History and exam

Key diagnostic factors

common

presence of risk factors

Risk factors strongly associated with tic disorder include age <18 years, male sex, family history of tics or of obsessive-compulsive disorder (OCD), ADHD, or depression, or presence of a behavioural disorder (e.g., ADHD or OCD).

observed tics

If the tics are not witnessed during the examination, the physician can ask the patient or the parents to provide a video for evaluation.

premonitory sensation

Up to 80% of all patients describe an inner urge or a local premonitory sensation that is then relieved by performing the tic.[3] This is more common for adults than for children.[2]

ability to suppress tics

Patients are able to temporarily control or suppress tics for short periods of time, which helps to differentiate from focal seizures that the patient cannot control.[1][2][3]

symptoms may improve when distracted

Tics may become less frequent if the patient is engaged in other mental tasks.[1][2]

otherwise normal neurological examination

Typically normal, except for observed tics.

However, minor abnormalities may occur and include minimal difficulties with coordination and fine motor tasks, and restlessness.[2]

Tics may still occur during sleep and are often associated with increased risk of sleep disorders.[49][50]

If neurological examination is abnormal (such as increased tone, spasticity, rigidity, or weakness), tics may be secondary to another condition, and magnetic resonance imaging of the brain, with and without contrast, should be performed. The patient should be referred to a neurologist.[3]

Other diagnostic factors

common

symptoms worse with stress, anxiety, excitement, or transitions

Tics may increase in frequency with increasing stress, anxiety, exciting situations, or transitions.[1][2]

variable severity over time

Tics can increase and decrease in severity (often described as waxing and waning) and change in character over time.[2]

symptoms of comorbid psychiatric disorder

Patients with tics, especially patients with Tourette's syndrome (Tourette's disorder), may have other comorbidities, including ADHD and obsessive-compulsive disorder (OCD).[3][46]

One lifetime prevalence study found that girls were more likely to have comorbid OCD and boys were more likely to have comorbid ADHD.[46]

The Brainstorm Consortium genome-wide association study of 265,218 patients and 784,643 controls identified a common variant genetic risk with Tourette's syndrome, ADHD, major depressive disorder, OCD, and migraine with aura.[47]

Other repetitive body-focused conditions such as hair-pulling disorder and skin-picking disorder have also been found among people with Tourette's syndrome, particularly among women.[51]

Risk factors

strong

onset at age <18 years

Tic disorders are most commonly present in children and adolescents.

The diagnostic criteria for Tourette's syndrome (Tourette's disorder) require that symptoms are present before 18 years of age.[3][38]

male sex

Tics are more common in boys than in girls in a ratio of 3:1.[2]

family history of tics

Common for patients with tics, in general.

The exact prevalence of a positive family history is unknown in patients with transient tics in childhood.

The family history is positive in up to 46% of patients with Tourette's syndrome.[39] One population-based cohort multi-generational study has shown that the heritability of tic disorders is estimated to be 0.77.[40]

The earlier the onset of tics, the more likely there will be a positive family history.[41]

family history of obsessive-compulsive disorder (OCD), ADHD, or depression

Studies have shown an association between Tourette's syndrome/chronic tic disorders in offspring with having a parent or a first-degree relative with a psychiatric disorder, most commonly OCD, ADHD, or depression.[42][43]

antenatal maternal smoking

An analysis of 73,000 singleton pregnancies from the Danish National Birth Cohort found that antenatal heavy smoking was associated with a 66% increased risk for tic disorders, while both light and heavy smoking were related to an increased risk for tic disorder with any non-ADHD psychiatric comorbidity.[44]

A study of 180 patients with Tourette's syndrome revealed that maternal antenatal smoking was strongly associated with greater symptom severity, including tics and OCD.[45]

history of OCD or ADHD

Patients with tics, and especially patients with Tourette's syndrome, may have other comorbidities, including ADHD and OCD.[46]

In one lifetime prevalence study, over 66% of patients with Tourette's syndrome had obsessive-compulsive spectrum disorders, and 54% had ADHD.[46] Girls were more likely to have comorbid OCD and boys were more likely to have comorbid ADHD.[46]

The Brainstorm Consortium genome-wide association study of 265,218 patients and 784,643 controls identified a common variant genetic risk with Tourette's syndrome, ADHD, major depressive disorder, OCD, and migraine with aura.[47]

weak

history of autism spectrum disorder (ASD)

Although previous studies have suggested an elevated prevalence of ASD in Tourette's syndrome, difficulty in discriminating complex tics, OCD symptoms, and ASD symptoms may be contributing to such elevated rates of ASD symptoms in children with Tourette's disorder.[48]

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