Q. I am a Psych NP (Nurse Practitioner) student and have just done a presentation on Tourette's. A question posed to me was "How reliable are neurological soft signs in distinguishing Tourette's from Organic Brain Disorder?" The questioner stated that she was assessing a 7-year-old boy for elective surgery and had reported to the child's mother that he had facial tics.

In my research of Tourette's, I found that for it to be considered Tourette's there must be at least one vocal tic. If this child had no vocal tics, could one assume he did not have Tourette's, but rather a tic disorder?

A. The short answer is, if the patient demonstrates no vocal and motor tics, and NEVER has, he or she does not qualify for a diagnosis of Tourette's Disorder (TD). But as DSM-IV notes, "Both multiple motor and one or more vocal tics have been present at SOME TIME during the illness, although not necessarily concurrently."

So, not every TD patient will present with vocal or motor tics on a given day. Furthermore, DSM-IV notes that sometimes, "...the first symptoms to appear are bouts of a single tic, most frequently eye blinking...initial symptoms can also include tongue protrusion, squatting, sniffing, hopping, skipping.stuttering." and other symptoms (p. 102).

So the bottom line is, not every TD patient will present initially with the typical or expected TD symptoms. Examination by a pediatric neurologist or neuropsychiatrist is probably the best way to resolve the atypical case presentation.

July 2003

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