Tics

Definition

A tic is a nonvoluntary body movement or vocal sound that is made repeatedly, rapidly, and suddenly. It has a stereotyped but nonrhythmic character. The child or adolescent with a tic experiences it as irresistible but can suppress the movement or noise for a period of time. Tics are categorized as motor or vocal, and as simple or complex. The word "tic" itself is French.

Tics are a type of dyskinesia, which is the general medical term given to impairments or distortions of voluntary movements. Although tics vary considerably in severity, they are associated with several neuropsychiatric disorders in children and adolescents. The American Psychiatric Association (APA) defined four tic disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV. The disorders are distinguished from one another according to three criteria: the child's age at onset; the duration of the disorder; and the number and variety of tics.

• Transient tic disorder (also known as benign tic disorder of childhood): The criteria for transient tic disorder specify that the onset must occur before the age of 18 years; the tics must occur many times a day almost every day for at least four weeks but not longer than 12 months; and the child must not meet the criteria for Tourette syndrome or chronic tic disorder.
• Chronic motor or vocal tic disorder: To meet the diagnosis of chronic tic disorder, the child must be younger than 18 years of age; the tics must have occurred nearly every day or intermittently for a period longer than a year, without a tic-free interval longer than three months; the tics must be either vocal or motor but not both; and the child must not meet the criteria for Tourette disorder.
• Tourette disorder (also known as Tourette syndrome, or TS): Tourette disorder is considered the most serious of the four tic disorders. The DSM-IV criteria for Tourette disorder specify that the child must be younger 18 years of age at onset; the tics must include multiple vocal as well as motor tics, although not necessarily at the same time; the tics must occur many times a day, nearly every day or at intervals over a period longer than a year, without symptom-free intervals longer than six months; there must be variations in the number, location, severity, complexity, and frequency of the tics over time; and the tics cannot be attributed to the effects of a substance (such as stimulants) or a disease of the central nervous system.
• Tic disorder not otherwise specified: This category includes all cases that do not meet the full criteria for any of the other tic disorders.

Description

Tics most commonly affect the child's face, neck, voice box, and upper torso but may involve almost any body part. The experience of having a tic is difficult to describe to those who have never been troubled by them. Having tics may be compared to having the sensation of having to cough because something is tickling one's throat or nose. The sensation is irresistible and immediate.

Simple tics

Simple tics involve only a few muscles or sounds that are not yet words. Examples of simple motor tics include nose wrinkling, facial grimaces, eye blinking, jerking the neck, shrugging the shoulders, or tensing the muscles of the abdomen. Simple vocal tics include grunting, clucking, sniffing, chirping, or throat-clearing noises. Simple tics rarely last longer than a few hundred milliseconds.

Complex tics

Complex tics involve multiple groups or muscles or complete words or sentences. Examples of complex motor tics include such gestures as jumping, squatting, making motions with the hands, twirling around when walking, touching or smelling an object repeatedly, and holding the body in an unusual position. Complex motor tics last longer than simple motor tics, usually several seconds or longer. Two specific types of complex motor tics that often cause parents concern are copropraxia, in which the tic involves a vulgar or obscene gesture, and echopraxia, in which the tic is a spontaneous imitation of someone else's movements.

Similarly, complex vocal tics involve full speech and language, which may range from the spontaneous utterance of individual words or phrases, such as "Stop," or "Oh boy," to speech blocking or meaningless changes in the pitch, volume, or rhythm of the child's voice. Specific types of complex vocal tics include palilalia, which refers to the child's repetition of his or her own words; coprolalia, which refers to the use of obscene words or abusive terms for certain racial or religious groups; and echolalia, in which the child repeats someone else's last word or phrase.

Sensory tics

Sensory tics are less common than either motor or vocal tics. The term refers to repeated unwanted or uncomfortable sensations, usually in the child's throat, eyes, or shoulders. The child may feel a sensation of tickling, warmth, cold, or pressure in the affected area.

Phantom tics

Phantom tics are the least common type of tic. A phantom tic is an out-of-body variation of a sensory tic in which the person feels a sensation in other people or objects. People with phantom tics experience temporary relief from the tic by touching or scratching the object involved.

Other features of tics

Tics typically occur in bouts or episodes alternating with periods of tic-free behavior lasting from several seconds to several hours. They generally diminish in severity when the child is involved in an absorbing activity such as reading or doing homework, and increase in frequency and severity when the child is tired, ill, or stressed. Some children have tics during the lighter stages of sleep or wake up during the night with a tic.

Severe complex motor tics carry the risk of physical injury, as the child may damage muscles or joints, fracture bones, or fall down during an episode of these tics. Some children harm themselves deliberately by self-cutting or self-hitting, while others hurt themselves unintentionally by touching or handling lighted matches, razor blades, or other dangerous objects. Severe complex vocal tics may interfere with breathing or swallowing.

Transmission

Tics as such are symptoms and are not transmitted directly from one person to another. Tic disorders, however, are known to run in families. In addition, some doctors think that tic disorders are more likely to develop in children who have had certain types of infections. These theories are discussed more fully below.

Demographics

Prevalence of tic disorders

The statistics given for tics and tic disorders vary from source to source, in part because tics vary considerably in severity, and many children with mild tics may never come to a doctor's attention. Estimates for the general North American population range from 3 to 20 percent for transient tics (particularly among children below the age of ten); 2–5 percent for chronic tic disorders; and 0.1–0.8 percent for Tourette syndrome. A Swedish study done in 2003 reported that 6.6 percent of a sample of Uppsala school children between the ages of 7 and 15 met DSM-IV criteria for tic disorders: 4.8 percent for transient tic disorder, 0.8 percent for chronic motor tic disorder, 0.5 percent for chronic vocal tic disorder, and 0.6 percent for Tourette syndrome. One study of American volunteers for military service reported a prevalence of 0.5 cases of TS per 1000 for males and 0.3 cases per 1000 for females. Tourette syndrome is known to be more common in males than in females, although the gender ratio is variously reported as 3: 1, 5: 1, or even 10: 1.

Little is known as of 2004 about the prevalence of tic disorders across racial or ethnic groups. One small study that was done in western North Carolina reported that Caucasian children were slightly more likely to have tic disorders than either African American or Native American children (2.1 percent to 1.5 percent and 1.5 percent respectively). The authors of the study cautioned, however, against applying their findings to larger groups of children in other parts of the United States.

Tic disorders and comorbid disorders

One important characteristic of tics and tic disorders is that they rarely occur by themselves. Tic disorders—particularly TS—have a high rate of comorbidity with other childhood disorders. The term comorbid is used to refer to a disease or disorder that occurs at the same time as another disorder. The frequencies of the most common disorders that may be comorbid with tic disorders and Tourette syndrome are as follows:

• attention-deficit/hyperactivity disorder (ADHD): 50 percent comorbidity with tic disorders, 90 percent comorbidity with TS
• obsessive-compulsive disorder (OCD): 11 percent and 80 percent respectively
• major depression: 40 percent and 44 percent respectively

Other psychiatric problems that often coexist with tics and tic disorders include learning disorders , impulse control disorders , school phobia, sensory hypersensitivity, and rage attacks.

Causes and symptoms

The causes of tics and tic disorders are not fully understood as of the early 2000s, but most researchers believe that they are multifactorial, or the end result of several causes. In the early twentieth century, many doctors influenced by Freud thought that tics were caused by hysteria or other emotional problems, and treated them with psychoanalysis. Psychoanalytic treatment, however, had a very low rate of success.

Since the 1970s, researchers have been looking at genetic factors in tic disorders and Tourette syndrome. With regard to TS, genetic factors are present in about 75 percent of children diagnosed with TS, with 25 percent having inherited genetic factors from both parents. The exact pattern of genetic transmission was not known as of 2004, however; autosomal dominant, autosomal recessive, and sex-linked inheritance patterns have all been studied and rejected. Some candidate genes for TS have also been tested and excluded. What is known is that the patient's environment and heredity play a significant part in the severity and course of TS.

Tic disorders as well as OCD sometimes develop after infections (usually scarlet fever or strep throat ) caused by a group of bacteria known as group A beta-hemolytic streptococci, sometimes abbreviated as GABHS. These disorders are sometimes grouped together as PANDAS disorders, which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococci. Some researchers think that the tics develop when antibodies in the child's blood produced in response to the bacteria cross-react with proteins in the brain tissue. The connection between streptococcal infections and tic disorders is questioned by some researchers, however, on the grounds that most children have a GABHS infection at some point in their early years, but the vast majority (95 percent) do not develop OCD or a tic disorder. There appears to be a closer connection between Sydenham's chorea, which is a movement disorder, and GABHS infections than between tic disorders and these infections. One prospective study done at Yale reported in 2004 that new GABHS infections do not appear to cause a worsening of tics in children diagnosed with OCD or Tourette syndrome.

Neuroimaging studies have shown that tic disorders are related to abnormal levels of neurotransmitters known as dopamine, serotonin, and cyclic AMP in certain parts of the brain. A neurotransmitter is a chemical produced by the body that conveys nerve impulses across the gaps (synapses) between nerve cells. In addition to abnormalities in the production or absorption of these chemical messengers, imaging studies indicate that the blood flow and metabolism in a part of the brain called the basal ganglia are abnormally low. The basal ganglia are groups of nerve cells deep in the brain that control movement as well as emotion and certain aspects of thinking. In contrast to the low level of blood flow in the basal ganglia, the motor areas in the frontotemporal cortex of the brain show increased levels of activity.

The various types of tics themselves have already been described. Other symptoms that may be associated with tics and tic disorders include obsessive thoughts; difficulty concentrating or paying attention in school; forgetfulness; slowness in completing tasks; losing the thread of a conversation. These symptoms are usually regarded as side effects of interrupted thinking or behavior caused by the tics.

When to call the doctor

Most cases of mild tics do not require medical treatment and will clear up on their own over time. Doctors usually recommend that family members try to ignore simple tics, since teasing or other unwanted attention may make the tics worse. A visit to the doctor is recommended, however, under any of the following circumstances:

• The child is falling behind in school because of the tics.
• The child's relationships with peers and adults outside the family are affected by the tics.
• The child cannot carry out activities of daily living (self-feeding, bathing, getting dressed, etc.).
• The child has fallen, injured himself, or developed other physical problems because of the tics.
• Other family members have or have had tic disorders.
• The child has recently had an episode of strep throat or other streptococcal infection.
• The child has been diagnosed with OCD, ADHD, or depression.
• The tics have come on suddenly.

