Table of Contents

Tic Disorders (Tics) and Tourette's

Primer

Tics are sudden, rapid, recurrent, non-rhythmic motor movements or vocalizations. Individuals with tics experience a feeling of a mounting inner tension or urge (known as a premonitory urge), which is transiently relieved by tic expression. Tics will wax and wane with time, and can be worsened with stress, fatigue, or excitement. Although tics can include almost any muscle group or vocalization, certain tic symptoms, such as eye blinking or throat clearing, are more common. Tics are generally experienced as “involuntary” but are usually temporarily suppressible. Tourette’s Disorder is the most “famous” of the tic disorders.

Epidemiology
Prognosis
Comorbidity
Risk Factors

Classification and Terminology

Tic disorders can be classified in to 4 disorders:

  1. Tourette’s disorder
  2. Persistent (chronic) motor or vocal tic disorder
  3. Provisional tic disorder
  4. Other specified and unspecified tic disorders

Remember the Diagnostic Hierarchy

Tic disorders are hierarchical in order - once a tic disorder at one level of the hierarchy is diagnosed, a lower hierarchy diagnosis cannot be made (Criterion E). The escalating hierarchy of diagnosis is (1) other specified and unspecified tic disorders (lowest) → (2) provisional tic disorder → (3) persistent motor or vocal tic disorder → (4) Tourette’s disorder (highest).
Simple and Complex Tics

Tics can be either simple or complex:

  • Simple motor tics are of short duration (i.e., milliseconds) and can include eye blinking, shoulder shrugging, and extension of the extremities.
  • Simple vocal tics include throat clearing, sniffing, and grunting often caused by contraction of the diaphragm or muscles of the oropharynx.
  • Complex motor tics are of longer duration (i.e., seconds) and often include a combination of simple tics such as simultaneous head turning and shoulder shrugging.
  • Complex tics can appear purposeful, such as a tic-like sexual or obscene gesture (copropraxia) or a tic-like imitation of someone.

Does Someone With Tics Always Swear?

Coprolalia, the involuntary swearing or utterance of obscene words or socially inappropriate and derogatory remarks, is a common popular culture assumption of what tics look like. However, coprolalia has a point prevalence of only 15-20% of population (i.e. - 15-20% will have coprolalia at some point, and not consistently).

DSM-5 Diagnostic Criteria

Tourette’s Disorder

Criterion A

Both multiple motor and 1 or more vocal tics have been present at sometime during the illness, although not necessarily concurrently.

Criterion B

The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.

Criterion C

Onset is before age 18 years.

Criterion D

The disturbance is not attributable to the physiological effects of a substance (e.g. - cocaine) or another medical condition (e.g. - Huntington’s disease, post-viral encephalitis).

Persistent (Chronic) Motor or Vocal Tic Disorder

Criterion A

Single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal.

Criterion B

The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.

Criterion C

Onset is before age 18 years.

Criterion D

The disturbance is not attributable to the physiological effects of a substance (e.g. - cocaine) or another medical condition (e.g. - Huntington’s disease, post-viral encephalitis).

Criterion E

Criteria have never been met for Tourette’s disorder.

Specifiers

Specify if:

  • With motor tics only
  • With vocal tics only

Provisional Tic Disorder

Criterion A

Single or multiple motor and/or vocal tics.

Criterion B

The tics have been present for less than 1 year since first tic onset.

Criterion C

Onset is before age 18 years.

Criterion D

The disturbance is not attributable to the physiological effects of a substance (e.g. - cocaine) or another medical condition (e.g. - Huntington’s disease, post-viral encephalitis).

Criterion E

Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder.

Examples of Complex and Simple Tics

Simple vocal tics include:
  • Throat clearing
  • Sniffling
  • Squeaking
  • Grunting
  • Sounds like “eep!”

Complex vocal tics are:

  • Linguistically meaningful sounds
  • Sentences like “Oh boy now you've done it!”
  • Swearing
  • Echolalia
  • Palilalia

Comparison of Tic Disorders

Comparison

Tourette's Persistent Motor or Vocal Tic Disorder Provisional Tic Disorder
Type of Tics Multiple motor AND at least 1 vocal Motor OR Verbal Motor AND/OR Verbal
Length > 1 year > 1 year < 1 year
Age of onset Before age 18 Before age 18 Before age 18

Differential Diagnosis

Treatment

Education

Education and support for the patient's family and school is a first-line treatment.[6] Remember as a clinician to educated families that the natural history of tics is that they wax and wane, which can confound medication treatment. It’s possible the tics will get worse, despite treatment. Take your time.

