Premonitory Urges Reconsidered: Urge Location Corresponds to Tic Location in Patients With Primary Tic Disorders

Abstract

Objective: In patients with Tourette syndrome and other primary tic disorders (PTDs), tics are typically preceded by premonitory urges (PUs). To date, only a few studies have investigated the location and frequency of PUs, and contrary to clinical experience, the results suggest that PUs are not located in the same anatomic region as the tics. This study aimed to further explore PU location and frequency in detail, differentiating the kind and complexity of the corresponding tics, in a large sample of patients with PTD.

Methods: A total of 291 adult (≥ 18 years) patients with a confirmed diagnosis of chronic PTD were included. The study was conducted online, assement included tics and the general characterization of PUs and a sophisticated body drawing for locating PUs.

Results: We found that PUs were located in the same body area as, or in direct proximity to, the corresponding tic. Most frequently, PUs were located in the face and at the head (62.1%). Compared with simple tics, complex (motor and vocal) tics were more often preceded by a PU; but there was no difference in PU frequency observed between motor tics and vocal tics. PUs were more often experienced at the front than at the back of the body (73% vs. 27%), while there was no difference between the right and left sides (41.6% vs. 41.3%).

Conclusion: The strong association between PU and tic location further supports the hypothesis that PUs represent the core of PTD. Accordingly, future therapies should focus on treating PUs to achieve greater tic reduction.

Keywords: Premonitory feeling; Premonitory sensation; Premonitory urge; Primary tic disorder; Tics; Tourette syndrome.

Figure 1.

Density of premonitory urges (PU) for all tics (n = 232 participants). The 95 originally identified body regions were combined into 19 body areas. The calculation of PU density for these 19 body areas was based on the number of marks per body area for all tics in all participants divided by the number of marks for all body areas for all tics in all participants. Hence, PU density reflects how often one body area was marked compared to all body areas. Each body area was counted only once per participant per tic, even if the participant marked it several times. The density ranges from a maximum of 11.7% at the forehead to a minimum of 1.4% at the ears.

Figure 2.

Density of all motor tics and preceding premonitory urges (PU) by body part. Motor tics were assigned to six meaningful corresponding body parts. If the participant marked a body part several times for the same tic, it was counted only once. The following complex motor tics were not included in the analyses: copropraxia, echopraxia, spinning around, and autoaggressive actions (self-injuries) because no clear assignment to one body part was possible. ^*density (%) of motor tics is based on the absolute number of 32 different motor tics reported by all participants (n = 291) in the particular body part divided by the total number of motor tics reported by all participants; ^†density (%) of PU is based on the absolute number of marks per body part for motor tics divided by the number of marks for all body parts for motor tics.

Figure 3.

Density of premonitory urge (PU) of all 20 vocal tics investigated. Density (%) of PU is based on the number of marks per body area for vocal tics divided by the number of marks for all body areas for vocal tics. If the participant marked a body area several times for the same tic, it was counted only once.

Figure 4.

Frequency of premonitory urges (PUs) of tics clustered for motor, vocal, simple, and complex tics. Frequency of PUs is calculated as follows: participants reporting a PU (“always” or “sometimes”) divided by the total number of participants reporting the particular tic. Absolute numbers of tics are given in brackets. ^*simple tics, including simple motor and vocal tics; ^†complex tics, including simple motor and vocal tics.

Figure 5.

Density of premonitory urges (PU) of “eight common motor and phonic tics,” as selected by Leckman et al., [10] from our study (n = 232 participants) compared to Leckman et al.’s [10] original figure (n = 101 participants). The left figure is based on 19 body areas (for definition see text) corresponding to the full body scheme used by Leckman et al. [10] If the participant marked a body area several times for the same tic, it was counted only once. Densities (%) of each body area are based on the number of marks per body area of the eight tics for all participants divided by the number of marks of all body areas of the eight tics for all participants. The density ranges from a maximum of 14% at the cheeks to a minimum of 0.2% at the legs and feet. In contrast to Figure 1, we decided for a black-and-white illustration to enable the best possible comparability with the original figure given by Leckman et al., [10] which can be seen on the right side.