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 dur- ing adulthood, to compare clinical char- acteristics 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. Protected copyright. an environmental factor. In one patient with CASE REPORTS new adult onset tics, the disorder developed New onset tics during adulthood during an extended cocaine binge. In two Case 2—This patient developed a tendency to patients, a new tic disorder developed after a grunt in his 30s. With time, the grunting head injury sustained during a car accident. A became more frequent and intrusive, and was fourth patient described the onset of neck tics joined by several other stereotyped sounds and after straining her neck during weight lifting. A vocalisations, including frequent short verbal fifth had tardive tics due to neuroleptic utterances: “yo” “hey, hey”, “me too”. The exposure. A sixth patient developed a promi- vocalisations began to interfere with the nent throat clearing tic after a severe pharyng- patient’s social life, preventing him from going itis. Symptomatic or secondary tic disorders to the cinema or social gatherings. He de- always presented as a new onset tic disorder in scribed a premonitory sensation but was pow- adults, and never as recurrent childhood tics, a erless to control the vocalisations. Treatment relation that was statistically significant with haloperidol, benztropine, clonidine, and (p<0.05, Fisher’s exact test). clonazepam did not help, and he experienced The clinical characteristics of our patients akathisia on haloperidol. The tics were im- with new adult onset tics are listed in table 1. proved on verapamil. There was no history of Among 13 patients with new onset adult tics, previous tics or psychopathology, but the fam- three patients had isolated motor tics, five ily history was positive for tic disorders. On patients had multiple motor tics, three patients examination, the patient exhibited his stere- 740 Chouinard, Ford J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.6.738 on 1 June 2000. Downloaded from

Table 1 Clinical characteristics of patients with new adult onset tics

Family history Associated Age of Distribution of of tic psychiatric Follow up Patient Sex onset Description of tics tics disorder? symptoms Medication trials Course (y) Additional features 1 M 24 Multiple motor tics Neck and Y — No benefit from TRHX, Stable 2 arms CLNZ, TBZ, PMZ 2 M 30 Primary Face, arms Y — Improvement on VPM Waxing and 45 vocalization tics waning, with multiple improved by motor tics follow up 3 F 32 Single motor tic Neck N — No benefit Stable 18 Tic developed after straining neck while weight lifting 4 M 33 Multiple vocal and Larynx, neck, N — No benefit from CBZ, Stable 2 Tics developed after motor tics arms CLNZ MVA with head trauma 5 M 40 Multiple motor tics Face N — No benefit from DZP, Waxing and 4 CLNZ, TBZ, PMZ waning 6 M 41 Multiple phonic Face, neck, N — Botulinum toxin Improved 20 Tics developed after and motor tics arms MVA 7 M 42 Primary neck tic Face, neck Y OCD Untreated Improved 6 with multiple facial and arm tics 8 M 49 Multiple motor tics Face, neck, N OCD No benefit from CLNZ, Waxing and 1.5 arms HAL, PMZ waning 9 F 69 Single vocalisation Vocal N OCD Untreated Stable 5 Tics developed during pharyngitis 10 M 46 Multiple complex Face, neck, Y Substance Unresponsive to Waxing and 2 Tics developed during motor tics arms misuse levodopa, helped with waning period of heavy disorder- CLNZ cocaine use 11 M 40 Single complex Face N Schizo Untreated/lost to follow Persistent 5 Tic status developed motor tic: blowing aVective up after 5 year exposure movements to molindone 12 M 46 Single respiratory Face, larynx N OCD Improvement on DZP Waxing and 3 tic waning 13 M 25 Multiple verbal Vocal Y OCD Untreated Waxing and 15 tics, including waning coprolalia

CBZ=Carbamazepine; CLNZ=clonazepam; DZP=diazepam; HAL=haloperidol; MVA=motor vehicle accident; OCD=obsessive- compulsive disorder; PMZ= pimozide; TBZ=tetrabenazine; TRHX=trihexiphenidyl; VPM=verapamil.