Diagnosis

Tic disorders are diagnosed by a process of excluding other possibilities; there are no definitive tests for these disorders as of the early 2000s. For this reason, the diagnosis of tic disorders is often delayed or sometimes missed altogether in milder cases. One study reported an average delay of five to 12 years between the initial symptoms and the correct diagnosis. In addition, diagnosis is complicated by the fact that children often learn to mask their tics by converting them to more socially acceptable or apparently voluntary movements or sounds.

History and physical examination

The first part of a medical workup for tics is the taking of a medical history and a general physical examination. The doctor will want to know whether there is a family history of tics or tic disorders, whether the child has been diagnosed with other childhood developmental or psychiatric disorders, and whether he or she has recently had strep throat or a similar infection.

The physical examination helps the doctor rule out such other possible diagnoses as Sydenham's chorea, a self-limited movement disorder that most commonly affects children between five and 15 years of age; other movement disorders ; seizure disorders; encephalitis ; neurosyphilis; Wilson's disease (a rare inherited disease that causes the body to retain copper); schizophrenia ; carbon monoxide poisoning ; cocaine intoxication; brain injuries caused by trauma; cerebral palsy ;or the side effects of certain medications, particularly stimulants and antiepileptic drugs.

The doctor may not be able to observe the tic(s) during the child's first office visit, often because the child has learned to suppress or mask them. In some cases, a follow-up visit may be scheduled, or the doctor may refer the child to a child psychiatrist or neurologist for further observation. Another approach that can be used to confirm the diagnosis is to audiotape or videotape the child at home or in another less stressful setting.

Psychiatric inventories

Most child psychiatrists will administer the Yale Global Tic Severity Scale (YGTSS) during the intake interview and at follow-up visits in order to identify the particular tic disorder affecting the child, identify comorbid disorders if present, evaluate the severity of the tics, and monitor the child's response to treatment.

The YGTSS, which was first published in 1989, is a semi-structured interview that is widely used by researchers who study tic disorders. "Semi-structured" means that it is an open-ended set of questions that allow the child's parents to describe the tics and other symptoms in detail rather than just answer brief yes-or-no questions.

Laboratory tests

As mentioned earlier, there are no laboratory tests to diagnose tics as such. In some cases, however, the doctor may order a blood test to rule out Wilson's disease or other metabolic disorders, or order a throat culture if the child has recently had strep throat. If the doctor suspects that the child has a PANDAS disorder, he or she may order a blood test to measure the level of antibodies against group A streptococci.

Imaging studies

As of 2004, imaging studies were not routinely performed on children or adolescents with tics unless the doctor suspects a brain injury, infection, or structural abnormality. Magnetic resonance imaging (MRIs), PET scans, and single-photon emission computed tomography (SPECT) scans have been used by researchers, however, to study the brains of patients diagnosed with Tourette syndrome.

In the summer of 2004, two engineers in Taiwan reported on the development of a computerized diagnostic system that will allow radiologists to use SPECT imaging to distinguish between chronic tic disorder and Tourette syndrome with a much higher degree of accuracy. The system appears to be potentially useful in speeding up the process of diagnosis and allowing earlier treatment of TS.

Treatment

After psychoanalysis was discredited in the 1970s as a treatment for tic disorders, some doctors urged using such antipsychotic drugs as haloperidol (Haldol) to treat TS by suppressing the tics. These drugs, which are sometimes called neuroleptics, have severe side effects and are likely to interact with other medications that the child may be taking. In addition, tics are increasingly recognized as complex phenomena that have an emotional as well as a physical dimension. As a result, the treatment of tic disorders has changed in the early 2000s in the direction of minimizing the use of medications in favor of a multidisciplinary approach.

The approach to assess a child with a tic disorder is as follows:

• Administer the YGTSS in order to evaluate the areas of the child's functioning that are most severely affected by the tics.
• Identify any comorbid disorders if present. In many cases, the tics do not interfere with the child's life as much as ADHD, OCD, or depression. ADHD should be the primary target of management in children diagnosed with a tic disorder and comorbid ADHD.
• Rank the symptoms in order of importance in order to focus treatment on the ones that are most significant to the child and the family.
• Emphasize controlling the tics and learning to live with them rather than trying to eliminate them with drugs.
• Use behavioral and psychotherapeutic approaches as well as medications.
• Involve the patient's teachers and other significant adults as well as parents in order to help monitor the child's symptoms and response to treatment.

Medications

There is no medication that can cure a tic disorder; all drugs that are used to treat these disorders as of the early 2000s are used only to manage tics. In general, doctors prefer to avoid medications in treating mild tics; start the treatment of moderate or severe tics with medications that have relatively few side effects, and prescribe stronger drugs only when necessary.

Children whose throat cultures or blood tests are positive for a GABHS infection are treated aggressively with antibiotics , most commonly penicillin V.

Psychotherapy

Psychotherapy for tics and tic disorders typically involves education about tic disorders and therapy for the family as well as individual treatment for the child. The American Academy of Child and Adolescent Psychiatry (AACAP) urges parents to avoid blaming or punishing the child for the tics, as shaming or harsh treatment increases the child's level of emotional stress and usually makes the tics worse.

Cognitive-behavioral approaches are the most common type of individual psychotherapy used to treat tics and tic disorders. Specific behavioral approaches include the following:

• Massed negative practice: In this form of behavioral treatment, the child is asked to perform the tic intentionally for specified periods of time interspersed with rest periods.
• Competing response training: This is a form of treatment of motor tics in which the child is taught to make the opposite movement to the tic.
• Self-monitoring: In awareness training, the child keeps a diary, small notebook, or wrist counter for recording tics. It is supposed to reduce the frequency of tic bouts by increasing the child's awareness of them.
• Contingency management: This approach works best in the home and is usually carried out by the parents. The child is praised or rewarded for not performing the tics and for replacing them with acceptable alternative behaviors.

As of the early 2000s, however, no controlled studies have been done comparing the effectiveness of these various behavioral approaches. At best, they appear to produce mixed results.

Surgery

Surgery is used very rarely to treat tic disorders; it is usually tried only if the tic has not responded to any medication and interferes significantly with the patient's life. Some patients with TS, however, have been successfully treated with stereotactic surgery involving high-frequency stimulation of the thalamus. Stereotactic surgery involves an approach that calculates angles and distances from the outside of the patient's skull to locate very small lesions or structures deep inside the brain. It allows the surgeon to remove tissue or treat injured areas through much smaller incisions.

Alternative treatments

The place of alternative or complementary therapies in treating tics is debated. One group of Chinese physicians reported successfully treating patients diagnosed with TS with acupuncture. However, a group of researchers studying traditional medicine in Bali found it ineffective in treating tic disorders, and a second group at Johns Hopkins reported that relaxation therapy did not have a statistically significant effect in treating children diagnosed with TS. There is also some evidence that gingko, ginseng, and some other herbs taken for their stimulant effects may increase the severity of tics in children and adolescents.

Nutritional concerns

Although some nutritionists have suggested a possible connection between sugar or food coloring and tic severity, no studies published as of 2004 had demonstrated such a connection. One study done at the University of Kansas did find a connection between caffeine (which is found in cola beverages and some other soft drinks as well as tea and coffee) consumption and tic severity in children. The study sample, however, was quite small.

Prognosis

The prognosis for most tics and tic disorders is quite good. In the majority of cases, the tics diminish in severity and eventually disappear as the child grows older. Even in Tourette syndrome, about 85 percent of children find that their tics diminish or go away entirely during or after adolescence . Tics that persist beyond the teenage years, however, usually become permanent.

Factors associated with a poorer prognosis for all tic disorders include the following:

• history of complications during the child's birth
• chronic physical illness in childhood
• physical or emotional abuse in the family or a history of family instability
• exposure to anabolic steroids or cocaine
• comorbid psychiatric or developmental disorders

Prevention

There are no known ways to prevent either tics or tic disorders.

Nutritional concerns

In some cases, parents may find it helpful to monitor the child's intake of cola, iced tea, other drinks containing caffeine, and certain herbal teas.

Parental concerns

Parental concerns related to tics and tic disorders are difficult to address in general terms, because tics can range in type and severity from simple noises or movements of short duration that do not attract much attention from others to complex tics of a physically harmful or socially embarrassing nature that attract a lot of attention. In addition, tics must often be managed in the context of another disorder affecting the child. Since the treatment of tics is individualized, it is best for parents to consult with the child's doctor(s) regarding special educational programs or settings, explaining the tics or tic disorder to others, dealing with the side effects of medications, and managing rage attacks or other symptoms that may be associated with the tics.

See also Movement disorders; Tourette syndrome.

KEY TERMS

Basal ganglia —Brain structure at the base of the cerebral hemispheres involved in controlling movement.

Chorea —Involuntary movements in which the arms or legs may jerk or flail uncontrollably.

Comorbidity —A disease or condition that coexists with the disease or condition for which the patient is being primarily treated.

Compulsion —A repetitive or ritualistic behavior that a person performs to reduce anxiety. Compulsions often develop as a way of controlling or "undoing" obsessive thoughts.

Coprolalia —The involuntary use of obscene language.

Copropraxia —The involuntary display of unacceptable/obscene gestures.

Dopamine —A neurotransmitter made in the brain that is involved in many brain activities, including movement and emotion.

Dyskinesia —Impaired ability to make voluntary movements.

Echolalia —Involuntary echoing of the last word, phrase, or sentence spoken by someone else.

Echopraxia —The imitation of the movement of another individual.

Multifactorial —Describes a disease that is the product of the interaction of multiple genetic and environmental factors.

Neuroleptic —Another name for the older type of antipsychotic medications, such as haloperidol and chlorpromazine, prescribed to treat psychotic conditions.

Neurotransmitter —A chemical messenger that transmits an impulse from one nerve cell to the next.

Palilalia —A complex vocal tic in which the child repeats his or her own words, songs, or other utterances.

PANDAS disorders —A group of childhood disorders associated with such streptococcal infections as scarlet fever and strep throat. The acronym stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococci.

Semi-structured interview —A psychiatric instrument characterized by open-ended questions for discussion rather than brief questions requiring yes or no answers.

