What Are Tics?

Tourette syndrome (TS) is a neurological disorder that commonly appears in childhood that is marked by repetitive, involuntary movements and utterances (tics). These tics may be simple (e.g., eye blinking, grunting) or complex (e.g., body twisting, touching objects, repeating words, uttering obscenities).

Named after George Gilles de la Tourette, the French neurologist who first described the condition, TS may also be referred to as Tourette disease or Tourette disorder.

An estimated 200,000 people in the United States have a severe form of TS, according to the National Institute of Neurological Disorders and Stroke (NINDS). Some sources estimate that 1 to 2 percent of American children and adults have the condition. However, the actual number of people with TS may be higher because many individuals may have minor tics that go undiagnosed.

Medical scientists do not completely understand the causes of the disorder. Because TS can manifest in complex motor skill dysfunction, it is likely that a complex mechanism of central nervous system interaction is involved. Environmental factors may also play a role.

Some researchers believe that an abnormality or dysfunction in regions of the brain responsible for movement (e.g., the basal ganglia, cerebral cortex) may contribute to the disorder. The neurons (nerve cells) in these regions send messages via the spinal cord through chemical neurotransmitters such as dopamine, serotonin and norepinephrine. Muscles contract or move in response to signals from these chemicals. However, when these neurons or neurotransmitters do not function properly, communication between the brain and various muscle groups is disrupted, and movement disorders can occur. Medications commonly prescribed to treat TS work by blocking the production of dopamine, serotonin and norepinephrine. This in turn helps to reduce, and in some cases eliminate, the number of tics associated with TS.

Because of the unusual behavior associated with the condition, some people mistakenly believe that individuals with TS have a mental illness.

Many people with TS also tend to have certain other disorders, such as attention-deficit hyperactivity disorder and obsessive-compulsive disorder. There also appears to be an increased risk of depression and substance abuse among patients with TS.

How is it diagnosed?

There are no blood or other laboratory tests to confirm whether an individual has Tourette syndrome (TS). A pediatrician, neurologist or other physician will obtain a complete family medical history and conduct a physical examination of the patient.

Since minor muscle tics are not unusual in some children, parents may be asked to observe and report their child's symptoms for at least one year. They will also likely be asked the following:

• Is the tic motor or vocal? Does it occur alone or in combination with other motor or vocal tics?
• How many times a day or week does the tic occur? Do tics continue during sleep?
• Where on the body are the tics located? What is the duration of the tic?
• Has a parent or other observer witnessed the tics or recorded (videotaped) them in any way?

If motor and vocal tics continue beyond a year, the physician may then diagnose TS as a possible cause.

Another important factor in diagnosis is whether the patient experiences urges or feelings prior to having a tic (premonitory urges) and whether they are able suppress the tic. The ability to suppress an involuntary tic distinguishes TS from other movement disorders that are completely uncontrollable.

Physicians may also look for the presence of certain other behavioral disorders that are often present concurrently in individuals with TS. These include attention deficit hyperactivity disorder (ADHD) and obsessive compulsive disorder (OCD).

Atypical symptoms such as adult onset TS may take longer to diagnose. Diagnosis may also be delayed in children who exhibit symptoms only sporadically or whose family members or physicians may overlook the symptoms. Repeated sniffing, for example, may be confused with having allergies and repetitive eye blinking may be mistaken for vision problems.

The neurologist or pediatrician may order one of the following neuroimaging studies (primarily to rule out the presence of other disorders that may be causing the symptoms):

• Magnetic resonance imaging (MRI). MRI is a noninvasive procedure that uses powerful magnets and radio waves to produce clear, cross-sectional or three-dimensional images of bodily tissues.
• Computed axial tomography (CAT) scan. A CAT scan is a noninvasive or minimally invasive test that uses a rotating x-ray device and computer to create three-dimensional, cross-sectional images (or slices) of the brain and skull.
• Electroencephalogram (EEG). During this painless test, small metal devices called electrodes are attached to the scalp. The electrodes are connected by wires (leads) to an electroencephalograph machine that charts the electrical activity of the brain.

Treatment of Tourette syndrome

There is no cure for Tourette syndrome (TS), which can go into remission or vary in severity or frequency over time. Many children outgrow the condition by as early as age 18, although they may experience periodic recurrences later in life.

For the majority of people with TS, motor and vocal tics are not severe enough to warrant any kind of treatment. When tics are severe or cause behavior that disrupts normal social activities (work, school or daily life), treatment is considered to control the involuntary movements or outbursts.

Severe cases of TS may respond well to medication therapy. Antipsychotic drugs that block dopamine receptors in the central nervous system may help reduce the frequency and severity of tics. In addition, antidepressants (selective serotonin reuptake inhibitors), stimulants and alpha adrenergic inhibitors may also be prescribed to help control tics.

Antidyskinetics may also be recommended to treat TS. These medications are typically prescribed at low doses and slowly increased over time to a level that best controls tics while minimizing side effects. Use of these medications must be weighed against any associated side effects, including sedation.

Patients must be sure to inform their physicians of all prescription and over-the-counter medications or herbal supplements they are taking. In addition, there is a risk of a patient developing tardive dyskinesia (which also involves repetitive, involuntary movement) as a result of using certain medications. Patients' medications for TS should be monitored over time to ensure that they are always receiving the proper dosage level and to determine whether therapy may be discontinued.

Other treatment options may include:

• Psychotherapy. Counseling from a mental health professional can help reduce stress and anxiety that often precede TS tics. It may also be helpful in treating any accompanying behavior disorders, such as attention deficit hyperactivity disorder (ADHD) or obsessive compulsive disorder (OCD). Counseling may also help a person cope with the disorder, as well as the social and emotional problems that sometimes result from having TS.
• Muscular injections. Injections of botulinum toxin (Botox) appear to significantly reduce tics as well as the premonitory urges that precede them.
• Deep brain stimulation. In rare cases where patients have disabling tics that do not respond to other treatment methods, the neurologist may recommend deep brain stimulation of the globus pallidus, thalamus or other subcortical regions of the brain. The procedure involves using a battery-powered device (neurostimulator) to help control the tics.
• Complementary and alternative medicine. People have tried using relaxation techniques, biofeedback, cognitive behavior modification, hypnosis and various herbal supplements to reduce the number and severity of tics they experience. However, none of these treatments have been scientifically proven to be effective.

There is no known prevention method for TS. Some people with the condition report the ability to temporarily suppress muscle or vocal tics when they feel premonitory urges. However, the tic eventually occurs, sometimes in a more explosive release.

Medications

Geodon (Ziprasidone), Klonopin (Clonazepam)

What might complicate it?

Stressful situations can aggravate tics. Also, the presence of an underlying disease such as a tumor may complicate this disorder.

Predicted outcome

The course of this disorder is unpredictable; relapses and remissions are common. Tics may be temporary or permanent.

Alternatives

Retardation, autism, schizophrenia, drug-induced tardive dyskinesia, tic douloureux, and essential myoclonus are other possibilities.

Appropriate specialists

Neurologist and psychiatrist.

Last updated 30 June 2015