Understanding Coprolalia: A Misunderstood Symptom

Sue Levi-Pearl & Joanne E. Cohen

What is Coprolalia?

Coprolalia is the medical term used to describe one of the most puzzling and socially stigmatizing symptoms of Tourette Syndrome—the involuntary outburst of obscene words or socially inappropriate and derogatory remarks. Other examples may include references to genitals, excrement and sexual acts. Although coprolalia is the most widely known symptom of TS, it occurs in only a minority of patients with TS. It is most often expressed as a single word, but may involve complex phrases. There is no way to predict who will develop coprolalia. Copropraxia is a related complex motor tic symptom involving obscene gestures. For years doctors mistakenly believed that a diagnosis of TS could not be confirmed unless coprolalia was present. Until recently, professionals thought that coprolalia was caused by psychological problems such as extreme frustration, repressed rage or sexuality. It is now understood that the root of this symptom is physical—that is, neurobiological in nature. While little research has focused on understanding coprolalia, data now indicate that fewer than one third of all people with TS exhibit this symptom at some time during their lives. However, for those with coprolalia who are trying to deal with the world—in public places, school, at home or work—just getting through the day can be excruciatingly difficult.

 

How is Coprolalia Manifested?

While obscenities and profanities may be common in everyday conversation in our culture, coprolalia is different from simply swearing or using bad language. Usually these vocal tics are not uttered within social or emotional contexts, and often are spoken or repeated compulsively in a louder tone or different cadence or pitch than normal conversational speech. Particularly embarrassing for some individuals with coprolalia are involuntary outbursts within social contexts, such as racial or ethnic slurs in the company of the very people who would be most offended by such remarks. A minority of people with coprolalia have this particular problem. It is crucial to understand that these words or complex phrases do not necessarily reflect the thoughts, beliefs or opinions of the person with coprolalia. Some phrases can be quite complex, often meaningless and even comical. One young man with TS has been known to shout, “Help me, my underwear is on fire!!” Some people with TS do not actually say the inappropriate words out loud, but may repeat them mentally. Although not socially apparent, these individuals find their subvocalized coprolalia distressing. The words are usually expressed in a person’s native language, but it is not uncommon for someone with TS to swear in a language he or she has learned. What Causes Coprolalia? The most commonly accepted explanation of what causes coprolalia involves the same “faulty wiring” of the inhibitory mechanism of the brain that causes involuntary movements that typify TS. It seems that the innate ability we all have to suppress unwanted movements and unconscious thoughts is somehow impaired in people with TS. Just as people with TS must satisfy the overwhelming urge to twitch, so they must “let out” sounds and words that build up and must be expressed before momentary relief can be felt. Depending on the symptom severity, the pressure to express those symptoms will reoccur, because the irresistible, unbearable urge to twitch, curse or shout cannot be inhibited indefinitely. The particular choice of such language may have to do with the individual’s stronger emotional content in certain parts of the brain. Such symptoms have been seen in individuals following stroke or other brain injury to the deep frontal regions of the brain. As with all tics, increased symptoms may occur with heightened emotional stress, pleasant excitement or even fatigue. The emotional state does not cause the tic symptoms, but rather may increase them.

How Do People Cope?

Some people with coprolalia have discovered ingenious ways to hide or mask their outbursts when they are in social or work situations. They might utter only the first letters of a four letter word, (e.g. “ff” or “shhh”). Others may quietly mumble the unacceptable words or cover their mouths to muffle the obscenities. These masking techniques help to relieve the irrepressible urge to let out the involuntary symptoms, while at the same time mute the unacceptable and disruptive outbursts. Often the ability to substitute the obscenity with another word is limited, because a major change in the sound leaves the underlying urge unsatisfied. One way to understand this is to imagine that one has a cold, but that it is socially unacceptable to sneeze in public. It may be possible to cough instead of sneeze, but the urge to sneeze persists, and eventually we just have to sneeze. Children may also have coprolalia. Because they are less socially sophisticated, youngsters may not try or even be able to mask or hide their outbursts. Severely affected adults with continual vocal tics may not be able to suppress or mask these symptoms. Unfortunately, some have no warning when coprolalia is about to occur. Summary Coprolalia is surely among the most difficult symptoms that a minority of individuals with TS must endure. The public often views these behaviors as either strange or offensive and hostile. However, the presence of coprolalia symptoms is not related to one’s intelligence or character. Somehow, there are people with coprolalia who develop an exceptional ability to cope with TS and its ramifications. Understanding and acceptance of the symptoms of Tourette Syndrome is a key element in helping people with TS lead full and productive lives.