Accommodating Tics

Accommodations should be made in the individual's environment to make tics for manageable for the patient and the people around them. Examples include:
  • Asking parents and teachers to accept/ignore minor tics
  • Accommodate for other tics where possible by:
    • Using objects (rugs, foam) to dampen sounds from motor tics
    • Replacing words (saying “shoot” instead of “shit”)
  • Work with the child in problem solving
  • Allow graceful exits
  • Encourage accountability through restoration and reparations

Behavioural

Habit reversal therapy (HRT) is a behavioural treatment used to reduce repetitive behaviours. It is a second line treatment for Tourette's, after providing education about the disorder.[7]

Medications

Pharmacotherapy is primarily with alpha-2 agonists or antipsychotics. Note that rebound hypertension can occur if clonidine is stopped abruptly and not tapered.[8]

Pharmacological Treatment for Tic Disorders

1st line Clonidine 0.05 mg PO daily as a starting dose, and titrate to 0.15 to 0.3mg PO once daily
2nd line
3rd line
Adjunctive therapy
Not recommended

Do Stimulants Exacerbate Tics?

Historically, it has been recommended that stimulants not be used to treat ADHD associated with tic disorders. Some current guidelines still recommend that stimulants are contraindicated in children with Tourette's or even a family history of Tourette's. However, more recent studies have found that on average, stimulants do not exacerbate tics in children with tic disorders, and guidelines have not been updated to reflect this.[9] Therefore, having tics or Tourettes is not a contraindication to use of stimulants in ADHD but careful monitoring is required. required.

Guidelines

Guidelines

Guideline Location Year PDF Website
Canadian Guidelines for the Evidence Based Treatment of Tourette Syndrome Canada 2012 Link -
American Academy of Neurology (AAN) USA 2019 - Link

Resources

For Patients

For Providers

Articles
Research

References

1) Kumar, A., Trescher, W., & Byler, D. (2016). Tourette syndrome and comorbid neuropsychiatric conditions. Current developmental disorders reports, 3(4), 217-221.
2) Leckman, J. F., Grice, D. E., Barr, L. C., de Vries, A. L., Martin, C., Cohen, D. J., ... & Rasmussen, S. A. (1994). Tic‐related vs. non‐tic‐related obsessive compulsive disorder. Anxiety, 1(5), 208-215.
3) Hirschtritt, M. E., Lee, P. C., Pauls, D. L., Dion, Y., Grados, M. A., Illmann, C., ... & Cath, D. C. (2015). Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette syndrome. JAMA psychiatry, 72(4), 325-333.
4) Robertson, M. M., Eapen, V., Singer, H. S., Martino, D., Scharf, J. M., Paschou, P., ... & Črnčec, R. (2017). Gilles de la Tourette syndrome. Nature reviews Disease primers, 3, 16097.
5) Attig, E., Amyot, R., & Botez, T. (1994). Cocaine induced chronic tics. Journal of neurology, neurosurgery, and psychiatry, 57(9), 1143.
6) Murphy, T. K., Lewin, A. B., Storch, E. A., & Stock, S. (2013). Practice parameter for the assessment and treatment of children and adolescents with tic disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 52(12), 1341-1359.
7) McGuire, J. F., Ricketts, E. J., Piacentini, J., Murphy, T. K., Storch, E. A., & Lewin, A. B. (2015). Behavior therapy for tic disorders: an evidenced-based review and new directions for treatment research. Current developmental disorders reports, 2(4), 309-317.
8) Leckman, J. F., Ort, S., Caruso, K. A., Anderson, G. M., Riddle, M. A., & Cohen, D. J. (1986). Rebound phenomena in Tourette's syndrome after abrupt withdrawal of clonidine: Behavioral, cardiovascular, and neurochemical effects. Archives of General Psychiatry, 43(12), 1168-1176.
9) Bloch, M. H., Panza, K. E., Landeros-Weisenberger, A., & Leckman, J. F. (2009). Meta-analysis: treatment of attention-deficit/hyperactivity disorder in children with comorbid tic disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 48(9), 884-893.