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Driving with Tic Disorders: An International
Survey of Lived Experiences
Lorena Fernández de la Cruz, PhD,
1
Helene Ringberg, MSc,
2
Seonaid Anderson, PhD,
3
Jeremy S. Stern, FRCP,
4,5
and
David Mataix-Cols, PhD
1,
*
ABSTRACT: BackgroundBackground: Little is known about the lived experiences of individuals with tic disorders when
driving vehicles or trying to obtain a driving license.
ObjectiveObjective: To survey the driving-related experiences of adults with tic disorders.
MethodsMethods: A global survey was disseminated via social media, international patient organizations, and experts
between April 27, 2020 and July 20, 2020.
ResultsResults: Participants were 228 adult individuals self-reporting a confirmed diagnosis of Tourette syndrome or
chronic tic disorder. Of these, 183 (87.7%) had a driver’s license. A minority (9%) reported that they had found it
hard to pass the driving test. Tics only interfered with driving “a bit”(58.5%) or “not at all”(33%). A majority of
participants reported being able to suppress their tics (39.5%) or that their tics are unchanged (28.5%) while
driving. Nearly half of the participants (46.5%) had been involved in accidents, but only a negligible percentage
(3.2%) considered that these were linked to the tics. Participants without a driver’s license (n = 28, 12.3%)
reported significantly more severe tics, compared to those with a license. The majority of these (60.7%)
identified their tics as the main reason for not having a license and 64.3% said that they would like to receive
support to obtain one.
ConclusionsConclusions: The majority of surveyed participants with chronic tic disorders reported minimal difficulties with
driving. However, a non-negligible minority of more severe cases struggle with driving or refrain from driving
altogether and would benefit from additional support. The results have implications for clinicians and vehicle
licensing agencies.
Tourette syndrome (TS) and chronic tic disorder (CTD) are
childhood-onset movement disorders characterized by multiple
motor and/or vocal tics persisting for more than 1 year.
1
Whether tics interfere with driving and constitute a safety risk
is an important research question that remains poorly explored.
In some countries, like Sweden or the United Kingdom, indi-
viduals with TS are encouraged or required to report their
diagnosis to their licensing authorities, particularly if they feel
that their tics interfere with driving.
2,3
A large Swedish
population-based study
4
found that individuals with TS/CTD
(n = 3450) had a small increased risk of serious transport
accidents, compared to individuals from the general popula-
tion, but the risk was largely explained by the presence of
comorbid attention-deficit/hyperactivity disorder (ADHD).
However, the study could not determine if individuals with
TS/CTD are less likely to obtain a driving license or simply
refrain from driving because of their tics. Data on the driving
experiences of persons with TS/CTD and whether they per-
ceive particular challenges when obtaining a driving license are
lacking. Here, we partnered with the leading charity Tourettes
Action to design a global survey to capture the driving experi-
ences of adults with TS/CTD.
1
Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden;
2
Stockholm Health Care Services, Region Stockholm,
Stockholm, Sweden;
3
Neuro Diverse, London, United Kingdom;
4
St. George’s University of London, London, United Kingdom;
5
Honorary Medical Advisor, Tourettes
Action, Farnborough, United Kingdom
*Correspondence to: Professor David Mataix-Cols, Karolinska Institutet, Department of Clinical Neuroscience, Child and Adolescent Psychiatry
Research Centre, Gävlegatan 22B, 8th floor, 113 30 Stockholm, Sweden; E-mail: david.mataix.cols@ki.se
Keywords: tic disorders, Tourette syndrome, chronic tic disorder, driving, motor vehicles, licensing agencies.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribu-
tion in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Received 30 September 2020; revised 14 January 2021; accepted 24 January 2021.
Published online 10 March 2021 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/mdc3.13177
412 MOVEMENT DISORDERS CLINICAL PRACTICE 2021; 8(3): 412–419. doi: 10.1002/mdc3.13177
© 2021 The Authors. Movement Disorders Clinical Practice published by Wiley Periodicals LLC. on behalf of International Parkinson and Movement Disorder Society.
RESEARCH ARTICLE
CLINICAL PRACTICE
Methods
The Swedish Ethics Review authority determined that the study
was exempt from ethical review according to Swedish law
because participation in the survey was anonymous and no
sensitive personal data was stored. Participants consented to
participate in the study. They were asked to confirm that they
were 18 years old or over and that they understood that their
anonymous data would be used for research purposes.
