2000/11/01 by Samuel H. Zinner · 2 citations
Psychology · #Obsessive-Compulsive Spectrum Disorders #Body Image and Dysmorphia Studies #Tics #Psychology #Psychiatry #Tourette syndrome #Unconscious mind #Neurosis #Obsessive compulsive #Psychotherapist #Psychoanalysis
paper · doi:10.1542/pir.21-11-372
openalex publication_date 2000/11/01 · openalex created_date 2022/05/12 · openalex updated_date 2026/07/22
After completing this article, readers should be able to:Although first reported more than 175 years ago, the features that later would comprise Tourette Disorder(TD) and its common comorbid conditions have been widely recognized only within the past 2 decades. The disorder’s namesake is Georges Gilles de la Tourette, a young French neurologist and friend to the pioneering psychoanalyst Sigmund Freud. In 1885, Gilles de la Tourette published an account of nine patients characterized by convulsive tics, obscene utterances, repetition of the words of others, extreme provocative behaviors, and frequent testing of social or physical boundaries. Fourteen years later, he described obsessive-compulsive behaviors among these patients. Freud’s seminal ideas regarding neurosis, which describe unconscious processes and the resulting maladaptive behaviors,often were used in an attempt to understand the nature of tics and related behaviors. Until recently, TD was considered a very rare psychiatric diagnosis that was witnessed perhaps once in a medical professional’s life. Although no longer considered rare, this disorder often is undetected, partly because of its diverse expression. The increasingly appreciated range of comorbid features has so complicated classification that disagreement persists about whether this represents a“syndrome” or a “disorder.” Because of the variety of cardinal and comorbid features in TD, many different health-related specialties often contribute to its treatment. The most favorable outcome is associated with early recognition and coordinated management, with treatment directed at those areas most disruptive to the child.Although the progression of tics often follows a typical course, as described in the text, it is important to recognize that there is no “typical case.”An otherwise well 8-year-old boy develops an eye-blink tic that goes unnoticed or is presumed to be a seasonal allergic response. A few months later, he begins to clear his throat softly, so no one hears except for a shy classmate at an adjacent desk. One month later, a stuffy nose compels him to mouth-breathe and to lubricate his lips with his tongue,cultivating a new tic and resulting in severely excoriated lips. The tics abate, the lips heal, and all is forgotten for 1 month until he begins to jerk his head rapidly in succession 10 or more times, sometimes followed by a momentary pause, then another succession of head jerks. This pattern persists for months,although the jerking is not noticed at school because the child “saves it” until break time or after he returns home, when no one is around. The jerks are very apparent at home and are so forceful that he develops a strained neck muscle.Through adolescence and into adulthood, his tics wax and wane and include eye-rolling, abdominal tensing, shoulder popping, sudden bursts of air blown through his nostrils, and tongue clicking, among others, with up to five tics present during some weeks. Others seldom notice these tics because he is able to “sneak” them in at strategic moments, such as when a companion is looking away. Often, he performs only those tics that are not openly visible or audible, such as tensing the soles of his feet,reserving the more florid tics for private moments. While daydreaming on a bus, he suddenly utters a loud“TUH!” at the moment he mentally reaches a word with the phoneme“T,” such as “terrible.” A neighboring girl giggles, but he quickly recovers by sniffing in and wiping his nose, simulating a sneeze.Tics are motor or vocal, “involuntary,”purposeless, sudden and rapid,repetitive, and stereotyped productions. They can be categorized by motor or vocal expression, age of onset, frequency, severity,complexity (simple versus complex),duration, anatomic site, and interference with function. Four diagnosable tic disorders are described in the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition(DSM-IV), distinguished by chronicity and modality (motor versus vocal).TD (Table 1) is characterized by movement-based (motor) and phonic-based (vocal) tics, although they are not necessarily concurrent,that have a duration of more than 1 year during which time no more than 3 consecutive months pass without tics. It is usually the most severe of the tic disorders, having more complex tics and a greater incidence of comorbid conditions. The diagnostic criteria for Chronic Motor or Vocal Tic Disorder differ from TD only in that they describe the presence of either motor or vocal tics, but not both. Transient Tic Disorder (Table 2) is the least enduring of these four disorders,lasting at least 4 weeks but no more than 1 year, and may be characterized by either motor or vocal tics, or both. In all three disorders, tics occur many times daily nearly every day, there is secondary distress or impairment in an important area of functioning, the onset occurs before 18 years of age, and there is no other explanation for the disturbance. Tic Disorder Not Otherwise Specified