Psych · Child and adolescent psychiatry — neurodevelopmental
Tic disorders and Tourette syndrome
Also known as Tourette syndrome · Tourette's disorder · Gilles de la Tourette syndrome · Chronic tic disorder · Persistent motor tic disorder · Provisional tic disorder · CBIT · Habit reversal training
Exam-exhaustive fellowship reference on tic disorders and Tourette syndrome — DSM-5-TR classification, CSTC pathophysiology, CBIT evidence, alpha-2 agonists and antipsychotics with dosing and monitoring, and ADHD/OCD comorbidity management. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Self-injurious tics (e.g. repeated striking, severe cervical tics) — urgent specialist review, safety plan, escalate behavioural and pharmacological intensity
- Abrupt late-adolescent or adult-onset elaborate tic-like behaviours without childhood course — consider functional tic-like behaviours; avoid premature lifelong Tourette labelling
- Progressive neurological signs, cognitive regression, or seizure-like events — do not assume primary tic disorder; investigate
- Severe metabolic deterioration, EPS, or QTc risk on antipsychotic treatment — stop/review agent, monitor, treat adverse effects
- Rebound hypertension risk if clonidine or guanfacine stopped abruptly — taper when discontinuing
- Bullying, school refusal, or suicidal ideation secondary to shame and stigma — full risk assessment; treat comorbidity, not only visible tics
Meet the patient
An 11-year-old boy is referred because he "can't stop blinking and sniffing." His teacher thinks he is being defiant. He blinks in bursts, clears his throat every few sentences, and describes a building "itch" in his eyes and throat that the movement briefly relieves. He also can't sit still, loses his homework, and has been told for years that he has "just ADHD."[5][19]
The blink and the sniff are tics. The itch that the tic relieves is the premonitory urge — the single feature that tells you this is a tic disorder and not defiance. And the ADHD sitting next to it is the comorbidity that will decide his function far more than the tics do.[6][9]
References20ShowHide
- [1]Piacentini J, Woods DW, Scahill L, et al. Behavior therapy for children with Tourette disorder: a randomized controlled trial JAMA, 2010.PMID 20483969
- [2]Wilhelm S, Peterson AL, Piacentini J, et al. Randomized trial of behavior therapy for adults with Tourette syndrome Arch Gen Psychiatry, 2012.PMID 22868933
- [3]Pringsheim T, Okun MS, Müller-Vahl K, et al. Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders Neurology, 2019.PMID 31061208
- [4]Pringsheim T, Holler-Managan Y, Okun MS, et al. Comprehensive systematic review summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders Neurology, 2019.PMID 31061209
- [5]Murphy TK, Lewin AB, Storch EA, Stock S Practice parameter for the assessment and treatment of children and adolescents with tic disorders J Am Acad Child Adolesc Psychiatry, 2013.PMID 24290467
- [6]Hirschtritt ME, Lee PC, Pauls DL, et al. Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette syndrome JAMA Psychiatry, 2015.PMID 25671412
- [7]Bloch MH, Leckman JF Clinical course of Tourette syndrome J Psychosom Res, 2009.PMID 19913654
- [8]Freeman RD, Fast DK, Burd L, et al. An international perspective on Tourette syndrome: selected findings from 3,500 individuals in 22 countries Dev Med Child Neurol, 2000.PMID 10972415
- [9]Tourette's Syndrome Study Group Treatment of ADHD in children with tics: a randomized controlled trial Neurology, 2002.PMID 11865128
- [10]Scahill L, Chappell PB, Kim YS, et al. A placebo-controlled study of guanfacine in the treatment of children with tic disorders and attention deficit hyperactivity disorder Am J Psychiatry, 2001.PMID 11431228
- [11]Scahill L, Leckman JF, Schultz RT, et al. A placebo-controlled trial of risperidone in Tourette syndrome Neurology, 2003.PMID 12682319
- [12]Sallee F, Kohegyi E, Zhao J, et al. Randomized, Double-Blind, Placebo-Controlled Trial Demonstrates the Efficacy and Safety of Oral Aripiprazole for the Treatment of Tourette's Disorder in Children and Adolescents J Child Adolesc Psychopharmacol, 2017.PMID 28686474
- [13]Yoo HK, Joung YS, Lee JS, et al. A multicenter, randomized, double-blind, placebo-controlled study of aripiprazole in children and adolescents with Tourette's disorder J Clin Psychiatry, 2013.PMID 24021518
- [14]Roessner V, Eichele H, Stern JS, et al. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part III: pharmacological treatment Eur Child Adolesc Psychiatry, 2022.PMID 34757514
- [15]Andrén P, Jakubovski E, Murphy TL, et al. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part II: psychological interventions Eur Child Adolesc Psychiatry, 2022.PMID 34313861
- [16]Müller-Vahl KR, Szejko N, Verdellen C, et al. European clinical guidelines for Tourette syndrome and other tic disorders: summary statement Eur Child Adolesc Psychiatry, 2022.PMID 34244849
- [17]Pringsheim T, Doja A, Gorman D, et al. Canadian guidelines for the evidence-based treatment of tic disorders: pharmacotherapy Can J Psychiatry, 2012.PMID 22397999
- [18]Knight T, Steeves T, Day L, et al. Prevalence of tic disorders: a systematic review and meta-analysis Pediatr Neurol, 2012.PMID 22759682
- [19]Leckman JF, Riddle MA, Hardin MT, et al. The Yale Global Tic Severity Scale: initial testing of a clinician-rated scale of tic severity J Am Acad Child Adolesc Psychiatry, 1989.PMID 2768151
- [20]Bloch MH, Panza KE, Landeros-Weisenberger A, Leckman JF Meta-analysis: treatment of attention-deficit/hyperactivity disorder in children with comorbid tic disorders J Am Acad Child Adolesc Psychiatry, 2009.PMID 19625978