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Thread: What is The Premonitory Urge?

  1. #1
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    Post What is The Premonitory Urge?

    Thanks to:
    Source: Tourette Syndrome Foundation of Canada London Chapter
    August 15, 2013


    Tics are often preceded by a feeling or sensation that has been termed an urge. The urge that precedes the tics is felt to be
    completely involuntary and may be the driving force for the tic to occur. Interesting, medication used to treat tics often decreases
    the urge as well. This urge is a unique feature that distinguishes tics disorders from other movement disorders such as chorea,
    myoclonus or dystonia. The urge or warning, allows people to suppress or ”hold in" the tic. However, not everyone reports the
    presence of this urge or warning.

    What is the premonitory urge?
    The warning or premonitory urge associated with tics disorders may take many forms. It is usually a sensation or feeling.
    Descriptions include an ”urge to move”, an impulse, a feeling of ”having to do it”, increased tension, anxiety, pressure, fullness, a
    feeling that something is not ”just right", an ache, itching, tingling, burning, numbness, and cold. The urge may be very brief (less
    than one second) or more prolonged. In many cases the feeling is very difficult to put into words.

    Suppression of the tics usually makes the urge feeling worse and expression of the tic usually temporarily reduces the urge feeling.
    In younger children, they often do not describe the warning urge, but are still able to suppress the tic implying that they may have
    some sort of warning feeling that the tic is coming.

    Does everyone get the urge to tic?
    In studies of older children and adults with Tourette syndrome about 80 to 90% of people describe a premonitory urge occurring
    some of the time but not with every tic. Only 1/3 of people describe that every tic is associated with a preceding urge. Therefore, in
    most people the warning urge only occurs some of the time. There are many theories as to why this might occur. It may be that
    not all tics are associated with urge feelings; it may be that the urge is so brief that the person is not aware of it; or it may be related
    to attention.

    In children less than 10 years of age, the rate of urge is much lower and very inconsistent. The typical age of onset of tics is 6 or 7
    years of age and it has been found that children do not report having the urge feeling until 10 years of age. It is not known if that is
    because the urge develops as the disorder progresses or if the child becomes more aware of the urge feelings as they age. It is also
    postulated that young children may not have the vocabulary to describe the urge. Regardless, younger children generally are not
    aware of having the urge occur before the tic.

    Are these movements still considered tics If there is no associated urge?
    The short answer is YES! As stated above, not every person experiences a warning urge and most people do not
    experience a warning urge with each and every tic. If the movements behave otherwise like tics, then that is probably the
    best explanation. However, if the movements are never associated with an urge and are never suppressible, then other
    neurological disorders should be considered.


    Attached is the PUTS scale for evaluating the premonitory urge in a given individual in form for viewing / download / printing
    Attached Files Attached Files

  2. #2
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    Default Re: What is The Premonitory Urge?

    1. Am J Psychiatry.
    1993 Jan;150(1):98-102.

    Premonitory urges in Tourette's syndrome.
    Leckman JF, Walker DE, Cohen DJ.

    Premonitory urges in Tourette's syndrome

    Child Study Center, Yale University School of Medicine, New Haven, CT 06510.

    Abstract
    OBJECTIVE: Tourette's syndrome traditionally has been viewed as a hyperkinetic movement disorder characterized by involuntary motor and phonic tics. Many patients, however, describe their tics as a voluntary response to premonitory urges. This cross-sectional study evaluated premonitory urges and related phenomena in subjects with tic disorders.

    METHOD: A total of 135 subjects with tic disorders, aged 8 to 71 years, completed a questionnaire concerning their current and past tic symptoms. Subjects were asked to describe and, if possible, localize their premonitory urges. The Yale Global Tic Severity Scale was used to assess current tic severity. The method of case finding does not provide prevalence data for premonitory urges.

    RESULTS: Ninety-three percent of the subjects reported premonitory urges. Anatomical regions with the greatest density of urges were the palms, shoulders, midline abdomen, and throat. Eighty-four percent of the subjects reported that tics were associated with a feeling of relief. A substantial majority (92%) also indicated that their tics were either fully or partially a voluntary response to the premonitory urges.

