Adult Onset Tic Disorders

738 J Neurol Neurosurg Psychiatry 2000;68:738–743 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.6.738 on 1 June 2000. Downloaded from Adult onset tic disorders Sylvain Chouinard, Blair Ford Abstract to a movement disorder clinic with tic dis- Background—Tic disorders presenting orders are reviewed, analysed, and dis- during adulthood have infrequently been cussed in detail. Clinical evidence described in the medical literature. Most supports the concept that tic disorders in reports depict adult onset secondary tic adults are part of a range that includes disorders caused by trauma, encephalitis, childhood onset tic disorders and and other acquired conditions. Only rare Tourette’s syndrome. reports describe idiopathic adult onset tic (J Neurol Neurosurg Psychiatry 2000;68:738–743) disorders, and most of these cases repre- Keywords: Tourette’s syndrome; secondary tic disor- sent recurrent childhood tic disorders. ders; obsessive-compulsive disorder; attention-deficit Objective—To describe a large series of hyperactivity disorder patients with tic disorders presenting during adulthood, to compare clinical characteristics between groups of patients, and Tic disorders are commonly considered to be to call attention to this potentially disa- childhood syndromes. Childhood onset is a bling and underrecognised neurological defining feature of Tourette’s syndrome, a disorder. chronic disorder of severe motor and vocal tics Methods—Using a computerised data- that begins before the age of 181 or 21,2 base, all patients with tic disorders who depending on the criteria. The childhood onset presented between 1988 and 1998 to the of tic disorders has been consistently described movement disorders clinic at Columbia- since Gilles de la Tourette’s seminal report, in Presbyterian Medical Center after the age which all eight patients presented with tics of 21 were identified. Patients’ charts were during childhood.3 The DSM-IV classification retrospectively reviewed for demographic of tic disorders does not include a category for information, age of onset of tics, tic tic disorders that develop during adulthood, phenomenology, distribution, the pres- other than tic disorder “not otherwise speci- ence of premonitory sensory symptoms fied”. Tic disorders experienced during adult- and tic suppressibility, family history, and hood are largely considered to be persistent tics associated psychiatric features. These pa- from childhood.4–6 In adults presenting with a tients’ videotapes were reviewed for diag- tic disorder, it is often assumed that the nostic confirmation and information was patients cannot remember having experienced obtained about disability, course, and childhood tics.7 As such, tic disorders newly response to treatment in a structured fol- presenting during adulthood have only occa- low up interview. sionally been described in isolated case reports, http://jnnp.bmj.com/ Results—Of 411 patients with tic disorders and mostly in the context of symptomatic, or in the database, 22 patients presented for secondary, tic disorders. The goal of the the first time with tic disorders after the present study was to describe a large series of age of 21. In nine patients, detailed ques- patients with tic disorders presenting during tioning disclosed a history of previous adulthood, to compare clinical characteristics childhood transient tic disorder, but in 13 between groups of patients, and to call patients, the adult onset tic disorder was attention to this potentially disabling and new. Among the new onset cases, six underrecognised neurological disorder. on September 27, 2021 by guest. Protected copyright. patients developed tics in relation to an external trigger, and could be considered to Methods Department of have secondary tic disorders. The remain- From a computerised database of patients, we Neurology, University ing patients had idiopathic tic disorders. extracted the records of all patients who of Montreal, Quebec, Comparing adult patients with recurrent presented between 1988 and 1998 to the Canada childhood tics and those with new onset S Chouinard Center for Movement Disorders, Columbia adult tics, the appearance of the tic disor- Presbyterian Medical Center, for evaluation or Department of der, the course and prognosis, the family treatment of a tic disorder that had developed Neurology, Columbia history of tic disorder, and the prevalence after the age of 21. All patients were initially University New York, of obsessive-compulsive disorder were diagnosed by a movement disorder specialist, New York, USA found to be similar. Adults with new onset based on the clinical appearance of tics as sud- B Ford tics were more likely to have a symptomatic den, brief, purposeless, stereotyped move- Correspondence to: or secondary tic disorder, which in this ments or sounds. We reviewed videotaped Dr Blair Ford, Neurological series was caused by infection, trauma, examinations of the patients for diagnostic Institute, 710 168th Street, cocaine use, and neuroleptic exposure. confirmation. We considered a tic