Tic disorders

• TYPE OF PSYCHOLOGY: Emotion; language; personality; psychopathology

A tic is defined as a sudden involuntary movement or twitch, usually in the face but sometimes in the neck or in other parts of the body, that occurs without any obvious external cause. It may also manifest itself in the victim’s speech or breathing.

Introduction

The tics that occur with some frequency in young children and in adolescents are often confined to the face, particularly the eyes and lips, although these muscle contractions can also affect other parts of the body, notably the shoulders, the neck, the arms, the hands, and the trunk. They can also affect breathing and may be vocal.

Most people have had some experience with tics, but as people mature, the frequency of such tics usually diminishes. In cases of this sort, the condition is identified as provisional tic disorder and does little to interfere with people’s normal activities.

Some victims of the disorder, however, experience tics so frequently that it significantly affects their normal functioning. These people have chronic tic disorder, which, especially in its vocal manifestations, called coprolalia, makes it difficult for them to interact with people and to be involved in social and learning situations. Such people may erupt unexpectedly and quite frequently into loud streams of profanity directed at those around them. There usually is not any identifiable trigger for these eruptions, which often leave those who hear and see them bewildered and frightened.

Although coprolalia may be a provisional condition, its manifestations require immediate attention because those with the condition are usually disruptive in social situations and school settings. In some situations, this disruptiveness may cause victims of coprolalia to be isolated because their presence in classroom settings can make it impossible for teachers to deal with them in average-sized classes.

Causes

Tics in young people are likely hereditary. Twenty-first-century research established a strong genetic link in the development of tic disorders, and individuals with a first-degree relative are ten to one hundred times more likely to have a tic. For example, Tourette syndrome is an autosomal dominant disorder, meaning that parents with Tourette syndrome have a one in two chance of passing the gene to their children. Environmental causes appear to be present in some cases in which tics develop. It is also thought that stress may contribute to tics, and it has been observed that sometimes people who develop tics experience reduced symptoms if their stress level is reduced.

Among adults, the overuse of caffeine, defined as more than the equivalent of five cups of coffee a day, can result in tics, twitches, or tremors that can be virtually eliminated if caffeine consumption is drastically reduced. The regular use of alcoholic beverages may also result in the tics, twitches, and tremors associated with the overuse of caffeine and can be controlled by eliminating alcoholic beverages from the patient’s diet.

In some people, tics coexist with other mental health or emotional conditions, in which case they may be treated by psychologists or psychiatrists. Where a psychological basis exists for the condition, stress reduction is imperative.

Types and Frequency

Tics may be motor or verbal. Although tics may disappear almost as quickly as they appeared, they are irresistible. Willpower and distractions may mitigate them temporarily, but once the distraction disappears, the tic reappears. Researchers have found that tics greatly relieve stress in those experiencing them, so they question the advisability of doing anything to prevent or discourage them.

Although tics are often associated with Tourette syndrome (TS), they may also occur in people with Asperger syndrome, bipolar disorders, learning disabilities, and attention-deficit hyperactivity disorder (ADHD). Sometimes, stimulant medications may cause tics. Some neurologists have associated them with such conditions as chronic nail biting, nose picking, and air swallowing.

Tics often are closely associated with obsessive-compulsive disorders (OCD). Those who experience provisional tic disorders, defined as those that last for at least four weeks but for no longer than a year, generally exhibit behaviors associated with both motor and verbal (also called phonic) tics, sometimes simultaneously.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) (2022) classifies three types of tic disorders: Tourette syndrome, persistent (or chronic) motor or vocal tic disorder, and provisional (formerly transient) tic disorder.

Provisional tic disorders disappear as the individual matures and are usually present for less than one year. They are rarely found in people over eighteen years old. In some cases, however, the disorder persists into adulthood, which may complicate the afflicted individuals' lives. However, as neurologist Oliver Sacks demonstrated in seven case studies involving individuals with Tourette syndrome, the most difficult type of tic disorder, some of those with the disorder have learned to live with it and lead productive lives despite it. Sacks cites case studies he has made of seven physicians who suffer from Tourette syndrome and practice actively in surgery, ophthalmology, and internal medicine.

A 2012 study conducted by the Centers for Disease Control indicated that 1 in 360 children between the ages of six and seventeen have Tourette syndrome. However, a decade later, research indicated the rate to be closer to 1 in 162. School-age boys develop Tourette syndrome (and tics in general) at a rate as high as five to one over their female counterparts.

The condition has been reported throughout recorded medical history. At one time, tics were considered to be evidence that those who had them, at least in their more extreme manifestations, were possessed. A degree of shame was associated with them. Tics were considered to stem from psychological causes well into the twentieth century, even though Tourette syndrome was identified in the last half of the nineteenth century.

In the United States, Tourette syndrome affects more whites than African Americans or Latinos. Young children suffer more frequently from Tourette than older children do. Children between twelve and seventeen are twice as likely to be diagnosed with Tourette syndrome than younger children.

Many tic disorders go unobserved and unreported. Therefore, some researchers have speculated that the actual occurrence of some kind of tic disorder may be as high as one in every hundred people between five and eighteen.

Young people who suffer from Tourette syndrome, even if they attend school, are often shunned by their classmates and may be dreaded by their teachers, who view them as disruptive. Most school districts have some special education programs for those who need them, but a person with Tourette can seriously obstruct the learning processes of other students. Teachers on an intellectual level can understand the problems that face the person with Tourette, but this understanding does little to remedy the disruptions that such a student may create.

Students coping with Tourette syndrome have legal protection under Section 504 of the Americans with Disabilities Act (ADA). This law protects the rights of all Americans with disabilities and is particularly relevant in educational and vocational training programs. Protection is granted under the ADA to anyone whose physical or mental impairment places a limitation on them in one of several areas, including walking, seeing, hearing, speaking, breathing, and several other areas that are commonly found in those with Tourette. People with Tourette often have badly damaged caused by their inability to fit into the social and educational settings in which most young people participate. Discussions of what Tourette syndrome is and how it affects people often increase the understanding of the teenage tormentors of those with the syndrome.

Treatment

Most tic disorders are sufficiently mild and provisional that they do not require treatment. Given time, the symptoms will probably diminish and finally disappear entirely. Those dealing with young people who have tic disorders are usually advised not to encourage them to suppress their tics because they often are essential in helping them release their stress and deal with their emotions.

For cases in which patients experience such severe tics that treatment is indicated, benzodiazepines and antipsychotic medications are sometimes employed. Such treatment is considered extreme and usually is resorted to only in cases in which there are such severe involuntary contractions of the muscles between the chest and the abdomen that the patient makes loud grunting noises and exhibits distinct symptoms of Tourette syndrome. In such cases, some instances of relief have been reported following acupuncture, acupressure, yoga, and massage.

Tourette syndrome usually involves two or more kinds of motor tics simultaneously as well as a phonic tic, generally coprolalia. Such extreme manifestations of this obsessive-compulsive disorder are infrequent and are usually dealt with both psychologically and medicinally. When it is considered necessary, however, limited doses of agonists, notably bromocriptine and pramipexole, may be administered.

Mild tics often respond to small quantities of a blood pressure medication, clonidine, or to an antiseizure medication, clonazepam. Multiple tics can be controlled by small doses of such antipsychotic drugs as haloperidol, pimozide, and fluphenazine, but each of these medications has significant side effects that cause most physicians to limit their use to the most extreme cases.

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