Editing Tourette syndrome (section)

== Diagnosis ==
{{quote box
|title = Main screening and assessment tools<ref name= Martino2017>{{cite journal |vauthors=Martino D, Pringsheim TM, Cavanna AE, et al |title=Systematic review of severity scales and screening instruments for tics: Critique and recommendations |journal=Mov. Disord. |volume=32 |issue=3 |pages=467–473 |date=March 2017 |pmid=28071825 |pmc=5482361 |doi=10.1002/mds.26891 |type= Review}}</ref>{{sfnp|Sukhodolsky|Gladstone|Kaushal|Piasecka|2017|p= 248}}
|quote = {{Bulleted list
|[[Yale Global Tic Severity Scale]] (YGTSS), recommended in international guidelines to assess "frequency, intensity, complexity, distribution, interference and impairment" of or due to tics{{efn|The YGTSS is considered the gold standard in tic assessment.<ref name=EuropeanPartI/>}} 
|[[Tourette Syndrome Clinical Global Impression]] (TS–CGI) and [[Shapiro TS Severity Scale]] (STSS), for a briefer assessment of tics than YGTSS 
|[[Tourette's Disorder Scale]] (TODS), to assess tics and comorbidities 
|[[Premonitory Urge for Tics Scale]] (PUTS), for individuals over age ten 
|[[Motor tic, Obsessions and compulsions, Vocal tic Evaluation Survey]] (MOVES), to evaluate complex tics and other behaviors 
|[[Autism—Tics, AD/HD, and other Comorbities]] (A–TAC), to screen for other conditions }}
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According to the ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM-5),{{efn|There were no changes in the fifth text revision of 2022, [[DSM-5-TR]].<ref>{{cite web |url= https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-DiagnosesforChildren.pdf |publisher= American Psychiatric Association |title= DSM-5-TR Fact Sheets |date= 2022 |access-date= July 9, 2022 |archive-date= August 18, 2022 |archive-url= https://web.archive.org/web/20220818193942/https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-DiagnosesforChildren.pdf |url-status= live }}</ref>}} Tourette's may be diagnosed when a person exhibits both multiple motor tics and one or more vocal tics over a period of one year. The motor and vocal tics need not be concurrent. The onset must have occurred before the age of 18 and cannot be attributed to the effects of another condition or substance (such as [[cocaine]]).<ref name=DSM5>{{cite book |chapter= Tourette's Disorder, 307.23 (F95.2) |title= Diagnostic and Statistical Manual of Mental Disorders |date= 2013 |edition = 5th |publisher= American Psychiatric Association |page= 81}}</ref> Hence, other medical conditions that include tics or tic-like movements—for example, [[autism spectrum|autism]] or other causes of tics—must be ruled out.<ref name=WalkupDSMV />

Patients referred for a tic disorder are assessed based on their family history of tics, vulnerability to ADHD, obsessive–compulsive symptoms, and a number of other chronic medical, psychiatric and neurological conditions.<ref name=Assessment />{{sfnp|Sukhodolsky|Gladstone|Kaushal|Piasecka|2017|p= 247}} In individuals with a typical onset and a family history of tics or OCD, a basic physical and neurological examination may be sufficient.<ref name=Bagheri>{{cite journal |vauthors=Bagheri MM, Kerbeshian J, Burd L |title=Recognition and management of Tourette's syndrome and tic disorders |journal= Am Fam Physician |volume=59 |issue=8 |pages=2263–2272, 2274 |date=April 1999 |pmid=10221310 |type= Review |url= http://www.aafp.org/afp/990415ap/2263.html|archive-url=https://web.archive.org/web/20050331083858/http://www.aafp.org/afp/990415ap/2263.html |archive-date=March 31, 2005 }}</ref> There are no specific medical or screening tests that can be used to diagnose Tourette's;<ref name=Swain>{{cite journal |vauthors=Swain JE, Scahill L, Lombroso PJ, King RA, Leckman JF |title=Tourette syndrome and tic disorders: a decade of progress |journal=J Am Acad Child Adolesc Psychiatry |volume=46 |issue=8 |pages=947–968 |date=August 2007 |pmid=17667475 |doi=10.1097/chi.0b013e318068fbcc |s2cid=343916 |type= Review}}</ref> the diagnosis is usually made based on observation of the individual's symptoms and family history,<ref name=Singer2011 /> and after ruling out secondary causes of tic disorders ([[tourettism]]).<ref name= WhatisTS>{{cite web |url= http://tourette.org/media/WhatisEnglish.proof_.r1.pdf |publisher= [[Tourette Association of America]] |title= What is Tourette syndrome? | access-date= January 19, 2020 |archive-date= February 26, 2020 |archive-url= https://web.archive.org/web/20200226223254/http://tourette.org/media/WhatisEnglish.proof_.r1.pdf |url-status= live}}</ref>

