2. Medical Assessment And Treatment Of Tic Disorders
What are motor tics?
They a brief, sudden repetitive and purposeless movements affecting any part of the body. When they first appear they tend to be in the face and head, the most common being exaggerated eye blinking. They may move down from head to toe over time and can include facial grimaces, head nods, shoulder shrugs, or abdominal wall tensing. These movements which involving isolated muscle groups, are known as Simple Motor Tics.
Tics can also seem to be more purposeful in nature and occur in an orchestrated fashion, for example making a facial gesture, touching things or family members, bending or hopping. When these are present they are called Complex Motor Tics.
An individual can experience a variety of motor tics over time, occurring in different sequences and sometimes occurring in bouts.
What are vocal tics?
Vocal tics are involuntary repetitive sounds. They too can be divided into Simple Vocal Tics such as, coughs, sniffs, grunts, throat clearing, yelps or Complex Vocal Tics such as words or phrases.
Are there different types of tic disorders?
Transient Tic disorder.
This is common, affecting up to 20% of children at primary school age. They comprise simple motor or vocal tics, usually affecting the head and neck region lasting a few months. They may recur and many dismiss them as ‘little habits’.
Chronic Tic disorder
These motor or vocal tics persist beyond a year and tend to be located in the one body site. Blinking is a common form.
The diagnosis of Tourette Syndrome (TS) requires the presence of a history of multiple motor and at least one vocal tic, although not necessarily at the same time, which occur many times in the day, have persisted for more than a year and which have been present before the age of 21. However for the majority the onset of symptoms is before puberty. These tics tend to come and go (wax and wane). Many individuals report being able to suppress tics for periods of time, but this can require considerable effort (see later – can tics be controlled?)
Are people aware of their tics?
Many children are totally unaware of their tics. It is their parents or teachers who notice them and may draw the child’s attention to them in the misunderstanding that the child has control over them. This failure to appreciate that they are involuntary movements or noises can sometimes lead to conflict between the adult and child. Adults with TS are usually aware of tics, but may not have known what they were if they were not diagnosed during their childhood/teenage years.
Can tics ever be controlled?
As people with TS get older they may become aware of an urge or sensation before a tic is about to occur. Performing the tic gets rid of the sensation but it may recur. However many report that when they get the sensation that they can suppress tics for a while at school or work. This may
involve doing a movement that counteracts the tic, which is the basis of Habit Reversal Therapy which is discussed elsewhere, or distracting themselves in some other way. Sometimes suppression is followed by a period of release of tics at home which parents /family/others can find confusing or upsetting. Some people find it very difficult to suppress the tics, and many people report that suppressing tics can take a lot of energy and concentration, which may lead to tiredness or poor attention in school or at work. A history of being able to suppress tics helps to distinguish tics from other movement disorders.
How is TS Diagnosed?
The diagnosis of Tourette Syndrome is based on history as well as observation. There are no blood tests or X-rays that can confirm the diagnosis. The clinician will get a detailed account of the tics, when they first appeared and how they have developed. In particular the clinician will want to clarify whether the tics interfere in any way with the person’s life. For children and young people, the clinician will want to check if tics are affecting a child’s normal educational or social development – for example, do they interfere in the classroom, while with friends or at home. It is also necessary to clarify whether the tics are causing pain or worry for the child or parent /adult. Does the person experience ‘urges’ to tic or are there any triggers for tics such as worry, excitement, or time of year? Has the child/young person/adult developed any strategies for controlling tics? Finally the clinician will also want to rule out the presence of other medical or neurological conditions.
The clinician will want to establish whether there is a history of one of the other co-occurring conditions which are often present and will also want to enquire about a family history of tics and the co-occurring conditions.
While the history of the development of the Tic Disorder forms the major part of the assessment the clinician will take account of what is observed at the clinic. Frequently tics are not to be observed during the clinical assessment; they are more likely to be observed in the waiting area!
Who should assess and treat TS.
Many parents or people with tics wonder why they are being referred to psychiatry services and not a neurologist for assessment of a movement disorder. While the diagnosis of Tourette Syndrome can be confirmed by either clinician the main reason psychiatrists (adult or child depending on age) are involved is because of the symptoms/conditions that often co-occur with Tourette Syndrome. These include:
• Attention Deficit Hyperactivity Disorder in 60% of children with TS
• Obsessive Compulsive Disorder in 50%
• Specific Learning Difficulties
These conditions, when present, are often the reason a parent or adult sufferer seeks help. The behaviours linked to them may be the reason why a child or adult may be experiencing significant difficulties. This may be particularly true for children at school, while the tics themselves may not be causing problems for the child. Your GP is often the best person to advise you on what services are available in your area, and can help facilitate referral to a specialist for assessment and support.
Are there other conditions that can be confused with Tourette Syndrome?
Yes a number of conditions may be confused with Tourette Syndrome.
• Sometimes tics are confused with other types of movement disorder such as Dystonia which is a sustained muscle contraction that may lead to an abnormal posture or Tremor which is a rhythmic oscillation of a body part such as a hand.
• Inherited conditions such a Huntington’s Chorea or Wilson’s Disease, a disorder of Copper metabolism may present with tics and other symptoms
• Some tics may arise following the use of certain medications over a long period or a high doses
• If simple tics have not been present or the history is not typical or arises in adolescence or adulthood the presence of a condition other than a Tic disorder should be considered in collaboration with a Neurologist.
What treatments are available?
The first thing to remember is that tics seldom need treatment in their own right. There are many people who have tics and only take note of them when attention is drawn them by someone else. This is particularly true of children. It is their parents who notice them more. While it is understandable that a parent would want the tics to stop it is important to be sensitive to the fact that the child may be unaware of then and unconcerned about them. If they are not causing a problem for the child it is best that a parent avoid commenting about them, even if it’s difficult! Focus instead on the child’s strengths.
The most important treatment intervention is having information about Tic Disorders, a child’s particular repertoire of tics and the factors that influence them, together with the knowledge from research that Tics may fade in adolescence in the majority of children. Basic knowledge helps parents, children and teachers cope and adapt the child’s environment to minimise the impact of the Tic Disorder. This is also true for adults with tics. See our information leaflet ‘Living with TS’ for moreinformation on strategies to manage tics on a day to day basis.
For people who would like more detailed information a range of books options suitable for children, parents, adults, health professionals or teachers are included in our booklist.
For those with persistent tics that are causing ongoing distress and interference in day to day life, additional treatment options may be considered or available. These include non-medical strategies such as Habit Reversal Therapy or Exposure and Response Prevention. Medications may be used by specialists to reduce the severity of tics, however, it is important to know that medications do not ‘cure’ or completely stop tics. As for all medications the decision to consider their use should only be made with your doctor who will discuss the appropriateness, benefits and risks of any medication with you. Finally as discussed before many people with TS may have co-occuring conditions which may require treatment in their own right (see More than Just Tics for more information).