PHENOMENOLOGY AND CLASSIFICATION OF TICS
Identifieur interne : 003117 ( Istex/Corpus ); précédent : 003116; suivant : 003118PHENOMENOLOGY AND CLASSIFICATION OF TICS
Auteurs : Joseph JankovicSource :
- Neurologic Clinics [ 0733-8619 ] ; 1997.
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DOI: 10.1016/S0733-8619(05)70311-X
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B. Saunders Company, ©1997</p></availability><date>1997</date></publicationStmt><notesStmt><note>Address reprint requests to Joseph Jankovic, MD, Baylor College of Medicine, Department of Neurology, 6550 Fannin, Houston, TX 77030</note><note type="content">Table 1: TICS</note><note type="content">Table 2: MOVEMENTS</note><note type="content">Table 3: TICS: CHARACTERISTICS</note><note type="content">Table 4: DIAGNOSTIC CRITERIA</note><note type="content">Table 5: CLASSIFICATION OF TICS</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a">PHENOMENOLOGY AND CLASSIFICATION OF TICS</title><author><persName><forename type="first">Joseph</forename><surname>Jankovic</surname></persName><roleName type="degree">MD</roleName><note type="biography">From the Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas</note><affiliation>From the Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas</affiliation></author></analytic><monogr><title level="j">Neurologic Clinics</title><title level="j" type="abbrev">NCL</title><idno type="pISSN">0733-8619</idno><idno type="PII">S0733-8619(05)X7022-0</idno><imprint><publisher>ELSEVIER</publisher><date type="published" when="1997"></date><biblScope unit="volume">15</biblScope><biblScope unit="issue">2</biblScope><biblScope unit="page" from="267">267</biblScope><biblScope unit="page" to="275">275</biblScope></imprint></monogr><idno type="istex">A88C6031ACE640441D67D0E7A9C2CE641715F918</idno><idno type="DOI">10.1016/S0733-8619(05)70311-X</idno><idno type="PII">S0733-8619(05)70311-X</idno></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>1997</date></creation><langUsage><language ident="en">en</language></langUsage></profileDesc><revisionDesc><change when="1997">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><original>false</original><mimetype>text/plain</mimetype><extension>txt</extension><uri>https://api.istex.fr/document/A88C6031ACE640441D67D0E7A9C2CE641715F918/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="Elsevier doc found" wicri:toSee="Elsevier, no converted or simple article"><istex:xmlDeclaration>version="1.0" encoding="UTF-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//ES//DTD journal article DTD version 5.0.1//EN//XML" URI="art501.dtd" name="istex:docType"></istex:docType><istex:document><article docsubtype="fla"> <item-info> <jid>NCL</jid> <aid>70311</aid> <ce:pii>S0733-8619(05)70311-X</ce:pii><ce:doi>10.1016/S0733-8619(05)70311-X</ce:doi> <ce:copyright type="other" year="1997">W. B. Saunders Company</ce:copyright> </item-info> <ce:floats> <ce:table frame="topbot" rowsep="0" id="cetable1"> <ce:label>Table 1</ce:label> <ce:caption> <ce:simple-para>TICS</ce:simple-para> </ce:caption> <tgroup cols="1" colsep="0" rowsep="0"> <colspec colnum="1" colname="col1" colwidth="100*"></colspec> <tbody> <row> <entry colname="col1" align="left"><ce:bold>Simple motor tics:</ce:bold> isolated, involving only one group of muscles, may be single or repetitive</entry> </row> <row> <entry colname="col1" align="left"> 1. <ce:bold>Clonic:</ce:bold> brief (usually <100 msec), jerklike</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Examples:</ce:italic> blinking, nose twitching, head jerking</entry> </row> <row> <entry colname="col1" align="left"> 2. <ce:bold>Dystonic:</ce:bold> sustained (usually >300 msec), twisting or squeezing movement or posture</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Examples:</ce:italic> blepharospasm, oculogyric movements, bruxism, mouth opening, torticollis, shoulder rotation</entry> </row> <row> <entry colname="col1" align="left"> 3. <ce:bold>Tonic:</ce:bold> sustained (usually >500 msec), isometric contraction</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Examples:</ce:italic> abdominal or limb tensing</entry> </row> <row> <entry colname="col1" align="left"><ce:bold>Complex motor tics:</ce:bold> coordinated, sequential movements that may resemble normal motor acts or gestures but are inappropriately intense and timed; may be repetitive (stereotypic)</entry> </row> <row> <entry colname="col1" align="left"> 1. <ce:bold>Seemingly nonpurposeful:</ce:bold></entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Examples:</ce:italic> head shaking, trunk bending</entry> </row> <row> <entry colname="col1" align="left"> 2. <ce:bold>Seemingly purposeful:</ce:bold> may be difficult to differentiate from