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]

Management plan

I take a stepped approach aimed at function rather than tic elimination. I begin with psychoeducation and reassurance and secure school accommodation, including a quiet space, reduced pressure during tic surges, and a learning-support plan for his literacy. Because his tics cause impairment through teasing and withdrawal, the first active treatment is Comprehensive Behavioural Intervention for Tics, or CBIT, which the Piacentini randomised trial showed significantly reduces tic severity, and I refer him to a behavioural therapy service for an eight-session habit-reversal programme. [1] [2]

His comorbidities are treated in parallel. His attention-deficit or hyperactivity disorder is managed with classroom strategies and, if these are inadequate, with stimulant or non-stimulant medication, and I would reassure the family that the modern evidence shows stimulants do not routinely worsen tics, so effective treatment should not be withheld. His obsessive-compulsive disorder is treated with cognitive behavioural therapy using exposure and response prevention, with a selective serotonin reuptake inhibitor for his moderate to severe symptoms. If the tics themselves remain impairing, I would start an alpha-2 agonist such as clonidine, which addresses both the tics and the attention-deficit or hyperactivity disorder, moving to an antipsychotic such as aripiprazole only for moderate to severe tics with metabolic and extrapyramidal monitoring. [2] [5]

Prognosis and counselling

The prognosis for his tics is favourable. Tic severity peaks around 10 to 12 years, which he has now reached, and improves substantially for most children through late adolescence, with only a minority carrying severe tics into adulthood. I would add the nuance that his obsessive-compulsive symptoms may persist or rise even as the tics fade, so I will follow his obsessive-compulsive disorder over time rather than assuming it will resolve with the tics. I would counsel the family that treatment targets function, that tics fluctuate and a bad week is not deterioration, that he is approaching the age at which the tics are expected to ease, and that the long-term outlook is good. [11]