Delayed diagnosis often occurs because professionals mistakenly believe that TS is rare, always involves coprolalia, or must be severely impairing.{{sfnp|Müller-Vahl|2013|p=625}} The DSM has recognized since 2000 that many individuals with Tourette's do not have significant impairment;<ref name=DSMAppraisal /><ref name=WalkupDSMV /><ref name=DSMIVTRsummary>{{cite web |url= http://www.dsmivtr.org/2-3changes.cfm |title= Summary of Practice: Relevant changes to DSM-IV-TR |publisher= American Psychiatric Association |access-date= December 29, 2011|archive-url= https://web.archive.org/web/20080511220758/http://www.dsmivtr.org/2-3changes.cfm |archive-date= May 11, 2008 }}</ref> diagnosis does not require the presence of coprolalia or a comorbid condition, such as ADHD or OCD.<!--this is sort of a medical [[tautology]] isn't it? "Diagnosis of that defined as A, and only A, does not require the presence of that defined as B". See talk. This is here because the NEJM once published an incorrect definition of the condition, a perception that persists.--><ref name=Singer2011 />{{sfnp|Müller-Vahl|2013|p=625}} Tourette's may be misdiagnosed because of the wide expression of severity, ranging from mild (in the majority of cases) or moderate, to severe (the rare but more widely recognized and publicized cases).<ref name=YaleTicSeverity /> About 20% of people with Tourette syndrome do not realize that they have tics.<ref name=Zinner />

Tics that appear early in the course of TS are often confused with [[allergies]], [[asthma]], vision problems, and other conditions. Pediatricians, allergists and ophthalmologists are among the first to see or identify a child as having tics,<ref name=EuropeanPartI/><ref name=phenomenology /><ref name= Horner2022/> although the majority of tics are first identified by the child's parents.{{sfnp|Müller-Vahl|2013|p=625}} Coughing, blinking, and tics that mimic unrelated conditions such as asthma are commonly misdiagnosed.<ref name=Singer2011 /> In the UK, there is an average delay of three years between symptom onset and diagnosis.<ref name= Hollis /> <!-- p. xl. -->

