Disorders (Third Edition-Revised), American Psychiatric Association, 1987.


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