By M. Cristina Victorio , MD, Akron Children's Hospital
Clinically evaluated Apr 2021
Tics are defined as sudden, rapid, repetitive, non-rhythmic muscle movements, including sounds or vocalizations. Tourette syndrome is diagnosed after people have had vocal and motor tics for > 1 year. The diagnosis is clinical. Tics are treated only if they interfere with the child's activities or self-image; treatment may include comprehensive behavioral intervention for tics and clonidine or an antipsychotic.
Tics vary greatly in severity; they occur in about 20% of children, many of whom are not evaluated or diagnosed. Tourette syndrome, the most severe type, occurs in 3 to 8/1000 children. The male/female ratio is 3:1.
Tics begin before age 18 (typically between ages 4 and 6); their severity increases and peaks around age 10 to 12 and decreases during adolescence. Over time, most tics disappear on their own. However, in about 1% of children, tics persist into adulthood.
The etiology is not known, but tics tend to run in families. In some families, they manifest in a dominant pattern with incomplete penetrance.
Comorbidities
Comorbidities are common.
Children with a tic may have one or more of the following:
Attention Deficit/Hyperactivity Disorder (ADHD)
· Obsessive-compulsive disorder (OCD)
· Anxiety disorders
· Learning disorders
These disorders often interfere more with children's development and well-being than tics. Attention-deficit/hyperactivity disorder (ADHD) is the most common comorbid condition, and tics sometimes appear first when children with ADHD are treated with a stimulant; these children likely have an underlying tendency to tics.
Teenagers (and adults) may have
· Infralevel
· Bipolar disorder
· Substance use disorder
Classification of tic disorders
Tic disorders are divided into 3 categories by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5):
· Provisional tic disorder: single or multiple motor and/or vocal tics present for < 1 year.
· Persistent tic disorder (chronic tic disorder): single or multiple motor or vocal (but not motor and vocal) tics have been present for > 1 year.
· Tourette syndrome (Gilles de la Tourette syndrome): both motor and vocal tics are present for > 1 year.
These categories typically form a continuum where patients begin with a transient tic disorder and sometimes progress to a persistent tic disorder or Tourette's syndrome. In all cases, the age of onset must be < 18 years and the disturbance cannot be due to the physiological effects of a substance (eg, cocaine) or another disorder (eg, Huntington's disease, postmenopausal encephalitis). -viral).
Signs and symptoms of tic disorders
Patients tend to exhibit the same set of tics at any given time, although tics tend to vary in type, intensity, and frequency over a period of time. They may occur several times in an hour, then remit or hardly be present for ≥ 3 months. Generally, tics do not occur during sleep.
Tics can be:
Simple tics: these are very brief movements or vocalizations, usually without social meaning.
Motor: Blinking, Grimacing, Jerking Head, Shrugging.
Vocal: Grunt or growl, Sniff or snort, Clear throat.
Complex tics: Last longer and may involve a combination of simple tics. Complex tics may have social meaning (recognizable gestures or words) and therefore appear intentional. However, although some patients may voluntarily suppress their tics for a short period of time (seconds to minutes) and some may experience a premonitory urge to perform the tic, the tics are not voluntary and do not represent inappropriate behavior.
Stress and fatigue can make tics worse, but they are often more prominent when the body is relaxed, such as when watching television. Tics may lessen when patients are engaged in tasks (eg, school or work activities). Tics rarely interfere with coordination. Mild tics rarely cause problems, but severe tics, particularly coprolalia (which is rare), are physically and/or socially disabling.
Sometimes tics come on suddenly, appearing and becoming constant within a day. Children with sudden-onset tics and/or related obsessive compulsion sometimes have a streptococcal infection—a phenomenon sometimes called pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Many researchers do not believe that PANDAS are distinct from the spectrum of tic disorders.
Motor: Combinations of simple tics (eg, turning head and shrugging). Copropraxia: using sexual or obscene gestures, Ecopraxia: imitating someone's movements.
Vocal: Coprolalia: uttering socially inappropriate words (eg, obscenities and ethnic slurs).
Echolalia: repeating own or other people's sounds or words
Diagnosis of tic disorders
· Clinical evaluation
The diagnosis is clinical. To differentiate Tourette's syndrome from other transient tics, doctors need to monitor patients around the clock. Tourette syndrome is diagnosed after people have had vocal and motor tics for > 1 year.
Treatment of tic disorders
Comprehensive Behavioral Intervention for Tics (ICAT)
· Sometimes clonidine or antipsychotics
· Treatment of comorbidities
(See also summary of the American Academy of Neurology review of the treatment of tics in people with Tourette syndrome and persistent tic disorder.)
Treatment to suppress tics is recommended only if they significantly interfere with children's activities or self-image; treatment does not change the natural history of the disorder. Treatment can often be avoided if clinicians help children and their families understand the natural history of tics and if school staff help classmates understand the disorder.
A type of behavioral therapy called ICAT can help some older children control or reduce the number or severity of tics. It includes cognitive-behavioral therapy such as habit reversal (learning a new behavior to replace the tic), tic instruction, and relaxation techniques.
Sometimes the natural oscillations of the tics make it appear that the tics have responded to a given treatment.
Drugs
Oral clonidine 0.05 to 0.1 mg 1 to 4 times daily is effective in some patients. Adverse effects of fatigue may limit daytime dosing; hypotension is rare.
Oral antipsychotics may be needed—for example:
· Risperidone, 0.25 to 1.5 mg 2 times a day
· Haloperidol, 0.5 to 2 mg orally 2 or 3 times a day
· Pimozide, 1 to 2 mg orally 2 times a day
· Olanzapine, 2.5 to 5 mg orally once a day
Fluphenazine is also effective in suppressing tics.
With any drug, the lowest doses that make the tics tolerable are used and discontinued when the tics disappear. Adverse effects of dysphoria, parkinsonism, akathisia, and tardive dyskinesia are rare but may limit the use of antipsychotics; using lower doses during the day and higher doses before bed may lessen adverse effects.
Treatment of comorbidities
Treating comorbidities is important.
Attention-deficit/hyperactivity disorder (ADHD) can sometimes be successfully treated with low doses of stimulants without exacerbating the tics, but an alternative treatment (eg, atomoxetine) may be preferable.
If obsessive or compulsive traits are bothersome, a selective serotonin reuptake inhibitor (SSRI) may be helpful.
Children with tics who are struggling in school should be screened for learning disorders and support provided as needed.
key points
· Tics are rapid, repetitive, sudden, muscular, non-rhythmic movements or vocalizations that develop in children < 18 years of age.
· Tics are common, but the most severe manifestation of tics, coprolalia, is rare.
· Simple tics are brief movements or vocalizations (eg, jerking of the head, mumbling), usually without a social meaning.
· Complex motor tics may have social meaning (recognizable gestures or words) and therefore appear intentional, but they are not.
· Comprehensive behavioral intervention for tics (ICAT) and sometimes clonidine or an antipsychotic can lessen severe or troublesome tics, which also tend to subside over time, although some persist into adulthood.
· Comorbidities (eg, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder) are common and must also be diagnosed and treated.
Additional Information
The following English resource may be helpful. Please note that The Manual is not responsible for the content of this resource.
· American Academy of Neurology: Review summary of the treatment of tics in people with Tourette syndrome and chronic tic disorders.
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