Tic Disorders

Provisional Tic Dx

• Duration: < 1 year

• Can have any combination of tics: only motor, only vocal, or both

Persistent (Chronic) Tic Dx

• Duration: ≥ 1 year

• Only motor or only vocal tics

Tourette’s Dx

• Duration: ≥ 1 year

• Both motor and vocal tics

Prevalence

• Tics ≈ 3%

• Tourette’s ≈ 1%

Gender Ratio

3 Males:1 Female

Age of Onset

• 5-7

• Onset in adulthood is rare

Comorbidity of those with Tourette’s

ADHD (50-60%)

OCD (50%)

Sequence

• Simple motor (eye blinking, shoulder shrug, 5-7 yrs) →

• Simple vocal (throat clearing) →

• Complex motor (simple combine, hand gestures, copropraxia: obscene gesture →

• Complex vocal (phrases, echolalia, coprolalia: obscene utterances (particular cadence, “barking” sound)

obscene gesture

copropraxia

obscene utterances

coprolalia

genetics

• Heritable, polygenic, no specific genes identified as yet

• Over-activity of the dopaminergic system

• Increased rapid onset tics in adolescence 

What are premonitory urges?

Sensation that a tic is about to happen, 80% of those with Tic Dxs have them

• ½ of those can sense them

Do premonitory urges always occur?

• No 

• Children less likely to have them than teens or adults 

• Even among those who have them, they only occur sometimes (30-40% of the time)

Can people suppress tics?

• Yes

• For secs to min but often the urge to tic intensifies the longer they suppress it

Have premonitory urges been misunderstood?

• Yes

• Others have mistakenly assumed that it means people have voluntary control over their tics and that tics are willful behaviors 

  • Results in blaming behaviors

What is the most effective treatment?

Comprehensive Behavioral Intervention for Tics (CBIT)

Comprehensive Behavioral Intervention for Tics (CBIT)

Relaxation training, psychoeducation, relapse prevention, etc but main component is habit reversal to manage tics

What is Habit Reversal

• Teach awareness of tic coming (awareness of premonitory urges)

• Teach person to engage willfully in behavior that cannot be performed at the same time as tic

  • ex/ can’t slowly roll shoulders and jerk shoulders at the same time 

• Generally found to be modestly more successful with motor tics 

What anti-psychotic meds can be used

• Topiramate (AED)

  • Can cause weight loss, sleep loss, and memory issues 

• Clonidine 

  • More helpful for comorbid ADHD cases

What are some caveats to treatment

• Limited number of providers trained in CBIT/Habit Reversal 

• Under diagnosed because of lack of provider training 

• Children <10 not much awareness of when going to have tic (harder to use habit reversal)

• Advocacy group feel important to stress neurological disorder to decrease stigma 

  • Concerns → if behavioral treatment will emphasize control and perpetuate misunderstanding of willfulness of behavior