otyped verbalisations, as well as a loud yelling preceded by an inner sensation. Treatment with tic, facial grimacing, and arm movements. haloperidol, pimozide, tetrabenazine, and di- Case 5—This 63 year old man was referred azepam gave no relief. There was no history of for evaluation of abnormal facial movements. tics or obsessive-compulsive disorder, or family Since the age of 40, he had been aware of invol- history of tic disorders or obsessive-compulsive untary blinking, head bobbing, and neck jerking disorder. A review of the videotape taken during movements. There was no history of abnormal the first examination showed numerous minor http://jnnp.bmj.com/ vocalisation. He described that he was able to tics consisting of blinking, anterocollic jerks, partially suppress the movements, which were shoulder jerks, and lower face grimacing. On a

Table 2 Clinical characteristics of patients with recurrent childhood tics

Associated Duration Age of Family psychiatric of follow Patient Sex onset Description of tics Distribution of tics Childhood tics history symptoms Medication trials Course up (y) on September 27, 2021 by guest. Protected copyright. 14 M 25 Phonations and larynx, face, neck, Multiple motor Tics OCD No benefit from Waxing and waning, 20 multiple motor tics limbs tics DZP, ALPZ, PMZ improved 15 M 31 Multiple motor Face, neck Unspecified — — Improvement on Waxing and waning, 11 tics CLNZ, FLUOX, improved VPA 16 M 32 Multiple motor Face, neck Ear wiggling OCD — No benefit from Waxing and waning, 8 tics CLNZ improved 17 M 41 Multiple motor Face Blinking and OCD OCD and Untreated Waxing and waning 16 tics mannerisms anxiety disorder 18 F 28 Multiple motor Face, neck Blinking Tics OCD Improvement on Relapsing-remitting 20 tics CLNZ 19 M 61 Throat clearing Face, larynx, neck Unspecified Tics OCD No benefit on Stable 13 phonation and TRHX, multiple motor tics improvement on CLNZ 20 F 62 Jaw opening tic, Face, abdomen Blinking — — No benefit from Stable 10 abdominal tensing TRHX, BAC tic 21 M 63 Multiple Neck, face, Facial grimacing Tics — No benefit from Stable 17 phonations, facial abdomen CLNZ, CLON, tics HAL 22 F 29 Single tongue Tongue Blinking — — Untreated Stable 12 thrusting tic

ALPZ=alprazolam; BAC=baclofen; CLNZ=clonazepam; CLON=clonidine; DZP=diazepam; FLUOX=fluoxetine; HAL= haloperidol; OCD=obsessive compulsive disorder; PMZ=pimozide; TRHX=trihexiphenidyl; VPA=valproate. Adult onset tic disorders 741 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.6.738 on 1 June 2000. Downloaded from