Survey Design
An online survey was developed, with feedback from Tourettes
Action, and hosted at www.surveygizmo.com. The survey took
approximately 10 to 15 minutes to complete and consisted of
both multiple-choice and open-ended questions (see Supporting
Information).
The survey included several sections. The first section
gathered information on sociodemographic (gender, age group,
and country) and clinical characteristics, including comorbidities
and current tic severity, measured with the Adult Tic Question-
naire (ATQ).
5
The ATQ is a self-report questionnaire that
provides intensity and severity scores for 27 specific vocal and
motor tics. Scores can be summed to produce a total tic severity
score (range = 0–216). The ATQ has adequate psychometric
properties.
5
The next section asked whether the person had a driver’s
license. A skip logic algorithm showed 1 of 2 different sets of
questions depending on whether the answer was affirmative or
negative. Participants with a driver’s license were asked about the
process of obtaining the license, the interference caused by the
tics and/or comorbidities when driving, whether the treatment
for tics and/or comorbidities impacted their driving, traffic
accidents, road rage and dangerous behaviors when driving, and
their perceived need for support with their driving. Participants
without a driver’s license were asked whether not having a
license was related to their tics or other comorbidities, previous
attempts or plans to get a license, and the perceived need of
support to obtain a license.
Participants and Procedure
Recruitment was done by distributing a link to the online survey
via social media (eg, Reddit, Twitter, and Facebook) and by
emailing it to patient organizations and international TS experts
that could share the link among colleagues and patients.
The survey was open to participants from any country who
could read in English. A minimum reported age of 18 years,
consent to participate in the study, and a self-reported confirmed
diagnosis of TS or CTD were required for participation. The
survey was open from April 27, 2020 to July 20, 2020.
Statistical Analyses
The completed surveys were downloaded into a Microsoft Excel
spreadsheet and data managed and analyzed in Stata, version 13.1
(StataCorp LLC, College Station, TX). Frequencies and percent-
ages for each question were calculated for the whole sample and
separately for the participants with and without a driver’s license.
Further, because previous literature has reported a small increased
risk of traffic accidents in TS/CTD mainly driven by ADHD
comorbidity,
4
analyses were repeated stratifying by the presence
or absence of ADHD in those with a driver’s license.
χ
2
and Student’sttests were used as appropriate to compare
groups. All tests used 2-tailed significance set at P< 0.05.
Common themes were extracted from the open-ended questions
and summarized.
Results
Survey Participants
Figure 1 shows the flow of participants. The final sample consisted
of 228 individuals. Their demographic and clinical characteristics are
shown in Table 1. A substantial majority of participants (75%)
reported comorbid psychiatric disorders. Insomnia was reported by
14.9% of the sample. The ATQ score was 51.9 (SD = 31.2), with a
reasonable representation of tic severities (range 0–184).
200 have a driver’s license
266 completed surveys from April 27 to July 20, 2020
228 surveys included in the analyses
38 excluded
4 are not 18 or older and/or do not consent to participate
34 do not have a confirmed TS/CTD diagnosis
28 do not have a driver’s license
FIG. 1. Flow of survey participants. CTD, chronic tic disorder; TS, Tourette syndrome.
MOVEMENT DISORDERS CLINICAL PRACTICE 2021; 8(3): 412–419. doi: 10.1002/mdc3.13177 413
L. FERN
ANDEZ de la CRUZ ET AL. RESEARCH ARTICLE
Of the 228 participants, 200 (87.7%) reported having a driver’s
license. There were significant differences between those with
and without a driver’s license in gender (χ
2
= 22.453, P< 0.001)
and age group (χ
2
= 13.915, P= 0.008). Specifically, those with-
out a driver’s license defined themselves more often as “other
gender”or “preferred not to say”and tended to be younger
(Table 1). For the clinical variables, there was a significantly
higher proportion of individuals with autism spectrum disorder
in the group without, compared to the group with, a driver’s
license (χ
2
= 7.826, P= 0.005). Additionally, participants
without a driver’s license reported more severe tics than those
with a license (ATQ score: ttest = 3.081, P= 0.002; Table 1).
