Mortimer's Tic Inventory – Dale Mortimer, M.D.

Tics are abrupt, sudden, brief, rapid, recurrent, repetitive, non–rhythmic involuntary movements, gestures, and/or utterances/vocalizations that typically occur in bouts at irregular intervals (“remitting/relapsing” course), and mimic some aspect of a normal behavioral repertoire. Tics are usually of brief duration, with individual tics rarely last more than a second or two. Around 20% of children experience transient and benign tic disorders (– which are more likely to occur during the winter months). In the minority of those with chronic tics, by age 10-11 years, many of these children report premonitory experiences that precede the tics, and are relieved with the performance of the tic. These sensory experiences, which may be intrinsic to the phenomenology of the tic, typically consist of a feeling of tightness, tension, increased sensitivity, or a mounting discomfort/ anxiety located in a specific part of the body. The sensory prodrome ( – which is likened to the expectation that precedes a hiccup, sneeze or an itch) is felt as requiring some type of vigorous, quick, tic–like action for its attenuation. Although the performance of a tic may lead to short–term relief, the child/adolescent (or adult) soon feels the mounting of renewed tension to which he or she will inevitably and perhaps shamefully capitulate. Sometimes those with tics feel that an effective action to relieve the building pressure (or prodromal sensation) must include a dangerous or aggressive behavior, as an essential constituent of the tic experience. Tics may be difficult to distinguish between normal behavior – although the tics are frequently contextually odd or inappropriate behaviors. Early–onset tic symptoms may be misdiagnosed and mistaken for other medical conditions (– for example, throat clearing, sniffing, coughing, snorting, hissing, and noisy breathing are often mistaken for allergy symptoms) and it often requires a trained eye (or ear) to correctly identify tics.‍

Simple motor tics (many of these tics are difficult to adequately describe in words):

• ❒ eyebrow raising or lowering
• ❒ eyeball turning (e.g., eyeball rolling or darting)
• ❒ eyelid blinking
• ❒ nose twitching/wrinkling
• ❒ grimaces; mouth twitching; mouth opening/widening
• ❒ nostril flaring or nose scrunching
• ❒ various lip motions such as licking lips; biting lips
• ❒ jaw snapping
• ❒ horizontal head movements
• ❒ vertical head movements
• ❒ head jerking/head snapping
• ❒ shoulder shrugs, shoulder raising, shoulder rolling
• ❒ arm movements (e.g., arm extending)
• ❒ hand or finger movements (e.g., knuckle “cracking;’ pinching); hand jerking
• ❒ toe clenching or curling; foot raising while seated; other various leg movements
• ❒ jumping; kicking movements
• ❒ sudden tightening/tensing of stomach muscles or diaphragm
• ❒ torso motions (e.g., “back cracking”)
• ❒ tapping
  

Complex motor tics involve more than one muscle group, and moving in a certain stereotyped sequence. The motor tics may appear dance–like. They can also be obscene in character or they may appear self-injurious. While the complex motor tics may appear intentional, they serve no purpose for the person who performs them.

• ❒ hitting oneself
• ❒ jumping or hopping
• ❒ taking three steps forward, one step backward, then kicking oneself in the buttocks
• ❒ touching self repeatedly; repeatedly pulling one’s shirt/blouse
• ❒ touching others inappropriately [e.g., poking other students; grabbing someone’s crotch] or being too physically affectionate (especially with strangers)
• ❒ punching others; striking out at others; tripping others as they walk or run by
• ❒ making socially unacceptable or obscene gestures (e.g., flipping people off [copropraxia]; grabbing one’s genitals; reaching out to touch other’s breasts or grabbing others’ genitals)
• ❒ smelling hands; and/or smelling other unusual objects
• ❒ clapping hands
• ❒ biting self; biting lips; biting other people
• ❒ scab picking
• ❒ head banging
• ❒ kissing; hugging inappropriately
• ❒ tearing paper; tearing one’s underwear
• ❒ making elaborate gestures (e.g., twirling completely around) while leaping through doorways
• ❒ touching chin, touching chest, then shrugging shoulder
• ❒ squeezing eyes shut, pushing out chin, then touching chin to chest
• ❒ squatting, then hopping forward or backward
• ❒ spinning around while walking
• ❒ jumping, twirling around, touching objects or body parts, then smelling one’s hands
• ❒ pulling one’s clothing; repeatedly seemingly intentionally ripping and tearing one’s clothes
• ❒ running into the street in front of moving car, only to jump out of the way at the last moment
• ❒ pinching women’s nipples
• ❒ with shoes on feet, flinging shoes off of feet, with shoes subsequently flying across the room
• ❒  snapping shoulder a certain way, sometimes even if this causes pain (or shoulder dislocation)
• ❒ involuntary imitation or echoing of gestures and motions observed in others [echopraxia]
• ❒ writing sexually offensive words or images
• ❒ re–writing
  

Phonic tics are non–word utterances/ sounds involving the passage of air in some capacity (phonic tics may be difficult to distinguish from normal – although contexually odd or inappropriate – behavior).