recent follow up, the patient described that his Diazepam helped to reduce the movement. tics were still present but had fluctuated over There was history of previous tics, and the the years. family history was notable for Parkinson’s Case 9—This 72 year old woman had disease. As a child, the patient had obsessive developed a stereotyped socially disabling vo- rituals that did not impair him. calisation 3 years earlier in the context of Case 13—A 25 year old writer developed pharyngitis. She developed a harsh expectora- involuntary repetitive vocalisations, including tion sound, like a person forcefully clearing their coprolalia. These vocalisations were generally throat. With time, the vocalisation became more suppressible but occasionally came out during frequent, stereotyped, and more prominent stress or anxiety. He stated that often a vocali- when under stress. She described the problem as sation would occur without warning, triggered a “strainful exudement”. The sound was often by the sudden recollection of an unpleasant absent, particularly when she was quiet, relaxed, event. Alone, he often experienced prolonged concentrating on a task, or asleep. On neurologi- bouts of cursing and other vocalisations. He cal examination, the major abnormality was the also had a tendency to ruminate excessively, vocalisation itself, which sounded like an exag- imagining himself involved in elaborate rescue gerated, raspy, explosive throat clearing. The missions for members of his family in danger. vocalisation did not interrupt speech, chewing, There was no history of motor tics or previous or swallowing. The vocalisation could be sup- childhood tics. A paternal uncle had stere- pressed when she spoke, counted, or even otyped facial winking. The patient declined recited numbers in her head without speaking. treatment for his tics or obsessive rumination. Although never treated for obsessive-compulsive disorder, the patient had a lifelong compulsive Recurrent childhood tics tendency to keep notes, which she meticulously Case 20—This 62 year old woman developed catalogued, stored, and revised periodically. She sudden brief stereotyped jaw opening, preceded was especially interested in the act of recording by a sensory prodrome of skin tightness around and the reiteration of detail. There was no her mouth. By allowing the jaw opening move- history of neuroleptic exposure or head trauma ment to occur, the tightness sensation tempo- before the vocalisation, and no history of child- rarily abated. The movement could be sup- hood tics. She underwent trials of phenytoin, pressed by clenching her teeth tightly together. haloperidol, clonidine, trihexiphenidyl, clon- She experienced about 10 events daily, without azepam, pimozide, and baclofen, all in low dose much change over time. There was no exposure and without benefit. to neuroleptic drugs. As a 12 year old child, she Case 10—This 46 year old man developed recalls being sent home from camp one summer stereotyped facial grimacing duringa2year because of frequent eye blinking attributed to period of daily intranasal cocaine use. He had nervousness that resolved. been aware of twisting facial movements that Case 21—This 79 year old man was referred occurred transiently during cocaine intoxica- for a 16 year history of breathing problems. He tion, but the movements always subsided as the complained of shortness of breath attributed to drug eVect waned. At one point during the abdominal twitching. On examination, he had period of cocaine intake, he became aware that a frequent tendency to expel air against a his movements were persisting even when oV closed glottis, producing a suppressed cough- http://jnnp.bmj.com/ the drug. With time, he developed a prominent ing sound. In addition, he had frequent complex tic consisting of stereotyped head blowing, snorting, sniYng and panting, all of turning and rotational shoulder movements. which could be temporarily suppressed or dis- The movements were only briefly suppressible, tracted. He also had a stereotyped winking ten- up to 10 seconds. There was no history of pre- dency, with tight eyelid closure, and screwing vious tics, neuroleptic exposure, head trauma, up the left cheek. The facial grimacing had anoxia, or encephalitis. The patient’s sister had been present as a child, but had waned. In the facial movements, but the precise nature of family history, a nephew had disabling on September 27, 2021 by guest. Protected copyright. these could not be determined as she lived out Tourette’s syndrome, with multiple motor tics of the country. Clonazepam helped to suppress and vocalisations, including coprolalia. the tics. Within several months, the facial Case 22—This patient developed a stere- grimacing and shoulder movements resolved, otyped tongue movement at the age of 29 during but he developed a stereotyped flicking move- a particularly stressful period in her life. Her ment of the left hand. movement consisted of a tendency for the Case 12—A 46 year old man with obsessive- tongue to curl back and press itself against the compulsive disorder was referred by his upper teeth. The tongue movements were psychiatrist because of frequent yawning spells. relieved by a dental appliance but this was so It soon became apparent that his movements, uncomfortable that she eventually stopped superficially resembling yawning, were diVer- wearing it. The movement stopped for about 1 ent from his normal yawning. The yawning year after onset but then recurred, and remained movements were preceded by a sensation of for the next 10 years. The patient described the drowning or suVocation that could only be tongue movement as transiently suppressible, at relieved if the yawning movement was “just the cost of a sense of rising inner tension. With right: I need that good breath”. The yawning each tongue movement, there was transient was temporarily suppressible, and did not relief. On examination, the tongue tip quickly occur if the patient was distracted. The elevated, and her tongue retracted and pulled yawning could be substituted for by a sigh, back to the left side of her mouth in a which also abolished the sensation of asphyxia. stereotyped manner. The movement did not 742 Chouinard, Ford J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.6.738 on 1 June 2000. Downloaded from

Table 3 Previously reported cases of idiopathic tic disorders occurring during adulthood