is inclusive of tic disorders that do not meet criteria for a specific tic disorder. It is critical to note that the comorbid conditions may determine functional status more strongly than the tic disorder.The prevalence of TD has been widely appreciated over the past 2 decades, but epidemiologic parameters remain ill-defined. Although the diagnostic criteria are discretely and clearly delineated, TD often remains overlooked for a number of reasons. The diagnosis is based on history and clinical examination. Studies of its prevalence have returned widely divergent results. The disparity in estimates reflects a number of factors, including population sampling errors, variations in screening methods and inclusion criteria, and the potential recruitment of less experienced diagnosticians,an event more likely to occur when studying less common disorders. Data from most studies suggest a lifetime prevalence of 5 to 10 per 10,000 (0.05% to 0.1%) of the general population, with the male:female ratio typically ranging from 2:1 to 4:1. With inclusion of all tic disorders, the prevalence is estimated at 3% to 18% for boys and 1% to 10% for girls.In addition to male gender, risk factors include genetic predisposition,younger age, environmental influences, and comorbid modifiers. The presence of these comorbid conditions is the norm rather than the exception in clinically referred youth who have TD. The conditions may include any combination of attention deficit disorder with hyperactivity,learning difficulties/disorders,obsessive-compulsive symptoms/disorder,phobias and other anxiety disorders, speech and language disorders, mood disorders,sleep disorders, impairment in executive function, and disruptive and other behavioral disorders. However, the association between comorbid conditions and tic severity, persistence, or recurrence is unknown. The natural history of TD has not been studied well, and its prevalence and course among adults is unclear.Several lines of investigation have strongly suggested the contribution of genetic, environmental,infectious, and psychosocial factors in the etiology of TD (Table 3). The spectrum of tic disorders generally has been understood to be of autosomal dominant inheritance, with increased penetrance for phenotypic expression in males. Recent studies challenge this hypothesis, suggesting an additive model, with increased susceptibility in individuals inheriting the gene(s) from both parents. At this time, no genetic locus has been identified, although two prevailing models include a dominant single major locus and an intermediate single major locus, with the number of involved genes unknown. Most probably, a susceptibility to tics (and comorbid disorders) is inherited genetically, and the phenotypic expression as tics, obsessions and compulsions, and learning and other difficulties is influenced by many other factors.Nongenetic factors that may influence the development and expression of TD include perinatal events such as lower birthweight,(1)gestational influences of maternal stress,(2) and obstetric complications.(3)Androgenic hormonal influences may contribute to the higher prevalence of tics among males.(4) Other hormones, including those released during periods of stress, appear to exacerbate tic severity and frequency reversibly. Autoimmune mechanisms may play a role in tic onset and exacerbation; in particular,pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are receiving considerable attention for their possible (although unproven)association with tic, obsessive-compulsive,and other developmental disorders.Neuroanatomic models of this disorder implicate abnormalities along circuits connecting the brain’s cortex and subcortex. A circuit is a pathway of interconnecting neurons that work together to produce specific functions, such as the planning,sequencing, and execution of movements or motivational drives and cognition. There is likely a failure in filtering at points along the circuit,resulting in the ineffective removal of unwanted, interfering information.For example, before a tic is expressed, a psychic tension or “premonitory urge” in affected muscle groups may occur in response to messages originating in cortical areas that are not effectively inhibited in subcortical areas. The proposed filtering mechanism may link TD to its frequent comorbid conditions,such that an ineffectively filtered thought or “obsession” creates the psychic tension that triggers compulsive behaviors, and poorly filtered executive functions originating in prefrontal cortical regions result in impulsive reactions in attention deficit disorder.The development of tics in TD generally follows a typical course,although there is no “typical case.”Tics evolve over time from “simple”to “complex,” and they begin in midline body regions and progress to include more peripheral regions. Simple tics are brief, sudden and meaningless, and involve one or only a few muscle groups; complex tics appear more purposeful, often are slower and of a more sustained duration, and involve several muscle groups.Tics involving head and neck muscles usually present first, typically at about the age of 6 or 7 years. These simple motor tics may include eye blinking (the most prevalent tic), eye movements, nose twitching, head jerks, or facial grimacing. Phonic tics typically present 2 or more years later and may include simple