Palicoprolalia: An Unusual Variant of Palilalia in Gilles de la Tourette's Syndrome

SIR: Palilalia is an involuntary repetition, two or more times, of a patient's own phrase or word that is semantically adequate and compulsive in nature. The reiteration occurs in spontaneous speech or when replying to questions.¹ Characteristically the reiteration occurs with increasing rapidity and decreasing voice volume until no more sound is produced, although the patient may continue to move his or her lips for a while. It has been described in association with a variety of disorders affecting frontal-subcortical circuits, including Gilles de la Tourette's syndrome (GTS), where it is estimated that it occurs in 6% to 15% of clinic patients.² Most authors emphasize the compulsive nature of this phenomenon.

Coprolalia is characterized by the inappropriate and involuntary uttering of obscenities, swear words, or blasphemous words.³ It is a classic feature of GTS, although it is not considered an operational diagnostic criterion,⁴ since it occurs in only 10% of cases overall.

To date coprolalia has been reported as utterances of words or phrases that occur with a varied frequency, but to our knowledge it has never been described with “palilalic” characteristics.

We report the histories of 4 patients with GTS who presented with utterances of swear words with a palilalic quality. We have tentatively named this behavior palicoprolalia.

Case Reports

A.B. was a 14-year-old schoolgirl who met DSM-IV and ICD-10 criteria for GTS and also DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). When she was first seen, more than 50 motor tics and up to 8 vocalizations were documented. She also had a range of obsessive-compulsive behaviors (OCBs) such as clicking her fingers, forced touching, arithmomania, and echophenomena. She did not have classic palilalia, but she had palipraxia (repetition of her own acts). The Yale Global Tic Severity Scale score was 36%.

She had no evidence of coprolalia, but she uttered swear words in contextually appropriate situations—not inappropriately or involuntarily (e.g., “fuck!” if frustrated or upset)—followed by the compulsion to repeat the swear word several times (usually 4 or 5 times) in a palilalic fashion. She reported that she could not stop repeating herself.

C.D. was a 9-year-old schoolboy who met DSM-IV and ICD-10 criteria for GTS and also DSM-IV criteria for ADHD and ODD. More than 30 motor tics and several vocal tics were documented. His Yale Global Tic Severity Scale score was 54%. He did not have echophenomena but displayed OCBs (arithmomania, “evening up,” and self-injurious behavior). He did not have coprolalia, copropraxia, or palilalia, but he uttered a swear word (“git”) in contextually appropriate situations (not inappropriately or involuntarily), followed by the compulsion to repeat the swear word up to 6 times with palilalic characteristics.

E.F. was a 16-year-old girl in whom 32 motor tics and 13 vocal tics were documented. She met DSM-IV and ICD-10 criteria for GTS and DSM-IV criteria for ODD. Her Yale Global Tic Severity Scale score was 55%. She also displayed OCBs (forced touching and rituals to ward off danger). She had coprolalia, copropraxia, palilalia, and also palilalia for swear words, where she would feel compelled to repeat twice a swear word (“cunt”) that she had just spoken voluntarily.

G.H. was a 34-year-old unemployed single man who met DSM-IV and ICD-10 criteria for GTS in whom up to 49 motor tics and 13 vocalizations were documented. His Yale Global Tic Severity Scale score was 56%. He also met DSM-IV diagnostic criteria for ADHD and conduct disorder in childhood. He did not have coprolalia, but he had copropraxia (involuntarily producing the “V” sign). He also had OCBs (self-injurious behavior, tunes in his mind, arithmomania, echophenomena, washing rituals, and “evening up” phenomenon). He would swear purposefully (“fuck”), but then he would feel compelled to repeat the word several times (3 to 4) with decreasing voice volume.

Coprolalia and palilalia share a compulsive nature. The differentiation between this phenomenology and classic obsessive-compulsive symptoms is often difficult to establish, if indeed such a difference exists. Only 1 of our 4 patients had typical coprolalia, but all of them displayed repetition of swear words (following a willingly uttered obscene word) that had an involuntary quality and was socially inappropriate; hence, they had certain coprolalic characteristics. The repetitions themselves were palilalic in nature and had also the sense of compulsion and the decreasing volume of voice that define this phenomenon.