The Phenomenology of Tics in Adults: Data From the Calgary and Paris Adult Tic Disorders Registry

ABSTRACT

Introduction

This study investigated the phenomenology of tics in adults with primary tic disorders (Tourette syndrome, persistent motor or phonic tic disorders) and how these features are influenced by sex. It also examined the prevalence of comorbid psychiatric conditions and psychotropic medication use.

Methods

A cross‐sectional study was conducted on 227 adults with primary tic disorders from the Calgary and Paris Adult Tic Registry. Data collected included demographics, tic characteristics (using the Yale Global Tic Severity Scale), psychiatric comorbidities, and medication use. Statistical analyses were performed to compare data between sexes.

Results

The sex ratio was 1.8 males to 1 female. The most common motor tics were simple (eye blinking, simple head movements), and the most common phonic tic was throat clearing. There were no significant sex differences in tic phenomenology or severity. Generalized anxiety disorder (49.5%) and attention deficit hyperactivity disorder (ADHD) (35.8%) were the most common comorbidities. A lower proportion of women were diagnosed with ADHD, while a higher proportion were diagnosed with obsessive compulsive disorder.

Conclusion

The male predominance of tic disorders is less marked in adulthood compared to childhood. Tic phenomenology and severity do not significantly differ between sexes. These findings provide valuable insights into the clinical presentation of tic disorders in adults. Future research will explore severity of comorbid mental health conditions, how these influence tic severity, treatment outcomes and quality of life.

The two most common tics in adults with Tourette syndrome (TS) are simple eye blinking and simple head movements, which are present in more than 50% of adults with TS.

1. Introduction

Primary tic disorders are common neurodevelopmental conditions that include Tourette syndrome (TS), persistent (chronic) motor or phonic tic disorders and provisional tic disorder [1]. Tics can be either simple (when affecting a single muscle or localized group of muscles) or complex (when involving a more coordinated or prolonged pattern of behavior). In our prior work analyzing 203 children and adolescents with primary tic disorders, the most common tics were simple motor facial tics, and throat clearing [2]. On average, the first tics appear at an age of 6.4 years [3]. Tic severity typically increases in childhood, reaching a peak around 10–12 years [4] and usually declines in late adolescence and early adulthood. As described in a prospective cohort of 314 youths with TS in Denmark: after the age of 16, 17.7% of participants had no tics, 59.5% had minimal or mild tics, and 22.8% still had moderate to severe tics [5]. Because there is comparatively less research on tic disorders focused on adults [6, 7] it is unclear if tics follow a similar distribution, phenomenology and severity in adults as children.

TS has an estimated prevalence of 7.7 per 1000 in children (95% confidence interval [CI] 3.9–10.51) [8] and 0.66 per 1000 (95% CI: 0.42–0.90) in adults [9]. The sex ratio is 3–4 males for every 1 female in childhood [8], whereas in adulthood this sex ratio tends to be more balanced, with approximately 2 males for one female [3, 9, 10]. This suggests differential symptom severity or resolution based on sex, or greater health‐care seeking tendencies among adult females with tic disorders. In children, there has been much interest recently in sex differences in tic presentation and severity, with evidence showing that tic severity and related impairment may be greater in females compared to males that increases with age [11, 12, 13, 14]. A sex/gender‐specific phenotype has been suggested in other neurodevelopmental disorders (e.g., autism spectrum disorder) [15, 16], and requires further research in tic disorders.

Tic disorders are commonly associated with comorbid psychiatric disorders, of which attention deficit/hyperactivity disorder (ADHD), obsessive‐compulsive disorder (OCD), depression and anxiety disorders are the most common [17]. Screening for these disorders is essential in clinical practice, as the presence and severity of comorbidities strongly influences health‐related quality of life [18]. Adults with tic disorders also exhibit high rates of coexisting psychiatric disorders, including OCD, depression, anxiety disorders, and, less often, ADHD [11, 19].

