Tics & Tourette Syndrome

Contributed by Hubert Fernandez, MD
Department of Neurology
Cleveland Clinic
Cleveland, Ohio USA

A “tic” is an involuntary movement or vocalization that is usually sudden onset, brief, repetitive, stereotyped but non rhythmical in character, frequently imitating normal behavior, often occurring out of a background of normal activity.  Tics are usually associated with a premonitory sensation or “build up” sensation to perform the specific movement, and usually are associated with the sensation of relief once performed.

Tics can be classified as motor or vocal. Motor tics are associated with movements, while vocal tics are associated with sound.   Tics can also be categorized as simple or complex.  Simple motor tics involve only a few muscles usually restricted to a specific body part.   They can be clonic (abrupt in onset and rapid), tonic (isometric contraction of the involved body part) or dystonic (sustained abnormal posture).  Examples of simple motor tics include: eye blinking, shoulder shrugging, facial grimacing, neck stretching, mouth movements, jaw clenching and spitting. Simple vocal tics consist of sounds that do not form words, such as: throat clearing, grunting, coughing, and sniffing.

The DSM-IV divide tic disorders in three main categories: transient tic disorders, chronic motor or vocal tic disorder and Tourette disorder.  For the diagnosis of Tourette syndrome, both multiple motor and one or more vocal tics should have been present at some time during the illness, although not necessarily concurrently; the tics should occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year; and during this period there should never be a tic-free period of more than 3 consecutive months; the onset should be before age 18 years; and the disturbance should not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).

Pharmacological treatment for the tics may not be needed unless they cause severe interference with social development.  Most patients with mild symptoms will benefit from education regarding the diagnosis and what to expect from the condition.  Education should be extended to parents as well as teachers to create a suitable environment for the affected individual and explain them they are not a mental disorder.  If medical therapy is necessary, the mainstay of treatment for tics is the dopamine receptor blocking agent (examples include haloperidol, pimozide, and fluphenazine). Atypical antipsychotics have also been reported to be beneficial and may be associated with a lower incidence offside effects when compared with the typical antipsychotics (aripiprazole, risperidone, olazapine, quetiapine, amilsupride, ziprasidone and sulpiride) Other treatments reported to be beneficial to reduce tic frequency in patients with TS include: mecamylamine, tetrabenazine, benzodiazepines (such as clonazepam), baclofen, botulinum toxin for (focal tics) and clonidine.

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