Can Covid-19 (Coronavirus disease 2019) cause Tourette syndrome, especially in pediatric or adolescent patients or those with a history of neurological conditions?

COVID-19 Does Not Cause Tourette Syndrome

COVID-19 does not cause true Tourette syndrome, but the pandemic has been associated with a dramatic surge in functional tic-like behaviors (FTLBs), particularly among adolescent females exposed to social media content—a phenomenon clinically and pathophysiologically distinct from neurodevelopmental Tourette syndrome. 1, 2

Understanding the Distinction

What COVID-19 Actually Causes

The pandemic period has witnessed an unprecedented increase in functional tic-like behaviors, not Tourette syndrome 1, 2, 3. These are fundamentally different conditions:

• Functional tic-like behaviors emerged acutely during the pandemic in 105 consecutive patients at a single specialist center, with 69% being female adolescents and young adults 1
• 75% of these patients reached peak severity within 1 month of onset, contrasting sharply with the gradual rostro-caudal evolution typical of Tourette syndrome 1, 2
• Half of affected patients reported exposure to tic-related social media content, particularly TikTok videos displaying similar behaviors 1, 3

Neurological Effects vs. Tourette Syndrome

While COVID-19 does cause extensive neurological damage through multiple mechanisms, none of these lead to true Tourette syndrome 4, 5:

• 36.4% of COVID-19 patients experience neurological manifestations including confusion, encephalopathy, and corticospinal tract signs—symptoms not characteristic of Tourette syndrome 4, 5
• The neurological damage involves neuroinflammation, neuronal injury, and microglial reactivity, but does not trigger the specific basal ganglia dysfunction underlying Tourette syndrome 5
• Mixed axonal neuropathy and primary myopathy are the predominant neuromuscular findings in severe COVID-19, fundamentally different from the motor neuron patterns in movement disorders 5

Clinical Red Flags: Distinguishing FTLBs from True Tourette Syndrome

Demographics and Onset Pattern

Functional tic-like behaviors:

• Female predominance (69% in the largest cohort) versus male predominance in Tourette syndrome 1
• Acute/explosive onset in teenage years (75% peak within 1 month) versus gradual childhood onset in Tourette syndrome 1, 2
• Later age of onset (adolescence/young adulthood) versus typical onset before age 18 in Tourette syndrome 2, 6

Tic Characteristics

Functional tic-like behaviors show atypical patterns:

• 81% have complex movements and 75% have complex vocalizations from onset, whereas Tourette syndrome typically begins with simple tics 1
• High rates of coprophenomena and "tic attacks" that mirror social media content rather than natural tic evolution 3
• Involvement of trunk and extremities more prominently than the rostro-caudal progression of Tourette syndrome 3
• Lack of suppressibility, contrasting with the characteristic ability to temporarily suppress tics in Tourette syndrome 2

Associated Features

Key distinguishing psychiatric comorbidities:

• 70% have anxiety disorders and 40% have affective disorders in FTLBs 1
• 41% have additional functional neurological disorders beyond the tic-like behaviors 1
• 23% have pre-existing Tourette syndrome with functional overlay, representing a distinct subgroup 1

The Social Media Mechanism

The pandemic created a perfect storm for FTLBs through multiple converging factors 2, 3:

• Increased social media consumption during lockdowns, particularly among adolescents experiencing social isolation 3
• Viral spread of misleading tic videos on platforms like TikTok that perpetuate false beliefs about Tourette syndrome 3
• Maladaptive response to pandemic-related anxiety and life stressors, manifesting as functional neurological symptoms 2
• This represents a spreading neuropsychiatric disorder potentially fostered by the psychosocial impact of COVID-19, not a direct viral effect 2

Critical Pitfalls to Avoid

Misdiagnosis and Inappropriate Treatment

Many patients with FTLBs are being misdiagnosed as late-onset refractory Tourette syndrome 2:

• These patients are referred to Movement Disorders Clinics after failing multiple pharmacological treatments for tics that were never appropriate 2
• Tourette syndrome medications will not help FTLBs because the underlying mechanism is functional, not neurodevelopmental 2, 6
• The appropriate treatment for FTLBs involves addressing anxiety, reducing social media exposure, and functional neurological disorder-specific therapies, not dopamine-blocking agents 2, 3

Confusing COVID-19 Symptoms with Tics

Some Tourette syndrome symptoms may mimic COVID-19, creating diagnostic confusion in the opposite direction 7:

• Dry cough and sniffing (phonic tics) can be mistaken for COVID-19 respiratory symptoms 7
• Spitting, inappropriate touching, and socially inappropriate behaviors may cause problems during pandemic restrictions 7
• Clinicians must recognize that 85% of Tourette syndrome patients have psychiatric comorbidities that may be exacerbated by pandemic stress, without representing new-onset disease 7

The Bottom Line for Clinical Practice

When evaluating a patient with new-onset tics during or after the pandemic:

1. Consider FTLBs first if the patient is a female adolescent with acute onset, complex tics from the start, and social media exposure 1, 2
2. Do not prescribe typical Tourette syndrome medications without confirming the diagnosis meets established criteria for neurodevelopmental tic disorders 6, 2
3. Screen for anxiety, depression, and other functional neurological symptoms as these are present in the majority of FTLB cases 1
4. Inquire specifically about social media consumption and exposure to tic-related content 1, 3
5. Educate patients and families that FTLBs are a recognized functional neurological disorder requiring different treatment approaches than Tourette syndrome 2, 3