Stereotactic technique —A technique used by neurosurgeons to pinpoint locations within the brain. It employs computer imaging to guide the surgeon to the exact location for the surgical procedure.

Stereotyped —Having a persistent, repetitive, and senseless quality. Tics are stereotyped movements or sounds.

Streptococcus —Plural, streptococci. Any of several species of spherical bacteria that form pairs or chains. They cause a wide variety of infections including scarlet fever, tonsillitis, and pneumonia.

Tic —A brief and intermittent involuntary movement or sound.

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders,4th ed., Text Revision. Washington, DC: American Psychiatric Association, 2000.

"Dyskinesias." Section 14, Chapter 179 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

PERIODICALS

Dale, R. C., et al. "Dyskinesias and Associated Psychiatric Disorders Following Streptococcal Infections." Archives of Disease in Childhood 89 (July 2004): 604–10.

Evidente, Virgilio G. H. "Is It a Tic or Tourette?" Postgraduate Medicine 108 (October 2000): 175–82.

Khalifa, N., and A. L. von Knorring. "Prevalence of Tic Disorders and Tourette Syndrome in a Swedish School Population." Developmental Medicine and Child Neurology 45 (May 2003): 315–19.

Lavenstein, Bennett L. "Treatment Approaches for Children with Tourette's Syndrome." Current Neurology and Neuroscience Reports 3 (2003): 143–48.

Lemelson, R. B. "Traditional Healing and Its Discontents: Efficacy and Traditional Therapies of Neuropsychiatric Disorders in Bali." Medical Anthropology Quarterly 18 (March 2004): 48–76.

Luo, F., et al. "Prospective Longitudinal Study of Children with Tic Disorders and/or Obsessive-Compulsive Disorder: Relationship of Symptom Exacerbations to Newly Acquired Streptococcal Infections." Pediatrics 113 (June 2004): 578–85.

McEvoy, J. P., and T. B. Allen. "The Importance of Nicotinic Acetylcholine Receptors in Schizophrenia, Bipolar Disorder, and Tourette's Syndrome." Current Drug Targets: CNS and Neurological Disorders 1 (August 2002): 433–42.

Yin, T. K., and N. T. Chiu. "A Computer-Aided Diagnosis for Distinguishing Tourette's Syndrome from Chronic Tic Disorder in Children by a Fuzzy System with a Two-Step Minimization Approach." IEEE Transactions on Biomedical Engineering 51 (July 2004): 1286–95.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016–3007. Web site: <www.aacap.org.>.

National Institute of Neurological Disorders and Stroke (NINDS). National Institutes of Health. 9000 Rockville Pike, Bethesda, MD 20892. Web site: <www.ninds.nih.gov>.

Tourette Syndrome Association Inc. 42–40 Bell Blvd., Bayside, New York 11361–2820. Web site; <http://tsa-usa.org>.

WEB SITES

Black, Kevin J., and Heather Webb. "Tourette Syndrome and Other Tic Disorders." eMedicine, November 9, 2004. Available online at <www.emedicine.com/neuro/topic664.htm> (accessed December 1, 2004).

Ellis, Cynthia R., and Holly Jean Zumpfe. "Childhood Habit Behaviors and Stereotypic Movement Disorder." eMedicine, October 26, 2004. Available online at <www.emedicine.com/ped/topic909.htm> (accessed December 1, 2004).

OTHER

American Academy of Child and Adolescent Psychiatry (AACAP). Tic Disorders. AACAP Facts for Families #35. Washington, DC: AACAP, 2000.

National Institute of Neurological Disorders and Stroke (NINDS). Tourette Syndrome Fact Sheet. Bethesda, MD: NINDS, 2001.

Rebecca Frey, PhD

Tic Disorders

Definition

Description

Demographics

Causes and symptoms

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Tic disorders are characterized by the persistent presence of tics, which are abrupt, repetitive involuntarymovements and sounds that have been described as caricatures of normal physical acts. The revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) lists three main types of tic disorders: Tourette’s syndrome, chronic motor or vocal tic disorder, and transient tic disorder. The best known of these disorders is Tourette’s syndrome, named after Georges Gilles de la Tourette (1857–1904), who first described its symptoms in 1885.

Description

Tics are sudden, painless, nonrhythmic behaviors that are either motor (related to movement) or vocal and that appear out of context—for example, knee bends in science class. They are fairly common in childhood; in the vast majority of cases, they are temporary conditions that resolve on their own. In some children, however, the tics persist over time, becoming more complex and severe.

Tics may be simple (using only a few muscles or simple sounds) or complex (using many muscle groups or full words and sentences). Simple motor tics are brief, meaningless movements like eye blinking, facial grimacing, head jerks, or shoulder shrugs. They usually last less than one second. Complex motor tics involve slower, longer, and more purposeful movements like sustained looks, facial gestures, biting, banging, whirling or twisting around, or copropraxia (obscene gestures).

Simple phonic tics are meaningless sounds or noises like throat clearing, coughing, sniffling, barking, or hissing. Complex phonic tics include syllables, words, phrases, and such statements as “Shut up!” or “Now you’ve done it!” The child’s speech may be abnormal, with unusual rhythms, tones, accents, or intensities. The echo phenomenon is a tic characterized by the immediate repetition of one’s own or another’s words. Coprolalia is a tic made up of obscene, inappropriate, or aggressive words and statements. It occurs in fewer than 10% of people with tic disorders.

Children under the age of 10 with simple tics find them to be difficult to suppress, or control. Many older patients and children with complex tics describe feeling strong sensory urges in their joints, muscles, and bones that are relieved by the performance of a motor tic in that particular body part. These patients also report inner conflict over whether and when to yield to these urges. A sensation of relief and reduction of anxiety frequently follows the performance of a tic. Unless the tic disorder is very severe, most people with tics can suppress them for varying periods of time.

Motor and vocal tics may be worsened by anxiety, stress, boredom, fatigue, or excitement. Some people have reported that tics are intensified by premenstrual syndrome, additives in food, and stimulants. The symptoms of tic disorders may be lessened while the patient is asleep. Cannabis (marijuana), alcohol, relaxation, playing a sport, or concentrating on an enjoyable task are also reported to reduce the severity and frequency of symptoms.

Tics are the core symptom shared by transient tic disorder, chronic motor or vocal tic disorder, and Tourette’ syndrome. The age of onset for these disorders is between two and 15 years. It is the severity and course that distinguishes these disorders from one another. Tourette’s symptoms typically appear before the age of 18. In most patients, Tourette’s symptoms subside after adolescence.

Demographics

An estimated 200,000 Americans have the most severe form of Tourette’s syndrome, but as many as one in 100 people exhibit minor tics. Tourette’s syndrome is three-to-five times more common in males than females. Tic disorders have been reported in

people of all races, ethnic groups, and socioeconomic classes, but they appear to occur more frequently in Caucasians than African Americans.

Causes and symptoms

Causes

Emotional factors were once viewed as the cause of tics, but this explanation has been largely discounted. The search for causes now focuses on biological, chemical, and environmental factors. As of 2007, however, no definitive cause of tics has been identified.

There appear to be both functional and structural abnormalities in the brains of people with tic disorders. While the exact neurochemical cause is unknown, it is believed that abnormal neurotransmitters (chemical messengers within the brain ) contribute to the disorders. The affected neurotransmitters are dopamine, serotonin, and cyclic AMP. Researchers have also found changes within the brain itself, for example in the basal ganglia (an area of the brain concerned with movement) and the anterior cingulate cortex. Functional imaging using positron emission tomography (PET) and single photon emission computerized tomography (SPECT) has highlighted abnormal patterns of blood flow and metabolism in the basal ganglia, thalamus, and frontal and temporal cortical areas of the brain. Magnetic resonance imaging (MRI) has identified a reduction in frontal lobe tissue in patients with Tourette’s. Researchers have also shown a correlation between reduced corpus callosum size and the severity of tics in children with Tourette’s.

Evidence from twin and family studies suggests that vulnerability to tic disorders is genetic, or transmitted within families. Several genes have been suspected as contributing to the development of Tourette’s, including variations to the SLITRK1 gene. Gender-related inheritance patterns play a role in determining symptoms. Males are more likely to develop tics, while females are more likely to develop the related obsessive-compulsive disorder. Researchers have not found a pattern suggesting that certain types of parenting or childhood experiences lead to the development of tic disorders, although some think that there is an interaction between genetic and environmental factors. Researchers are paying close attention to prenatal factors, which are thought to influence the development of the disorders. Some research has indicated that maternal smoking increases the severity of symptoms in Tourette’s syndrome.

In some cases, tic disorders appear to be caused or worsened by recreational drugs or prescription medications. The drugs most commonly involved are such psychomotor stimulants as methylphenidate (Ritalin), pemoline (Cylert), amphetamines, and cocaine. It is not clear whether tics would have developed in these cases if stimulants had not been used. In a smaller percentage of cases, antihistamines, tricyclic antidepressants, antiseizure medications, and opioids have been shown to worsen tics.

Some forms of tics may be triggered by the environment. A cough that began during an upper respiratory infection may continue as an involuntary vocal tic. New tics may also begin as imitations of normally occurring events, such as mimicking a dog barking. How these particular triggers come to form enduring symptoms is a matter for further study.

Tourette’s syndrome often occurs together with obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD). People with Tourette’s syndrome are about 20 times more likely than those in the general population to develop OCD. Tic disorders are also associated with behaviors such as depression, rage, sexual aggressiveness, and anxiety.

In some cases, neuropsychiatric disorders, such as tic disorders and obsessive-compulsive disorder, have been shown to develop after streptococcal infection. No precise mechanism for this connection has been determined, although it appears to be related to the autoimmune system. There are other illness-related causes of tics, though they appear to be rare. These include the development of tics after head trauma, viral encephalitis, or stroke.

Symptoms

The diagnostic criteria of all tic disorders specify that the symptoms must appear before the age of 18 and that they cannot result from ingestion of such substances as stimulants or from such general medical conditions as Huntington’s disease. Tic disorders can be seen as occurring along a continuum of severity in terms of disruption and impairment, with transient tic disorder being the least severe and Tourette’s disorder being the most.

