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Tourette Syndrome and Other Tic Disorders Workup

  • Author: William C Robertson, Jr, MD; Chief Editor: Amy Kao, MD  more...
Updated: Sep 21, 2015

Approach Considerations

When an appropriately experienced physician finds typical indications of Tourette syndrome (TS) in the patient's history and examination, no further workup is generally necessary. Further workup may be needed if unusual features are present in the history or physical examination or if other abnormalities are found on neurological examination.

Unusual findings may include rigidity, bradykinesia, spasticity, myoclonus, chorea, dementia, or psychosis. Further workup may include corroboration of the patient's history with that of another source, with clinical follow-up, or with laboratory testing.

Go to Pediatric Tourette Syndrome for complete information on this topic.


Serum Ceruloplasmin or Slit-Lamp Examination

Serum ceruloplasmin or slit lamp examination for Kayser-Fleischer rings might be considered. This examination is not always necessary. However, if unusual features are present, these tests may lead to lifesaving measures by confirming the presence of Wilson disease.


Neuropsychological Testing

Neuropsychological testing may be useful: Patients with difficulties in the school or work setting may benefit from an evaluation for learning disorders so that adaptive strategies can be identified.


Imaging Studies

Structural imaging studies are not routinely needed in the evaluation of patients with a typical history and examination findings. These studies are indicated only to exclude specific illnesses suggested by abnormal history or examination findings.

At present, functional imaging studies have no proven clinical utility in the evaluation of tic disorders.

Data from unpublished reports suggest possible future clinical benefits of neuroimaging. For example, caudate volume in childhood is inversely associated with illness severity in adulthood.[155]

Contributor Information and Disclosures

William C Robertson, Jr, MD Professor, Departments of Neurology, Pediatrics, and Family Practice, Clinical Title Series, University of Kentucky College of Medicine

William C Robertson, Jr, MD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Amy Kao, MD Attending Neurologist, Children's National Medical Center

Amy Kao, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, Child Neurology Society

Disclosure: Have stock from Cellectar Biosciences; have stock from Varian medical systems; have stock from Express Scripts.

Additional Contributors

Raj D Sheth, MD Chief, Division of Pediatric Neurology, Nemours Children's Clinic; Professor of Neurology, Mayo College of Medicine; Professor of Pediatrics, University of Florida College of Medicine

Raj D Sheth, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, American Neurological Association, Child Neurology Society

Disclosure: Nothing to disclose.

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Tourette syndrome and other tic disorders. Schematic of the hypothetical reorganization of the basal ganglia output in tic disorders, with excitatory projections (open arrows) and inhibitory projections (solid arrows). Line thickness represents the relative magnitude of activity. When a discrete set of striatal neurons becomes active inappropriately (right), aberrant inhibition of a discrete set of internal segment of globus pallidus (GPi) neurons occurs. The abnormally inhibited GPi neurons disinhibit thalamocortical mechanisms involved in a specific unwanted competing motor pattern, resulting in a stereotyped involuntary movement.
Tourette syndrome and other tic disorders. Segregated anatomy of the frontal-subcortical circuits: dorsolateral (blue), lateral orbitofrontal (green), and anterior cingulate (red) circuits in the striatum (top), pallidum (center), and mediodorsal thalamus (bottom).
Tourette syndrome and other tic disorders. Graphic shows the relative likelihood of lifetime sensory tics in a given region, as based on self-report of patients with Tourette syndrome. Overt tics are distributed similarly.
Tourette syndrome and other tic disorders. Immunologic response found in patients with Sydenham chorea is also found in patients with Tourette syndrome and obsessive-compulsive disorder. Points on the graph represent percent expression of D8/17 antigen on circulating B lymphocytes.
Tourette syndrome and other tic disorders. In a randomized controlled trial of habit reversal therapy (HRT), results differed significantly from those of a control therapy (massed practice; P < .001, analysis of variance). The HRT group had a 97% reduction in tics at 18-month follow-up, with 80% of patients tic-free.
Table. Symptoms of TS
Sensory hypersensitivityCannot stand to have wrinkly socks, cuts the tags off his or her shirts, refuses all but bland food, or becomes agitated in a visually complex environment
Learning disabilityApproximately 20% in clinical samples, more closely associated with comorbid ADHD than with tics; also associated with male sex, earlier onset, severity, perinatal problems, and lower rates in family members[140]
School phobiaCan be an adverse effect of neuroleptic treatment
Complex socially inappropriate behaviorInsults, racial slurs, and paraphilias (or, more commonly, suppressed urges) are present in a large minority of patients with TS, associated with comorbid ADHD
Rage attacksSudden outbursts lasting approximately 5-30 min, usually in children or teenagers; inconsolable, unremitting violent frustration, commonly after being denied an unreasonable request; often followed by apparently sincere contrition and remorse
Insistence on samenessRefusal to take a different route home or omit a step in a routine, even when hurried; often without a clear obsession or other obsessive-compulsive symptoms
Anxiety and depressionCommon in patient samples but not clearly more common in the general TS population
TS with both OCD and episodes of maniaSurprisingly high rates of mania in patients with TS and OCD shown in at least 2 studies, management frequently difficult
ADHD = attention deficit hyperactivity disorder; OCD = obsessive-compulsive disorder.
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