compulsions</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Examples:</ce:italic> touching, throwing, hitting, jumping, kicking, copropraxia, echopraxia</entry> </row> <row> <entry colname="col1" align="left"><ce:bold>Simple phonic tics:</ce:bold> single, meaningless sounds and noises</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Examples:</ce:italic> throat clearing, grunting, sniffing, squeaking, coughing, barking, screaming, whistling, blowing, sucking</entry> </row> <row> <entry colname="col1" align="left"><ce:bold>Complex phonic tics:</ce:bold> linguistically meaningful utterances and verbalizations</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Examples:</ce:italic> coprolalia, echolalia, palilalia</entry> </row> <row> <entry colname="col1" align="left"><ce:bold>Compulsive tics:</ce:bold> movements or sounds that occur in response to inner urge or feeling</entry> </row> </tbody> </tgroup> </ce:table> <ce:table id="cetable2" frame="topbot" colsep="1" rowsep="0"> <ce:label>Table 2</ce:label> <ce:caption> <ce:simple-para>MOVEMENTS</ce:simple-para> </ce:caption> <tgroup cols="1" colsep="0" rowsep="0"> <colspec colnum="1" colname="col1" colwidth="100*"></colspec> <tbody> <row rowsep="1"> <entry colname="col1" align="left"><ce:bold>VOLUNTARY</ce:bold></entry> </row> <row> <entry colname="col1" align="left">Intentional (planned, self-initiated)</entry> </row> <row rowsep="1"> <entry colname="col1" align="left">Responsive (induced by external stimulus)</entry> </row> <row rowsep="1"> <entry colname="col1" align="left"><ce:bold>SEMIVOLUNTARY (UNVOLUNTARY)</ce:bold></entry> </row> <row> <entry colname="col1" align="left">Induced by an inner sensory stimulus</entry> </row> <row rowsep="1"> <entry colname="col1" align="left">Induced by an unwanted feeling/compulsion</entry> </row> <row rowsep="1"> <entry colname="col1" align="left"><ce:bold>INVOLUNTARY</ce:bold></entry> </row> <row> <entry colname="col1" align="left">Non-suppressible (reflexes, seizures, myoclonus)</entry> </row> <row rowsep="1"> <entry colname="col1" align="left">Suppressible (tics, tremor, dystonia, chorea, stereotypy)</entry> </row> <row> <entry colname="col1" align="left"><ce:bold>AUTOMATIC (learned, without conscious effort [gait, speech])</ce:bold></entry> </row> </tbody> </tgroup> </ce:table> <ce:table frame="topbot" rowsep="0" id="cetable3"> <ce:label>Table 3</ce:label> <ce:caption> <ce:simple-para>TICS: CHARACTERISTICS</ce:simple-para> </ce:caption> <tgroup cols="1" colsep="0" rowsep="0"> <colspec colnum="1" colname="col1" colwidth="100*"></colspec> <tbody> <row> <entry colname="col1" align="left">Premonitory feelings or sensations</entry> </row> <row> <entry colname="col1" align="left">Temporary suppressibility</entry> </row> <row> <entry colname="col1" align="left">Suggestibility</entry> </row> <row> <entry colname="col1" align="left">Increase with stress</entry> </row> <row> <entry colname="col1" align="left">Increase during relaxation after stress</entry> </row> <row> <entry colname="col1" align="left">Decrease with distraction <ce:italic>and</ce:italic> concentration</entry> </row> <row> <entry colname="col1" align="left">Waxing and waning, transient remissions</entry> </row> <row> <entry colname="col1" align="left">Persist during sleep</entry> </row> </tbody> </tgroup> </ce:table> <ce:table frame="topbot" rowsep="0" id="cetable4"> <ce:label>Table 4</ce:label> <ce:caption> <ce:simple-para>DIAGNOSTIC CRITERIA</ce:simple-para> </ce:caption> <tgroup cols="1" colsep="0" rowsep="0"> <colspec colnum="1" colname="col1" colwidth="100*"></colspec> <tbody> <row rowsep="1"> <entry colname="col1" align="left"><ce:bold>DEFINITE TOURETTE'S SYNDROME</ce:bold></entry> </row> <row> <entry colname="col1" align="left">Both multiple motor and one or more phonic tics have been present at some time during the illness, although not necessarily concurrently</entry> </row> <row> <entry colname="col1" align="left">The tics occur many times a day, nearly every day, or intermittently throughout a period of more than one year</entry> </row> <row> <entry colname="col1" align="left">The anatomic location, number, frequency, type, complexity, or severity of tics change over time</entry> </row> <row> <entry colname="col1" align="left">Onset before age 21 years</entry> </row> <row> <entry colname="col1" align="left">Involuntary movements and noises cannot be explained by other medical conditions</entry> </row> <row rowsep="1"> <entry colname="col1" align="left">Motor and/or phonic tics must be witnessed by a reliable examiner directly at some point during the illness or be recorded by videotape or cinematography</entry> </row> <row rowsep="1"> <entry colname="col1" align="left"><ce:bold>PROBABLE TOURETTE SYNDROME</ce:bold></entry> </row> <row> <entry colname="col1" align="left"><ce:bold>Type 1.</ce:bold> Meets all criteria for <ce:bold>definite</ce:bold> TS, except 3 and/or 4.