Tourette syndrome

The syndrome starts before the age of 21 and follows a course punctuated by remissions and exacerbations. Clinical features

• Motor tics are usually the presenting feature, with a mean age of onset of 7 years. Simple tics such as eye blinking are followed by complex stereotypies (i.e. touching, licking).

• Vocal tics (i.e. throat clearing) appear later (mean age of onset 11 years).

• Tics, often preceded by premonitory feelings or sensations, occur many times a day and are exacerbated by anxiety, boredom, fatigue, and excitement and lessened by alcohol, relaxation, and sleep. Patients may be able to suppress tics for long periods at the expense of a build-up of tension.

• Other common symptoms are coprolalia (utterance of obscenities), copropraxia (obscene gestures), echolalia and echopraxia (repetition of words and actions), and self-injurious behaviour.

• The course of the illness is variable. Two-thirds of patients can expect improvement or lasting remissions in early adult life, but recovery is rare. Psychiatric comorbidity

Different psychiatric conditions are associated with the Tourette syndrome,(21.) but it is uncertain whether they should be considered part of the phenotype. About half of the patients meet criteria for other psychiatric disorders.

• Depression and anxiety are common (around 25 per cent), but this may not be a specific association.

• Personality disorder is present in two-thirds of patients. Borderline, obsessive-compulsive, and paranoid types are most common, although no specific association has been claimed with a particular type.

• Attention-deficit hyperactivity disorder occurs in severe forms of the Tourette syndrome and may be more common in males. It has serious educational and behavioural implications. Wide variations in prevalence have been reported depending on the population under study (8 to 80 per cent).

• Obsessive-compulsive disorder may be more common in females, occurring after the onset of tics and reaching its peak in late adolescence. Obsessive-compulsive symptoms in Tourette syndrome differ from those in primary obsessive-compulsive disorder. While compulsions of cleanliness are rare in this syndrome, concern for symmetry, violent and sexual thoughts, forced touching, fear of harming self and others, and a need to do things 'just right' are more common.

• Attention-deficit hyperactivity disorder and obsessive-compulsive disorder are often more troublesome and difficult to manage than the symptoms of Tourette syndrome.

• The frequency of psychotic symptoms does not appear to be increased.

• Patients are usually of normal intellectual ability, but poor performance in complex attentional tests is commonly associated with attention-deficit hyperactivity disorder.

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