Participants with a Driver’s
License
About the Process of Obtaining a Driver’s
License
Of the 200 participants with a driver’s license, only 18 (9%)
responded that it was hard for them to pass the test (Table 2). A
minority (n = 29; 14.5%) said that they had been obligated to
disclose their diagnosis to the driving licensing agency. These
individuals were spread across a number of countries including
9 in the United Kingdom (31.0%), 7 in Norway (24.1%), 4 in
Sweden (13.8%), 3 in the United States (10.3%), 2 in the Neth-
erlands (6.9%), and 1 each (3.4%) in Australia, Canada, Finland,
and Ireland. For 26 individuals (13%), a doctor had to write a
report supporting their application. In 10 cases (5%), the doctor
or the licensing agency had told them that they could not drive
because of the tics, and in 5 cases (2.5%) the license was revoked
because of the tics.
The open-ended question revealed a few common themes.
Many participants reported not having developed symptoms or
that the tics were not affecting them substantially at the time
they got their license. Some participants did not disclose their
diagnosis and/or purposely tried to hide it during the driving
lessons or the exam because of the fear that the symptoms would
hinder their chances of getting the license or because of the
economic costs associated with obtaining a medical report that
certified them fit for driving. Other participants reported that
other psychiatric and somatic comorbidities (eg, anxiety, ADHD,
TABLE 1 Demographic and clinical characteristics of the survey participants (N = 228), by driving license status
All participants
N = 228
Participants
with a driver’s license
n = 200 (87.7%)
Participants without
a driver’s license
n = 28 (12.3%)
Demographic variables
Gender*
Woman 130 (57.0) 114 (57.0) 16 (57.1)
Man 93 (40.8) 85 (42.5) 8 (28.6)
Other/prefer not to say 5 (2.2) 1 (0.5) 4 (14.3)
Age group*
18–25 yr 98 (43.0) 77 (38.5) 21 (75.0)
26–35 yr 59 (25.9) 56 (28.0) 3 (10.7)
36–45 yr 36 (15.8) 34 (17.0) 2 (7.1)
46–55 yr 23 (10.1) 21 (10.5) 2 (7.1)
56 yr or older 12 (5.3) 12 (6.0) 0 (0)
Country
**
United States 66 (28.9) 62 (31.0) 4 (14.3)
Norway 42 (18.4) 40 (20.0) 2 (7.1)
United Kingdom 40 (17.5) 32 (16.0) 8 (28.6)
Canada 13 (5.7) 8 (4.0) 5 (17.9)
Sweden 12 (5.3) 11 (5.5) 1 (3.6)
The Netherlands 11 (4.8) 11 (5.5) 0 (0)
Germany 11 (4.8) 9 (4.5) 2 (7.1)
Other countries 33 (14.5) 27 (13.5) 6 (21.4)
Clinical variables
Any psychiatric comorbidity 171 (75.0) 146 (73.0) 25 (89.3)
Attention-deficit/hyperactivity disorder 79 (34.6) 66 (33.0) 13 (46.4)
Obsessive–compulsive disorder 87 (38.2) 73 (36.5) 14 (50.0)
Anxiety disorder 98 (43.0) 82 (41.0) 16 (57.1)
Depression 81 (35.5) 70 (35.0) 11 (39.3)
Autism spectrum disorder* 23 (10.1) 16 (8.0) 7 (25.0)
Other 13 (5.7) 11 (5.5) 2 (7.1)
Insomnia 34 (14.9) 32 (16.0) 2 (7.1)
ATQ total score, mean (SD)* 51.9 (31.2) 49.6 (29.4) 68.6 (38.1)
ATQ motor tics scale, mean (SD)* 33.6 (17.7) 32.5 (17.1) 41.3 (20.8)
ATQ vocal tics scale, mean (SD)* 18.3 (16.5) 17.1 (15.7) 27.3 (19.4)
Figures correspond to frequencies (percentages), unless otherwise specified.
*
Indicates statistically significant differences between participants with and without driver’s license in χ
2
tests (all categorical variables) and
Student’sttests (ATQ variables) at P< 0.05.
**
Only the countries endorsed by more than 10 participants (when all 228 participants are taken into account) are listed. The rest of countries
are grouped under “Other.”