</entry> </row> <row> <entry colname="col1" align="left"><ce:bold>Type 2.</ce:bold> Meets all criteria for <ce:bold>definite</ce:bold> TS, except 1. Includes either single motor tic with phonic tics or multiple motor tics with possible phonic tic(s).</entry> </row> </tbody> </tgroup> </ce:table> <ce:table frame="topbot" rowsep="0" id="cetable5"> <ce:label>Table 5</ce:label> <ce:caption> <ce:simple-para>CLASSIFICATION OF TICS</ce:simple-para> </ce:caption> <tgroup cols="1" colsep="0" rowsep="0"> <colspec colnum="1" colname="col1" colwidth="100*"></colspec> <tbody> <row rowsep="1"> <entry colname="col1" align="left"><ce:bold>PHYSIOLOGIC TICS</ce:bold></entry> </row> <row rowsep="1"> <entry colname="col1" align="left">Mannerisms</entry> </row> <row rowsep="1"> <entry colname="col1" align="left"><ce:bold>PATHOLOGIC TICS</ce:bold></entry> </row> <row> <entry colname="col1" align="left">Primary</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Sporadic</ce:italic></entry> </row> <row> <entry colname="col1" align="left"> 1. Transient motor <ce:italic>or</ce:italic> phonic tics (<1 year)</entry> </row> <row> <entry colname="col1" align="left"> 2. Chronic motor <ce:italic>or</ce:italic> phonic tics (>1 year)</entry> </row> <row> <entry colname="col1" align="left"> 3. Adult-onset (recurrent) tics</entry> </row> <row> <entry colname="col1" align="left"> 4. Tourette syndrome</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Inherited</ce:italic></entry> </row> <row> <entry colname="col1" align="left"> 1. Tourette's syndrome</entry> </row> <row> <entry colname="col1" align="left"> 2. Huntington's disease</entry> </row> <row> <entry colname="col1" align="left"> 3. Primary dystonia</entry> </row> <row> <entry colname="col1" align="left"> 4. Neuroacanthocytosis</entry> </row> <row> <entry colname="col1" align="left">Secondary (<ce:italic>Tourettism</ce:italic>)</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Infections:</ce:italic> encephalitis, Creutzfeldt-Jakob disease, Sydenham's chorea</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Drugs:</ce:italic> stimulants, levodopa, carbamazepine, phenytoin, phenobarbital, antipsychotics (tardive tics)</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Toxins:</ce:italic> carbon monoxide</entry> </row> <row> <entry colname="col1" align="left"> <ce:italic>Developmental:</ce:italic> static encephalopathy, mental retardation syndromes, chromosomal ab ; normalities</entry> </row> <row rowsep="1"> <entry colname="col1" align="left"> <ce:italic>Other:</ce:italic> head trauma, stroke, neurocutaneous syndromes, chromosomal abnormalities, schizophrenia, neuroacanthocytosis degenerative disorders</entry> </row> <row rowsep="1"> <entry colname="col1" align="left"><ce:bold>RELATED DISORDERS</ce:bold></entry> </row> <row> <entry colname="col1" align="left"> Stereotypies</entry> </row> <row> <entry colname="col1" align="left"> Self-injurious behaviors</entry> </row> <row> <entry colname="col1" align="left"> Hyperactivity syndrome</entry> </row> <row> <entry colname="col1" align="left"> Compulsions</entry> </row> <row> <entry colname="col1" align="left"> Excessive startle</entry> </row> <row> <entry colname="col1" align="left"> “ Jumping Frenchman,” Latah, Myriachit</entry> </row> </tbody> </tgroup> </ce:table> </ce:floats> <head> <ce:article-footnote> <ce:note-para><ce:italic>Address reprint requests to</ce:italic> Joseph Jankovic, MD, Baylor College of Medicine, Department of Neurology, 6550 Fannin, Houston, TX 77030</ce:note-para> </ce:article-footnote> <ce:title>PHENOMENOLOGY AND CLASSIFICATION OF TICS</ce:title> <ce:author-group> <ce:author> <ce:given-name>Joseph</ce:given-name> <ce:surname>Jankovic</ce:surname> <ce:degrees>MD</ce:degrees> <ce:cross-ref refid="fn1"><ce:sup>*</ce:sup></ce:cross-ref> </ce:author> <ce:footnote id="fn1"> <ce:label>*</ce:label> <ce:note-para>From the Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas</ce:note-para> </ce:footnote> </ce:author-group> </head> <body> <ce:sections> <ce:section id="cesec1"> <ce:section-title>HISTORICAL PERSPECTIVE</ce:section-title> <ce:para>Motor and phonic (vocal) tics constitute the clinical hallmark of Tourette's syndrome (TS). Comorbid conditions, particularly obsessive-compulsive disorder (OCD) and attention deficit disorder (ADD), often accompany tics and may dom inate the clinical picture in some cases.<ce:cross-refs refid="bib3 bib8 bib12 bib15 bib25 bib34 bib35 bib39"><ce:sup>3,8,12,15,25,34,35,39</ce:sup></ce:cross-refs> These disorders also are re viewed elsewhere in this issue.</ce:para> <ce:para>One of the earliest reports of TS dates to 1825, when Itard<ce:cross-ref refid="bib9"><ce:sup>9</ce:sup></ce:cross-ref> described a French noblewoman with body tics, barking sounds and uncontrollable utterances of obscenities. Sixty years later, the French neurologist and a student of Charcot, George Gilles de la Tourette reviewed Itard's original case and added eight more patients.