Recurrent childhood tics or new onset adult Associated psychiatric Reference Age/sex tics? Clinical description Family history symptoms 11 35 M New onset Multiple motor and vocal tics — Anxiety/depression 12 46 F Recurrent Multiple motor and vocal tics — none 13 35 M New onset Multiple motor and vocal tics Tic disorder ADHD 14 62 F Recurrent Multiple motor and vocal tics — — 71 M Recurrent Multiple motor and vocal tics — — 65 M Recurrent Multiple motor and vocal tics — — 63 F Recurrent Multiple motor and vocal tics — — 15 53 F Recurrent Multiple motor and vocal tics — — 16 55 M New onset Multiple motor and vocal tics Tic disorder Depression 17 81 M New onset Multiple vocal and phonic tics — — 18 30 M New onset Multiple motor and vocal tics — —

occur during speaking, and there was no dysar- not be available. As such, it is important to thria or other speech impediment. Sometimes divide adult onset tic disorders into two catego- during the interview there was a rapid stere- ries based on the time course of presentation: a otyped lateral jaw deviation to the left, but no new tic disorder after the age of 21 years or the other repetitive or stereotyped movements, such recurrence of childhood tics that had previously as tongue protrusion, sustained posturing, pala- resolved. In the present series, the categorical tal myoclonus, or pharyngeal movements. When breakdown among 22 patients was: idiopathic she was 5 years old, the patient had had motor new onset tics in seven (32%), new onset tics consisting of blinking, which resolved spon- secondary tic disorder in six (27%), and recur- taneously within several months. There was no rent childhood tic disorder in nine (41%). history of vocalisations, repetitive rituals, obses- The clinical features of adult onset tic disor- sions, or other related symptoms. ders resemble those described in childhood onset tic disorders.72021 However, the range of Discussion tic phenomenology in our population seemed Tic disorders newly presenting during adult- more restricted relative to childhood tics, and hood have occasionally been described in the the severity of tic disorders was milder. There neurological literature, mostly in relation to an was little coprolalia, as has been previously acquired brain lesion,8–10 or as incidental tics in noted in childhood tics persisting into the context of another neurological or psychi- adulthood.6 Automatisms of the type described atric disease, such as Huntington’s disease.8 in autistic children were not found in this sam- There are few descriptions of primary, or idio- ple, but may reflect referral bias, as adults with pathic, adult onset tics in the literature, and autistic behaviours are not generally referred to about 55% of reported cases represent recur- our clinic. In our population, there were no rences of childhood tic disorders,11-14–19 as phenomenological diVerences between patients shown in table 3. The largest report is that of with de novo adult onset tics and those patients Klawans and Barr, who described four patients with recurrent childhood tics. Both groups with childhood onset tics that remitted before exhibited tics that most often involved the face, the age of 21, only to recur after the age of 60.14 neck, and shoulder. Most patients had multiple http://jnnp.bmj.com/ Taken together, the paucity of reports of adult motor tics. In the series, only six patients had an onset tic disorders suggests that they represent isolated single tic disorder, but three others had an unusual entity, especially idiopathic tic dis- a primary tic that overshadowed a background orders, rarely encountered in clinical practice, of multiple, minor tics. Single tics and domi- in marked contrast to the high prevalence of nant tics persisted over the full course of the childhood tic disorders. disorder, waxing and waning in severity but not The present series of 22 patients is the largest varying in repertoire. In both groups, no patient report describing the clinical features of tic dis- had a complete remission of their tics in adult- on September 27, 2021 by guest. Protected copyright. orders presenting during adulthood. In our hood. Treatment attempts were generally not population, adults newly presenting with tic successful, and rarely sustained. Eventually, disorders represent 5.4% of patients of all ages most patients elected to discontinue medical evaluated for tics. We cannot estimate the treatment, prefering to live with their tics than prevalence of adult onset tic disorders in the to experience the side eVects of medication. general population, but the number of patients The concept that obsessive-compulsive disor- we have encountered suggests that the phenom- der is part of the range of neurobehavioral enon is more common than previously re- manifestations of Tourette’s syndrome is well ported. When adults present for the first time to accepted,22 23 and in our series was present in a physician for evaluation of a tic disorder, a nine of 22 patients (40.9%). certain number will have true new onset tics, Disability was not formally quantified in our whereas the rest will prove to have a recurrence population, and we could not distinguish of a childhood tic disorder. Among adults with disability due to tics from disability caused by new onset tics, about 50% will have an apparent attendant psychopathology. In general, patients external precipitant of the disorder. Establish- stated that they were mainly socially disabled by ing that an adult patient with apparent new their tics, in agreement with studies describing onset tics did not have tics during childhood social embarrassment and isolation as the most can rarely be done with certainty because some disabling consequences of tic disorders.24 All of patients are unaware of their tics, and reliable our patients were self referred for tics, a referral observers who knew the patient as a child may bias that usually selects for more severely Adult onset tic disorders 743 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.6.738 on 1 June 2000. Downloaded from

