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Tics

Severity of Tourette Syndrome and comorbidities, by age. Lancet 2002;360(9345)1577-86.

IntroductionEdit

A great overview of tic disorders can be found in the review article J Neurol (2006) 253:1-15.

This article focuses on clinically relevant aspects of tic disorders.


What are "Tics"Edit

Hallmark of tic disorders are involuntary/semivoluntary, sudden, rapid, recurrent, unpredicatable, non-rhythmic movements (motor tics) and sounds (vocal tics)

Distinguishing tics from other hyperkinetic movement phenomena can be tricky; the following characteristics of tics are useful in making accurate diagnosis:

  • Motor and vocal tics are often preceded by premonitory urges
  • Patients are generally able to briefly suppress onset of tics, but the premonitory tension or discomfort/anxiety rises
  • Once an episode of tics occur, there is a brief feeling of relief
  • Stress, fatigue, and even excitement can exacerbate tics
  • Consider in the differential diagnosis: stereotypies of autism spectrum disorders, chorea, athetosis, myoclonus, dystonia, paroxysmal dyskinesias, compulsions of OCD, seizures, and, of course, “pseudoseizures”


Tics can be simple or complex:Edit

Simple Tics Complex Tics
Motor Tics Eye blinking, sticking tongue out, head jeking

Coordinated patterns of sequential movements: touching the nose, echopraxia, copropraxia, smelling objects, kissing self, others, arm flapping

Vocal Tics Barking, yelling, throat clearing Coprolalia, echolalia, palilalia

DSM-IV-TR diagnosisEdit

While tics can be primary (idiopathic or inherited) or secondary (due to drugs, infection, or developmental disorders), the DSM-IV classifies tics by other characteristics:

  • Tourette Syndrome involves frequent motor AND vocal tics (must have both, but not necessarily concurrently), starting before age of 18 and lasting for 1 year
  • If the above tics had been observed for more than 4 weeks, but less than 1 year, the diagnosis is Transient Tic Disorder
  • If frequent vocal OR motor tics start before 18 and last for a year, the diagnosis is Chronic Motor or Vocal Tic Disorder
  • All other possibilities (onset >18yo, duration <4w) fit under Tic Disorder NOS

Diagnostic PearlsEdit

  • Document family history of tics when evaluating a child
  • Order TSH: this is a frequent comoridity
  • Sudden onset or worsening of symptoms: obtain Group A beta-hemolytic strep swab, ASO titer, and anti-DNAse B leves (think PANDAS)
  • Rule out other secondary causes: head trauma, stroke, autism, CO poisoning, hypoglycemia
  • Rule out drugs and intoxication as potential causes: antidepressants, anticholinergics, antihistamines, levodopa, antiepileptics

Treatment PearlsEdit

  • Behavioral and supportive treatments
sleep hygeine, physical exercise, emotional support
habit reversal is a behavioral therapy centered on rinterruption of stimulus-response sequences, shown effective in RCTs
  • Pharmocological treatments
Dopamine-R antagonists: pimozide (most effective, but requires EKG monitoring for arrhythmias), chlorpromazine, haloperidol, fluphenazine, risperdone (may be best tolerated)
Alpha-adrenergics can ameliorate both tics and comorbid ADHD with milder side effects: clonidine, guanfacine are safe and effective
Dopamine-R agonists, at low doses (pergolide), benzodiazepines (clonazepam), and calcium-channel blockers (not diltiazem) may have a role;
SSRIs are used for comorbid OCD

High-yield factsEdit

TicsEdit

  • Coprolalia/copropraxia = obscene words and gestures are complex vocal and motor tics
  • Echolalia/echopraxia = mimicking other’s sounds and gestures are complex tics as well
  • Jerks that last less than 200ms are most likely myoclonus (not tics)
  • Cannabis, alcohol, and nicotine may decrease tics
  • Stimulants, stress, fatigue, heat exposure, caffeine, dopamine agonists, and beta-hemolytic strep infection can exacerbate tics

Tourette syndromeEdit

  • to diagnose TS, need 2 or more motor tics and at least 1 vocal tic at some time during the illness
  • onset typically before age of 7
  • symptoms typically peak around 9-11 years of age, and subside in adolescence
  • less than 10% fully recover
  • Common comorbidities include OCD and ADHD
  • M:F ratio is 5:1

Further ReadingEdit

Facts for Families from AACAP website. Updated in 2004; 1 page pdf

Prescribing Psychotropic Medications to Children Practice parameters from AACAP. Updated 2009

Tourette Syndrome Association has medical articles, family information, and videos on TS


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