<ce:cross-ref refid="bib5"><ce:sup>5</ce:sup></ce:cross-ref> He noted that all nine patients shared one feature—they all exhibited brief involuntary movements or tics. An additional six made noises, five shouted obscenities (<ce:italic>coprolalia</ce:italic>), five repeated the words of others (<ce:italic>echolalia</ce:italic>) and two mimicked other's gestures (<ce:italic>echopraxia</ce:italic>). Although Gilles de la Tourette considered the disorder he described to be hereditary, the etiology was ascribed to psychogenic causes for nearly a century following the original report. The perception of TS began to change in the 1960s, however, when the beneficial effects of neuroleptic drugs on the symptoms of TS began to be recognized. This observation helped to refocus attention from psychogenic causes to primarily organic etiologies involving a dysfunction of the central nervous system (CNS). A reexamination of biographical material has led to the recognition that many notable historical figures, including Dr. Samuel Johnson, and possibly Wolfgang Amadeus Mozart,<ce:cross-ref refid="bib38"><ce:sup>38</ce:sup></ce:cross-ref> were afflicted with TS.</ce:para> <ce:para>The clinical expression of this genetic disorder varies from one person to another, even within the same family.<ce:cross-ref refid="bib26"><ce:sup>26</ce:sup></ce:cross-ref> Symptoms typically fluctuate in severity and change character within the same person. This variable expression often contributes to diagnostic confusion and a misdiagnosis. In the absence of a specific biologic marker, the diagnosis depends on a careful evaluation of the patient's symptoms and signs by an experienced clinician.</ce:para> </ce:section> <ce:section id="cesec2"> <ce:section-title>CLASSIFICATION OF TICS</ce:section-title> <ce:para><ce:italic>Tics</ce:italic> are defined as relatively brief and intermittent movements (<ce:italic>motor tics</ce:italic>) or sounds (<ce:italic>phonic tics</ce:italic>). The term <ce:italic>phonic tic</ce:italic> is preferred instead of <ce:italic>vocal tic,</ce:italic> because not all the abnormal sounds and noises made by patients with tics are produced by vocal cords. Currently accepted criteria require both types of tics, motor and phonic, to be present for the diagnosis of TS.<ce:cross-ref refid="bib42"><ce:sup>42</ce:sup></ce:cross-ref> This division into motor and phonic tics, however, seems artificial because phonic tics are actually motor tics involving respiratory, laryngeal, pharyngeal, oral, and nasal musculature. Contractions of these muscles may produce sounds by moving air thorough the nose, mouth, or throat.</ce:para> <ce:para>Tics are usually abrupt in onset, fast, and brief (<ce:italic>clonic tics</ce:italic>), but they may also be slow and sustained. The sustained tics are divided into 1) <ce:italic>dystonic tics,</ce:italic> if they are associated with a twisting or other type of movement, or 2) <ce:italic>tonic tics,</ce:italic> if the muscle contractions are isometric and are not associated with any movement (e.g., arm or abdominal muscle tensing; <ce:cross-ref refid="cetable1">Table 1</ce:cross-ref><ce:float-anchor refid="cetable1"></ce:float-anchor>).<ce:cross-refs refid="bib11 bib14"><ce:sup>11,14</ce:sup></ce:cross-refs> To characterize clonic and dystonic tics further, we studied 156 patients with TS; 89 (57%) exhibited dystonic tics, including oculogyric deviations (28%), blepharospasm (15%), and dystonic neck movements (7%).<ce:cross-ref refid="bib13"><ce:sup>13</ce:sup></ce:cross-ref> Because patients with dystonic tics did not significantly differ from those with only clonic tics, we concluded that clonic and dystonic (and tonic) tics represent variants of motor tics and that they can occur in different combinations within the same individual. Dystonic tics are more likely to be associated with the premonitory symptoms (see below) than are clonic tics. Some patients with disabling, repetitive, dystonic tics may be successfully treated with botulinum toxin injections in the affected muscles.<ce:cross-ref refid="bib18"><ce:sup>18</ce:sup></ce:cross-ref> The treatment ameliorates not only involuntary movements but also the premonitory sensory component associated with some tics. Dystonic tics should be distinguished from persistent dystonia, typically seen in patients with idiopathic torsion dystonia.<ce:cross-ref refid="bib17"><ce:sup>17</ce:sup></ce:cross-ref> Motor tics in patients with torsion dystonia are relatively rare but may occur more frequently than in the general population. In nine patients with coexistent TS and persistent dystonia, the onset of tics was at a mean age of 9 years, whereas dystonia followed the onset of tics by mean of 22 (10-38) years.