Tics increase in frequency when a person is under any form of mental or physical stress, even if it is of a positive nature (e.g., excitement about a party). Some people’s tics are most obvious when the person is in a relaxed situation, such as quietly watching television. Tics tend to diminish when the person is placed in a new or highly structured situation, such as a doctor’s office—a factor that can complicate diagnosis. When the symptoms of a tic are present over long time periods, they do not remain constant but will wax and wane in their severity.

Transient tic disorder occurs in approximately 4–24% of schoolchildren. It is the mildest form of tic

disorder, and may be underreported because of its temporary nature. In transient tic disorder, there may be single or multiple motor and/or vocal tics that occur many times a day nearly every day for at least four weeks, but not for longer than one year. If the criteria have been met at one time for Tourette’s disorder or for chronic motor or vocal tic disorder, transient tic disorder may not be diagnosed.

Chronic motor or vocal tic disorder is characterized by either motor tics or vocal tics, but not both. The tics occur many times a day nearly every day, or intermittently for a period of more than one year. During that time, the patient is never without symptoms for more than three consecutive months. The severity of the symptoms and functional impairment is usually much less than for patients with Tourette’s disorder.

Tourette’s is defined by the DSM-IV-TR as the presence of both vocal and motor tics for a period of more than one year. The tics occur many times a day, usually in bouts, nearly every day or intermittently. The patient is never symptom-free for more than three months at a time.

Children and adolescents with Tourette’s disorder frequently experience additional problems including aggressiveness, self-harming behaviors, emotional immaturity, social withdrawal, physical complaints, conduct disorders, affective disorders, anxiety, panic attacks, stuttering, sleep disorders, migraine headaches, and inappropriate sexual behaviors.

Tics seem to worsen during the patient’s adolescence, although some clinicians think that the symptoms become more problematic rather than more severe, because the patient experiences them as more embarrassing than previously. The symptoms do become more unpredictable from day to day during adolescence. Many teenagers may refuse to go to school when their tics are severe. Coprolalia (uttering obscene, hostile, or inappropriate words) often appears first in adolescence; this symptom causes considerable distress for individuals and their families.

Behavioral problems also become more prominent in adolescence. There is some evidence that temper tantrums, aggressiveness, and explosive behavior appear in preadolescence, intensify in adolescence, and gradually diminish by early adulthood. Interestingly, aggression appears to increase at approximately the same time that the tics decrease in severity.

Diagnosis

There are no diagnostic laboratory tests to screen for tic disorders. Except for the tics, the results of the patient’s physical and neurological examinations are normal. The doctor takes a complete medical history including a detailed account of prenatal events, birth history, head injuries, episodes of encephalitis or meningitis, poisonings, and medication or drug use. The patient’s developmental, behavioral, and academic histories are also important. Measurement of thyroid-stimulating hormone levels can be helpful, because tics are often associated with hyperthyroidism (overactive thyroid gland). Also, a strep-A test is useful if the patient suddenly developed tic symptoms after a throat or ear infection.

There is an average delay of five to 12 years between the initial symptoms of a tic disorder and the correct diagnosis. This delay is largely related to the misperception that tics are caused by anxiety and should be treated by psychotherapy. This misperception in turn is fueled by the fact that tics tend to increase in severity when the affected person is angry, anxious, excited, or fatigued. It is also common for the patient to manifest fewer tics in a doctor’s office than at home, leaving parents feeling frustrated and undermined and physicians confused. In addition, children quickly learn to mask their symptoms by converting them to more socially acceptable movements and sounds. The diagnosis of a tic disorder can be aided in some cases by directly observing, videotaping, or audiotaping the patient in a more natural setting.

Clinicians can also become confused by such additional symptoms of tic disorders as touching, hitting, jumping, smelling hands or objects, stomping, twirling, and doing deep-knee bends. They disagree, however, as to whether such symptoms should be classified as tics or compulsions. There appears to be a significant overlap between the symptoms of tic disorders and those of obsessive-compulsive disorder (OCD).

Abnormal obsessive-compulsive behavior has been found in 40% of patients with Tourette’s disorder between the ages of six and 10 years. Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive, inappropriate, senseless, and repetitive. Compulsions are defined as repetitive behaviors performed to reduce the anxiety or distress caused by the obsessions. For those diagnosed with OCD, common obsessions have to do with dirt, germs, and contamination. Patients with Tourette’s disorder often have obsessions that involve violent scenes, sexual thoughts, and counting; their compulsions are often related to symmetry (e.g., lining things up and getting them “just right”) OCD symptoms occur considerably later than tics, and appear to worsen with age. Some theorists have suggested that obsessive thoughts are cognitive tics.

Tic disorders can be differentiated from movement disorders by the following characteristics: they are sup-pressible; they tend to persist during sleep; they are preceded by sensory symptoms; they have both phonic and motor components; and they wax and wane.

Dual diagnoses

Children and adults with tic disorders are at increased risk for depression and other mood disorders, as well as anxiety disorders. This comorbidity may be due to the burden of dealing with a chronic, disruptive, and often stigmatizing disorder. The energy and watchfulness required to suppress tic symptoms may contribute to social anxiety, social withdrawal, self-preoccupation, and fatigue. Low self-esteem and feelings of hopelessness are common in patients diagnosed with tic disorders.

While OCD behaviors have been noted in as many as 80% of individuals with tic disorders, only 30% meet the full criteria for OCD. Distinguishing complex tics from simple compulsions can be difficult. Touching compulsions appear to be characteristic of the tic-related type of OCD. Compared to obsessive-compulsive disorder in persons without a history of tics, there will likely be an earlier age of onset, a greater proportion of male sufferers, a more frequent family history of chronic tics, and a poorer therapeutic response to selective serotonin reuptake inhibitors (SSRIs)—although the addition of a neu-roleptic to the treatment regimen sometimes brings about improvement.

More than 25% of children with Tourette’s syndrome also have attention-deficit hyperactivity disorder (ADHD), including a short attention span, restlessness, poor concentration, and diminished impulse control. On average, ADHD will manifest two-and-a-half years before the tics appear. A dual diagnosis of ADHD and tic disorder is associated with more severe tics and greater social impairment than for tic disorder by itself. Over time, the problems caused by the inattention, impulsivity, motor overactivity, and the resultant under-achievement in school associated with ADHD are often more disabling than the tics themselves.

Children with tic disorders are five times as likely as other children to require special education programs. The tics may be disruptive and mistakenly interpreted by teachers as intended to disturb the class. Often, children with tic disorders have underlying learning disabilities as well. While there does not appear to be any impairment in general intellectual functioning, researchers have identified patterns of specific learning problems in children with tic disorders. These problems include abnormal visual-perceptual performance, reduced visual-motor skills, and discrepancies between verbal and performance IQ. Many of these learning difficulties are also commonly found in children with ADHD.

Increasing numbers of children with tic disorders are also diagnosed with a conduct disorder. Children with conduct disorder show inappropriate and sometimes severe aggression toward people and animals. They may also act out other destructive impulses. Unfortunately, some of these children grow up to develop a personality disorder.

Treatments

A holistic approach is recommended for the treatment of tic disorders. A multidisciplinary team should work together with the affected child’s parents and teachers to put together a comprehensive treatment plan. Treatment should include:

• Educating the patient and family about the course of the disorder in a reassuring manner.
• Completion of necessary diagnostic tests, including self-reports (by child and parents); clinician-administered ratings; and direct observational methods.
• Comprehensive assessment, including the child’s cognitive abilities, perception, motor skills, behavior and adaptive functioning.
• Collaboration with school personnel to create a learning environment conducive to academic success.
• Therapy, most often behavioral or cognitive-behavioral, though other modalities may be appropriate.
• If necessary, evaluation for medication.

Behavioral and cognitive-behavioral therapy

Habit reversal is the most commonly used technique, combining relaxation exercises, awareness training, and contingency management for positive reinforcement. This method shows a 64-100% success rate. Adding a cognitive component to habit reversal involves the introduction of flexibility into rigid thinking, and confronting the child’s irrational expectations and unrealistic anticipations. The specific cognitive technique of distraction has been shown to help patients resist sensory urges and to restore the patient’s sense of control over the tic.

Massed negative practice is behavioral therapy technique used in the treatment of children with tic disorder. The patient is asked to deliberately perform the tic movement for specified periods of time interspersed with brief periods of rest. Patients have shown some decrease in tic frequency, but the long-term benefits of massed negative practice are unclear.

Contingency management is another behavioral treatment. It is based on positive reinforcement, usually administered by parents. Children are praised and rewarded for not performing tics and for replacing them with alternative behaviors. Contingency management, however, appears to be of limited use outside of such controlled settings as schools or institutions.

Self-monitoring consists of having the patient record tics by using a wrist counter or small notebook. It is fairly effective in reducing some tics by increasing the child’s awareness.

Medications

Medication is the main treatment for motor and vocal tics. Because medications can cause side effects, patients and their families should be evaluated fully and use other treatment methods in conjunction with medication. Because the symptoms of tic disorders overlap those of OCD and ADHD, it is essential to determine which symptoms are causing the greatest concern and impairment, and treat the patient according to the single diagnostic category that best fits him or her, whether it is a tic disorder, OCD, or ADHD.

These medications may be prescribed for patients with tic disorders:

• Typical neuroleptics (antipsychotic medications), including haloperidol (Haldol), resperidone (Risper-dal), and pimozide (Orap). Neuroleptics can have significant side effects, which include concentration problems, cognitive blunting, sedation, and rarely, tardive dyskinesia (a movement disorder that consists of lip, mouth, and tongue movements).
• Alpha-adrenergic receptor agonists, including cloni-dine (Catapres) and guanfacine (Tenex). Clonidine has fewer and milder side effects than the neuroleptics in general, with the most common being sedation. Sedation occurs in 10-20% of cases and can often be controlled through adjusting the dosage.
• The phenothiazines may be used when haloperidol or pimozide has proven ineffective.
• A typical antipsychotics such as aripiprazole (Abil-ify) and other agents that block dopamine receptors including risperidone (Risperdal) and clozapine (Clozaril).
• Tetrabenazine is a promising new medication with fewer side effects than other typical neuroleptics. It can be used in combination with the older antipsychotic medications, allowing for lower doses of both medications with substantial relief. However, it may cause depression and Parkinson’s-like symptoms.
• Selective serotonin reuptake inhibitors (SSRIs), which include such medications as fluoxetine (Prozac) and sertraline (Zoloft), can be used to treat the obsessive-compulsive behaviors associated with Tourette’s disorder. They can also be helpful with depression and impulse control difficulties, though they must be given at higher dosages for OCD than for depression. The SSRIs, however, can cause gastric upset and nausea.
• Benzodiazepines are used in some cases to decrease tic severity and lower the patient’s anxiety level, but are often avoided because they can cause dependence and tolerance.
• Nicotine chewing gum appears to reduce tics when added to ongoing treatment with haloperidol, but is in need of further study.
• Calcium channel blockers, such as verapamil (Calan) and nifedipine (Adalat) may ease symptoms by reducing the release of neurotransmitters in the brain.