aVected people. However, based on interviews typical of childhood onset tic disorders. The with the patients and review of the patients’ clinical evidence suggests that adult tic disor- videotaped neurological examinations, the pa- ders are part of a range of illness that includes tients in this series would be considered to have childhood onset tics and Tourette’s syndrome. only mild (score 0 to 24) or moderate (score 25 We therefore propose that classifications of tic to 39) severity tic disorder, using a standard rat- disorders include an adult age category that is ing scale.25 We did not encounter any patient subdivided by disease course into tic disorders presenting during adulthood with a tic disorder that persist from childhood, tic disorders that at the extreme end of the severity range, with tics represent a recurrence of transient childhood so disruptive and intractable that social, familial, tics, and genuine new onset adult tic disorders. or occupational functioning is all but precluded. Within the category of adult onset tics, it also All adults with this degree of disease severity fol- seems important to diVerentiate primary from lowed at our centre developed their disorders secondary tic disorders, and most of the during childhood. secondary cases will fall into the new onset The prevalence of symptomatic tic disorders adult tic disorder category. We anticipate that seems significantly higher among adults with the classification of tic disorders, now based new onset tic disorders than for adults with entirely on clinical criteria, will become clearer recurrent childhood tics, a finding inferred with the development of genetic markers. from the number of published reports of 9 secondary tic disorders in the literature. We are grateful to Dr Paul Greene for his critical review of the Adults with new onset tics are also more likely manuscript and help with the computerised database, and to Dr Stanley Fahn for his support. to have an underlying cause or provocative event for their tics than children with tic disor- 1 American Psychiatric Association. Task force on nomenclature ders. By contrast, childhood onset tic disorders and statistics. Diagnostic and statistical manual of mental disor- ders. 4th edition (DSM-IV). Washington DC: APA, 1994. are only rarely linked to a specific aetiology. 2 The Tourette syndrome classification study group. Defini- Almost one third of the patients in this series tions and classification of tic disorders. Arch Neurol 1993;50:1013–16. reported the onset of tics after a clear inciting 3 Gilles de la Tourette G. Etude sur une aVection nerveuse event, including neck strain, head injury, local caractérisée par de l‘incoordination motrice accompagnée d‘écolalie et de coprolalie. Arch Neurol (Paris) 1885;9:19– infection, cocaine binge usage, and exposure to 42,158–200. neuroleptic drugs, all conditions known to pre- 4 Shapiro AK, Shapiro E, Wayne HH. Birth, developmental 7 and family histories and demographic information in cipitate tics. The literature suggests that tics Tourette’s syndrome. JNervMentDis1972;155:335–44. caused by peripheral trauma tend to be single, 5 Burd L, Kerbeshian J, Wikenheiser M, et al. Prevalence of Gilles de la Tourette syndrome in North Dakota adults. Am non-varying isolated tics, and the two patients J Psychiatry 1986;143:787–8. in our series who come closest to a peripheral 6 Goetz CG, Tanner CM, Stebbins GT, et al. Adult tics in Gilles de la Tourette’s syndrome: description and risk fac- physical injury (cases 3 and 9) support this tors. Neurol 1992;42:784–8. notion. The question arises as to whether those 7 Jankovic J. Phenomenology and classification of tics. Neurol Clin 1997;15:267–75. with secondary tics would have gone on to 8 Sacks OW. Acquired tourettism in adult life. Adv Neurol develop tics in the absence of the precipitating 1982;35:89–92. 9 Kumar R, Lang AE. Secondary tic disorders. Neurologic Clin event. In our cases of secondary tic disorders, 1997;15:309–31. and among adult onset post-traumatic cases 10 Factor SA, Molho ES. Adult-onset tics associated with peripheral injury. Mov Disord 1997;12:1052–5. described in the literature, about half had a 11 Araneta E, Magen J, Musci MN, . Gilles de la Tourette’s

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