disorder to New York, NY 10032, USA [email protected] Conclusions—Adult onset tic disorders be present when the patient stated that the tics represent an underrecognised condition were socially, occupationally, or functionally Received 12 August 1999 that is more common than generally disabling in any way. Only those patients in and in revised form 6 December 1999 appreciated or reported. The clinical whom a tic disorder was the sole complaint and Accepted 14 December 1999 characteristics of adults newly presenting primary diagnosis were considered in this Adult onset tic disorders 739 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.6.738 on 1 June 2000. Downloaded from study, but we included patients with sympto- had multiple motor and vocal tics, one patient matic or secondary tics if their movement dis- had an isolated vocal tic, and one patient expe- order consisted exclusively of tics. Patients with rienced multiple vocal tics. Tic suppressibility tics caused by somatoform illness and related was noted in nine patients and eight patients conditions were not included. All patients who had a premonitory sensory symptom before the presented with tic disorders developing after tics. A family history of tic disorder was present the age of 21 were considered to have adult in five patients and five had symptoms of onset tics. We attempted to establish whether obsessive-compulsive disorder. The duration of patients with adult onset tics had experienced illness in patients with new adult onset tics was tics during childhood. Patients with tic disor- on average 10.5 years at the time of most recent ders that began during childhood and persisted follow up, ranging from 1.5 to 45 years. Nine through adulthood were not included. We did patients elected to have treatment, and in four, not exclude patients with adult onset tics if there was modest improvement. Over the their tic disorder began after the age of 21 but course of the illness, tics tended not to vary in who had experienced tics lasting less than 12 repertoire, and isolated tics remained un- months during childhood, and who did not changed. Tic severity tended to wax and wane, present to a physician at that time. and no patient experienced a prolonged symp- We retrospectively reviewed patients’ charts tom remission. for demographic information, age of onset of The clinical characteristics of patients with a tics, description of tics, distribution, the recurrent childhood tic disorder during adult- presence of premonitory sensory symptoms, hood are listed in table 2. For the nine patients the degree of tic suppressibility, family history, with recurrent childhood tics, the mean age of associated psychiatric features, disability, recurrence was 47 years, ranging from 25 to 63 course, and response to treatment. Where pos- years. All patients had experienced transient sible, we obtained psychiatric records. The childhood tics of mild degree, and the mean diagnosis of obsessive-compulsive disorder was symptom free hiatus in these patients was 1 based on DSM-IV criteria, requiring recurrent about 32 years, ranging from 12 to 56 years. obsessions or compulsions severe enough to be Five patients exhibited multiple motor tics, time consuming or cause significant distress or three patients had multiple motor and phonic impairment. To obtain more recent follow up tics, and one had an isolated motor tic. No information, a structured questionnaire was patients had verbal tics. All patients described a administered to 18 patients by phone or direct premonitory sensory symptom and were able interview. to suppress the tics. The childhood tics consisted of facial tics or blinking in seven Results patients and in two patients, the appearance of Of 411 patients with tic disorders in our data- the childhood tics was not specified. No patient base, 22 (5.4%) presented for evaluation of tics had undergone evaluation or treatment during after the age of 21. For 20 patients, videotaped childhood. Four patients had symptoms of examinations were available for confirmation obsessive-compulsive disorder. A positive fam- of diagnosis. There were 17 men and five ily history for tic disorder was present in four women. The mean age of onset was 40 years, patients and two had a family history of http://jnnp.bmj.com/ ranging from 24 to 63 years. Nine patients had obsessive-compulsive disorder. The mean du- a history of tics during childhood, but in 13, ration of illness from the recurrence of tics to there was no prior history of tics, as far as could the most recent follow up was 13 years, ranging be determined from interview with the patient from 3 to 20 years. Seven patients underwent and family members. treatment for their tics, of whom three noted In 16 patients, the aetiology of the tic disor- some improvement. No patient had a full or der was considered idiopathic, but in six, all sustained remission during adulthood. with new onset tic disorder, there seemed to be a causal relation between the tic disorder and on September 27, 2021 by guest.

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