We have developed an Adult Tic Registry based in Calgary, Canada and Paris, France to prospectively study tic disorders in adults. The aim of this study is to assess the phenomenology of tics in adults with primary tic disorders, by describing the types and distribution of tics and their severity, and investigate how these features are influenced by sex. We also present data on the prevalence of comorbid psychiatric conditions and psychotropic medication use and how these vary by sex.

2. Methods

Adults with tic disorders have been prospectively included in our Adult Tic Disorders Clinical Registry at the Movement Disorder Clinic at the Foothills' Hospital in Calgary, Canada, and in La Pitié‐Salpêtrière in Paris, France, since 2021. Participants were recruited for the registry during routine clinical care. For this study, we analyzed registry participants with chronic primary tic disorders (TS, persistent motor and phonic tic disorders), which were defined according to the diagnostic criteria of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) [1]. We excluded registry participants with functional tic‐like behaviors [20], co‐existing primary tic disorder and functional tic‐like behaviors, provisional tic disorder, secondary tics, or adult‐onset tics.

In this cross‐sectional study, we recorded sex, nationality, age at first clinical assessment and age at tic onset. Tics at the first clinical assessment were evaluated using the Yale Global Tic Severity Scale (YGTSS) revised version, which is a freely available, reliable and valid clinician‐rated measure of tic severity and tic‐related impairment [21, 22]. The YGTSS includes a detailed tic inventory, that is, the different types of simple and complex tics, both motor and phonic, collected with reference to the past week. Motor and phonic tics are rated separately on a 0–5 scale across five dimensions: number, frequency, intensity, complexity, and interference. The Total Tic Severity Score (range 0–50) is calculated based on the sum of the motor tic score (0–25) and the phonic tic score (0–25). The tic‐related impairment is assessed based on the impact that the tics have on the patient's social life, schoolwork, family life and self‐esteem (0–50, by 10‐point thresholds). We confirmed diagnoses of psychiatric comorbidities, including OCD, ADHD, generalized anxiety disorder, major depressive disorder, substance use disorder, schizophrenia, bipolar disorder and personality disorder, either through our own clinical examination based on fulfillment of DSM‐5 criteria, or according to the outcome of a diagnostic consultation with a psychiatrist. We reported the type and number of treatments that participants were taking by class, including alpha agonists, antipsychotics, selective serotonin reuptake inhibitors (SSRIs), botulinum toxin injections, and psychostimulants. We compared psychiatric comorbidities, treatment, tic phenomenology, tic severity, and tic‐related impairment (using the YGTSS) between men and women.

This project received ethical approval from the University of Calgary Conjoint Health Research Ethics Board (REB20‐1643) and Ethics Committee Ouest (Project 2021‐A01758‐33). Research was undertaken with the understanding and written consent of each subject, and the study conforms with the World Medical Association Declaration of Helsinki.

2.1. Statistical Analysis

Data were assessed for normal distribution using tests of skew and kurtosis. We summarized data using means, standard deviations and percentages. Odds ratios (OR) were used to compare the proportion of females versus males diagnosed with comorbid psychiatric conditions, using medical treatments, and having specific types of tics on the YGTSS inventory. A t‐test was used to compare mean scores between males and females on the YGTSS. Using an alpha of 0.05, a beta of 20% and a standard deviation of 8 on the YGTSS total tic severity score in our sample, we had adequate power to detect a 3‐point difference between males and females on this outcome. All statistical analyses were performed using StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC. Given the exploratory nature of our analysis, p‐value < 0.05 was considered significant for all analyses.

3. Results

A total of 227 adults with primary tic disorders were included from the Calgary and Paris Adult Tic Registry in our study: 210 (92.5%) with TS, 16 (7.05%) with persistent motor tic disorder, and 1 (0.4%) with persistent vocal tic disorder. There were 145 males (63.9%), which makes a sex ratio of 1.8 males: 1 female. Mean age at registry inclusion was 31.2 years (95% CI: 29.5–32.9); mean age of tic onset was 7.7 years (95% CI: 7.2–8.2); there was no difference between sexes. All participants had childhood onset of tics. The most common associated comorbidities were generalized anxiety disorder (49.5%) and ADHD (35.8%), followed by major depressive disorder (34.4%) and OCD (19.7%); 21.1% had no comorbidity. Table 1 describes the characteristics of the population.

