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Combined Vocal and Multiple Motor Tic Disorder [de la Tourette] F95.2 - ICD10 Description, World Health Organization

A form of tic disorder in which there are, or have been, multiple motor tics and one or more vocal tics, although these need not have occurred concurrently. The disorder usually worsens during adolescence and tends to persist into adult life. The vocal tics are often multiple with explosive repetitive vocalizations, throat-clearing, and grunting, and there may be the use of obscene words or phrases. Sometimes there is associated gestural echopraxia which may also be of an obscene nature (copropraxia).
Tourette's Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with Tourette's disorder needs to meet all of the following criteria:

  • Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.)

  • The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.

  • Onset is before age 18 years.

  • The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington's disease, postviral encephalitis).

This disorder is characterized by both multiple motor and one or more vocal tics that have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.) The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months. The onset is before age 18 years. By early adulthood, only approximately 20% of patients will still have moderately debilitating tics, with most having mild tics or even remittance of their symptoms. This disorder is not due to a drug, medication or general medical condition. It is very important to educate teachers, family, and peers regarding the symptoms and natural course of this disorder. Obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD) frequently accompany this disorder, and require treatment in addition to the tic management.

Effective Therapies

First-line treatment for mild-to-moderate tics is with an alpha-2 agonist (e.g., clonidine and guanfacine) or a benzodiazepine (e.g., clonazepam). OnabotulinumtoxinA (formerly known as botulinum toxin type A) injections may be considered when first-line treatment fails to improve mild-to-moderate tics. Individuals with severe tics that are refractory to first- and second-line therapy should be treated with neuroleptics or tetrabenazine. Out of the neuroleptics, risperidone is the preferable choice, followed by aripiprazole, ziprasidone, olanzapine, quetiapine, and the typical neuroleptics haloperidol and pimozide. Associated ADHD can effectively be treated with low-dose CNS stimulants (dextroamphetamine, levoamphetamine, and methylphenidate), or alpha-adrenergic agents (clonidine and guanfacine). Unfortunately, CNS stimulants sometimes increase tic disorder. Cognitive behavioral therapy (CBT) [exposure and response prevention] is a first-line treatment for any associated OCD. Second-line treatments for associated OCD are SSRI antidepressants and clomipramine. Medications can be tapered when the patient is experiencing fewer symptoms (e.g., on summer vacation).


  • Tourette syndrome - Epocrates Online
  • Gilles de la Tourette syndrome - PubMed Health
  • Tourette Syndrome - Wikipedia
  • What is Tourette Syndrome? - Tourette's Syndrome Foundation of Canada
  • Clinical course of Tourette syndrome. - Tics typically have an onset between the ages of 4 and 6 years and reach their worst-ever severity between the ages of 10 and 12 years. On average, tic severity declines during adolescence. By early adulthood, roughly three-quarters of children with TS will have greatly diminished tic symptoms and over one-third will be tic free. Comorbid conditions, such as OCD and other anxiety and depressive disorders, are more common during the adolescence and early adulthood of individuals with TS than in the general population. Although tics are the sine qua non of TS, they are often not the most enduring or impairing symptoms in children with TS. Measures used to enhance self-esteem, such as encouraging strong friendships and the exploration of interests, are crucial to ensuring positive adulthood outcome in TS.



  • Tourette Syndrome Treatments - Centers For Disease Control And Prevention
  • Cognitive Behavioural Intervention For Tics - Tourette's Syndrome Foundation of Canada
  • Tourette syndrome. (2012) - Tourette syndrome (TS) is a neurodevelopmental disorder consisting of multiple motor and one or more vocal/phonic tics. TS is increasingly recognized as a common neuropsychiatric disorder usually diagnosed in early childhood and comorbid neuropsychiatric disorders occur in approximately 90% of patients, with attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) being the most common ones. Moreover, a high prevalence of depression and personality disorders has been reported. Although the mainstream of tic management is represented by pharmacotherapy, different kinds of psychotherapy, along with neurosurgical interventions (especially deep brain stimulation, DBS) play a major role in the treatment of TS. The current diagnostic systems have dictated that TS is a unitary condition. However, recent studies have demonstrated that there may be more than one TS phenotype. In conclusion, it appears that TS probably should no longer be considered merely a motor disorder and, most importantly, that TS is no longer a unitary condition, as it was previously thought.
  • Tourette syndrome: evolving concepts. (2011) - Tourette syndrome is a common childhood-onset neurobehavioral disorder characterized by multiple motor and phonic tics affecting boys more frequently than girls. Premonitory sensory urges prior to tic execution are common, and this phenomenon helps to distinguish tics from other hyperkinetic movement disorders. Tourette syndrome is commonly associated with attention deficit hyperactivity disorder, obsessive-compulsive disorder, learning difficulties, and impulse control disorder. The pathophysiology of this complex disorder is not well understood. Involvement of basal ganglia-related circuits and dopaminergic system has been suggested by various imaging and postmortem studies. Although it is considered a genetic disorder, possibly modified by environmental factors, an intense search has thus far failed to find causative genes. Symptomatic treatment of tics chiefly utilizes various alpha adrenergic agonists, antidopaminergic drugs, topiramate, botulinum toxin, and deep brain stimulation. Habit reversal therapy and other behavioral approaches may be a reasonable option for some cases.


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