    CONCLUSIONS: While epidemiological studies of tic disorders have yet to incorporate questions concerning premonitory urges, these results suggest that such urges may be commonplace in adolescent and adult subjects with tic disorders. These results challenge the conventional wisdom that tic behaviors are wholly involuntary in character. They also implicate brain regions involved in the processing of sensorimotor information in the pathobiology of tic disorders.

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    Post Re: What is The Premonitory Urge?

    Tic disorders and the premonitory urge
    Journal of Neural Transmission
    2010 February; 117(2): 277284.
    Published online 2009 December 23. doi: 10.1007/s00702-009-0353-3
    PMCID: PMC2809309

    Abstract
    The aims of this study were to examine a non-English (Hebrew) version of a scale that measures the premonitory urge in children suffering from tic disorder, as well as examine the correlations of the urge with demographic and clinical aspects of Tourette Syndrome. Forty children and adolescents, suffering from tics participated in this study. They were assessed with the Premonitory Urge for Tics Scale (PUTS); the Yale Global Tic Severity Scale (YGTSS); the Childhood Version of the Yale Brown Obsessive Compulsive Scale (CYBOCS); the ADHD Rating Scale IV (Conners) Scale; the Screen for Child Anxiety Related Emotional Disorders (SCARED); and the Child Depression Inventory (CDI). The mean PUTS score was 20.15 (SD = 5.89). For the entire sample the PUTS was found to be internally consistent at a = 0.79. Youths older than 10 years had higher consistency (a = 0.83) than youths younger than 10 (a = 0.69). Premonitory urge was not correlated with tic severity in the entire sample. In youths older than 10, as opposed to youths younger than 10, premonitory urge did correlate with obsessions, compulsions and depression, but not with anxiety or with ADHD. The premonitory urge can be measured reliably and the PUTS is a useful instrument for measuring this important phenomena. Premonitory urges seems to be related to obsessions, compulsions, and depression in older children and this may have implications for the developmental psychopatholgy of these symptoms.

    Keywords: Tourette syndrome, Premonitory urge, OCD, Anxiety, Depression, ADHD

    Conclusions
    Premonitory urge and other sensory phenomenon are common in TS and tic disorders. They appear to be related to obsessional thoughts. There now appears to be a tool that can help in investigating this phenomenon. This tool appears to cross language boundaries and could be helpful in developing new therapies for tics and also help in unraveling the semantic confusion surrounding the tic-movement disorder-OCD spectrum of conditions.



    Complete article is attached to this post for viewing / download / printing
    Attached Files Attached Files

  4. #4
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    Default Re: What is The Premonitory Urge?

    Are premonitory urges a prerequisite of tic inhibition in Gilles de la Tourette syndrome?
    J Neurol Neurosurg Psychiatry 2012;83:975-978 doi:10.1136/jnnp-2012-303033


    Abstract
    Background Despite the common notion that premonitory urges facilitate tic inhibition, no studies have investigated this question systematically. We examined the relation of the trait of premonitory urges with tics and tic suppression. We hypothesised that patients with more urges would be more efficient at inhibiting tics.

    Methods 15 adult (14 men, mean age 32.27.9 years) pure Gilles de la Tourette syndrome patients participated. Tic severity was evaluated using the modified Rush Video Scale and by employing the Yale Global Tic Severity Scale. Tic suppressibility was assessed from videos of additional periods where patients were instructed to maximally suppress their tics. Rush score based inhibition potency was synthesised by combining the scores in the two conditions. A measure of pure motor tic inhibition potency was also generated based on the number of motor tics alone. Premonitory urges were assessed by the Premonitory Urge for Tics Scale.

    Results All participants reported urges preceding their tics and were able to voluntarily suppress their tics. However, there was no correlation between urge scores and the Rush score based inhibition potency or the pure motor tic inhibition potency. Scores of the Premonitory Urge for Tics Scale correlated with the interference subscale item of the Yale Global Tic Severity Scale.

    Conclusions Urges and tic inhibition are not directly related. There seem to exist at least two distinct neurophysiological systems of urge/tic generation and tic control in adult Gilles de la Tourette syndrome patients.

  5. #5

    Default Re: What is The Premonitory Urge?

    Thanks, Steve! I have wondered about this because my 8 year old daughter, while mild says she has never felt a premonitory urge! Thanks for filling in the gaps!

  6. #6
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    Default Re: What is The Premonitory Urge?

