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Tourette Syndrome and Other Tic Disorders

by Margaret C. McBride, MD

Tics are rapid, purposeless, repetitive but not rhythmic involuntary movements (muscle or motor tics) or involuntary, abrupt, often repetitive sounds and/or words (vocal tics). They can be suppressed but only for a short time and only with conscious effort. Tourette syndrome is diagnosed when people have had both motor and vocal tics for more than a year.

  • The urge to blink, grimace, jerk the head, move in some other way, or make a sound is irresistible, but the action is not voluntary.

  • Doctors base the diagnosis on symptoms.

  • Many tics disappear on their own, but if they are troublesome or severe, clonidine or antipsychotic drugs may help.

Tics vary widely in severity. One in five children has a tic of some sort for a period of time. Many of these tics are mild and often not recognized as a disorder by parents and doctors. Tourette syndrome is the most severe tic disorder and occurs in fewer than 1 in 100 children. Tics are 3 times as likely to occur in boys as in girls.

Tics begin before age 18 years (typically between ages 4 and 6 years), increase in severity to a peak at about age 10 to 12 years, and decrease during adolescence. Eventually, most tics disappear. However, in about 1% of children, tics persist into adulthood.

Children with tics often have other disorders such as attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), an anxiety disorder, depression, or learning problems. These disorders often interfere more with children's development and well-being than the tics. Sometimes tics first appear when children with ADHD are treated with a stimulant drug such as methylphenidate. These children probably have an underlying tendency to develop tics.

Causes

The cause of tic disorders is not known, but tic disorders often occur in families, so doctors think heredity plays a part.

Sometimes people who have another disorder, such as Huntington disease or a brain infection (encephalitis), develop tics. Tics can also result from use of certain drugs, such as cocaine or amphetamines. However, tics caused by other disorders or by drugs are not considered a tic disorder.

Sometimes when tics start in a child, doctors detect evidence that the child has recently had a streptococcal (strep) infection. Such cases are called pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS). Some people think that antibodies produced by the body to fight the streptococcal bacteria may cause tics or make them worse. However, most investigators think that the proof of this connection is lacking.

Symptoms

Before a tic occurs, an urge to do the tic may be felt. This urge is similar to the need to sneeze or scratch an itch. Tension builds up, usually in the affected body part. Giving in to the tic provides brief relief.

The tic can sometimes be postponed for seconds to minutes but only with conscious effort and difficulty. Usually, the urge to do the tic eventually becomes irresistible. Trying to control tics is usually difficult, especially during times of emotional stress. Stress and fatigue can make tics worse. However, tics often also become worse when the body is relaxed, as when watching TV. Calling attention to a tic, particularly in children, may make the tic worse. Typically, tics do not occur during sleep, and they rarely interfere with coordination. Tics may lessen when people are concentrating on a task such as school or work activities or when people are in an unfamiliar place.

People with severe tics, particularly Tourette syndrome, may have difficulty functioning and experience considerable anxiety in social situations. In the past, they were shunned, isolated, or even thought to be possessed by the devil. They may become impulsive and aggressive and behave in self-destructive ways. Children with severe tic disorders or Tourette syndrome are more likely to have another disorder, such as OCD, ADHD, and/or learning problems. These problems seem to result from the brain abnormalities that cause tics and Tourette syndrome. However, when a tic disorder is severe, the extraordinary stresses of living with the disorder may make these problems worse.

Tics tend to vary in type, intensity, and frequency. Sometimes they start suddenly and dramatically. They may occur several times an hour, then almost disappear for many months.

Types of tics

Tics may be simple or complex and motor or vocal. Simple tics are extremely brief. They may begin as nervous mannerisms. Complex tics last longer and may combine several simple tics. In some complex tics, people may call out obscenities or words related to feces (called coprolalia). Although people often associate coprolalia with Tourette syndrome, at least 85% of people with Tourette syndrome do not have coprolalia. Complex tics may appear purposeful, as in coprolalia or when a person repeats another person's movements or words, but they are not intentional.

Types of Tics

Classification

Motor

Vocal

Simple

Blinking

Grimacing

Head jerking

Shoulder shrugging

Grunting or barking

Sniffing or snorting

Throat clearing

Complex

Combinations of simple tics (such as head turning plus shoulder shrugging)

Copropraxia: Using sexual or obscene gestures

Echopraxia: Imitating someone's movements

Coprolalia: Uttering socially inappropriate words (such as obscenities or ethnic slurs)

Echolalia: Repeating one's own or another's sounds or words

Did You Know...

  • Most people with Tourette syndrome do not randomly shout out obscenities.


Diagnosis

The diagnosis is based on the symptoms and their duration. There are three major types of tic disorder:

  • Provisional tic disorder: Children have had motor and/or vocal tics for less than a year.

  • Persistent tic disorder: Children have had motor or vocal tics (but not both) for more than a year

  • Tourette syndrome: Children have had both motor and vocal tics for more than a year.

Early diagnosis can help parents understand that the tics their children have are not intentional and that punishment cannot stop the tics and may even make them worse. To distinguish Tourette syndrome from other tic disorders, doctors may have to evaluate children periodically, over a period of time.

Doctors also check children for disorders that often accompany tics, such as ADHD and OCD.

Treatment

If symptoms are mild, reassurance is often best, with as little attention paid to the tic as possible until it disappears on its own. Treatment can often be avoided if the family understands the disorder and if the disorder is explained to and understood by the child's teachers and schoolmates. Drugs to stop tics are recommended only if tics persist and are interfering with the child's activities or self-image. The lowest dose needed to make tics tolerable is used, and doses are decreased as tics lessen.

Clonidine is a drug that occasionally helps. It can also help control anxiety and hyperactivity, which may accompany a tic disorder. However, clonidine can cause drowsiness, which may interfere with the child's daytime activities. Although clonidine is also used to treat high blood pressure, it rarely causes low blood pressure in children. However, after children have taken clonidine for a while, suddenly stopping clonidine may cause blood pressure to increase temporarily.

For severe tics, antipsychotic drugs may be effective even though psychosis is not the cause of tics. Effective drugs include risperidone, haloperidol, pimozide, and olanzapine. Side effects (see Antipsychotic drugs) include restlessness, muscle stiffness, symptoms similar to those of Parkinson disease (parkinsonism), and tardive dyskinesia, which consists of repetitive slow involuntary movements. However, these side effects are uncommon because the doses used to treat tics are low.

Children who have tics and who are struggling in school should be evaluated for learning disorders and provided with support as needed. If obsessive or compulsive traits are bothersome, a drug such as a selective serotonin reuptake inhibitor (SSRI) may be useful. ADHD can be difficult to treat because the stimulant drugs typically used to treat it may worsen tics. Sometimes low doses of these drugs can effectively treat ADHD without making tics worse. Or, if needed, a different drug can be used.

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Drugs Mentioned In This Article

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  • CATAPRES
  • CONCERTA, RITALIN
  • ORAP
  • HALDOL
  • RISPERDAL
  • ZYPREXA