Surgical treatments

Surgery to the frontal lobe (prefrontal lobotomy) and limbic system (limbic lencotomy) have not been shown effective in treating tic disorders. However, deep brain stimulation—the high-frequency stimulation of the brain with electrodes—has been shown in studies to reduce tic severity by 70%.

Alternative therapies

There is growing interest in dietary changes and nutritional supplements to prevent and manage the symptoms of tic disorders, although formal studies have not yet been conducted in this area. Some theorists have suggested that hidden food and chemical allergies or nutritional deficiencies may influence the development and maintenance of tic disorders. Recommendations include eating organic food and avoiding pesticides, taking antioxidants, increasing intake of folic acid and the B vitamins, eating foods high in zinc and magnesium, eliminating caffeine from the diet, and avoiding artificial sweeteners, colors and dyes.

Prognosis

There is presently no cure for tic disorders, and there is no evidence that early treatment alters prognosis. When a child is first evaluated, it is not possible to determine whether the tics will be chronic or transient, mild or severe.

As recently as twenty years ago, tic disorders were considered to be lifelong conditions, with remissions believed to be rare. There is now a general consensus that if a tic disorder is the only diagnosis, the prognosis is favorable. Up to 73% of patients report that their tics decreased markedly or disappeared as they entered the later years of adolescence or early adulthood.

KEY TERMS

Atypical antipsychotics —A group of medications for the treatment of psychotic symptoms that were introduced in the 1990s. The atypical antipsychotics include clozapine, risperidone, quetiapine, ziprasi-done, and olanzapine. They are sometimes called serotonin dopamine antagonists, or SDAs.

Basal ganglia —A group of masses of gray matter located in the cerebral hemispheres of the brain that control movement as well as some aspects of emotion and cognition.

Behavioral therapy —An approach to treatment that focuses on extinguishing undesirable behavior and replacing it with desired behavior.

Benzodiazepines —A group of central nervous system depressants used to relieve anxiety or to induce sleep.

Cognitive-behavioral therapy —An approach to psychotherapy that emphasizes the correction of distorted thinking patterns and changing one’s behaviors accordingly.

Comorbidity —Association or presence of two or more mental disorders in the same patient. A disorder that is said to have a high degree of comorbidity is likely to occur in patients diagnosed with other disorders that may share or reinforce some of its symptoms.

Compulsion —A strong impulse to perform an act, particularly one that is irrational or contrary to one’s will.

Coprolalia —A vocal tic characterized by uttering obscene, hostile, or inappropriate words. A motor tic characterized by obscene gestures is called copropraxia.

Cyclic AMP —A small molecule of adenosine mono-phosphate (AMP) that activates enzymes and increases the effects of hormones and other neurotransmitters.

Dopamine —A chemical in brain tissue that serves to transmit nerve impulses (is a neurotransmitter) and helps to regulate movement and emotions.

Holistic —A treatment approach that is comprehensive and respectful of a person’s emotional, social, cognitive, and interpersonal needs.

Neuroleptic —Another name for the older antipsychotic medications, such as haloperidol (Haldol) and chlorpromazine (Thorazine).

Neurotransmitter —A chemical in the brain that transmits messages between neurons, or nerve cells.

Obsession —A persistent image, idea, or desire that dominates a person’s thoughts or feelings.

Onset —The point in time at which the symptoms of a disorder first became apparent.

Phenothiazines —A class of drugs widely used in the treatment of psychosis.

Remission —In the course of an illness or disorder, a period of time when symptoms are absent.

Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle, and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.

Stigma —A mark or characteristic trait of a disease or defect; by extension, a cause for reproach or a stain on one’s reputation. Tic disorders are sometimes regarded as a stigma by the patient’s family.

Tardive dyskinesia —A condition that involves involuntary movements of the tongue, jaw, mouth, or face or other groups of skeletal muscles that usually occurs either late in antipsychotic therapy or even after the therapy is discontinued. It may be irreversible.

Thalamus —The middle part of the diencephalon (a part of the human forebrain), responsible for transmitting and integrating information from the senses.

Tic —A sudden involuntary behavior that is difficult or impossible for the person to suppress. Tics may be either motor (related to movement) or vocal, and may become more pronounced under stress.

In a small number of patients, the most severe and debilitating forms of a tic disorder occur in adult life. In addition, stress in later life can cause tics to re-emerge. The tics may be new developments in adulthood, a phenomenon that may be more common than previously thought. Remission rates for tic disorders are difficult to pinpoint among this seldom-studied population, but appear to be extremely low.

While the tics themselves may decline, however, the associated problems often continue into adult life. Obsessive-compulsive symptoms and other behavioral

problems, as well as learning disabilities, may grow worse. Obsessive-compulsive behaviors become most pronounced at age 15 and remain at that level. Panic attacks, depression, agoraphobia, and alcoholism are most significant in the early adult years, while a tendency toward obesity increases steadily with age, particularly in women.

In adulthood, a patient’s repertoire of tics is reduced and becomes predictable during periods of fatigue and heightened emotionality. Some studies suggest remission rates, with the complete cessation of symptoms, to be as high as 50%. Cases of total remission appear to be related to the family’s treatment of the patient when he or she was a child. Persons who were punished, misunderstood and stigmatized because of their tics experience greater functional impairment as adults than those who were supported and understood as children.

Prevention

There are few preventive strategies for tic disorders. There is some evidence that maternal emotional stress during pregnancy and severe nausea and vomiting during the first trimester may affect tic severity. Attempting to minimize prenatal stress may possibly serve a limited preventive function.

Similarly, because people with tic disorders are sensitive to stress, efforts to maintain a low-stress environment can help minimize the number or severity of tics (e.g., reducing the number of social gatherings, which can provoke anxiety). This approach cannot prevent tics altogether, and must be undertaken with an awareness that it is neither healthful nor advisable to attempt to eliminate all stressful events in life.

See alsoAbnormal involuntary movement scale; Neuropsychological testing; Stereotypic movement disorder.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington D.C.: American Psychiatric Association, 2000.

Chowdhury, Uttom and Isobel Heyman. Tics and Tourette Syndrome: A Handbook for Parents and Professionals. London: Jessica Kingsley Publishers, 2004.

Kurlan, Roger, Editor. Handbook of Tourette’s Syndrome and Related Tic and Behavioral Disorder. New York: Marcel Dekker, 2005.

Woods, Douglas W. and Raymond G. Miltenberger, eds. Tic Disorders, Trichotillomania, and Other Repetitive Behavior Disorders: Behavioral Approaches to Analysis and Treatment. 1st ed. Norwell, Massachusetts: Kluwer Academic Publishers, 2006.

ORGANIZATIONS

Association for Comprehensive Neurotherapy. P.O. Box 1967, Tarpon Beach, FL 34688-1967. (561) 798-0472. http://www.latitudes.org

National Institutes of Health/National Institute of Neurological Diseases and Stroke (NINDS). P.O. Box 5801, Bethesda, MD 20824. (800) 352-9424. http://www.ninds.nih.gov

The Tourette Syndrome Association, Inc. 42-40 Bell Boulevard, Bayside, NY 11361-2861. (718) 224-2999. http://www.tsa-usa.org

Holly Scherstuhl, M.Ed.

Stephanie N. Watson

Tic disorders

Definition

Tic disorders are characterized by the persistent presence of tics, which are abrupt, repetitive involuntary movements and sounds that have been described as caricatures of normal physical acts. The best known of these disorders is Tourette's disorder, or Tourette's syndrome.

Description

Tics are sudden, painless, nonrhythmic behaviors that are either motor (related to movement) or vocal and that appear out of context— for example, knee bends in science class. They are fairly common in childhood; in the vast majority of cases, they are temporary conditions that resolve on their own. In some children, however, the tics persist over time, becoming more complex and severe.

Tics may be simple (using only a few muscles or simple sounds) or complex (using many muscle groups or full words and sentences). Simple motor tics are brief, meaningless movements like eye blinking, facial grimacing, head jerks or shoulder shrugs. They usually last less than one second. Complex motor tics involve slower, longer, and more purposeful movements like sustained looks, facial gestures, biting, banging, whirling or twisting around, or copropraxia (obscene gestures).

Simple phonic tics are meaningless sounds or noises like throat clearing, coughing, sniffling, barking, or hissing. Complex phonic tics include syllables, words, phrases, and such statements as "Shut up!" or "Now you've done it!" The child's speech may be abnormal, with unusual rhythms, tones, accents or intensities. The echo phenomenon is a tic characterized by the immediate repetition of one's own or another's words. Coprolalia is a tic made up of obscene, inappropriate or aggressive words and statements. It occurs in fewer than 10% of people with tic disorders.

Children under the age of 10 with simple tics find them to be difficult to suppress, or control. Many older patients and children with complex tics describe feeling strong sensory urges in their joints, muscles and bones that are relieved by the performance of a motor tic in that particular body part. These patients also report inner conflict over whether and when to yield to these urges. A sensation of relief and reduction of anxiety frequently follows the performance of a tic. Unless the tic disorder is very severe, most people with tics can suppress them for varying periods of time.

Motor and vocal tics may be worsened by anxiety, stress , boredom, fatigue , or excitement. Some people have reported that tics are intensified by premenstrual syndrome, additives in food, and stimulants. The symptoms of tic disorders may be lessened while the patient is asleep. Cannabis (marijuana), alcohol, relaxation, playing a sport, or concentrating on an enjoyable task are also reported to reduce the severity and frequency of symptoms.

Tics are the core symptom shared by transient tic disorder, chronic motor or vocal tic disorder, and Tourette's disorder. It is the severity and course that distinguishes these disorders from one another. The age of onset for these disorders is between two and 15 years. In 75% of Tourette's disorder patients, the symptoms appear by age 11.