vocalizations, such as throat clearing, coughing, sniffing,grunting, barking, squealing, and many others. Over time, tics may become increasingly complex; motor tics may express as an unusual sustained regard, touching, gyrating,bending, jumping, dystonic posturing,or echopraxia (imitation of the observed movements of another person). Phonic tics may incorporate words or phrases; speech atypicalities that involve unusual rhythms;accentuation of syllables, consonants,or vowel sounds; or linguistically meaningful utterances, such as palilalia (repetition of one’s own sounds) or echolalia (repetition of another’s utterance). These may appear to mimic a stutter, stammer,or other speech irregularity. Vocal signs often occur at linguistic transitions,such as at the beginning or end of a word or sentence, and are characterized by a a in or a of a Although widely recognized as a specific of TD, and are rare, only in a of affected typically wax and wane over periods of and ranging from to weeks or tics may or they may be to a Tic severity generally by age 10 or the first of who have TD describe a or “premonitory a This occurs in the muscle the tic and is described as a tension that is by the understand this it may be to the of an on one’s The may the to increasingly With this in the tic usually can be to a greater or However, the tic is the tension and become The longer in duration that tics are the greater be both the of tension and the duration and severity of the tics In tics are during periods of or extreme may not be noticed they are or into more movements to the tic or in the are of the nature or of tics and tic disorders to tics is by comorbid that present greater interference to the nearly all clinically referred who have TD have one or more comorbid conditions (Table may that of tics. generally these conditions rather than the and of who have TD have a comorbid diagnosis of attention disorder of present with diagnostic features of to the onset of tics. and learning difficulties are in to of who have TD. and language difficulties to be and there is a greater incidence of among those who have comorbid who have TD are increased of some have anxiety obsessive-compulsive in about one of affected The between a complex tic and a can be with compulsive such as until it up to to an may appear to be a complex may be phenotypic of a common to the later of more complex in TD typically present in later or early disorders occur often among clinically referred youth who have TD, with and major most disorders are frequent and include when comorbid with and complex tics as to the of severe or resulting in strained muscles or and such as are or represents a poorly understood that is reported in about of clinically referred youth who have TD. The are characterized by extreme of physical or that are by or no apparent after which the child often These are not of mood but a result of or anxiety in executive often developmental disorders. functions are a of functions that include and several to social and the to The behaviors in TD that executive may be to and can a on the of TD a to be more and less than their from any of the comorbid conditions social of and may be present and are when the child from or and or from or may with to or or for not to time with the of school may have been to in and tic as severity, and Most are based on some combination of and include the Tic and the Motor and Vocal Tic They are for by with tics and tic disorders and on both and They are for diagnostic and to the severity of functional and to the of over testing is can be to other example, be there is a history of (the 2 weeks to 6 associated with the onset of and A throat and for and may to the movements, such as or sustained can be with or A history for and with observed or in a child may for a usually can this remains to recognize that tics specific and these features are in disorders. history and may be to these for testing may be as head for a history of tic onset head Because on studies of who have TD are this should not be without a history of or is from from the clinical at present there is no genetic or that can the factors may the of the diagnostic affected do not recognize that they have tics, perhaps to of the or to having to their tics. The and other as and are to this In may be by of TD or and the of TD are the and nature of the of tic incidence at 6 to 7 years and at to the of tics into as one’s from the at the moment of a and the of become with the range of tic from the more tics of eye blinking and sniffing to the more or interfering and include TD in the It is to from several who are in with the such as or other well as to the child about the tics. Because often tics when they are of it may be to the child in the from an area or to events by the the child is of the presence of tics, about able to the for a and tension in the after have the suggest the diagnosis of TD be with criteria, it is to and for comorbid conditions because they usually present the most and interference with and psychosocial Because clinical for of tics do not typically features of such conditions be for The be of the potential comorbid diagnosis of TD among who present with other developmental and behavioral of the child the to diagnosis and A of tics and comorbid medical and developmental including tics and other developmental and behavioral environmental and school