How did I get interested in Tic Disorders and make treating them one of the passions of my psychiatric practice? My husband and I were at a group meeting at an adoption agency waiting for a second child when they passed out papers that had all types of medical disorders and social situations. They asked which ones in the child or birth parents would be acceptable to you and which ones would not be acceptable. One lady stood up and said that none of them would be acceptable. I laughed and said that all of them would be acceptable. In fact, I said that we had all of them except Tourette’s Syndrome in our family already. God must have smiled because two months later we had our newborn son who would eventually be diagnosed with Tourette’s Syndrome.
There are many types of Tic Disorders besides Tourette’s Syndrome (the most severe).
- Tourette’s Disorder (multiple motor tics and at least one vocal tic)
- Persistent (Chronic) Motor or Vocal Tic Disorder
- Provisional Tic Disorder (less than 1 year)
- Other Specified Tic Disorder (does not meet the full criteria)
- Unspecified Tic Disorder (clinician does not want to specify)
What is a tic? A tic is an isolated disinhibited fragment of normal motor or vocal behavior. It is sudden and stereotypic (unexpected or meaningless within the context). It is not involuntary nor voluntary but rather “unvoluntary” (which means involuntary but temporarily suppressible). Tics are simple or complex depending on how involved they are. Tics are either motor or vocal behavior.
Why are tics so rarely diagnosed? Mainly because they are not looked for. Tics are seen in people with ADHD and OCD but unless you are a neurologist, you will not see them. Why do tics in adults go unnoticed? Usually because they are mild and intermittent. Adults have learned to suppress the tics or cover them up: spitting into a tissue, coughing following a vocal tic, changing a flap into a wave, or just pretending to be goofing around. Why do most adult psychiatrists lack familiarity with tics? It is because most children with tics outgrow them by age 23. Most adults who still have tics will not complain of them and will suppress them in their doctor’s or therapist’s office. If anything, they will tell you they have obsessions and compulsions or odd habits. Why is it important to notice tics and to treat them (if the patient wants treatment) even if something else is the focus of treatment? Adults with tics will tell you the relief is enormous. They will be grateful to you. Most children with tics are belittled, beaten or abused by parents and teachers. They are bullied by classmates. They may develop lifelong depression or use substances to cope. Being diagnosed (even if never treated) will give them a whole new perspective on their childhood. One patient of mine said his nickname growing up was “Johnny Stop.”
If there is considerable lack of experience noticing and treating tics by doctors, how are adults commonly diagnosed? My own personal experience is that 50% adults are self-diagnosed after their children were diagnosed, 49% are self-diagnosed through the Internet, and 1% are diagnosed by a doctor.
What is the difference between compulsions and tics? Both may look exactly the same. You must ask the patient what is happening. Compulsions are triggered by anxiety or a desire to avoid something. Tics are not, although if the person is going through a high stress period, tics may be increased. What the person with tics experiences right before the tic is a physical sensation that is uncomfortable. This is called the premonitory sensation. For an ordinary person it is like what you feel just before a sneeze or an itch that needs to be scratched. Tics are also meaningless. Unlike compulsions they have no hidden agenda or anything brewing in the subconscious.
What are some examples of tics:
- Simple motor tics: blinking, grimacing, nose twitching, head jerks, shoulder shrugs, arm jerks, abdominal muscle tensing, finger movements, toe tapping, knee bouncing.
- Complex motor tics: Staring, biting, touching objects repetitively, gestures with the hands, cracking knuckles, skin picking, jumping up and down when excited, repeating others’ gestures, self-mutilation or self-injurious tics, obscene gestures (copropraxia).
- Simple vocal tics: throat clearing, coughing, sniffing, spitting, screeching, barking, grunting, moans, whistling, humming, hoots, and “What?”. Only 10% of patients with Tourette’s have Coprolalia, which is expressing words that are taboo in your culture (In Western culture, it is sexual remarks.)