<ce:cross-ref refid="bib13"><ce:sup>13</ce:sup></ce:cross-ref></ce:para> <ce:para>Tics also may be classified as either <ce:italic>simple or complex</ce:italic> (see <ce:cross-ref refid="cetable1">Table 1</ce:cross-ref>). <ce:italic>Simple motor tics</ce:italic> involve only one group of muscles, causing a brief, jerklike movement or a single, meaningless sound. <ce:italic>Complex motor tics</ce:italic> consist of coordinated, sequenced movements resembling normal motor acts or gestures that are inappropriately intense and timed. They may be seemingly nonpurposeful, such as head shaking or trunk bending, or they may seem purposeful, such as touching, throwing, hitting, jumping, and kicking. Additional examples of complex motor tics include gesturing (e.g., “giving the finger”) and grabbing or exposing one's genitalia (<ce:italic>copropraxia</ce:italic>) or imitating gestures (<ce:italic>echopraxia</ce:italic>).</ce:para> <ce:para>Similar to motor tics, phonic tics can be classified as either <ce:italic>simple</ce:italic> or <ce:italic>complex</ce:italic> (see <ce:cross-ref refid="cetable1">Table 1</ce:cross-ref>). <ce:italic>Simple phonic tics</ce:italic> typically consist of sniffing, throat clearing, grunting, squeaking, screaming, coughing, blowing, and sucking sounds. <ce:italic>Complex phonic tics</ce:italic> include linguistically meaningful utterances and verbalizations, such as shouting of obscenities or profanities (<ce:italic>coprolalia</ce:italic>), repetition of someone else's words or phrases (<ce:italic>echolalia</ce:italic>), and repetition of one's own utterances particularly the last syllable, word, or phrase in a sentence (<ce:italic>palilalia</ce:italic>). Some TS patients also manifest sudden and transient cessation of all motor activity without alteration of consciousness. These so-called blocking tics may be due to prolonged tonic or dystonic tics that interrupt ongoing motor activity such as speech, or they may be due to sudden inhibition of motor activity.</ce:para> <ce:para>To better understand the categorization of tics in the general schema of movement disorders, it might be helpful to review a classification of movements [<ce:cross-ref refid="cetable2">Table 2</ce:cross-ref><ce:float-anchor refid="cetable2"></ce:float-anchor>]<ce:cross-ref refid="bib14"><ce:sup>14</ce:sup></ce:cross-ref> All movements can be categorized into one of four classes: 1) <ce:italic>voluntary:</ce:italic> <ce:bold>intentional</ce:bold> (planned, self-initiated, internally generated), or <ce:bold>externally triggered</ce:bold> (in response to some external stimulus, e.g., turning head toward a loud noise or withdrawing hand from a hot plate); 2) <ce:italic>semivoluntary (unvoluntary):</ce:italic> induced by <ce:bold>inner sensory stimulus</ce:bold> (e.g., need to “stretch” a body part), or induced by <ce:bold>unwanted feeling or compulsion</ce:bold> (e.g., compulsive touching or smelling); 3) <ce:italic>involuntary:</ce:italic> <ce:bold>nonsuppressible</ce:bold> (e.g., reflexes, seizures, myoclonus), or <ce:bold>suppressible</ce:bold> (tics, tremor, dystonia, chorea, stereotypy); and 4) <ce:italic>automatic</ce:italic> (learned motor behaviors performed without conscious effort, e.g., the act of walking or speaking). Most tics can be categorized as either semivoluntary (unvoluntary) or involuntary (suppressible). In some cases learned voluntary motor skills are incorporated into the tic repertoire. This is exemplified by a case of a woman with TS who incorporated sign language into her tic behavior.<ce:cross-ref refid="bib28"><ce:sup>28</ce:sup></ce:cross-ref> Some support for this classification of movement is provided by the findings of Papa et al.<ce:cross-ref refid="bib33"><ce:sup>33</ce:sup></ce:cross-ref> They recorded normal premovement (readiness) electroencephalographic, slow, negative potential (the <ce:italic>Bereitschaftspotential</ce:italic>) 1 to 1.5 seconds prior to self-induced, internally generated (voluntary) movement in normal subjects, but not in externally triggered movement induced by electrical stimulation.</ce:para> <ce:para>Premonitory feelings or sensations precede motor and vocal tics in over 80% of patients.<ce:cross-ref refid="bib2"><ce:sup>2</ce:sup></ce:cross-ref> These premonitory phenomena may be localizable sensations or discomforts, such as burning feeling in the eye before an eye blink, a tension or crick in the neck relieved by stretching of the neck or jerking of the head, a feeling of tightness or constriction relieved by arm or leg extension, nasal stuffiness before a sniff, dry or sore throat before throat clearing or grunting, and itching before a rotatory movement of the scapula. Rarely, these premonitory feelings, termed in one report as “extracorporeal 'phantom' tics,” involve sensations in other people and in objects and are temporarily relieved by touching or scratching them.