TABLE 1.

Description of the sample.

	All (n = 227)	Females (n = 82, 36.1%)	Males (n = 145, 63.9%)	OR (95% CI), p
Nationality, n (% of total)
Canadian	108 (47.6)	39 (47.6)	69 (47.6)
French	119 (52.4)	43 (52.4)	76 (52.4)
Diagnosis, n (%)
Tourette syndrome	210 (92.5)	76 (92.7)	134 (92.4)
PMTD	16 (7.05)	6 (7.3)	10 (6.9)
PVTD	1 (0.4)	0	1 (0.7)
Comorbidities, n (%)	N = 218	N = 78	N = 140
ADHD	78 (35.8)	20 (25.6)	58 (41.4)	0.49 (0.27–0.90), 0.02
OCD	43 (19.7)	23 (29.5)	20 (14.3)	2.51 (1.27–4.95), 0.008
Anxiety	108 (49.5)	44 (56.4)	64 (45.7)	1.54 (0.88–2.68), 0.13
Depression	75 (34.4)	31 (39.7)	44 (31.4)	1.44 (0.81–2.56), 0.2
Schizophrenia	2 (0.9)	1 (1.3)	1 (0.7)	1.81 (0.11–29.27), 0.7
Bipolar disorder	2 (0.9)	0	2 (0.9)	—
Personality disorder	4 (1.8)	2 (2.6)	2 (1.4)	1.82 (0.25–13.15), 0.6
Substance use disorder	6 (2.8)	0	6 (4.3)	—
None	46 (21.1)	12 (15.4)	34 (24.3)	0.57 (0.27–1.17), 0.13
Treatment, n (%)	N = 227	N = 82	N = 145
Alpha agonists	16 (7.1)	7 (8.5)	9 (6.2)	1.41 (0.50–3.94), 0.5
Antipsychotics	95 (41.9)	33 (40.2)	66 (45.5)	1.31 (0.72–2.37), 0.4
SSRIs	64 (28.2)	26 (31.7)	38 (26.2)	0.81 (0.47–1.40), 0.4
Botulinum toxin	31 (13.7)	6 (7.3)	25 (17.2)	0.38 (0.15–0.97), 0.04
Psychostimulants	21 (9.3)	8 (9.8)	13 (9.0)	1.10 (0.44–2.77), 0.8

Abbreviations: ADHD: attention deficit/hyperactivity disorder, OCD: obsessive compulsive disorder, PMTD: persistent motor tic disorder, PVTD: persistent vocal tic disorders, SSRI: selective serotonin reuptake inhibitor.

3.1. Phenomenology of Tics

The most common motor tics were simple, including eye blinking (55%), simple head movements (53%), shoulder shrugs (30%), simple mouth movements (28%), facial grimace (26%), simple arm movements (24%) and simple eye movements (22%). The most common complex motor tics were tic‐related compulsions (15%). The most common phonic tics were simple as well, and included throat clearing (38%), sniffing (20%), grunting (14%) and coughing (12%). Coprolalia was the most common complex phonic tic, in 8% of cases.

Figures 1 and 2 describe the types and frequencies of all motor and phonic tics reported in the population.

FIGURE 1.

Prevalence of motor tics by type.

FIGURE 2.

Prevalence of vocal tics by type.

3.2. Sex Differences in Tics and Comorbidities

Participants had a mean of 3.1 simple motor tics (95% CI: 2.8–3.4), 0.8 complex motor tics (95% CI: 0.7–1.0), 1.3 simple phonic tics (95% CI: 1.1–1.5) and 0.4 complex phonic tics (95% CI: 0.3–0.5), which did not differ by sex. There was no difference in the proportion of females versus males with respect to having specific motor and phonic tics on the YGTSS inventory (see Tables S1, S2). There was no difference in severity of tics and tic‐related impairment by sex on the YGTSS (see Table 2).

TABLE 2.

Motor and phonic tic severity subscores (Yale Global Tic Severity Scale).

