History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors associated strongly with TS include early age of onset (3 to 8 years), male gender, family history of TS or of OCD, ADHD, or past psychiatric history of a behavioural disorder (e.g., ADHD or OCD).

early childhood onset

Symptoms begin in early childhood, tend to occur in a waxing and waning course, and worsen in late childhood or early adolescence.[2][3]

abnormal movements

Rapid, non-rhythmic repetitive movements (eye blinking, facial grimacing, shoulder shrugging) that are accompanied by an urge or 'need' to perform the movements.

vocal sounds

Repetitive sounds or vocalisations (sniffing, coughing, throat clearing) that are accompanied by an urge or 'need' to perform the sounds.

premonitory sensation or "urge"

A distinguishing characteristic of motor and vocal tics is the sensation(s) that may precede the tics, often termed premonitory sensations or 'urges'. Sometimes patients can localise these feelings to particular parts of the body, such as the body part from which the tic emerges, described as a 'burning or buildup of tension'.

otherwise normal neurological examination

Most patients have an otherwise normal neurological examination, which includes testing of cranial nerves, muscle strength, sensory modalities, coordination, gait, and mental status.

Other diagnostic factors

common

improvement of symptoms when focused on other tasks

Symptoms may become less frequent if the patient is engaged in mental tasks that require focus or concentration.[52]

worsening of symptoms under stress

Symptoms may increase in frequency or intensity with increasing arousal, whether positive or negative, such as with stress, anxiety, or excitement.[52]

ritualistic behaviours

Some patients may experience compulsions and/or describe a need to repeat a behaviour (e.g., checking, touching, arranging) to achieve a feeling of 'just right' or a sense of completion.

Risk factors

strong

male sex

TS is more common in boys than girls, at a ratio of 3:1 to 5:1.[14][15]

age 3 to 8 years

Symptoms begin in early childhood.[42]

family history of TS or tics

There is evidence of genetic factors in the transmission of this condition.[19][21]

history of OCD or ADHD

The majority of patients have behavioural and psychiatric comorbid disorders; only 12% across all ages have only tics.[7] ADHD is the most common psychiatric comorbid disorder, accounting for 55% of the behavioural and psychiatric findings.[18]

family history of OCD or ADHD

A family history of OCD or ADHD is common, with OCD more common in female relatives and ADHD more common in male relatives.[43] OCD significantly influences the development of OCD and tics in first-degree relatives.[44][45]

Unlike with OCD, genetic links between TS and ADHD have not been established.[46][47][48]

weak

maternal antenatal smoking

A study of 180 patients revealed that maternal antenatal smoking was strongly associated with greater symptom severity, including tics and OCD.[49]

first trimester maternal stress and severe nausea/vomiting

Significantly associated with tic severity.[50]

low birth weight

In a study of 16 pairs of monozygotic twins, there was a higher tic-severity score in the lower birth-weight twin that could not be accounted for by postnatal medical events.[51]

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