=== Differential diagnosis ===
Tics that may appear to mimic those of Tourette's—but are associated with disorders other than Tourette's—are known as [[tourettism]]<ref name=Mejia>{{cite journal |vauthors=Mejia NI, Jankovic J |title=Secondary tics and tourettism |journal=Braz J Psychiatry |volume=27 |issue=1 |pages=11–17 |date=March 2005 |pmid=15867978 |doi=10.1590/s1516-44462005000100006 |url= http://www.scielo.br/pdf/rbp/v27n1/23707.pdf|archive-url=https://web.archive.org/web/20070628191850/http://www.scielo.br/pdf/rbp/v27n1/23707.pdf |archive-date=June 28, 2007 |doi-access=free }}</ref> and are ruled out in the [[differential diagnosis]] for Tourette syndrome.<ref name=Bagheri /> The abnormal movements associated with [[chorea (disease)|choreas]], [[dystonia]]s, [[myoclonus]], and [[dyskinesia]]s are distinct from the tics of Tourette's in that they are more rhythmic, not suppressible, and not preceded by an unwanted urge.<ref name= Hash2017 /><ref name=Jankovic2001/> [[Developmental disorder|Developmental]] and [[autism spectrum]] disorders may manifest tics, other stereotyped movements,<ref>{{cite journal |vauthors=Ringman JM, Jankovic J |title=Occurrence of tics in Asperger's syndrome and autistic disorder |journal=J. Child Neurol. |volume=15 |issue=6 |pages=394–400 |date=June 2000 |pmid=10868783 |doi=10.1177/088307380001500608 |s2cid=8596251 |type= Case report}}</ref> and [[stereotypic movement disorder]].<ref name=Jankovic2006 /><ref name=FreemanBlog>{{cite web |author= Freeman RD |url= http://www.tourette-confusion.blogspot.com/ |title= Tourette's syndrome: minimizing confusion |archive-url= https://web.archive.org/web/20060411182519/http://www.tourette-confusion.blogspot.com/ |archive-date=April 11, 2006 |publisher= Roger Freeman, MD, blog |access-date= February 8, 2006}}</ref> The stereotyped movements associated with autism typically have an earlier age of onset; are more symmetrical, rhythmical and bilateral; and involve the extremities (for example, flapping the hands).<ref name=Rapin>{{cite journal |vauthors=Rapin I |title=Autism spectrum disorders: relevance to Tourette syndrome |journal=Adv Neurol |volume=85 |pages=89–101 |date=2001 |pmid=11530449 |type= Review}}</ref>

If another condition might better explain the tics, tests may be done; for example, if there is diagnostic confusion between tics and [[seizure]] activity, an [[Electroencephalography|EEG]] may be ordered. An [[MRI]] can rule out brain abnormalities, but such [[brain imaging]] studies are not usually warranted.<ref name=Assessment>{{cite journal |vauthors=Scahill L, Erenberg G, Berlin CM, et al |title=Contemporary assessment and pharmacotherapy of Tourette syndrome |journal=NeuroRx |volume=3 |issue=2 |pages=192–206 |date=April 2006 |pmid=16554257 |pmc=3593444 |doi=10.1016/j.nurx.2006.01.009 |type= Review}}</ref> Measuring [[thyroid-stimulating hormone]] blood levels can rule out [[hypothyroidism]], which can be a cause of tics. If there is a family history of [[liver disease]], [[Copper#Deficiency|serum copper]] and [[ceruloplasmin]] levels can rule out [[Wilson's disease]].<ref name=Bagheri /> The typical age of onset of TS is before adolescence.<ref name=Stern2018 /> In teenagers and adults with an abrupt onset of tics and other behavioral symptoms, a [[urine drug screen]] for [[stimulants]] might be requested.<ref name=Bagheri />