- Complex vocal tics: Sudden somewhat meaningful sounds like “Shut up,” “Stop that,” “Oh, okay,” “you know,” “Okay, honey,” “How about it?” Echo phenomena is repeating one’s own or someone else’s words. Complex coprolalia. Cluttering or cluttered speech, which is different from stuttering (“Ma-Ma-Mary will go to the store-store-store” as opposed to stuttering which is MMMM or SSSS.)
There is one more type of tic disorder which is related to infection. It can be associated with any severe infection but is more commonly found with streptococcus. The onset of tics (or symptoms of OCD) can be very sudden. It is called PANDAS which means Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep.
Tics are common in childhood, but most disappear and do not require any treatment. To be diagnosed as having Tourette’s, there needs to be a one year history of multiple motor tics and at least one vocal tic. Onset is often between 4 and 6 years of age with males more prominent. Peak severity is between 10 and 12 years of age, although it can occur at any age. It is highly genetic and the ratio of male to female is about 4:1. The incidence is the same across races and cultures, just the appearance and acceptance rate of the individual is different.
Many children with Tourette’s also have ADHD and/or OCD. What usually happens is the appearance of the ADHD comes first (tics can be sometimes triggered by stimulants), then the tic disorder, and lastly the OCD. The clinician must be careful to differentiate between Tourette’s and OCD because sometimes tics are repeated in order to get the tic done “just right” or perfect (which is actually a rationalization for repeating it). Compulsions are triggered by anxiety and have an intellectual reason behind them and are usually more complex.
OK, now you know you have some tics in addition to what you knew already was ADHD or OCD, what is next? If they do not bother you, do nothing. If they drive your parent or significant other to want to strangle you, you may want to see what is involved in treatment. There is both behavioral and medication treatment available. The behavioral treatment is called habit reversal or exposure/response prevention. There is also tic substitution in which an observable tic is substituted for one that is not observable (like fidgeting with a marble in your pocket or punch holes in a piece of cloth instead of your own clothes). There are also many different types of medication that can be used. You need to go to a neurologist or a psychiatrist who is experienced with treating tics. The only drug approved for Tourette’s is an old drug with lots of side effects called ORAP or Pimozide. It is an antipsychotic that is rarely used for anything these days. If that is the first drug suggested by your doctor, run in the opposite direction. Whatever the doctor prescribes, the basic pharmacological tenet is to start low and go slow.
The drugs most often used are:
- Clonidine or guanfacine (alpha2-adrenergic agonists)
- Risperidone or aripiprazole (Major tranquilizers/antipsychotics)—low dose
- Tetrabenazine (presynaptic dopamine-depleting agents)
- Clonazepam (benzodiazepines)
- Onabotulinumtoxin A (Botox) (neuromuscular blockers)
For those of you who are triply blessed (tics/ADHD/OCD), there is one more thing you need to know and that is “Rage-Generated Episodes.” Rage attacks are the things that most often bring the child or the adult to the psychiatrist. What happens is you see or think of something irrelevant (ADHD) and you fixate on it (OCD). You must have it or “life is over.” If you or someone else finds it, you calm down. If not, then you explode in a full rage attack. A child and even an adult may end up on the floor kicking and screaming. If the need is appeased, you are wonderful to be with. If not, then you will break things but only your own belongings. When later calmed down, you will apologize over and over and mean it. It is a neurophysiological breakdown.
These are the missing pieces of the puzzle with adults with ADHD and/or OCD.
- DSM-V. Tic Disorders.
- Pugliese, Maria A. and Hieble, J. Paul. The Missing Piece of the Puzzle: Tic Disorders in Adults with Obsessive-Compulsive Disorder or Attention Deficit Disorder. The course is given at the National Annual Meeting of the American Psychiatric Association. Philadelphia 2002 and New York 2004.
- Robertson, William C. et al. Tourette Syndrome and Other Tic Disorders.