ATQ, Adult Tic Questionnaire; SD, standard deviation.
414 MOVEMENT DISORDERS CLINICAL PRACTICE 2021; 8(3): 412–419. doi: 10.1002/mdc3.13177
RESEARCH ARTICLE DRIVING EXPERIENCES IN TIC DISORDERS
epilepsy, and vision problems), rather than the tics, played a
more relevant role when they applied for the license.
About the Driving Experience and the
Impact of Comorbidities
As reported in Table 2, the vast majority of respondents reported
driving regularly (n = 177, 88.5%). These, compared to those
that did not drive regularly, had a similar proportion of psychiat-
ric comorbidities (n = 128, 72.3% vs. n = 18, 78.3%, respec-
tively; χ
2
= 0.365, P= 0.546), but scored lower in tic severity
(mean [SD] ATQ score: 47.8 [2.0] vs. 62.9 [9.6], respectively;
ttest = −2.327, P= 0.021).
More than two-thirds of the drivers reported that, when they
drive, their tics either can be suppressed (n =79, 39.5%) or are
unchanged (n =57, 28.5%). However, 14% (n =28) of the par-
ticipants reported that their tics get worse when driving. The rest
of respondents (“other”category: n =36, 18%) reported that
their tics decrease, but are not completely suppressed, or a mix-
ture of responses, with tics manifesting differently when they
drive, mostly depending on levels of stress or anxiety. Others
expressed that they can “adapt”the tics to the driving so that
they will not interfere (eg, twitching right arm instead of right
leg that would affect the gas pedal).
The majority of the sample reported that, overall, their tics
either do not interfere with driving (n =66, 33%) or they do so
only a bit (n =117, 58.5%). Some participants highlighted their
ability to “self-regulate”in a way that when tics are worse or
more intense, they refrain from driving for a period or are able
to pull over, if the symptoms arise while they are driving. Some
individuals mentioned that, because of the interference of the
tics, they try to drive only when necessary or for short distances
or ask a relative or a friend to drive them to places. Specific tics,
like those related to the eyes or the head, were mentioned as
being the most interfering.
When asked about the problem that interfered the most with
their driving, one-fourth mentioned the tics (n =49, 24.5%),
but a larger proportion mentioned ADHD symptoms as the main
problem (n =75, 37.5%). Other comorbidities seemed to be less
problematic (Table 2).
About Traffic Accidents and Road Rage
Less than half of the sample (n =93, 46.5%) reported to have
previously been involved in a traffic accident while being in the
driving seat. Of these, only 3 (3.2%) mentioned that their tics
had something to do with the accident (Table 2).
A large majority of participants reported that they get angry
and frustrated when driving (all the time: n =56, 28%; often:
n=105, 52.5%). A lower but still significant proportion reported
that they experience road rage (eg, performing rude and offen-
sive gestures, uttering insults, and using dangerous driving moves)
when they drive (all the time: n =27, 13.5%; often: n =71,
35.5%) and that they feel that they do things that are a bit
dangerous when driving, like speeding too much or racing other
drivers (all the time: n =18, 9%; often: n =97, 48.5%; Table 2).
Treatment and Interference with Driving
One-fourth of the sample (n =51, 25.5%) were on medication
for their tics, whereas almost half (n =99, 49.5%) were on medi-
cation for other reasons. Approximately one-third (n =65,
32.5%) reported having received behavioral treatment for their
tics (Table 3).
For all treatments, including medication for the tics, medica-
tion for other reasons, and behavioral treatment for the tics, par-
ticipants reported that they did not affect their driving (in 43.1%,
73.7%, and 78.5% of the cases, respectively) or that these treat-
ments helped with the driving (in 39.2%, 17.2%, and 21.5% of
the cases, respectively). Smaller numbers of participants reported
that the medication impaired their driving (17.7% for medication
for the tics and 9.1% for medication for other reasons).
Need of Support for their Driving
A small percentage of participants (n =13, 6.5%) reported that
they feel they need support for their driving. For these, the main
ways they could be supported included having someone in the
car when they are driving who can provide reassurance and
reduce anxiety and having someone to rely on to take them to
places when the tics are too severe for them to drive. Other
topics included improving driving instructors’knowledge of tics,
so they are not negatively judged, and learning themselves to
identify when the tics might be too severe to drive.