	All (n = 227)	Females (n = 82)	Males (n = 145)	t‐test p
Number of motor tics	2.4 (2.3–2.6)	2.3 (2.1–2.6)	2.4 (2.3–2.6)	0.4
Number of phonic tics	1.2 (1.1–1.4)	1.3 (1.0–1.5)	1.2 (1.1–1.4)	0.6
Frequency of motor tics	3.1 (2.9–3.2)	3.1 (2.8–3.4)	3.1 (2.9–3.3)	0.9
Frequency of phonic tics	2.2; (2.0–2.5)	2.2 (1.9–2.6)	2.2 (2.0–2.5)	1.0
Intensity of motor tics	2.9 (2.8–3.0)	2.9 (2.7–3.2)	2.9 (2.7–3.1)	0.6
Intensity of phonic tics	2.1 (1.9–2.3)	2.1 (1.8–2.4)	2.1 (1.8–2.3)	0.9
Complexity of motor tics	1.7 (1.6–1.9)	1.8 (1.5–2.1)	1.7 (1.5–1.9)	0.6
Complexity of phonic tics	1.2 (1.0–1.3)	1.3 (1.0–1.6)	1.1 (0.9–1.3)	0.4
Interference of motor tics	2.0 (1.9–2.2)	2.0 (1.8–2.2)	2.0 (1.8–2.2)	1.0
Interference of phonic tics	1.5 (1.3–1.7)	1.5 (1.2–1.8)	1.5 (1.3–1.7)	1.0
Motor Tic Score (/25)	12.1 (11.5–12.8)	12.2 (11.3–13.1)	12.1 (11.3–12.9)	0.9
Phonic Tic Score (/25)	8.2 (7.5–9.0)	8.4 (7.1–9.6)	8.1 (7.2–9.1)	0.8
Total Tic Severity Score (/50)	20.4 (19.2–21.5)	20.5 (18.8–22.3)	20.3 (18.8–21.7)	0.8
Impairment (/50)	21.3 (19.8–22.7)	22.6 (20.2–25.0)	20.6 (18.7–22.4)	0.2

There was a significantly lower proportion of women than men diagnosed with ADHD (OR = 0.49, 95% CI: 0.27–0.90, p = 0.02) and a significantly higher proportion of women than men diagnosed with OCD (OR = 2.51, 95% CI: 1.27–4.95, p = 0.008) (see Table 1). There were no significant differences in proportions of women versus men diagnosed with other psychiatric comorbidities.

3.3. Treatment

Regarding medical treatment, 42% of our cohort was treated with antipsychotics (3% with risperidone, 36% with aripiprazole, 2% with pimozide), 14% with botulinum toxin injections, 7% with alpha agonists (3.5% with clonidine, 3.5% with guanfacine), 28% with SSRIs (8% with fluoxetine, 11% with sertraline, 2% with paroxetine, 1% with citalopram, 5% with escitalopram) and 9% with psychostimulants (5% with dextroamphetamine, 4% with methylphenidate). The only significant difference in medical treatment between sexes was for botulinum toxin injections, with a significantly lower proportion of females receiving this type of treatment.

4. Discussion

In this cross‐sectional study of 227 adults with tic disorders, the sex ratio was 1.8 males:1 female, indicating that the male predominance of TS is less marked in adulthood than in childhood. Eye blinking and simple head movements, and throat clearing were the most frequently reported tics. There was no sex‐related difference in the phenomenology of tics or tic‐related impairment. The most common associated comorbidities were anxiety, ADHD, and depression. Our findings are important for clinical practice as they clarify the clinical landscape of TS in adults.

Limitations of the study include that participants were included from expert centers, so these may represent the most severe forms of TS. The strengths of the study include its two‐center design, its relatively large size and the comprehensive tic assessment.