<ce:cross-ref refid="bib20"><ce:sup>20</ce:sup></ce:cross-ref> In one study, premonitory sensations were experienced by 92% of 135 patients with TS.<ce:cross-ref refid="bib29"><ce:sup>29</ce:sup></ce:cross-ref> These were localized chiefly to a shoulder girdle, palms, midline abdominal region, posterior thighs, feet, and eyes. Alternatively, the premonitory phenomenon may be nonlocalizable, less specific, and poorly described feeling, such as an urge, anxiety, anger, and other psychic sensations. The observed movement or sound sometimes occurs in response to these premonitory phenomena and have been previously referred to as sensory tics.<ce:cross-ref refid="bib25"><ce:sup>25</ce:sup></ce:cross-ref> In a study of 60 patients with tic disorders, 41 (68%) thought that all their tics were intentionally produced, and 15 (25%) additional patients had both voluntary and involuntary movements; thus 93% of the tics were perceived to be “irresistibly but purposefully executed.”<ce:cross-ref refid="bib27"><ce:sup>27</ce:sup></ce:cross-ref> The “intentional” component of the movement may be a useful feature in differentiating tics from other hyperkinetic movement disorders. The sensations or feelings that often precede motor tics usually occur out of a background of relative normalcy and are clearly involuntary, even though the movements (motor tics) or noises (phonic tics) that occur in response to these premonitory symptoms may be regarded as semivoluntary or involuntary. Many patients report that they have to repeat a particular movement to relieve the uncomfortable urge or until “it feels good.” The “just right” feeling has been associated with compulsive behavior and as such the involuntary movement may be regarded as a compulsive tic.<ce:cross-ref refid="bib30"><ce:sup>30</ce:sup></ce:cross-ref> Some coordinated movements resemble complex motor tics but may actually represent “pseudovoluntary” movements (<ce:italic>parakinesias</ce:italic>) designed to camouflage the tics by incorporating them into seemingly purposeful acts such as adjusting one's hair during a head jerk.</ce:para> <ce:para>Complex motor tics may be difficult to differentiate from compulsions, which frequently accompany tics, particularly in TS. A complex, repetitive movement or noise may be considered a <ce:italic>compulsive</ce:italic> tic when it is preceded by or associated with a feeling of anxiety, tension, or other discomfort and is relieved, at least temporarily, by the performance of the activity. Another clue that helps to differentiate a motor tic from a compulsive tic is that the latter usually is preceded by an irresistible urge to perform the movement or sound, or fear that if the movement or sound is not promptly or properly executed something “bad” will happen. Self-injurious behavior, such as scratching and picking, is an example of the borderline between a compulsion and a complex motor tic.<ce:cross-ref refid="bib19"><ce:sup>19</ce:sup></ce:cross-ref> The distinction between complex motor tics and compulsions is not always possible, particularly when the patient is unable to verbalize such feelings.</ce:para> <ce:para>In contrast to other hyperkinetic movement disorders, tics are usually intermittent but may be repetitive and stereotypic. Fluctuation or waxing and waning in frequency, intensity, and distribution is a typical feature of tics [<ce:cross-ref refid="cetable3">Table 3</ce:cross-ref><ce:float-anchor refid="cetable3"></ce:float-anchor>]. Typically tics can be suppressed volitionally, although this may require intense mental effort. Suppressibility is not unique or specific for tics, and it has been well documented in other hyperkinetic movement disorders.<ce:cross-ref refid="bib43"><ce:sup>43</ce:sup></ce:cross-ref> Besides temporary suppressibility, tics also are characterized by suggestibility, exacerbation with stress, excitement, boredom, fatigue, and exposure to heat.<ce:cross-ref refid="bib31"><ce:sup>31</ce:sup></ce:cross-ref> Tics also may increase during relaxation after a period of stress. In contrast to other hyperkinetic movement disorders that are usually completely suppressed during sleep, motor and phonic tics may persist during all stages of sleep.<ce:cross-refs refid="bib4 bib10 bib37"><ce:sup>4,10,37</ce:sup></ce:cross-refs> Many patients note a reduction in their tics when they are distracted while concentrating on mental or physical tasks (e.g., when playing a video game or during an orgasm). Others have increased frequency and intensity of their tics when distracted, especially when they no longer have the need to suppress the tics. Tics are also typically exacerbated by dopaminergic drugs and by CNS stimulants, including methylphenidate and cocaine.