Participants without a Driver’s
License
About Obtaining a Driver’s License
The majority of the 28 individuals with TS/CTD who reported
not to have a driver’s license (Table 4) attributed this to their tics
(n = 17, 60.7%). Others reported that they did not have a license
because of other problems (eg, anxiety disorders, ADHD).
Only 1 person (3.6%) reported that their application for a
driver’s license was denied because of their tics, but also reported
feeling that this decision was fair. A majority (n =18, 64.3%)
reported plans to get a driver’s license in the future and, of these,
14 (77.8%) were worried that their tics would make it hard to
obtain it. Two-thirds of these individuals reported that, for them,
getting a driver’s license would be much harder or harder
(n =12, 67.7%) than for other people (Table 4).
Need of Support to Obtain a Driver’s
License
Eighteen of the 28 individuals in this sample (64.3%) reported
that they feel they need support to obtain a driver’s license.
Among the most common themes identified in the open-ended
MOVEMENT DISORDERS CLINICAL PRACTICE 2021; 8(3): 412–419. doi: 10.1002/mdc3.13177 415
L. FERN
ANDEZ de la CRUZ ET AL. RESEARCH ARTICLE
question were the need to increase the awareness and under-
standing of the condition among driving instructors and exam-
iners, because their lack of knowledge may lead to individuals
being more self-aware of their tics or may add pressure and stress,
making the tics more severe or more noticeable. Other aspects
mentioned included more social support while studying for the
license or when learning to drive and getting additional help for
their psychiatric comorbidities.
Are Driving Experiences
Different for Those with and
without ADHD Comorbidity?
Among the 200 individuals with a driver’s license, 66 (33%)
reported a comorbid ADHD diagnosis. Those with ADHD,
compared to those without, had a significantly higher proportion
TABLE 2 Survey answers of those participants with Tourette syndrome or chronic tic disorder who have a driver’s license
(n =200)
n (%)
About obtaining a driver’s license
Age when the license was obtained
Younger than 18 yr 67 (34.0)
18–25 yr 111 (56.3)
26–35 yr 14 (7.1)
36–45 yr 5 (2.5)
Found it hard to pass the test due to the tics 18 (9.0)
Was obligated to disclose the TS diagnosis to the licensing agency 29 (14.5)
Doctor had to write a report supporting the application 26 (13.0)
Doctor or diving agency told them that could not drive due to the tics 10 (5.0)
Driver’s license has been revoked at some point due to the tics 5 (2.5)
About the driving experience and the impact of comorbidities
Drive regularly 177 (88.5)
What happens to the tics when they drive
Can suppress tics when they drive 79 (39.5)
Tics are unchanged when they drive 57 (28.5)
Tics get worse when they drive 28 (14.0)
Other 36 (18.0)
How much do the tics interfere with driving
Not at all (they drive normally) 66 (33.0)
A bit (tics sometimes interfere with driving) 117 (58.5)
Quite a bit (can drive but with difficulty due to the tics) 11 (5.5)
Extremely (tics make the driving unsafe) 6 (3.0)
What problem interferes the most with the driving
The tics 49 (24.5)
Attention-deficit/hyperactivity disorder 75 (37.5)
Obsessive–compulsive disorder 16 (8.0)
Autism spectrum disorder 20 (10.0)
Anxiety disorder 1 (0.5)
Depression 19 (9.5)
Insomnia 3 (1.5)
Other problem 2 (1.0)
The driving is not at all impaired 15 (7.5)
About traffic accidents and road rage
Has been involved in a traffic accident while driving 93 (46.5)
The tics had something to do with this/these accident(s) 3 (3.2)
Get angry or frustrated when driving
Never 3 (1.5)
Rarely 20 (10.0)
Often 105 (52.5)
All the time 56 (28.0)
They do not drive 16 (8.0)
Experience road rage when they drive
Never 3 (1.5)
Rarely 92 (46.0)
Often 71 (35.5)
All the time 27 (13.5)
They do not drive 7 (3.5)
Feel that they do things that are a bit dangerous when driving
Never 3 (1.5)
Rarely 79 (39.5)
Often 97 (48.5)
All the time 18 (9.0)
They do not drive 3 (1.5)
About support
Feel that they need support for their driving 13 (6.5)
TS, Tourette syndrome.