Causes and symptoms

Causes

Emotional factors were once viewed as the cause of tics, but this explanation has been largely discounted. The search for causes now focuses on biological, chemical and environmental factors. As of 2002, however, no definitive cause of tics has been discovered.

There appear to be both functional and structural abnormalities in the brains of people with tic disorders. While the exact neurochemical cause is unknown, it is believed that abnormal neurotransmitters (chemical messengers within the brain ) contribute to the disorders. The affected neurotransmitters are dopamine, serotonin, and cyclic AMP. Researchers have also found changes within the brain itself, specifically in the basal ganglia (an area of the brain concerned with movement) and the anterior cingulate cortex. Functional imaging using positron emission tomography (PET) and single photon emission computerized tomography (SPECT) has highlighted abnormal patterns of blood flow and metabolism in the basal ganglia, thalamus, and frontal and temporal cortical areas of the brain. [The reader may wish to consult the "Brain" entry for a diagram of the brain's structures.]

Vulnerability to tic disorders appears to be genetic, or transmitted within families. Genetic factors are present in 75% of cases, although no single gene has been found to cause tic disorders. Researchers have not found a pattern suggesting that certain types of parenting or childhood experiences lead to the development of tic disorders, although some think that there is an interaction between genetic and environmental factors. Researchers are paying close attention to prenatal factors, which are thought to influence the development of the disorders.

In some cases, tic disorders appear to be caused or worsened by recreational drugs or prescription medications. The drugs most commonly involved are such psychomotor stimulants as methylphenidate (Ritalin); pemoline (Cylert); amphetamines ; and cocaine. It is not clear whether tics would have developed anyway if stimulants had not been used. In a smaller percentage of cases, antihistamines, tricyclic antidepressants, antiseizure medications, and opioids have been shown to worsen tics.

Some forms of tic may be triggered by the environment. A cough that began during an upper respiratory infection may continue as an involuntary vocal tic. New tics may also begin as imitations of normally occurring events, such as mimicking a dog barking. How these particular triggers come to form enduring symptoms is a matter for further study.

In some cases, neuropsychiatric disorders, such as tic disorders and obsessive-compulsive disorder , have been shown to develop after streptococcal infection. No precise mechanism for this connection has been determined, although it appears to be related to the autoimmune system. There are other illness-related causes of tics, though they appear to be rare. These include the development of tics after head trauma, viral encephalitis or stroke .

Symptoms

The diagnostic criteria of all tic disorders specify that the symptoms must appear before the age of 18, and that they cannot result from ingestion of such substances as stimulants, or from such general medical conditions as Huntington's disease. Tic disorders can be seen as occurring along a continuum of least to most severe in terms of disruption and impairment, with transient tic disorder at one end and Tourette's disorder at the other.

Tics increase in frequency when a person is under any form of mental or physical stress, even if it is of a positive nature (excitement about an upcoming holiday, for example). Some people's tics are most obvious when the person is in a relaxed situation, such as quietly watching television. Tics tend to diminish when the person is placed in a new or highly structured situation, such as a doctor's office— a factor that can complicate diagnosis . When the symptoms of a tic are present over long time periods, they do not remain constant but will wax and wane in their severity.

Transient tic disorder occurs in approximately 4%–24% of schoolchildren. It is the mildest form of tic disorder, and may be underreported because of its temporary nature. In transient tic disorder, there may be single or multiple motor and/or vocal tics that occur many times a day nearly every day for at least four weeks, but not for longer than one year. If the criteria have been met at one time for Tourette's disorder or for chronic motor or vocal tic disorder, transient tic disorder may not be diagnosed.

Chronic motor or vocal tic disorder is characterized by either motor tics or vocal tics, but not both. The tics occur many times a day nearly every day, or intermittently for a period of more than one year. During that time, the patient is never without symptoms for more than three consecutive months. The severity of the symptoms and functional impairment is usually much less than for patients with Tourette's disorder.

For a diagnosis of Tourette's disorder, a patient must have experienced both multiple motor and one or more vocal tics at some time during the illness, though they do not have to occur at the same time. The tics occur many times a day, usually in bouts, nearly every day or intermittently for a period of more than one year. The patient is never symptom-free for more than three months at a time.

Children and adolescents with Tourette's disorder frequently experience additional problems including aggressiveness, self-harming behaviors, emotional immaturity, social withdrawal, physical complaints, conduct disorders, affective disorders, anxiety, panic attacks, stuttering , sleep disorders , migraine headaches, and inappropriate sexual behaviors.

Tics seem to worsen during the patient's adolescence, although some clinicians think that the symptoms become more problematic rather than more severe, because the patient experiences them as more embarrassing than previously. The symptoms do become more unpredictable from day to day during adolescence. Many teenagers may refuse to go to school when their tics are severe. Coprolalia often appears first in adolescence; this symptom causes considerable distress for individuals and their families.

Behavioral problems also become more prominent in adolescence. There is some evidence that temper tantrums, aggressiveness, and explosive behavior appear in preadolescence, intensify in adolescence, and gradually diminish by early adulthood. Interestingly, aggression appears to increase at approximately the same time that the tics decrease in severity.

Demographics

Tourette's disorder is three to four times more common in males than females. Tic disorders have been reported in people of all races, ethnic groups, and socioeconomic classes. Tic disorders appear to occur more frequently in Caucasians than African Americans.

Diagnosis

There are no diagnostic laboratory tests to screen for tic disorders. Except for the tics, the results of the patient's physical and neurological examinations are normal. The doctor takes a complete medical history including a detailed account of prenatal events, birth history, head injuries, episodes of encephalitis or meningitis, poisonings, and medication or drug use. The patient's developmental, behavioral, and academic histories are also important.

There is an average delay of five to 12 years between the initial symptoms of a tic disorder and the correct diagnosis. This delay is largely related to the misperception that tics are caused by anxiety and should be treated by psychotherapy . This misperception in turn is fueled by the fact that tics tend to increase in severity when the affected person is angry, anxious, excited or fatigued. It is also common for the patient to manifest fewer tics in a doctor's office than at home, leaving parents feeling frustrated and undermined and physicians confused. In addition, children quickly learn to mask their symptoms by converting them to more socially acceptable movements and sounds. The diagnosis of a tic disorder can be aided in some cases by directly observing, videotaping or audiotaping the patient in a more natural setting.

Clinicians can also become confused by such additional symptoms of tic disorders as touching, hitting, jumping, smelling hands or objects, stomping, twirling and doing deep knee bends. They disagree, however, as to whether such symptoms should be classified as tics or compulsions. There appears to be a significant overlap between the symptoms of tic disorders and those of obsessive-compulsive disorder (OCD).

Abnormal obsessive-compulsive behavior has been found in 40% of patients with Tourette's disorder between the ages of six and 10 years. Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive, inappropriate, senseless, and repetitive. Compulsions are defined as repetitive behaviors performed to reduce the anxiety or distress caused by the obsessions. For those diagnosed with OCD, common obsessions have to do with dirt, germs, and contamination. Patients with Tourette's disorder often have obsessions that involve violent scenes, sexual thoughts, and counting; their compulsions are often related to symmetry (lining things up and getting them "just right," for example). OCD symptoms occur considerably later than tics, and appear to worsen with age. Some theorists have suggested that obsessive thoughts are cognitive tics.

Tic disorders can be differentiated from movement disorders by the following characteristics: they are suppressible; they tend to persist during sleep; they are preceded by sensory symptoms; they have both phonic and motor components; and they wax and wane.

Dual diagnoses

Children and adults with tic disorders are at increased risk for depression and other mood disorders, as well as anxiety disorders. This comorbidity may be due to the burden of dealing with a chronic, disruptive, and often stigmatizing disorder. The energy and watchfulness required to suppress tic symptoms may contribute to social anxiety, social withdrawal, self-preoccupation, and fatigue. Low self-esteem and feelings of hopelessness are common in patients diagnosed with tic disorders.

While OCD behaviors have been noted in as many as 80% of individuals with tic disorders, only 30% meet the full criteria for OCD. Distinguishing complex tics from simple compulsions can be difficult. Touching compulsions appear to be characteristic of the tic-related type of OCD. Compared to obsessive-compulsive disorder in persons without a history of tics, there will likely be an earlier age of onset, a greater proportion of males, a more frequent family history of chronic tics, and a poorer therapeutic response to selective serotonin reuptake inhibitors (SSRIs)— although the addition of a neuroleptic to the treatment regimen sometimes brings about improvement.

As many as 50%–80% of children with Tourette's disorder have some symptoms of attention-deficit/hyperactivity disorder (ADHD), including a short attention span, restlessness, poor concentration, and diminished impulse control. On average, ADHD will manifest two and a half years before the tics appear. A dual diagnosis of ADHD and tic disorder is associated with more severe tics and greater social impairment than for tic disorder by itself. Over time, the problems caused by the inattention, impulsivity, motor overactivity and the resultant underachievement in school associated with ADHD are often more disabling than the tics themselves.

Children with tic disorders are five times as likely as other children to require special education programs. The tics may be disruptive and mistakenly interpreted by teachers as intended to disturb the class. Often, children with tic disorders have underlying learning disabilities as well. While there does not appear to be any impairment in general intellectual functioning, researchers have identified patterns of specific learning problems in children with tic disorders. These problems include abnormal visual-perceptual performance, reduced visual-motor skills, and discrepancies between verbal and performance IQ. Many of these learning difficulties are also commonly found in children with ADHD.

Increasing numbers of children with tic disorders are also diagnosed with a conduct disorder . Children with conduct disorder show inappropriate and sometimes severe aggression toward people and animals. They may also act out other destructive impulses. Unfortunately, some of these children grow up to develop a personality disorder.

Treatments

A holistic approach is recommended for the treatment of tic disorders. A multidisciplinary team should work together with the affected child's parents and teachers to put together a comprehensive treatment plan. Treatment should include the following:

• Educating the patient and family about the course of the disorder in a reassuring manner.
• Completion of necessary diagnostic tests, including self-reports (by child and parents); clinician-administered ratings; and direct observational methods.
• Comprehensive assessment, including the child's cognitive abilities, perception, motor skills, behavior and adaptive functioning.
• Collaboration with school personnel to create a learning environment conducive to academic success.
• Therapy, most often behavioral or cognitive-behavioral, though other modalities may be appropriate.
• If necessary, evaluation for medication.