    The fact that your daughter is unable to distinguish whether or not her tics are preceded by an urge may be due to her undeveloped sense of self awareness at her age. Usually self awareness becomes apparent in children between 10 and 13, which is particularly important when considering CBIT, where self awareness and recognizing the urge are important.

    Although I don't know the reference for the first article in this thread at this time, it alludes to your point:
    In children less than 10 years of age, the rate of urge is much lower and very inconsistent. The typical age of onset of tics is 6 or 7
    years of age and it has been found that children do not report having the urge feeling until 10 years of age. It is not known if that is
    because the urge develops as the disorder progresses or if the child becomes more aware of the urge feelings as they age. It is also
    postulated that young children may not have the vocabulary to describe the urge. Regardless, younger children generally are not
    aware of having the urge occur before the tic.

  7. #7

    Default Re: What is The Premonitory Urge?

    I wonder, and this may sound silly but does it feel like restless leg syndrome? I have RLS and I will try to fight the urge to move my legs but it gets more intense the more i fight it. Also, I have the urge to move them prior to moving them HOWEVER, I do physically move them due to the urge and do have control over it- although I feel i HAVE to do it due to the uncomfortable feeling if I do not. I know that with tics there is not a control over it other than possibly trying to hold off for a while.

  8. #8
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    Default Re: What is The Premonitory Urge?

    Quote Originally Posted by poshpoodle
    does it feel like restless leg syndrome?
    It's an interesting question, and I don't know the answer.

    According to the Mayo Clinic article describing causes for RLS:

    In many cases, no known cause for restless legs syndrome exists. Researchers suspect the condition may be due to an imbalance of the brain chemical dopamine. This chemical sends messages to control muscle movement
    and although Tourette Syndrome is thought to have a basis in dopamine levels, I believe it would be ill-advised to draw any conclusions about any correlation without some competent medical insights, which I, for one, am not qualified to make.

    Perhaps someone with an understanding of Restless Leg Syndrome could offer some insights into how this disorder manifests itself and if there is any relationship to the urge that people with Tourette Syndrome feel preceding a tic expression.

  9. #9

    Default Re: What is The Premonitory Urge?

    Interesting that they both deal with dopamine!! Thanks, Steve!

  10. #10
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    Default Re: What is The Premonitory Urge?

    Source: Pubmed.gov

    J Dev Behav Pediatr. 2005 Dec;26(6):397-403.

    Premonitory Urge for Tics Scale (PUTS): initial psychometric results and examination of the premonitory urge phenomenon in youths with Tic disorders.

    Woods DW1, Piacentini J, Himle MB, Chang S.

    Abstract
    Although motor tics and/or vocal tics are the defining features of chronic tic disorder (CTD) and Tourette syndrome (TS), older youths and adults often report their tics to be preceded by an unpleasant sensation or "premonitory urge." While premonitory urge phenomena may play an important role in behavioral interventions for CTD/TS, standardized assessments for premonitory urges do not exist.

    The current study of 42 youths with TS or CTD presents initial psychometric data for a new, brief self-report scale designed to measure tic-related premonitory urges. Results showed that the Premonitory Urge for Tics Scale (PUTS) was internally consistent (alpha = .81) and temporally stable at 1 (r = 0.79, p < .01) and 2 (r = 0.86, p < .01) weeks. PUTS scores were also correlated with overall tic severity as measured by the Yale Global Tic Severity Scale (YGTSS; r = 0.31, p < .05) and the YGTSS number (r = 0.35, p < .05), complexity (r = 0.49, p < .01), and interference (r = 0.36, p < .05) subscales.

    Finally, an examination of the psychiatric correlates of the premonitory urge phenomenon yielded significant correlations between the PUTS and the Child Behavior Checklist (CBCL) anxiety/depression (r = 0.33, p < .05), and withdrawal (r = 0.38, p < .05) subscales as well as the Children's Yale-Brown Obsessive Compulsive Scale (CYBOCS; r = 0.31, p < .05).

    However, a cross-sectional examination of the data showed that the psychometric properties of the PUTS were not acceptable for youths 10 years of age and younger.

    Likewise, significant correlations found between the YGTSS subscales, CBCL subscales, CYBOCS, and the PUTS did not emerge in this younger age group.

    The clinical and theoretical implications of these findings are discussed.

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