A 10-year-old boy is brought to the pediatrician by his parents for evaluation of "repetitive habits" that have been present for approximately 4 years but have worsened recently. The parents describe a history of frequent eye blinking and nose twitching that began around age 6. Over the years, these movements have waxed and waned in severity and type. Currently, he exhibits forceful head jerking to the right and shoulder shrugging. In addition to these movements, the parents report he has recently developed a high-pitched squeaking sound and repetitive throat clearing that occurs multiple times per hour. He reports a sensation of "tension" or an urge to perform these movements and feels relief after doing so. He can suppress them briefly while in school, but they increase significantly when he returns home. His academic performance is average, though his teacher notes he is often restless. There is no history of seizures, loss of consciousness, or regression of developmental milestones. He takes no medications. Family history is significant for a paternal uncle with "chronic tics" and obsessive-compulsive traits.

His height and weight are in the 50th percentile. He is alert and cooperative. During the interview, rapid, recurrent blinking and intermittent shoulder shrugging are observed. A brief, non-rhythmic squeaking sound is noted twice. The movements are suppressible when the patient is asked to hold still, but a rebound increase in activity is noted immediately after.