Tourette Syndrome and Other Tic Disorders: Diagnosis, Pathophysiology, and Treatment Harvey S. Singer, MD(1), and John T. Walkup, MD(2) Medicine, Vol. 70, No. 1, 1991

Introduction The Gilles de la Tourette syndrome (TS) and related tic disorders can no longer be considered rare and unusual diseases. Representing a spectrum of familial, involuntary motor and/or vocal tics and co-morbid neuropsychiatric problems, tic disorders have been described in the pediatric, neurologic, psychiatric, and lay literature (for comprehensive reviews see references 27 and 169). Nevertheless, despite this apparent emphasis, physicians are often reluctant to make the diagnosis, fail to appreciate the diversity of associated symptoms, or hesitate to use available medications. In this article, we review the clinical characteristics, epidemiology, pathophysiology, and therapy of these disorders. The approach presented is based on the authors' experiences, interpretation of the literature, and research investigations. The goal of this report is to provide the reader with a practical perspective of tic disorders and a background for understanding current research activities.

From the (1)Department of Neurology, (1,2)Pediatrics, and (2)Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland. Address reprint requests to: Harvey S. Singer, MD, Department of Neurology, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21205.

Premonitory Urges in Tourette's Syndrome James F. Leckman, MD, David E. Walker, BA, and Donald J. Cohen, MD Am J Psychiatry 150:1, January 1993

Abstract Objective: Tourette's syndrome traditionally has been viewed as a hyperkinetic movement disorder characterized by involuntary motor and phonic tics. Many patients, however, describe their tics as a voluntary response to premonitory urges. This cross-sectional study evaluated premonitory urges and related phenomena in subjects with tic disorders. Method: A total of 135 subjects with tic disorders, aged 8 to 71 years, completed a questionnaire concerning their current and past tic symptoms. Subjects were asked to describe and, if possible, localize their premonitory urges. The Yale Global Tic Severity Scale was used to assess current tic severity. The method of case finding does not provide prevalence data for premonitory urges. Results: Ninety-three percent of the subjects reported premonitory urges. Anatomical regions with the greatest density of urges were the palms, shoulders, midline abdomen, and throat. Eight-four percent of the subjects reported that tics were associated with a feeling of relief. A substantial majority (92%) also indicated that their tics were either fully or partially a voluntary response to the premonitory urges. Conclusions: While epidemiological studies of tic disorders have yet to incorporate questions concerning premonitory urges, these results suggest that such urges may be commonplace in adolescent and adult subjects with tic disorders. These results challenge the conventional wisdom that tic behaviors are wholly involuntary in character. They also implicate brain regions involved in the processing of sensorimotor information in the pathobiology of tic disorders. (Am J Psychiatry 1993; 150:98-102)

Address reprint requests to Dr. Leckman, I-269 SHM, Child Study Center, Yale University School of Medicine, P.O. Box 3333, New Haven, CT 06510.