Transient tics are common and can affect between 11% and 20% of school-age children at some point during childhood. In various studies and population samples, there is a wide range of prevalence estimates for Tourette Syndrome and chronic tic disorders. Studies have shown chronic tic disorders ranging from 0.3-5% for Chronic Motor Tic Disorder and 0.024-0.94% for Chronic Vocal Tic Disorder. Tourette Syndrome is defined by two or more motor tics and one or more vocal tics lasting at least one year with an onset before the age of 18. Tourette Syndrome affects approximately 1% of school aged children, with estimates ranging from 2.6 to 38 per 1000 children. Boys are more likely than girls to have the diagnosis.
The tics associated with tic disorders are characterized by sudden, rapid, recurrent movements, or vocalizations which are not rhythmic and not goal-directed. The tics are often preceded by a premonitory sensation which is a feeling of tension or tingling at the location where the tic arises combined with a mental urge to perform the tic. The feeling is relieved for a time by performing the tic. There is variability, but some tics can be voluntarily suppressed for seconds or even up to several hours. Suppression of the tic may be followed by a worsening of the feeling or urge. Tic frequency is usually reduced when the child is relaxed or distracted by an activity which requires mental and motor focus. Tics are often worsened by stress and lack of sleep.
Tics generally begin in childhood and demonstrate a waxing and waning course. Tic severity is at its worst between 10 and 12 years old. Most children experience an improvement in tics during adolescence. Because tics often naturally improve with time, watchful waiting is appropriate for individuals who do not experience significant functional impairment. There is no evidence that treatment is more effective the earlier it is started.
Treatment of Tic Disorders
Psychoeducation should be provided to the patient and family about tic disorders. If patients are comfortable and motivated, they can be encouraged to talk to their teachers and peers about tics and Tourette Syndrome. It can also be helpful to refer families to resources for psychoeducation to provide to teachers and peers, such as the Tourette Association of America. https://tourette.org/resources/back-to-school-resource
The first line treatment is therapy, specifically, Comprehensive Behavioral Intervention for Tics. Comprehensive behavioral intervention for tics (CBIT) is a therapeutic intervention which includes habit reversal training, relaxation training, and interventions designed to address situations which may worsen tics. Patients are trained to perform a competing behavior to avoid a tic whenever they feel a premonitory sensation. Habit reversal training can also be helpful if there is not access to a clinician trained in CBIT.
Because comorbidities are common in children with tic disorders, a number of other diagnoses should be screened for. This includes ADHD, Obsessive Compulsive Disorder, other anxiety disorders and Oppositional Defiant Disorder. Comorbid ADHD has prevalence ranging from 30% to 50%. When treating tics and ADHD, studies have shown clonidine and guanfacine are more likely than placebo to reduce tic severity and reduce ADHD symptoms. In children with tics and ADHD, atomoxetine and methylphenidate do not worsen tics relative to placebo.
Obsessive Compulsive Disorder cooccurs with tic disorders in 10%–50% of children. Trials of interventions for OCD in children with tics suggest that these children may not respond as well as those without tics to selective serotonin reuptake inhibitors. They do respond equally well to cognitive behavioral therapy (CBT). Because of this, CBT is considered first-line treatment of OCD in individuals with tic disorders.
Topiramate is currently recommended for use in relatively mild cases when other therapy cannot be tolerated. For localized bothersome motor or vocal tics, botulinum toxin injections can be a useful alternative to other medical therapies.
The use of antipsychotic medications for treatment of tics dates back to the late 1960s when haloperidol was approved by the US Food and Drug Administration for treatment of Tourette Syndrome. Pimozide was the second antipsychotic approved by the FDA for the treatment of Tourette Syndrome. In 2014 the FDA approved aripiprazole for Tourette Syndrome. Other studies have evaluated ziprasidone and risperidone and found them to be effective in reducing the frequency and intensity of tics compared to placebo. Because of the risks of treatment with antipsychotic medications, including tardive dyskinesia, weight gain, metabolic syndrome, prolactin increase, and QTC prolongation, they are not recommended as a first line agents for treating tics.
References:
- “An Update on the Diagnosis and Management of Tic Disorders”
Annal ofs Indian Academy of Neurology 2023 Nov 29;26(6):858–870. doi: 10.4103/aian.aian_724_23
www.bmj.com/content/376/bmj-2021-0693462.
2. American Academy of Neurology (AAN) practice guideline, “The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders,” Neurology ® online on May 6, 2019
- Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders.
Neurology. 2019 May 7;92(19):896–906. doi: 10.1212/WNL.0000000000007466
pmc.ncbi.nlm.nih.gov/articles/PMC6537133/
AUTHOR:
Dr. Melissa Lorang, MD
Child, Adolescent and Adult Psychiatrist
Vista Hill Foundation