Behavioral and cognitive-behavioral therapy

Massed negative practice has been one of the most frequently used behavioral therapy techniques in the treatment of children with tic disorder. The patient is asked to deliberately perform the tic movement for specified periods of time interspersed with brief periods of rest. Patients have shown some decrease in tic frequency, but the long-term benefits of massed negative practice are unclear.

Contingency management is another behavioral treatment. It is based on positive reinforcement , usually administered by parents. Children are praised and rewarded for not performing tics and for replacing them with alternative behaviors. Contingency management, however, appears to be of limited use outside of such controlled settings as schools or institutions.

Self-monitoring consists of having the patient record tics by using a wrist counter or small notebook. It is fairly effective in reducing some tics by increasing the child's awareness.

Habit reversal is the most commonly used technique, combining relaxation exercises, awareness training, and contingency management for positive reinforcement. This method shows a 64%–100% success rate.

Adding a cognitive component to habit reversal involves the introduction of flexibility into rigid thinking, and confronting the child's irrational expectations and unrealistic anticipations. It has not been shown as of 2002 to increase treatment effectiveness. The specific cognitive technique of distraction, however, has been shown to help patients resist sensory urges and to restore the patient's sense of control over the tic.

Medications

Medication is the main treatment for motor and vocal tics. Patients and their families, however, should be evaluated fully and use other treatment methods in conjunction with medication. Because the symptoms of tic disorders overlap those of OCD and ADHD, it is essential to determine which symptoms are causing the greatest concern and impairment, and treat the patient according to the single diagnostic category that best fits him or her, whether it is a tic disorder, OCD, or ADHD.

Medications prescribed for patients with tic disorders include:

• Typical neuroleptics (antipsychotic medications), including haloperidol (Haldol) and pimozide (Orap). Neuroleptics can have significant side effects, which include concentration problems, cognitive blunting, and rarely, tardive dyskinesia (a movement disorder that consists of lip, mouth, and tongue movements). Such side effects as stiffness, rigidity, tremor, sedation, and depression are common with haloperidol, but are less so with pimozide.
• Alpha-adrenergic receptor agonists, including clonidine (Catapres) and guanfacine (Tenex). Clonidine has fewer and milder side effects than the neuroleptics in general, with the most common being sedation. Sedation occurs in 10%–20% of cases and can often be controlled through adjusting the dosage.
• The phenothiazines may be used when haloperidol or pimozide has proven ineffective.
• Atypical antipsychotics and other agents that block dopamine receptors include risperidone (Risperdal) and clozapine (Clozaril).
• Tetrabenazine is a promising new medication with fewer side effects than other typical neuroleptics. It can be used in combination with the older antipsychotic medications, allowing for lower doses of both medications with substantial relief.
• Selective serotonin reuptake inhibitors (SSRIs), which include such medications as fluoxetine (Prozac) and sertraline (Zoloft), can be used to treat the obsessive-compulsive behaviors associated with Tourette's disorder. They can also be helpful with depression and impulse control difficulties, though they must be given at higher dosages for OCD than for depression. The SSRIs, however, can cause gastric upset and nausea.
• Benzodiazepines are used in some cases to lower the patient's anxiety level, but are often avoided because they can cause dependence and tolerance.
• Nicotine chewing gum appears to reduce tics when added to ongoing treatment with haloperidol, but is in need of further study.

Alternative therapies

There is growing interest in dietary changes and nutritional supplements to prevent and manage the symptoms of tic disorders, although formal studies have not yet been conducted in this area. Some theorists have suggested that hidden food and chemical allergies or nutritional deficiencies may influence the development and maintenance of tic disorders. Recommendations include eating organic food and avoiding pesticides; taking antioxidants; increasing intake of folic acid and the B vitamins; eating foods high in zinc and magnesium; eliminating caffeine from the diet; and avoiding artificial sweeteners, colors and dyes.

Prognosis

There is presently no cure for tic disorders, and there is no evidence that early treatment alters prognosis. When a child is first evaluated, it is not possible to determine whether the tics will be chronic or transient, mild or severe.

As recently as twenty years ago, tic disorders were considered to be lifelong conditions, with remissions believed to be rare. There is now a general consensus that if a tic disorder is the only diagnosis, the prognosis is favorable. Up to 73% of patients report that their tics decreased markedly or disappeared as they entered the later years of adolescence or early adulthood.

In a small number of patients, the most severe and debilitating forms of a tic disorder occur in adult life. In addition, stress in later life can cause tics to re-emerge. In rare cases, the tics may be new developments in adulthood, though this phenomenon may be more common than previously thought. Remission rates for tic disorders are difficult to pinpoint among this seldom-studied population, but appear to be extremely low.

While the tics themselves may decline, however, the associated problems often continue into adult life. Obsessive-compulsive symptoms and other behavioral problems, as well as learning disabilities, may grow worse. Obsessive-compulsive behaviors become most pronounced at age 15 and remain at that level. Panic attacks, depression, agoraphobia and alcoholism are most significant in the early adult years, while a tendency toward obesity increases steadily with age, particularly in women.

In adulthood, a patient's repertoire of tics is reduced and becomes predictable during periods of fatigue and heightened emotionality. Some studies suggest remission rates, with the complete cessation of symptoms, to be as high as 50%. Cases of total remission appear to be related to the family's treatment of the patient when he or she was a child. Persons who were punished, misunderstood and stigmatized experience greater functional impairment as adults than those who were supported and understood as children.

Prevention

There are few preventive strategies for tic disorders. There is some evidence that maternal emotional stress during pregnancy and severe nausea and vomiting during the first trimester may affect tic severity. Attempting to minimize prenatal stress may possibly serve a limited preventive function.

Similarly, because people with tic disorders are sensitive to stress, attempting to maintain a low-stress environment can help minimize the number or severity of tics (reducing the number of social gatherings, which can be anxiety-provoking, for example). This approach cannot prevent tics altogether, and must be undertaken with an awareness that it is neither healthful nor advisable to attempt to eliminate all stressful events in life.

See also Abnormal Involuntary Movement Scale; Neuropsychological testing; Stereotypic movement disorder

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revision. Washington, DC: American Psychiatric Association,2000.

Kurlan, Roger, ed. Handbook of Tourette's Syndrome and Related Tic and Behavioral Disorders. New York: Marcel Dekker, Inc., 1993.

Leckman, James. F., and Donald J. Cohen. Tourette's Syndrome Tics, Obsessions, Compulsions: Developmental Psychopathology and Clinical Care. New York: John Wiley and Sons, Inc., 1999.

Robertson, Mary M., and Simon Baron-Cohen. Tourette Syndrome: The Facts. New York: Oxford University Press, 1998.

PERIODICALS

Chouinard, Sylvain, and Blair Ford. "Adult onset tic disorders." Journal of Neurology, Neurosurgery, & Psychiatry (June, 2000): 68.

Evidente, Virgilio G. H., M.D. "Is it a tic or Tourette's?: Clues for differentiating simple from more complex tic disorders." Postgraduate Medicine (October, 2000): 108.

Kurlan, R., M.D., and others. "Prevalence of tics in school-children and association with placement in special education." Neurology (October, 2001): 57.

Marcus, David, M.D., and Roger Kurlan, M.D. "Tic and its disorders." Movement Disorders (August, 2001): 19.

O'Connor, K. P., and others. "Evaluation of a cognitive-behavioural program for the management of chronic tic and habit disorders." Behaviour Research and Therapy (June, 2001): 39.

O'Connor, Kieran P. "Clinical and psychological features distinguishing obsessive-compulsive and chronic tic disorders" Clinical Psychology Review (June, 2001): 21.

ORGANIZATIONS

Association for Comprehensive Neurotherapy. 1128 Royal Palm Beach Boulevard #283, Royal Palm Beach, FL33411. <http://www.latitudes.org>.

National Institutes of Health/National Institute of Neurological Diseases and Stroke (NINDS). P.O. Box 5801, Bethesda, MD 20824. <http://www.ninds.nih.gov>.

The Tourette Syndrome Association, Inc. 42-40 Bell Boulevard, Bayside, NY 11361-2861 <http://www.tsa-usa.org>.

OTHER

Nutritional Supplements and Tourette's Syndrome <www.latitudes.org>.

Holly Scherstuhl, M.Ed.

Tic Disorders

What Are Tics?

What Are the Symptoms of Tics?

What Are Tic Disorders?

How Are Tic Disorders Diagnosed?

Related Conditions

How Are Tics Treated?

Resource

Tic disorders are neurological* conditions characterized by sudden, rapid movements (for example, neck jerking) or sounds (words or other types of sounds, such as grunting or sniffing) that are repeated over and over in a consistent way many times a day .

* neurological

(NUR-o-LAH-ji-kal) relates to the nervous system. The nervous system is made up of the brain and spinal cord and their connections that regulate body functions.

KEYWORDS

for searching the Internet and other reference sources

Tourette syndrome

What Are Tics?

Tics have been described as brain-activated “involuntary” movements or sounds, meaning that the person does not produce them intentionally. People with tics often can suppress them, sometimes for up to hours at a time, just as one might suppress a cough or a sneeze for a period of time. Imagine, for example, suddenly having to cough in the middle of a concert. To avoid interrupting the musicians, people might try very hard not to cough until the intermission. When they finally cough, however, they might cough several times instead of just once or twice. The experience of trying to suppress a tic is similar. After a tic is suppressed, it may erupt with even greater force or frequency.

Tics tend to get worse when people feel anxious or tired and get better when they are calm and focused on an activity. One interesting aspect of the condition is that tics usually lessen around strangers and are expressed more freely among family members and other trusted people. This does not mean that a person is producing the tics purposely around family members. It probably reflects the fact that they are working harder to suppress them in less comfortable situations, while it is natural for a person to relax their suppression when they are in more familiar surroundings. It is not uncommon for a child to be taken to a doctor to diagnose the problem, only to have the child be unable to produce tics “on command.” Just as tics are experienced as uncontrollable, they cannot be voluntarily brought on. While tics may appear as early as 2 years of age, the average age at onset is about 7.

What Are the Symptoms of Tics?