416 MOVEMENT DISORDERS CLINICAL PRACTICE 2021; 8(3): 412–419. doi: 10.1002/mdc3.13177
RESEARCH ARTICLE DRIVING EXPERIENCES IN TIC DISORDERS
of “any psychiatric comorbidity”(n = 51, 77.3% vs. n = 80,
59.7%, respectively; χ
2
= 6.042, P= 0.014), as well as a higher
proportion of obsessive–compulsive disorder (n = 31, 47% vs.
n= 42, 31.3%; χ
2
= 4.659, P= 0.031). Those with ADHD,
compared to those without, reported more severe ATQ scores
(mean [SD]: 59.1 [4.3] vs. 44.9 [2.2], respectively; ttest = −3.296,
P= 0.001).
Those with ADHD obtained their driver’s license later than
those without ADHD (χ
2
= 9.245, P= 0.026), with more indi-
viduals with ADHD obtaining it at ages 26 to 35, compared to
the younger age group. Additionally, those with ADHD, com-
pared to those without, reported more often that they required a
doctor’s report to get their license (19.7% vs. 9.7%, respectively;
χ
2
= 3.906, P= 0.048). All 5 individuals in the sample that
reported that their driver’s license had been revoked had ADHD
(7.6% vs. 0%; χ
2
= 10.412, P= 0.001).
Those with ADHD reported driving as regularly as those
without ADHD (89.4% vs. 88.1%, respectively; χ
2
= 0.077,
P= 0.781). Similarly, there were no group differences regarding
how the tics varied while driving (ie, if they were suppressed,
unchanged or got worse; χ
2
= 1.159, P= 0.763) or regarding
the interference caused by the tics when driving (χ
2
= 2.304,
P= 0.512).
There were no significant differences between those with and
without ADHD in the number of reported traffic accidents
(40.9% vs. 49.2%, respectively; χ
2
= 1.238, P= 0.266). Those
with ADHD did not report experiencing more anger, road rage,
or dangerous driving, compared to those without ADHD
(χ
2
= 1.043, P= 0.791; χ
2
= 4.391, P= 0.222; χ
2
= 3.753,
P= 0.289, respectively). Those with ADHD, compared to those
without, reported more frequently that they need support with
driving (12.3% vs. 3.8%; χ
2
= 4.915, P= 0.027).
A similar proportion of individuals with and without ADHD
were on medication for their tics (18.2% vs. 29.10; χ
2
= 2.777,
P= 0.096). Both groups reported a similar proportion of use of
other medications, however, as expected, all 20 people on
ADHD drugs reported to have the diagnosis (54.0% vs. 0%;
χ
2
= 44.272, P< 0.001). Medication for problems other than
tics affected differently those with and without ADHD
(χ
2
= 10.606, P= 0.005). Those with ADHD were more likely
TABLE 3 Treatment and impact of treatment on driving of
those participants with Tourette syndrome or chronic tic
disorder who have a driver’s license (n =200)
n (%)
Type of treatment
On medication for the tics 51 (25.5)
Antipsychotics 23 (11.5)
Guanfacine 5 (2.5)
Other 27 (13.5)
On medication for other reasons 99 (49.5)
For attention-deficit/hyperactivity
disorder
20 (10.0)
For obsessive–compulsive disorder 17 (8.5)
For anxiety and/or depression 53 (26.5)
For insomnia 17 (8.5)
For other problems 40 (20.0)
Previous behavioral treatment for the tics 65 (32.5)
Treatment and driving
Medication for the tics affects the driving
Yes, helps with the driving 20 (39.2)
Yes, impairs the driving 9 (17.7)
No, does not affect the driving 22 (43.1)
Medication for other reasons affects the driving
Yes, helps with the driving 17 (17.2)
Yes, impairs the driving 9 (9.1)
No, does not affect the driving 73 (73.7)
Behavioral treatment for the tics affects the driving
Yes, helps with the driving 14 (21.5)
Yes, impairs the driving 0 (0)
No, does not affect the driving 51 (78.5)
TABLE 4 Survey answers of those participants with Tourette syndrome or chronic tic disorder who do not have a driver’s license
(n =28)
n (%)
About obtaining a driver’s license
Do not have a driver’s license because of the tics 17 (60.7)
Do not have a driver’s license because of other problems
Because of the attention-deficit/hyperactivity disorder 6 (21.4)
Because of the obsessive–compulsive disorder 4 (14.3)
Because of the anxiety disorder 9 (32.1)
Because of the depression 2 (7.1)
Because of the insomnia 0 (0)
Because of another psychiatric disorder 2 (7.1)
Does not have to do with any psychiatric disorder 8 (28.6)
Does not have psychiatric comorbidities 3 (10.7)
Application for driver’s license was denied because of the tics 1 (3.6)
Think it was a fair decision that the application was denied 1 (100)