all contribute to the A physical and should the presence of such as associated movements in muscle groups during execution of or sustained motor These signs are in disorders of development and to a because of may the variety of such as the of the the the of be used to and comorbid A number of screening of development are to the of TD those areas that are most or and is the of any may be for and and can include in child or or social time may be to a diagnostic functional and to a with the child and and comorbid conditions be over time because their range in and is to in all of TD is the child and about the disorder. and are frequent of tics and These behaviors may be as a and explanation can to the and often are in the of and or to with the of is a role for the and should and in his or with the The or may the nature of the difficulties with the to and to in any In all is important to at the and than the disorder. the of that may Tourette in the and these to and social the child and can work together to about the which can to behaviors and any associated and an of inclusion and should be to and and behavioral should be of should be such as and any or and can to and more methods of and or other may from and that the of is to a of and for one’s be for the behaviors that result from processes of the but some behaviors, such as at or obscene social and to the child these behaviors include of the child of the nature of the behaviors and with the child to or behaviors that such as into a of and are widely and methods in of behaviors through or behaviors, and or attention for or behaviors. may from and or other groups and from to with is through school and of of the Tourette or related and that include testing may be to as well as and other This can be used to determine whether are these are through the school as both by the with and by of the of These any child who has a to a in the least such can be to meet the and medical of the child and to difficulties related to tics, social other that who have TD can include to in a private to other and to the child to have tics and on the and in the may be and a can be to the child for times when become and can either or to or other can who are with their or who are school can be without through of the Tourette or by a and The may a of private who in the of who have of can be a to a The of should the most disruptive or These features are most likely to be related to obsessions and compulsions, and behavioral these are tics are less likely to The in that tics wax and wane and often are at their when first to the tics over time may a of not recognized at the time of the all have that may be more than the signs and for which they are may to the child who has TD to another who is with and treatment of this of may include Although there is some about the of other in this to or tics, it is understood that any potential of tics to be or and with of the Because tics wax and wane over time, any observed in tic frequency or severity with of should not necessarily be to of the may be all that is are usually the treatment for comorbid and should the the presence of such factors as risk for or severe complex tics, may be and tic should be include and include the and (Table mechanism of is not can be in either two to four times daily or by as as once is a very frequent can be in daily than to three times of its longer duration of and it less and in of either for and and of both should be because of the risk for and including or with other for comorbid to a experienced in patients who have TD. These include the and which some in of these are and of with and is The and the may tic an with of either is a that may be as an comorbid obsessive-compulsive and behavioral are effectively and a that and is most who have TD not to tics. to tics is of potential is frequent of these include in and often result in and The and nature of tics between the and to treatment. tic severity and frequency, but is should begin only a single Although play important in the functional of range of other and for The in tics and other comorbid features among who have TD. of are with or and executive with It should be that the onset of the with this often not occur until at least 6 weeks after of which is a with the nearly of the a sustained of up to 3 months is when an and the are for tic (Table The should begin with a the is for an of time, then and as for tic the either is with for comorbid or a different is include which is not by the and as an for TD. These generally of and usually are than the and may as may include and but the potential for and is studies of other in and and are very are very used most include and which and have at other are may include dystonic and motor but their incidence may be with such as or with to have or as although rare among of movements, is more likely to result from the of typical than to tics are In some such as in the specific and have in of to among more who have tic a to the expression of a example, a tic be by of the neck have described tics to and of generally to of within the or its to cortical is to and usually a a and However, by least one of who have TD tics, and they are less severe in another The for comorbid conditions are to the of and and their behavioral and The on and that of psychosocial treatment directed the features that are most or a with the would to two for their and