4.1. Description of Tic Phenomenology in Adults and Comparison With Children

We recently described the tic phenomenology in 203 children and adolescents included in a Child Tic Registry in Calgary, using the YGTSS the same way [2]. Phenomenology does not seem to significantly change as participants age. Regarding motor tics, simple eye movements and mouth movements were more frequent in children (48% and 46%, respectively) than in adults in this current analysis (22% and 28%, respectively). Like children, the five most frequent motor tics were simple tics located in the face, neck, or shoulder regions. Tic‐related compulsions (15%) were the most frequent complex motor tics, again similar to children (19%). Children showed overall more complex motor tics, such as self‐injurious behaviors (14% vs. 5% in adults). However, YGTSS total tic severity scores were not different: the total tic severity score was 20/50 in adults compared to 19/50 in children. The most frequent simple vocal tic in adults was throat clearing (38%), like in children (42%), followed by sniffing, grunting, coughing, and humming, which are also the five most common simple vocal tics in children. Only 0.4% of adults manifested tics consisting of animal noises, compared to 8% of children. The most common complex vocal tic in adults was coprolalia (7.9% compared to 5% in children) followed by speech blocking (6%), echolalia (5%), enunciation of syllables (4%), and words (5%). In comparison, the most frequent complex vocal tics in children were syllables, echolalia, palilalia, and speech atypicalities.

Eye blinking was the most common tic overall in adults, present in 55% of registry participants at the time of assessment. This is consistent with the findings of Martino and colleagues, who reported a lifetime prevalence of eyelid/eyebrow movement tics in 91.5% of 212 individuals with TS, suggesting that this core feature of TS should be routinely evaluated to strengthen confidence in the clinical diagnosis of this condition [23].

In an international study of 3500 individuals with TS published in 2000, coprolalia was found in 14% (range among sites reporting > 50 cases: 0%–41%). In another study of 597 patients with TS from 15 sites (506 children and 91 adults), coprolalia occurred at some point in the lifetime of 19.3% of males and 14.6% of females. The authors also found that coprophenomena might occur more often in adults compared with children [24]. We found a lower prevalence of coprolalia in our sample, which challenges the notion that coprolalia is a common and “representative” feature in adults with TS. This discrepancy likely reflects a change in the population seen in expert centers during the last 15 years, due to an increase in identification of individuals with mild forms of TS.

Familiarity with the clinical phenomenology of TS is critical for accurate diagnosis and management in clinical practice. This was particularly evident during the early years of the recent SARS‐CoV2 pandemic, when a significant increase in the number of patients with functional tic‐like behaviors (FTLBs) was reported [25]. Many of these patients were initially misdiagnosed with TS by clinicians. At the time, the establishment of consensus diagnostic criteria for FTLBs helped us recognize FTLBs based on the distinctive phenomenology such as large‐amplitude movements/hitting others or self/offensive gestures/freezing, behaviors not following the typical rostro‐caudal progression of tics, and offensive words/statements [20]. These behaviors strikingly contrast with the majority of simple tics found in our cohort of adults with neurodevelopmental tic disorders [26].

4.2. Sex Differences in Tics and Comorbidities

An important finding from our study is the 1.8:1 male/female ratio in adult patients with tic disorders, similar to findings of previous studies [24]. In childhood, the sex ratios have been reported to be 3.2:1 [2], 5.6:1 [24] or 5.2:1 [3], and significantly different than in adults [24]. We had hypothesized that TS has a worse prognosis in females than in males, with less resolution of symptoms with age. Accumulating evidence indicates that females may reach a slightly greater tic severity [11, 12, 14] and tic complexity [13] as they age compared with males. In our Child Tic Registry, we found that girls had higher frequency and intensity of motor tics than boys, associated with greater tic‐related impairment [26]. In a study in 75 adults with TS from a university‐based clinic, females were more likely than males to show expansion of the number of body regions affected by tics and to have a tic worsening in adulthood [11]. However, in our study, there was no difference in the tic inventory and in YGTSS motor and phonic tic severity subscores between men and women. Importantly, a recent large Swedish study (n = 3761) found that female sex was not associated with tic disorder persistence [27].