Increasing episodes of tic-like behavior among teenagers (predominantly adolescent girls) were reported in several countries during the [[COVID-19 pandemic]].<ref name= Ueda2021/><ref name= Horner2022/> Researchers linked their occurrence to followers of certain [[TikTok]] or [[YouTube]] artists.<ref name= EuropeanPartI/><ref name= Horner2022>{{cite journal |vauthors=Horner O, Hedderly T, Malik O |title=The changing landscape of childhood tic disorders following COVID-19 |journal=Paediatr Child Health (Oxford) |date=August 2022 |volume=32 |issue=10 |pages=363–367 |pmid=35967969 |pmc=9359930 |doi=10.1016/j.paed.2022.07.007 }}</ref> Described in 2006 as ''[[psychogenic disease|psychogenic]]'',<ref name= Jankovic2006/> abrupt-onset movements resembling tics are referred to as a ''[[functional neurologic disorder|functional movement disorder]]''<ref name= Ganos2019>{{cite journal |vauthors=Ganos C, Martino D, Espay AJ, Lang AE, Bhatia KP, Edwards MJ |title=Tics and functional tic-like movements: Can we tell them apart? |journal=Neurology |volume=93 |issue=17 |pages=750–758 |date=October 2019 |pmid=31551261 |doi=10.1212/WNL.0000000000008372 |s2cid=202761321 |url=http://openaccess.sgul.ac.uk/111278/1/WNL.0000000000008372.full.pdf |type=Review |access-date=April 3, 2022 |archive-date=June 3, 2022 |archive-url=https://web.archive.org/web/20220603195351/https://openaccess.sgul.ac.uk/id/eprint/111278/1/WNL.0000000000008372.full.pdf |url-status=live }}</ref> or ''functional tic-like movements''.<ref name=Horner2022/>{{efn|Movement disorders without an organic cause have been referred to over time using terms such as ''hysterical'', ''psychogenic'' and ''psychogenic movement disorders'';<ref name=Baizabal2015>{{cite journal |vauthors=Baizabal-Carvallo JF, Fekete R |title=Recognizing uncommon presentations of psychogenic (functional) movement disorders |journal=Tremor Other Hyperkinet Mov (N Y) |volume=5 |issue= |page=279 |date=2015 |pmid=25667816 |pmc=4303603 |doi=10.7916/D8VM4B13 |doi-broken-date=November 1, 2024 |type= Review}}</ref><ref name=Thenganatt2019>{{cite journal |vauthors=Thenganatt MA, Jankovic J |title=Psychogenic (functional) movement disorders |journal=Continuum (Minneap Minn) |volume=25 |issue=4 |pages=1121–1140 |date=August 2019 |pmid=31356296 |doi=10.1212/CON.0000000000000755 |s2cid=198984465 |type= Review}}</ref> [[DSM-5]] classifies them under [[Conversion disorder|functional neurological symptom disorder/conversion disorder]].<ref name= Espay2018>{{cite journal |vauthors=Espay AJ, Aybek S, Carson A, et al. |title=Current concepts in diagnosis and treatment of functional neurological disorders |journal=JAMA Neurol |volume=75 |issue=9 |pages=1132–1141 |date=September 2018 |pmid=29868890 |pmc=7293766 |doi=10.1001/jamaneurol.2018.1264 |type= Review}}</ref>}} Functional tic-like movements can be difficult to distinguish from tics that have an organic (rather than psychological) cause.<ref name= Ganos2019/><ref name= Thenganatt2019/> They may occur alone or co-exist in individuals with tic disorders.<ref name= Ganos2019/><ref name=Malaty2022>{{cite journal |vauthors=Malaty IA, Anderson S, Bennett SM, et al |title=Diagnosis and management of functional tic-like phenomena |journal=J Clin Med |volume=11 |issue=21 |date=October 2022 |page=6470 |pmid=36362696 |pmc=9656241 |doi=10.3390/jcm11216470 |doi-access=free }}</ref> These tics are inconsistent with the classic tics of TS in several ways:<ref name= Frey2022>{{cite journal |vauthors=Frey J, Black KJ, Malaty IA |title=TikTok Tourette's: are we witnessing a rise in functional tic-like behavior driven by adolescent social media use? |journal=Psychol Res Behav Manag |volume=15 |issue= |pages=3575–3585 |date=2022 |pmid=36505669 |pmc=9733629 |doi=10.2147/PRBM.S359977 |doi-access=free }}</ref> the premonitory urge (present in 90% of those with tics disorders<ref name= Baizabal2015/>) is absent in functional tic-like movements; the suppressibility seen in tic disorders is lacking;<ref name= Ganos2019/><ref name= Baizabal2015/><ref name= Thenganatt2019/><ref name= Espay2018/> there is no family or childhood history of tics and there is a female predominance in functional tics,<ref name= Horner2022/> with a later-than-typical age of first presentation;<ref name= Ganos2019/><ref name= Baizabal2015/><ref name= Thenganatt2019/> onset is more abrupt than typical with movements that are more suggestible;<ref name= Baizabal2015/> and there is less co-occurring OCD or ADHD and more co-occurring disorders.<ref name= Thenganatt2019/> Functional tics are "not fully stereotypical",<ref name=Espay2018/> do not respond to medications, do not demonstrate the classic waxing and waning pattern of Tourettic tics,<ref name= Ganos2019/> and do not progress in the typical fashion, in which tics often first appear in the face and gradually move to limbs.<ref name= Thenganatt2019/>