<ce:cross-ref refid="bib1"><ce:sup>1</ce:sup></ce:cross-ref></ce:para> <ce:para>TS, the most common cause of tics, is manifested by a broad spectrum of motor and behavioral disturbances. This clinical heterogeneity often causes diagnostic difficulties and presents a major challenge in genetic linkage studies. To aid in the diagnosis of TS, the Tourette Syndrome Classification Study Group formulated criteria for the diagnosis of definite and probable TS [<ce:cross-ref refid="cetable4">Table 4</ce:cross-ref><ce:float-anchor refid="cetable4"></ce:float-anchor>]<ce:cross-ref refid="bib42"><ce:sup>42</ce:sup></ce:cross-ref> These criteria are designed to assist in accurate diagnosis, in genetic linkage studies, and in differentiating TS from other tic disorders [<ce:cross-ref refid="cetable5">Table 5</ce:cross-ref><ce:float-anchor refid="cetable5"></ce:float-anchor>]<ce:cross-ref refid="bib16"><ce:sup>16</ce:sup></ce:cross-ref></ce:para> <ce:para>There is a body of evidence to support the notion that many, if not all, patients with other forms of idiopathic tic disorders represent one end of the spectrum in a continuum of TS.<ce:cross-ref refid="bib24"><ce:sup>24</ce:sup></ce:cross-ref> The commonest and mildest of the idiopathic tic disorders is the transient tic disorder (TTD) of childhood. This disorder is essentially identical to TS except the symptoms last less than 1 year and therefore the diagnosis can be made only in retrospect. TTD has been estimated to occur in up to 24% of school children.<ce:cross-ref refid="bib36"><ce:sup>36</ce:sup></ce:cross-ref> Chronic multiple tic disorder (CMTD) is also similar to TS, but the patients have either only motor or, less commonly, only phonic tics lasting at least 1 year. Chronic single tic disorder (CSTD) is same as CMTD, but the patients have only single motor or vocal tic. This separation into TTD, CMTD, and CSTD seems artificial because they all can occur in the same family and probably represent a variable expression of the same genetic defect.<ce:cross-ref refid="bib24"><ce:sup>24</ce:sup></ce:cross-ref> For these reasons, the use of this subclassification of tics should be discouraged.</ce:para> <ce:para>Although the diagnostic criteria require that the onset is present before the age of 21 years, in 96% of patients the disorder is manifested by age 11.<ce:cross-ref refid="bib34"><ce:sup>34</ce:sup></ce:cross-ref> In 36% to 48% the initial symptom is eye blinking, followed by tics involving the face and head. Vocalizations have been reported as the initial symptom in 12% to 37% of patients, with throat clearing being the most common. During the course of the disease, nearly all patients exhibit tics involving the face or head, two thirds have tics in the arms, and a half have tics involving the trunk or legs. In a study of 58 adults diagnosed with TS during childhood, Goetz et al found that tics persisted in all patients but were moderate or severe in only 24%, although 60% had moderate or severe tics during the course of the disease.<ce:cross-ref refid="bib7"><ce:sup>7</ce:sup></ce:cross-ref> Tic severity during childhood had no predictive value for the future course, but patients with mild tics during the preadult period had mild tics during adulthood. Poor motor control, which can lead to poor penmanship and at times almost illegible handwriting, may contribute to academic difficulties. About 20% patients with TS have exaggerated startle responses, which may fail to habituate with repetition.<ce:cross-ref refid="bib40"><ce:sup>40</ce:sup></ce:cross-ref></ce:para> <ce:para>Tics, although rarely disabling, can be quite troublesome for TS patients because they cause embarrassment, interfere with social interactions, and can be quite painful or uncomfortable. Rarely, they can cause secondary neurologic deficits, such as compressive cervical myelopathy in patients with violent head and neck tics.<ce:cross-ref refid="bib22"><ce:sup>22</ce:sup></ce:cross-ref></ce:para> </ce:section> <ce:section id="cesec3"> <ce:section-title>PATHOPHYSIOLOGY OF TICS</ce:section-title> <ce:para>Although the pathophysiologic mechanisms of TS are still unknown, the weight of evidence supports organic rather than psychogenic origin. Despite the observation that some tics may be, at least partly voluntary, physiologic studies suggest that tics are not mediated through normal motor pathways used for willed movements.<ce:cross-ref refid="bib32"><ce:sup>32</ce:sup></ce:cross-ref> Using backaveraging techniques, Obeso et al observed normal <ce:italic>Bereitschaftspotential</ce:italic> in six subjects who voluntarily simulated ticlike movements, but no such premovement potential was noted in association with an actual tic.