Planning on getting a driver’s license in the future 18 (64.3)
Worried that tics will make it hard to get a driver’s license 14 (77.8)
How difficult it would be to obtain a driver’s license
Easier than for other people 0 (0)
About the same than for other people 6 (33.3)
Harder than for other people 7 (38.9)
Much harder than for other people 5 (27.8)
About support
Feel that they need support to obtain a driver’s license 18 (64.3)
MOVEMENT DISORDERS CLINICAL PRACTICE 2021; 8(3): 412–419. doi: 10.1002/mdc3.13177 417
L. FERN
ANDEZ de la CRUZ ET AL. RESEARCH ARTICLE
to report that these medications helped with, rather than
impaired, their driving (χ
2
= 5.539, P= 0.019).
Discussion
This study sheds unique light on the lived experiences of indi-
viduals with tic disorders and identifies some areas for future
research and specific recommendations for clinicians and vehicle
licensing agencies.
A majority of participants in this study reported having a driver’s
license. Approximately 90% of these reported that passing the test
was not hard and that they drive regularly. A majority reported that
their tics do not interfere with their driving or that they do so only
a bit, with the tics remaining unchanged or being successfully
suppressed when they drive. In most cases, tics are highly dependent
on mental state, activity, and external environment, classically worse
with stress and better when absorbed in a task such as playing music,
sports, or video games. These effects are variable from person to per-
son. Clinical observation suggests that driving can be associated with
a decrease as well as an increase in tics, as also indicated by our
results. Approximately half of the sample reported to have been
involved in traffic accidents before, but only 3 individuals attributed
these to the tics. When asked about the problem that interfered the
most with their driving, approximately a quarter mentioned the tics,
although ADHD, if present, was perceived as being more interfer-
ing. Based on these results, the majority of participants in our survey
were generally able to obtain a driver’s license and drive without
significant interference from the tics.
Despite this generally positive picture, a smaller proportion of
individuals did report difficulties when driving or refrained from
driving altogether. Approximately 14% of the participants
reported that their tics are worse when driving and 12% of
individuals with a driver’s license reported not driving regularly;
these individuals had significantly higher tic severity. In fact, this
ability to “self-regulate”was reported by several participants,
who indicated that they would not drive or would stop the car if
they perceived that their symptoms were too severe or too inter-
fering. A smaller proportion of respondents (6%) reported
needing additional support for their driving.
A small proportion of participants (12.3%) did not have a
driver’s license, and 61% of these blamed their tics for it. Those
without a license had significantly more severe tics. Although a
majority of these individuals had plans to get a license in the
future, they anticipated that it would be hard to obtain it because
of their tics and wished for additional support to get it.
We found relatively few differences between participants with
and without comorbid ADHD. Interestingly, although those with
ADHD had more severe tics than those without, there were no
between-group differences in the degree of interference of the tics
while driving, number of traffic accidents or in expressing more
anger, road rage, or violent behaviors when driving. On the other
hand, individuals with tics and ADHD reported needing more
support with their driving. Of note, all 5 individuals that indicated
that their license had been revoked had ADHD. Together with
our previous epidemiological findings,
4
the results suggest that
individuals with comorbidities that are known to potentially inter-
fere with driving (ie, ADHD)
6
may require additional support.
Although direct comparisons are difficult because of the idio-
syncratic nature of our survey, which was specifically designed for
individuals with tic disorders, our results echo the findings of pre-
vious driving studies in individuals with other neuropsychiatric
disorders, such as ADHD,
6,7
autism spectrum disorders,8,9 or
depression.
