Tics and Tourette syndrome: Case

Case discussion

Diagnosis and reasoning

This boy has Tourette disorder by DSM-5 criteria. He has multiple motor tics, the eye-blinking, grimacing, shoulder-shrugging, and head-jerking, plus at least one vocal tic, the throat-clearing, present for over four years since age seven, with onset before 18 and no substance or medical cause. The defining phenomenology, the premonitory urge, the suppressibility with rebound, and the waxing-and-waning body-shifting course, confirms that these are tics rather than stereotypies or another movement disorder. The family history of paternal childhood tics and an aunt with obsessive-compulsive disorder reflects the shared genetic liability between Tourette, attention-deficit or hyperactivity disorder, and obsessive-compulsive disorder. ^{[2] [6]}

No investigation is required. The diagnosis is clinical and his examination is normal, so routine blood tests, neuroimaging, and electroencephalography are not indicated and would cause harm through radiation, incidental findings, and delay. I would request home video to confirm the tics in their natural setting and would grade severity with a clinician-rated scale such as the Yale Global Tic Severity Scale to track his response to treatment over time. ^[9]

The comorbidities

The features that most shape his management are not the tics but his comorbidities. His inattention, restlessness, and literacy failure indicate attention-deficit or hyperactivity disorder, present in about 60 per cent of children with Tourette and usually the dominant source of school impairment. His nightly checking and symmetry rituals indicate obsessive-compulsive disorder, present in about 30 per cent, and his withdrawal from sport and the teasing he faces mark the social burden that erodes self-esteem. These comorbidities, not the tic count, will determine his quality of life, and they drive the plan as much as the tics do. ^[6]