An 11-year-old boy is brought to the office by his mother for a routine examination. She is worried that her son will be laughed at or bullied because of some unusual behaviors. The boy has a 4-year history of episodes in which he clears his throat, grimaces, and blinks his eyes. He has also recently started shrugging his left shoulder, which his mother fears is very noticeable to others. His medical history is otherwise unremarkable. The boy is having difficulty in math but is earning passing grades in other subjects. He has a few friends at school but prefers to play the piano and clarinet by himself after school. The mother notes that his shoulder movements stop when he plays a musical instrument. Physical examination is unremarkable with the exception of sporadic left-sided shoulder shrugs. Which of the following disorders is most likely to develop in this boy?

Question

An 11-year-old boy is brought to the office by his mother for a routine examination.  She is worried that her son will be laughed at or bullied because of some unusual behaviors.  The boy has a 4-year history of episodes in which he clears his throat, grimaces, and blinks his eyes.  He has also recently started shrugging his left shoulder, which his mother fears is very noticeable to others.  His medical history is otherwise unremarkable.  The boy is having difficulty in math but is earning passing grades in other subjects.  He has a few friends at school but prefers to play the piano and clarinet by himself after school.  The mother notes that his shoulder movements stop when he plays a musical instrument.  Physical examination is unremarkable with the exception of sporadic left-sided shoulder shrugs.  Which of the following disorders is most likely to develop in this boy?

Quizplus · Accepted Answer

Tourette syndrome is characterized by multiple motor and one or more vocal tics that present before age 18; it occurs more frequently in males. The tics occur many times a day (frequently in bouts) nearly every day or at regular intervals for at least a year. Motor tics frequently observed include grimacing, eye blinking, nose twitching, head jerking, and shoulder shrugging. Vocal tics include barking, grunting, squeaking, coughing, and throat clearing. In a minority of cases, patients experience coprolalia (uttering of obscene words). Symptoms are exacerbated by stress and tend to subside during sleep. Patients with Tourette syndrome have high rates of comorbid conditions that complicate management and affect quality of life. Attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are the most prevalent comorbid conditions. Obsessive-compulsive disorder (OCD) typically develops within 3-6 years after tics first appear. It may peak in late adolescence or early adulthood when the tics are waning. Less common comorbid conditions include anxiety disorders; depression; autism spectrum disorders; learning disorders; and disruptive, impulse-control, and conduct disorders. (Choices A, B, C, and F) There is an increased incidence of antisocial personality disorder, autism spectrum disorder, conduct disorder, and oppositional defiant disorder in patients with Tourette syndrome, but ADHD and OCD are more common comorbid conditions. Autistic behaviors, when present, are typically evident from an early age and appear prior to the onset of tics. (Choices D and H) Patients with Tourette syndrome may have significant psychosocial impairment and are at increased risk for anxiety disorders and depression. However, these disorders are not as common as ADHD and OCD. (Choice G) There is no known association of Tourette syndrome with seizure disorder. Educational objective: Patients with Tourette syndrome have high rates of psychiatric comorbidity, with a significantly increased risk for attention-deficit hyperactivity disorder and/or obsessive-compulsive disorder. References: Tic disorders and Tourette syndrome: current concepts of etiology and treatment in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/26829367) Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25671412) Comorbidities, social impact, and quality of life in Tourette syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/27375503)

An 11-Year-Old Boy Is Brought to the Office by His