Objective: We report three cases of Tourette syndrome wherein aversions were extreme triggers for tics. These mundane sensory stimuli provoked intense tic exacerbation.

Background: Tic disorders are commonly associated with OCD, anxiety, and ADHD, which may compound disease burden and impact tic expression. Premonitory urges are known to play a role in driving tics, but certain stimuli may also drive tic urges, especially when perceived as distressing.

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Method: ​​​​​​Case series

Results: We report three cases of individuals with tics for whom benign environmental triggers were associated with severe negative emotional valence. These triggers precipitated severe, intense tic expression. Notably, these individuals all had child-onset tics and were not felt to have functional overlay.

Case 1: A 37yo M with family history of tics had onset at 8yo of simple motor and vocal tics that grew in complexity over years. He later developed an aversion to the word “sit”, which would trigger extreme fits of his usual tics, namely punching of his flank, side twisting, elbow flexion, and aggressive nose rubbing.  Hearing words containing “sit” (i.e. situation) would even trigger tic spells, causing him bodily harm (Video).

Case 2: A 21yo F with a blinking tic since 7yo developed gradually expanding motor and vocal tic repertoire over many years, also with severe comorbid anxiety, ADHD, and OCD, with contamination and sin-focused fears. She later developed intense aversion to seeing open circles, prompting the need to cross her Os and zeroes initially, and ultimately causing intense tic expression to the point of exhaustion upon seeing open bottles, straw holes, or even the mouth of a person whistling.

Case 3: A 14yo boy with autism and mostly motor tics had an aversion to the sight of clocks, immediately provoking fits of repetitive head and trunk jerking. This prompted him to take extreme measures to remove clocks from his surroundings. Similarly, the words “right” and “sorry” would trigger fits of tics that caused significant distress.

Conclusion: Individuals with tics and OCD may have internal associations wherein aversions can prompt severe bouts of tics, often until the overpowering urge is satisfied or the bad feeling is neutralized. It is critical to elicit these internal experiences, as OCD-targeted therapies may be needed to modify tic expression in these cases. Awareness of external modifiers of tics is key to optimize behavioral and pharmacologic care strategies.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/aversions-as-triggers-for-tic-exacerbations/