Simple tics

Simple tics involve a single movement, such as eye blinking or repeatedly sticking out the tongue. Tics also may be vocal, made up of a single sound, such as throat clearing or snorting, stuttering, or sniffing. The most common type of tics, and often the first to appear, are simple facial tics. Over time, more complex motor* tics may appear.

* motor

relates to body movement.

Complex tics

Complex motor tics involve several coordinated muscle movements, such as touching or smelling an object, jumping or twirling, or making deep knee bends while walking. These tics may include neck stretching, foot stamping, body twisting and bending, or mimicking the gestures of other people. Complex vocal tics can range from combining “simple” throat clearing or grunting with other vocal behaviors, to repeating a long but meaningless string of words at regular intervals.

With complex tics, the repeated phrase or gesture at first may seem meaningful, even when it is not. For example, the person with a complex motor tic may feel a need to do and then redo or undo the same action several times (for example, stretching out one arm ten times before writing or retracing the same letter or repeating the same word) before proceeding to another activity. Such forms of behavior can interfere with a person’s ability to accomplish school- or work-related tasks.

Researchers have identified more than 80 tics, which are a mix of simple and complex motor and vocal tics. Some recognizable tic patterns include:

• Echopraxia (EK-o-PRAX-ee-a): imitating other people’s movements or gestures
• Copropraxia (KO-pro-PRAX-ee-a): making obscene, rude, or socially unacceptable gestures
• Palilalia (PA-li-LAY-lee-a): repeating a person’s own words
• Echolalia (EK-o-LAY-lee-a): repeating someone else’s words
• Coprolalia (KO-pro-LAY-lee-a): shouting obscenities, or impolite and offensive language
• Repetition: repeating words or phrases out of context (for example, “Look before you leap”).

What Are Tic Disorders?

Doctors usually classify tic disorders into four categories: Tourette syndrome, chronic motor or vocal tic disorder, transient (TRAN-shent) tic disorder, and tic disorder (not otherwise specified).

Tourette syndrome

Tourette syndrome is the best known of the tic disorders, and it is characterized by a frequent and long-lasting pattern of both vocal and motor tics.

Chronic motor or vocal tic disorder

In contrast to Tourette syndrome, chronic* motor or vocal tic disorder involves only one of these two basic types of tics (either motor or vocal), but not both. In other respects, chronic tic disorder has many of the same symptoms as Tourette syndrome in that:

* chronic

(KRAH-nik) means lasting a long time or recurring often.

• The tics occur many times a day, nearly every day, and the condition lasts for more than a year.
• The tics may disappear for a time, but that period never exceeds more than 3 months in a row.
• The tics first appear before the age of 18.
• The tics are not the result of a medication or another medical condition.
• The tics cause significant impairment at school or work.

Transient tic disorder

In contrast to chronic motor or vocal tic disorder, transient tic disorder refers to a briefer problem with tics. Transient tics may be motor or vocal, or both. For a condition to be considered transient tic disorder, the tics must begin before age 18, occur several times a day, nearly every day for at least 4 weeks but for no longer than 12 months in a row. As with the other tic disorders, transient tics are not the result of another medical condition or a medication.

Tic disorder (not otherwise specified)

This is a category for tic disorders when they do not fit into any of the other three groups, usually because the tics last less than 4 weeks or because they begin when a person is older than 18.

How Are Tic Disorders Diagnosed?

While there are clear differences between tic disorders, a doctor may find it difficult to make a diagnosis, because tics often change in type or frequency over time. Transient tics, for example, are short-lived tics that last for less than a year. But a child may experience a series of transient tics over several years. Neck jerking may last for several months and then be replaced by finger snapping or stamping in place. Chronic tics, on the other hand, last longer than a year and tend to remain stable and constant over time.

Transient tics that change over time are believed to affect as many as one-fourth of all school-aged children. While they last, these tics may be quite odd. They might range from sticking out the tongue again and again to repeating a word or phrase a set number of times to poking or pinching various parts of the body. These strange kinds of behavior are more common than was once believed, but often they disappear as a child matures.

Distinguishing transient tics from chronic tics often requires careful evaluation by a physician over a period of years. In addition, it is important for a doctor to gather information about other members of the family (including parents, grandparents, and siblings) who also may have tics or related conditions. It is now known that the tendency for tics to develop is passed on genetically* (inherited) from generation to generation. Because a person may inherit the genetic tendency to tics without ever experiencing tics, it is possible for the disorder to skip several generations in one family. Research is under way to identify the specific gene (or genes) for tic disorders and to understand other factors that may influence whether a person at risk actually will experience tics.

* genetically

means stemming from genes, the material in the body that helps determine a person’s characteristics, such as hair or eye color.

Related Conditions

For most people who have tics, the real threat may not be the tics themselves but the sense of shame and social isolation that can result from this odd behavior. A child may have great difficulty dealing with these embarrassing, unwanted behaviors. It also may be hard for teachers, fellow students, and family members to understand that a person with tic disorder is not making these strange gestures and sounds intentionally, to gain attention or to avoid working. Other people can easily get that impression if the pattern of tics changes from day to day, as it often does. It can make matters even more difficult when tic disorders in children are associated with attention disorders, hyperactivity, impulsive behavior, obsessive-compulsive disorder*, irritability, or aggressiveness.

* obsessive-compulsive disorder

is a condition that causes people to become trapped in a pattern of repeated, unwanted thoughts, called obsessions (ob-SESH-unz), and a pattern of repetitive behaviors, called compulsions (kom-PUL-shunz).

It is estimated that as many as half of the children with Tourette syndrome also have the attention and impulse-control problems that are seen in attention deficit hyperactivity disorder. Children with Tourette syndrome also have higher than average rates of learning disabilities that cause reading or language problems.

How Are Tics Treated?

There are several therapies to help children with tics cope with the frightening feelings of being out of control and with the specific types of behavior related to their condition. These include relaxation and stress-reduction techniques, and biofeedback. Often, medication is an important part of the treatment plan. Because of associated stress, anxiety, and self-esteem and relationship issues, working with a mental health professional when concerns begin to interfere with the quality of life is particularly important. A combination of treatment approaches is often required when tics and associated mental health problems are serious.

See also

Attention Deficit Hyperactivity Disorder

Learning Disabilities

Obsessive-Compulsive Disorder

Tourette Syndrome

Resource

Organization

Nemours Center for Children’s Health Media, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803. This organization is dedicated to issues of children’s health and produces the KidsHealth website. Its website has articales about tic disorders. http://www.KidsHealth.org.

TICS

Tics can be described as abnormal movements characterized by suddenness, inopportune occurrence, nonproductivity, and variability. They can affect the muscles of the face, neck, or shoulders, and are sometimes generalized. We distinguish between simple tics, which are often transient, multiple tics, and the chronic tics found in Gilles de la Tourette's syndrome.

In Studies on Hysteria (1895), Sigmund Freud posited that tics are a compromise between an idea and its counter-idea (countercathexis) and constitute a particular mode of expression of neurotic conflicts. In the view of Sándor Ferenczi, subjects with tics, owing to the very fact of their strong narcissism or a fixation at this stage, have an increased tendency toward discharge and a reduced capacity for psychic binding. A traumatic memory that affects the body-ego spontaneously comes to the fore each time it has the opportunity to do so: Tics are thus the hysteria of the ego. Noting that tics have a veritable muscular eroticism, Ferenczi considered them the equivalent of repressed masturbation. He also drew attention to the importance of anal-sadistic components in tics and to the connection between them and coprolalia.

According to Melanie Klein, tics are based on genital, anal-sadistic, and oral tendencies directed against the object; her uncovering of these original object relations upon which tics are based led her to consider them as a secondary narcissistic symptom. She confirmed Ferenczi's conclusion—equating tics with masturbation—but added that masturbatory fantasies are closely linked to them. Analysis of these masturbatory fantasies appears as the key to understanding the tic. Behind the homosexual content of these fantasies can be discerned the child's identification with the father, that is, the heterosexual fantasy of sexual relations with the mother. The sublimation of these fantasies in other interests leads to the disappearance of the tic.

Margaret Mahler discussed "organ neurosis." Subjects with tics experience the drives as mechanical events that are in a sense foreign to the ego. Otto Fenichel viewed tics as a pregenital conversion comparable to stuttering, which Karl Abraham had noted; for Abraham, the tic was a symptom of conversion to the anal-sadistic stage.

Serge Lebovici proposed a psychosomatic explanation: Unrepresented excitation can lead to uncontrolled psychomotor discharges. Tics have the weight of an unelaborated discharge, but on the therapeutic level, the latent meaning can be sought by means of construction. He noted the fairly close relationship between isolated or complex tics and the structured completedness of obsessional neuroses, but at the same time mentioned that they are also found with conversion hysteria or in psychotic organizations. According to Bernard Golse, obsessive traits with fixation on the aggressive tendencies of the anal-sadistic stage are discernible in the subject with a tic; but whereas with obsessional neurosis the aggressive content is not apparent because it is repressed by the visible ritual, with tics, the aggressiveness is directly externalized in motricity, without prior mental working over of the conflicts.

The etiology of tics is complex. The difficulties described occur in children who show a neurobiological predisposition, and are registered within an inter-subjective relational economy that contributes to their persistence.

Christine Payan

See also: Emmy von N., case of; Mahler-Schönberger, Margaret; Repetition.

Bibliography

Abraham, Karl. (1954). Contribution to a discussion on tic. In Selected papers of Karl Abraham, M.D. (pp. 323-325; Douglas Bryan and Alix Strachey, Trans.). London and New York: Basic. (Original work published 1921)

Ferenczi, Sándor. (1926). Psycho-analytical observations on tic. In The selected papers of Sándor Ferenczi, M.D., vol. 2: Further contributions to the theory and technique of psychoanalysis (John Rickman, Comp.; Jane Isabel Suttie et al., Trans.). New York: Basic. (Original work published 1921)

Golse, Bernard. (1983). Pour une psychopathologie ou une psychogenèse des tics de l'enfant: Une revue de la littérature. Actualités psychiatriques, 1, 51-56.

Klein, Melanie. (1948). Contributions to psychoanalysis 1921-1945. London: Hogarth Press.

Mahler, Margaret. (1949). A psychoanalytical evaluation of tics in a psychopathology of children. Psychoanalytic Study of the Child, 3 (4), 279-310.