• ❒ throat clearing
• ❒ grunting
• ❒ coughing
• ❒ screaming, shrieking, squealing, yelping or other high–pitched cries
• ❒ snorting
• ❒ burping
• ❒ barking or other animal noises (e.g., cawing like a crow)
• ❒ clicking
• ❒ hissing; kissing noises
• ❒ repetition of letters of a word while speaking a sentence
• ❒ repeatedly or stereotypically saying “uh huh.”
• ❒ spitting
• ❒ sucking sounds (e.g., saliva sucking)

Verbal or vocal tics are stereotypical use of words or a series of words or word phrases. Again, verbal tics may be difficult to distinguish from normal (although contexually odd or inappropriate) behavior.

• ❒ unusual and stereotypical stuttering in the middle of a word or sentence
• ❒ unusual word accentuation
• ❒ stereotypical words, series of words, or phrases (e.g., “you know…” or “like”))
• ❒ socially unacceptable or obscene involuntary utterances of foul or obscene language, “potty talk,” sounds, and/or uttering insults or racial epithets to other persons [coprolalia]
• ❒ repetition of the previous speaker’s last sound, word, or sentence [echolalia]
• ❒ repeating one’s own sound, words, or sentence [palilalia]
• ❒ other verbal/phonic tics. Describe here:
  

Sensory tics are localized, uncomfortable sensations that occur in a repetitive fashion, often relieved by performing a motor or vocal tic. Descriptions will vary, but may include a feeling of pressure, tension, anxiety, an ache, tingling, energy, burning, or even a feeling that things are “just not right.” Alas, squeezing the affected muscles brings only temporary relief.

• ❒ feeling that certain muscles have to be stretched over and over again
• ❒ feeling as if one has to urinate frequently, even though small urine volumes are produced
• ❒ feeling of heaviness, lightness, tickling, heat/cold in joints, bone, muscles, and/or other parts of the body
• ❒ feeling that ledges are as if magnetic, pulling the person with Tourette’s to the ledge
• ❒ as one is driving a truck and passes a bicyclist to one’s right, experiencing an overwhelming feeling of wanting to abruptly turn the truck to the right in order to strike the bicyclist
• ❒ other sensory tics. Describe here:
  

Mental play is pleasurable and intentional visual, auditory, and cognitive number and word games (e.g., making up new words by breaking up or changing old ones, playing mental arithmetic games purely for entertainment, changing the appearance of images by squinting or moving one’s eyes in different ways).

• ❒ Example (or use your imagination!):
  

References/Recommended Reading or Viewing:

1. “Gilles de la Tourette Syndrome and Tic Disorders” - Elaine Shapiro, Ph.D. and Arthur K. Shapiro, M.D., Harvard Mental Health Newsletter (published in about 1989)
2. Yale Global Tic Severity Scale – James Leckman, M.D., Yale Child Study Center (1992)
3. “I Have Tourette’s, but Tourette’s Doesn’t Have Me,” HBO Special, directed and produced by Ellen Goosenberg Kent (2005)
4. A Mind of Its Own - Ruth Dowling Bruun, M.D. and Bertel Brunn, M.D. (1994)
5. Budman CL, Bruun RD, Park KS, Olsen MD, “Rage attacks in children and adolescents with Tourette’s disorder: a pilot study,” Journal of Clinical Psychiatry. 1998;59:576-580
6. Cohen DJ and Leckman JF, “Developmental psychopathology and neurobiology of Tourette’s syndrome,” Journal of the American Academy of Child & Adolescent Psychiatry, 1994, 33 (1):2-15
7. Darrow SM, Grados M, Sandor P, et al, “Autism spectrum symptoms in a Tourette’s disorder sample,” Journal of the American Academy of Child & Adolescent Psychiatry. 2017;56(7):610-617
8. da Silva Prado H, da Rosario MC, et al, “Sensory phenomena in obsessive–compulsive disorder and tic disorders: a review of the literature,” CNS Spectrums.2008; 13(5):425-432
9. Treatment and Management of Youth with Tourette Syndrome and Tic Disorders – Joseph McGuire, Tanya Murphy, John Piacentini, Eric Storch (editors) (2018)
10. Anything from the Tourette’s Association of America [formerly Tourette’s Syndrome of America]

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