The more even sex ratio in adulthood may be explained by the fact that girls with TS may be diagnosed later, similar to what has been observed in ADHD, another neurodevelopmental disorder [28]. In a study of 2403 individuals, females had a longer time‐to‐diagnosis than males and had 0.46 lower odds of being diagnosed with TS [29]. Higher severity of tics in young boys could facilitate TS detection in this subgroup compared to in girls [12]. Moreover, boys are more often affected by ADHD than girls and are therefore more likely to see pediatricians who will make the additional diagnosis of tics. This delay in diagnosis could lead to loss of opportunities and delayed treatment [19].

An alternative hypothesis was that adult women have a higher healthcare seeking tendency than men due to higher tic‐related impairment. A study of 185 females with tic disorders compared to 275 males, females reported experiencing greater tic‐related interference in their social lives [19]. However, in our study, tic‐related impairment did not vary significantly between men and women.

While delayed diagnosis, differences in symptom presentation, and healthcare‐seeking behaviors likely contribute to the more balanced sex ratio observed in adults, neurobiological differences may also play a role. Structural imaging data showed that females with TS had stronger cortico‐striatal and cortico‐thalamic connectivity than males across motor and associative cortical regions, independent of treatment status, suggesting intrinsic sex‐related differences in the organization of tic‐related brain networks [30].

4.3. Mental Health Comorbidities

In our cohort, the most common associated comorbidities are generalized anxiety disorder (50%) and ADHD (36%), followed by major depressive disorder (34%) and OCD (20%). There were significantly more men affected by ADHD and more women affected by OCD, as shown in other work [29]. In a large cross‐sectional study of 1374 patients with TS (mean age 19.1 years ±13.5) and 1142 unaffected family members, the two most common associated comorbidities were ADHD and OCD, with lifetime diagnosis' prevalence of 54% and 50%, respectively, followed by anxiety (30%) and mood disorders (30%). This differs from our results [17]. It has been reported that ADHD and OCD symptoms may improve in adolescence [5], and therefore this would explain the smaller proportion of individuals with TS and comorbid ADHD and OCD in our adult population, as previously reported. Females with TS are more likely than males to have mood and anxiety problems [17]. A recent systematic review and meta‐analysis of 12 studies (n = 3812) published between 1997 and 2022 on the prevalence of anxiety and depressive disorders in people with TS provides an estimated prevalence of 53.5% for anxiety disorders and 36.4% for depression [31]. Meta‐regression revealed a significant increase in the prevalence of both conditions with increasing age, consistent with our findings of a higher prevalence of anxiety and depressive disorders in our adult population compared to our pediatric cohort [14].

In conclusion, our work provides much needed data on the phenomenology of tics in adults, the prevalence of comorbid psychiatric conditions, and treatment utilization at two specialist centers in North America and Europe. No differences in phenomenology, tic severity, or tic‐related impairment by sex were found. In the future, the Calgary and Paris Registry will continue exploring the questions of sex differences in the severity of comorbid mental health conditions, health‐related quality of life, and differences between countries. We will also be able to prospectively assess changes in tic inventories over 12 months, treatment responses, and outcomes, and compare these results in adults with existing data in children.

Author Contributions

Christelle Nilles: writing – original draft, methodology, formal analysis, data curation. Yulia Worbe: conceptualization, writing – review and editing, data curation. Andreas Hartmann: conceptualization, writing – review and editing, data curation. Davide Martino: conceptualization, writing – review and editing, data curation. Julian Fletcher: writing – review and editing, data curation. Naoual Serari: writing – review and editing, data curation. Catherine Deans: writing – review and editing, data curation. Isabella Davenport: writing – review and editing, data curation. Emmanuel Roze: conceptualization, funding acquisition, writing – review and editing, data curation, supervision. Tamara Pringsheim: conceptualization, funding acquisition, writing – original draft, methodology, formal analysis, data curation, supervision.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1. Phenomenology of motor tics in adults with primary tic disorders and differences between sexes.

Table S2. Phenomenology of phonic tics in adults with primary tic disorders and differences between sexes.

Nilles C., Worbe Y., Hartmann A., et al., “The Phenomenology of Tics in Adults: Data From the Calgary and Paris Adult Tic Disorders Registry,” European Journal of Neurology 32, no. 7 (2025): e70252, 10.1111/ene.70252.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.