<ce:cross-ref refid="bib32"><ce:sup>32</ce:sup></ce:cross-ref> Karp et al, however documented premotor negativity in two of five patients with simple motor tics.<ce:cross-ref refid="bib21"><ce:sup>21</ce:sup></ce:cross-ref> The common absence of premotor potentials in simple motor tics suggests that tics are truly involuntary or that they occur in response to some external cue.<ce:cross-ref refid="bib33"><ce:sup>33</ce:sup></ce:cross-ref> Sleep studies have provided additional evidence that tics are truly involuntary. Polysomnographic studies in 34 TS patients recorded motor tics in various stages of sleep in 23 and vocal tics in 4.<ce:cross-refs refid="bib6 bib12"><ce:sup>6,12</ce:sup></ce:cross-refs> Further studies are needed to elucidate the physiologic and cellular mechanisms underlying tics and TS. Current knowledge of biologic and pathogenetic mechanisms is reviewed elsewhere inthis issue.</ce:para> </ce:section> <ce:section id="cesec4"> <ce:section-title>CONCLUSION</ce:section-title> <ce:para>The diagnosis of TS is based on the clinical recognition of phenomenology, which includes motor and phonic tics, further subdivided into simple and complex tics and compulsive tics. The latter represents a borderland between the classic motor manifestations of TS and OCD, a frequently associated comorbid condition. Another comorbid condition, ADHD, is often manifested by hyperactive and restless behavior, which may resemble stereotypic tics. Many tics, particularly the more sustained (dystonic or tonic) tics are frequently preceded by a premonitory urge or sensation that is relieved by the execution of the tic. This phenomenon may be present in as many as 80% to 90% of patients with TS. In the schema of categorization of movements, most tics can be classified as either <ce:bold>unvoluntary,</ce:bold> in response to an inner sensory stimulus or induced by an unwanted feeling or compulsion (compulsive tic) or <ce:bold>involuntary</ce:bold> (usually suppressible). 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<ce:surname>Sage</ce:surname> </sb:author> <sb:et-al></sb:et-al> </sb:authors> <sb:title> <sb:maintitle>A blinded study of the suppressibility of involuntary movements in Huntington's chorea, tardive dyskinesia, and L–dopa-induced chorea</sb:maintitle> </sb:title> </sb:contribution> <sb:host> <sb:issue> <sb:series> <sb:title> <sb:maintitle>Clin Neuropharmacol</sb:maintitle> </sb:title> <sb:volume-nr>13</sb:volume-nr> </sb:series> <sb:date>1990</sb:date> </sb:issue> <sb:pages> <sb:first-page>236</sb:first-page> <sb:last-page>240</sb:last-page> </sb:pages> </sb:host> </sb:reference> </ce:bib-reference> </ce:bibliography-sec> </ce:bibliography> </tail></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo><title>PHENOMENOLOGY AND CLASSIFICATION OF TICS</title></titleInfo><titleInfo type="alternative" contentType="CDATA"><title>PHENOMENOLOGY AND CLASSIFICATION OF TICS</title></titleInfo><name type="personal"><namePart type="given">Joseph</namePart><namePart type="family">Jankovic</namePart><namePart type="termsOfAddress">MD</namePart><description>From the Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas</description><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article">Full-length article</genre><originInfo><publisher>ELSEVIER</publisher><dateIssued encoding="w3cdtf">1997</dateIssued><copyrightDate encoding="w3cdtf">1997</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><note>Address reprint requests to Joseph Jankovic, MD, Baylor College of Medicine, Department of Neurology, 6550 Fannin, Houston, TX 77030</note><note type="content">Table 1: TICS</note><note type="content">Table 2: MOVEMENTS</note><note type="content">Table 3: TICS: CHARACTERISTICS</note><note type="content">Table 4: DIAGNOSTIC CRITERIA</note><note type="content">Table 5: CLASSIFICATION OF TICS</note><relatedItem type="host"><titleInfo><title>Neurologic Clinics</title></titleInfo><titleInfo type="abbreviated"><title>NCL</title></titleInfo><originInfo><dateIssued encoding="w3cdtf">19970501</dateIssued></originInfo><identifier type="ISSN">0733-8619</identifier><identifier type="PII">S0733-8619(05)X7022-0</identifier><part><date>19970501</date><detail type="volume"><number>15</number><caption>vol.</caption></detail><detail type="issue"><number>2</number><caption>no.</caption></detail><extent unit="issue pages"><start>239</start><end>473</end></extent><extent unit="pages"><start>267</start><end>275</end></extent></part></relatedItem><identifier type="istex">A88C6031ACE640441D67D0E7A9C2CE641715F918</identifier><identifier type="DOI">10.1016/S0733-8619(05)70311-X</identifier><identifier type="PII">S0733-8619(05)70311-X</identifier><recordInfo><recordOrigin>ELSEVIER</recordOrigin><recordContentSource>W. 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