Summary

Tourette's Syndrome (TS) is a childhood-onset neurodevelopmental disorder characterized by Multiple Motor Tics and at least one Vocal Tic, persisting for more than 1 year. Tics are sudden, rapid, recurrent, non-rhythmic movements or vocalizations. The condition waxes and wanes. It is often comorbid with ADHD and OCD (the "Tourette's Triad"). [1,2]

Key Facts

• Evolution: Tics typically start with simple motor tics (blinking) around age 5-7. Vocal tics appear later (age 11). Peak severity is early adolescence (10-12). Improvement often occurs in late adolescence.
• Premonitory Urge: 90% of patients describe an uncomfortable sensation (itch, tension, pressure) that builds up before the tic. Performing the tic relieves this urge. This is a crucial differentiator from other movement disorders (like chorea or myoclonus) which are involuntary and unexpected.
• Coprolalia: Involuntary swearing. Famous in media, but actually Rare (less than 10% of cases). Most vocal tics are simple grunts, coughs, or sniffing.

Clinical Pearls

Suppressibility: Unlike seizures or dystonia, tics are "unvoluntary" rather than involuntary. Patients can often suppress them temporarily (e.g., in the doctor's office or at school), often leading to a "rebound explosion" of tics when they get home.

The "Wax and Wane": It is normal for tics to change character. A child may have sniffing for 3 months, then that disappears and is replaced by shoulder shrugging. This fluctuation confirms the diagnosis.

PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections): A controversial entity where tics/OCD explode suddenly after a Strep throat infection. Test for Strep/ASOT if onset is explosive.

• Observation: Watch the child while talking to the parents. (Tics often vanish when staring directly at the child).
• Neurological Exam: Should be normal.
  • Rule out: Kayser-Fleischer rings (Wilson's), Chorea (Sydenham's/Huntington's), Ataxia.

• Rule of Thirds:
  • 1/3 disappear in adulthood.
  • 1/3 improve significantly.
  • 1/3 persist.
• Tics usually peak at 10-12 years and decline by 18.

Key Guidelines

Landmark Evidence

1. Piacentini et al (JAMA)

• Large RCT showed that CBIT is significantly more effective than supportive therapy, with effects lasting >6 months. This firmly established behavioural therapy as the first-line standard instead of jumping to antipsychotics.

What is Tourette's?

It is a condition where the brain sends extra "signals" to the muscles, causing sudden twitches (tics) or sounds. It's like having a hiccup - you might be able to hold it in for a moment, but eventually, it has to come out.

Why does he sweat?

People with Tourette's almost never swear (only 1 in 10). Most just blink, shrug, or make grunting noises.

Will he grow out of it?

Most likely. It tends to be worst around age 10-12 and gets much better as the brain matures in the late teens.

Is he doing it for attention?

No. In fact, most kids try very hard to hide it, which is exhausting. When they are relaxed at home, the tics often come out more because they stop holding them in.

Common Exam Questions

1. Diagnosis: "Definition?"
   • Answer: Motor + Vocal tics, >1 year duration, onset less than 18y.
2. Comorbidity: "Most common associated conditions?"
   • Answer: ADHD and OCD.
3. Treatment: "First line therapy?"
   • Answer: CBIT (Behavioural).
4. Symptom: "Coprolalia?"
   • Answer: Involuntary swearing.

Viva Points

• Differential Diagnosis: Sydenham's Chorea (Rheumatic fever - dancing hand movements, vanishing grip). Wilson's Disease. Drug-induced (Stimulants for ADHD can sometimes unmask tics, though recent evidence suggests therapeutic doses are usually safe).

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