Tourette's Syndrome: The nature of Tics and more symptoms

Tourette's Syndrome is a neuro-developmental 'spectrum' disorder. Tics are part of the disorder but not proportional to overall severity of TS in an individual.

Although often also referred to as 'Tic spectrum disorder', do not always expect to see overt tics in all individuals. Some motor tics will be in muscle groups that are not easily observed.

Motor and vocal tics are often suppressed or 'hidden'. Many older people are better able to hide their symptoms, an ability that is useful in order to negotiate 'social opposition' and prejudice by others.

• Vocal tics: throat clearing/coughing, words/phrases/grunts/squeals & indraw/expel air via mouth/nostrils, tongue clicks
• Motor tics: twitching/tightening/relaxing of any skeletal muscle group & face/neck/limbs/abdomen/gluteal muscles & also the diaphragm
• Complex tics: sequential movements or behaviours. 'Complex tics are distinct, coordinated patterns of sequential movements. They may appear purposeful, as if voluntary' .... TSA. Complex tics may mimic meaningful actions or gestures. Some individuals are able to disguise or hide tics by incorporating them into behaviours that appear 'normal.'
• Palilalia: Repeating one's own words or parts of phrases. Often repetition of the ending of a phrase
• Echolalia: The repetition of other's or heard words, phrases or sounds (including animal vocalisations)
• Palipraxia: Repetitive movements. An action may be performed over & over again before before compulsion/tic is completed
• Echopraxia: Copying/mimicking the movements & gestures of others
• Obsessive thinking and unwanted thoughts
• Compulsive/impulsive thoughts and behaviours (may involve risk-taking)
• OCD has traditionally been considered as a 'co-morbidity' however evidence suggests that the TS-related obsessive and compulsive behaviours that affect more than 60% of individuals, differ substantially in character and treatment-responsiveness to OCD.

• Enshrinement: fragmentary phrases, words, sounds, music or thoughts may 'stick' in the mind & reiterate
• Attention deficit and concentration difficulties (ADHD). Frequently difficulties with focusing on a single specific task. Tendency to take on many separate tasks simultaneously (taking on too much at once).
• Depression is very common among those with TS. Clinical depression may be worsened by 'reactive' low-mood. The seeming 'exuberance' and hyperactivity of TS in combination with low mood has lead to erroneous 'diagnoses' of bipolar disorder rather than TS and may also seemingly mask the extent of any underlying depression. Self-harming thoughts can become obsessive and in some suicide is felt to be the only way of escaping from their condition so must be taken seriously. Risk taking and impulsive behaviours in TS must also be considered. In many cases it is difficult to determine whether low-mood is 'clinical' and part of TS itself or whether of 'psychological' origin as a consequence of dealing with the challenges of the condition and the reactions of others.
• Thought-blocking. "Inner voice" distractions. Often referred to as "tics of the mind"
• Speech difficulties: include stuttering, speaking loudly, rapidly, indistinctly, broken speech-flow, poor intonation and vocal tics. Repetition and perseveration. Poor reciprocity in conversation and initiation/commencement. Socially inappropriate or non-intentional speech content. Cursing (coprolalia), although widely thought of as characteristic due to inaccurate media portrayal and over-emphasis, affects few people with TS and is a rare symptom.
• Difficulties in understanding or reading others intentions or in detecting deception (known as 'Theory of mind' difficulties). This is sometimes misconstrued as 'gullibility' or being too trusting. Many with TS tend to be quite 'direct' (open) and detailed in their own expressions of their thoughts, feelings and intentions, to avoid the 'ambiguities' they experience themselves in relation to understanding other people. Negative consequences from others reactions can lead to an intentional 'closing-up' or wariness. People with TS may over-estimate other people's understanding and ability to 'see' things that appear very obvious to them. This is perhaps a consequence of rapid, expansive and analytical thinking that appears characteristic in TS. Appropriate descriptions of the high level of cognitive activity that seems almost universal in TS are 'restless' and 'relentless.'
• Recent research suggests that of the common symptom set (or symptom 'spectrum') experienced by post-adolescent individuals with TS, anxiety and panic attacks are the most troublesome and represent the greater part of the disability-impact than other symptoms. Previously attention-deficit, hyperactivity and obsessive and compulsive symptoms have been considered the most disabling and may be so for children.
• 'Hyperempathy' - Many with TS experience intense feelings of concern and empathy for others (and for animals) which can provoke strong anxiety especially in regard to family and close friends. Such concern for their 'well-being' often extends to individuals who are unknown to them but whose plight has been reported. These behaviours may have a close association with obsessive-thinking. This is an area of TS behaviour that differs substantially from the apparent 'lack of concern' or empathy seen in some individuals with autistic spectrum disorders.
• Non-verbal learning difficulties (NLD) 
• Many individuals experience a lessening of motor and vocal tics as they progress into adulthood however the non-tic symptoms of TS may persist or can even worsen with age. There is a tendency for greater adaptation and compensation with age in suppressing/managing socially-relevant tics. This may give a false impression of resolution. As the individual ages they have a strong imperative to learn and adopt compensatory 'survival-strategies' to hide their condition as much as they are able. They may however incur considerable 'stress' due to suppression and social-vigilance.