10,11
Assuming that the results are generalizable to the larger popu-
lation of adults with tic disorders, our findings have some impli-
cations for both clinicians and licensing agencies. Clinicians
should be aware that some of their patients might struggle with
driving or encounter obstacles when trying to obtain a driver’s
license. Adequate long-term management and treatment of the
tics and associated comorbidities is a good starting point. A sub-
stantial proportion of survey participants reported that the treat-
ments they were receiving for their tics (medication or
behavioral treatment) were helpful with their driving. It is not
known if treatment can successfully allow driving in some indi-
viduals initially not able or licensed to drive because of their tics.
A non-negligible 15% of those with a driver’s license stated that
they were obligated to disclose their TS/CTD diagnosis to the
licensing agency in their country. For a similar proportion, a doc-
tor was required to write a report to support their application. In
light of our results, it may be timely for licensing agencies in some
countries to reconsider the need for applicants with TS/CTD to
report on their health status given that empirical evidence suggests
that, for the vast majority, tics do not necessarily interfere with the
safety of their driving. In relation to this, a number of survey par-
ticipants suggested that it would be helpful for driving instructors
and examiners to be more aware of tic disorders. This may help
avoiding negative judgment and attitudes that may inadvertently
lead sufferers to become more aware of their symptoms, leading in
turn to increased stress and tic outbursts that can make driving
more difficult, for example, during their driving test. In general,
decisions on whether or not to grant a driver’s license should not
be done based on the diagnosis of TS/CTD itself but on an
individual assessment of the individual in question.
The highest threat to the validity of our results is the non-
probabilistic sampling method. Although a lower prevalence risk
ratio for sex is expected in adults compared to children with
TS,
12
our sample still included a higher than expected proportion
of women (57%). Most participants were from Europe and
North America and the results may not generalize to other
populations. The accuracy of the diagnoses could not be verified
and, therefore, our sample may contain individuals with both
primary and functional tic disorders. Statistical power was limited
for some of the analyses. Finally, the study lacked a control
group, which makes it difficult to put some of the findings in
context (eg, road rage, accidents).
In sum, and with these caveats in mind, we found that the
majority of surveyed participants with TS/CTD reported mini-
mal difficulties with driving. However, a non-negligible minority
418 MOVEMENT DISORDERS CLINICAL PRACTICE 2021; 8(3): 412–419. doi: 10.1002/mdc3.13177
RESEARCH ARTICLE DRIVING EXPERIENCES IN TIC DISORDERS
of more severe cases struggle with driving or refrain from driving
altogether and would benefit from additional support. Clinicians
and licensing agencies should be aware of these struggles and
assess safety risks related to driving on an individual basis.
Author Roles
(1) Research project: A. Conception, B. Organization,
C. Execution; (2) Statistical Analysis: A. Design, B. Execution,
C. Review and Critique; (3) Manuscript: A. Writing of the first
draft, B. Review and Critique.
D.M-C.: 1A, 1B, 1C, 2A, 2C, 3A
H.R.: 1A, 1B, 1C, 2C, 3B
S.A.: 1A, 2C, 3B
J.S.S.: 1A, 2C, 3B
L.F.C.: 1A, 1B, 1C, 2A, 2B, 3B
Disclosures
Ethical Compliance Statement: The authors confirm that the
approval of the Swedish Ethics Review authority was not required
for this work because participation in the survey is anonymous
and no personal data was stored. Participants consented to partici-
pate in the study. They were asked to confirm that they were
18 or over and that they understood that their anonymous data
would be used for research purposes. We confirm that we have
read the Journal’s position on issues involved in ethical publication
and affirm that this work is consistent with those guidelines.
Funding Sources and Conflicts of Interest: No specific
funding was available for this project. The authors declare no
conflicts of interest.
Financial Disclosures for Previous 12 months: L.F.C.
receives royalties for contributing articles to UpToDate, Wolters
Kluwer Health, outside the submitted work. D.M-C. receives
royalties for contributing articles to UpToDate, Wolters Kluwer
Health and for editorial work from Elsevier, all outside the
submitted work. ■
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Supporting Information
Supporting information may be found in the online version of
this article.
Supplement 1. Online survey.
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ANDEZ de la CRUZ ET AL. RESEARCH ARTICLE