Other conditions that may manifest tics include [[Sydenham's chorea]]; [[idiopathic]] dystonia; and genetic conditions such as [[Huntington's disease]], [[neuroacanthocytosis]], [[pantothenate kinase-associated neurodegeneration]], [[Duchenne muscular dystrophy]], Wilson's disease, and [[tuberous sclerosis]]. Other possibilities include chromosomal disorders such as [[Down syndrome]], [[Klinefelter syndrome]], [[XYY syndrome]] and [[fragile X syndrome]]. Acquired causes of tics include drug-induced tics, head trauma, [[encephalitis]], [[stroke]], and [[carbon monoxide poisoning]].<ref name=Bagheri /><ref name=Mejia /> The extreme self-injurious behaviors of [[Lesch-Nyhan syndrome]] may be confused with Tourette syndrome or stereotypies, but self-injury is rare in TS even in cases of violent tics.<ref name=Rapin /> Most of these conditions are rarer than tic disorders and a thorough history and examination may be enough to rule them out without medical or screening tests.<ref name=Stern2018 /><ref name=Zinner /><ref name=Mejia />

=== Screening for other conditions ===
Although not all those with Tourette's have comorbid conditions, most presenting for clinical care exhibit symptoms of other conditions along with their tics.<ref name=Denckla /> ADHD and OCD are the most common, but autism spectrum disorders or [[Anxiety disorder|anxiety]], [[mood disorder|mood]], [[personality disorder|personality]], [[oppositional defiant disorder|oppositional defiant]], and [[conduct disorder]]s may also be present.<ref name=Martino2018 /> Learning disabilities and [[sleep disorder]]s may be present;<ref name=Singer2011 /> higher rates of sleep disturbance and [[migraine]] than in the general population are reported.<ref name=SingerBehavior /><ref name= Jimenez2020>{{cite journal |vauthors=Jiménez-Jiménez FJ, Alonso-Navarro H, García-Martín E, Agúndez JA|title=Sleep disorders in tourette syndrome |journal=Sleep Med Rev |volume=53 |issue= |pages=101335 |date=October 2020 |pmid=32554211 |doi=10.1016/j.smrv.2020.101335 |s2cid=219467176 |type= Review}}</ref> A thorough evaluation for comorbidity is called for when symptoms and impairment warrant,{{sfnp|Sukhodolsky|Gladstone|Kaushal|Piasecka|2017|p= 247}}<ref name=Bagheri /> and careful assessment of people with TS includes comprehensive screening for these conditions.<ref name= Martino2018 /><ref name= Efron2018 />

Comorbid conditions such as OCD and ADHD can be more impairing than tics, and cause greater impact on overall functioning.<ref name= PringHoller2019>{{cite journal |vauthors=Pringsheim T, Holler-Managan Y, Okun MS, et al |title=Comprehensive systematic review summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders |journal=Neurology |volume=92 |issue=19 |pages=907–915 |date=May 2019 |pmid=31061209 |pmc=6537130 |doi=10.1212/WNL.0000000000007467 |type= Review}}</ref><ref name=Zinner /> Disruptive behaviors, impaired functioning, or [[cognitive]] impairment in individuals with comorbid Tourette's and ADHD may be accounted for by the ADHD, highlighting the importance of identifying comorbid conditions.<ref name= Dale2017 /><ref name=Swain /><ref name=Singer2011 /><ref name=Disentangling>{{cite journal |vauthors=Spencer T, Biederman J, Harding M, et al|title=Disentangling the overlap between Tourette's disorder and ADHD |journal=J Child Psychol Psychiatry |volume=39 |issue=7 |pages=1037–1044 |date=October 1998 |pmid=9804036 |type= Comparative study |doi= 10.1111/1469-7610.00406}}</ref> Children and adolescents with TS who have learning difficulties are candidates for psychoeducational testing, particularly if the child also has ADHD.<ref name=Assessment />{{sfnp|Sukhodolsky|Gladstone|Kaushal|Piasecka|2017|p= 247}}