|Classification and external resources|
A tic is a sudden, repetitive, nonrhythmic motor movement or vocalization involving discrete muscle groups. Tics can be invisible to the observer, such as abdominal tensing or toe crunching. Common motor and phonic tics are, respectively, eye blinking and throat clearing.
Tics must be distinguished from movements of other movement disorders such as chorea, dystonia, myoclonus; movements exhibited in stereotypic movement disorder or some autistic people, and the compulsions of obsessive-compulsive disorder (OCD) and seizure activity.
|Video clips of tics|
Tics are classified as either motor or phonic, and simple or complex.
Motor or phonic
Motor tics are movement-based tics affecting discrete muscle groups.
Phonic tics are involuntary sounds produced by moving air through the nose, mouth, or throat. They may be alternately referred to as verbal tics or vocal tics, but most diagnosticians prefer the term phonic tics to reflect the notion that the vocal cords are not involved in all tics that produce sound.
Simple or complex
Simple motor tics are typically sudden, brief, meaningless movements that usually involve only one group of muscles, such as eye blinking, head jerking, or shoulder shrugging. Motor tics can be of an endless variety and may include such movements as hand clapping, neck stretching, mouth movements, head, arm or leg jerks, and facial grimacing.
A simple phonic tic can be almost any sound or noise, with common vocal tics being throat clearing, sniffing, or grunting.
Complex motor tics are typically more purposeful-appearing and of a longer nature. They may involve a cluster of movements and appear coordinated. Examples of complex motor tics are pulling at clothes, touching people, touching objects, echopraxia (repeating or imitating another person's actions) and copropraxia (involuntarily performing obscene or forbidden gestures).
Complex phonic tics include echolalia (repeating words just spoken by someone else), palilalia (repeating one's own previously spoken words), lexilalia (repeating words after reading them), and coprolalia (the spontaneous utterance of socially objectionable or taboo words or phrases). Coprolalia is a highly publicized symptom of Tourette syndrome; however, only about 10% of TS patients exhibit coprolalia.
Tics are described as semi-voluntary or unvoluntary, because they are not strictly involuntary—they may be experienced as a voluntary response to the unwanted, premonitory urge. A unique aspect of tics, relative to other movement disorders, is that they are suppressible yet irresistible; they are experienced as an irresistible urge that must eventually be expressed.
Tics may increase as a result of stress, fatigue, boredom, or high-energy emotions, which can include negative emotions, such as anxiety, but positive emotions as well, such as excitement or anticipation. Relaxation may result in a tic increase (for instance, watching television or using a computer), while concentration on an absorbing activity often leads to a decrease in tics. Neurologist and writer Oliver Sacks described a physician with severe Tourette syndrome (Canadian Mort Doran, M.D., a pilot and surgeon in real life, although a pseudonym was used in the book), whose tics remitted almost completely while he was performing surgery.
Immediately preceding tic onset, most individuals are aware of an urge that is similar to the need to yawn, sneeze, blink, or scratch an itch. Individuals describe the need to tic as a buildup of tension that they consciously choose to release, as if they "had to do it". Examples of this premonitory urge are the feeling of having something in one's throat or a localized discomfort in the shoulders, leading to the need to clear one's throat or shrug the shoulders. The actual tic may be felt as relieving this tension or sensation, similar to scratching an itch. Another example is blinking to relieve an uncomfortable sensation in the eye. Some people with tics may not be aware of the premonitory urge. Children may be less aware of the premonitory urge associated with tics than are adults, but their awareness tends to increase with maturity.
Tic disorders occur along a spectrum, ranging from mild (transient or chronic tics) to more severe; Tourette syndrome is the more severe expression of a spectrum of tic disorders, which are thought to be due to the same genetic vulnerability. Nevertheless, most cases of Tourette syndrome are not severe. The treatment for the spectrum of tic disorders is similar to the treatment of Tourette syndrome.
The fifth version of the DSM (DSM-5), published in May 2013, reclassified Tourette's and tic disorders as motor disorders listed in the neurodevelopmental disorder category, removed the word "stereotyped" from the definition of tic to better distinguish between stereotypies and tics, and replaced transient tic disorder with provisional tic disorder, but made few significant other changes.
Dystonias, paroxysmal dyskinesias, chorea, other genetic conditions, and secondary causes of tics should be ruled out in the differential diagnosis. Conditions besides Tourette syndrome that may manifest tics or stereotyped movements include developmental disorders, autism spectrum disorders, and stereotypic movement disorder; Sydenham's chorea; idiopathic dystonia; and genetic conditions such as Huntington's disease, neuroacanthocytosis, Hallervorden-Spatz syndrome, Duchenne muscular dystrophy, Wilson's disease, and tuberous sclerosis. Other possibilities include chromosomal disorders such as Down syndrome, Klinefelter syndrome, XYY syndrome and fragile X syndrome. Acquired causes of tics include drug-induced tics, head trauma, encephalitis, stroke, and carbon monoxide poisoning. Most of these conditions are rarer than tic disorders, and a thorough history and examination may be enough to rule them out, without medical or screening tests.
Although tic disorders are commonly considered to be childhood syndromes, tics occasionally develop during adulthood; adult-onset tics often have a secondary cause. Tics that begin after the age of 18 are generally not considered symptoms of Tourette's syndrome, but may be diagnosed as an "Other specified" or "Unspecified" tic disorder.
Tests may be ordered as necessary to rule out other conditions: For example, when diagnostic confusion between tics and seizure activity exists, an EEG may be ordered, or symptoms may indicate that an MRI is needed to rule out brain abnormalities. TSH levels can be measured to rule out hypothyroidism, which can be a cause of tics. Brain imaging studies are not usually warranted. In teenagers and adults presenting with a sudden onset of tics and other behavioral symptoms, a urine drug screen for cocaine and stimulants might be necessary. If a family history of liver disease is present, serum copper and ceruloplasmin levels can rule out Wilson's disease.
Individuals with obsessive-compulsive disorder (OCD) may present with features typically associated with a tic disorder, such as compulsions that may resemble motor tics. "Tic-related OCD" is hypothesized to be a subgroup of OCD, distinguished from non-tic-related OCD by the content and type of obsessions and compulsions; individuals with tic-related OCD have more intrusive thoughts, and exhibit more hoarding and counting rituals than individuals with non-tic-related OCD.
Tics must also be distinguished from fasciculations. Small twitches of the upper or lower eyelid, for example, are not tics, because they do not involve a whole muscle. They are twitches of a few muscle fibre bundles, which can be felt but barely seen.
- Leckman JF, Bloch MH, King RA, Scahill L. "Phenomenology of tics and natural history of tic disorders". Adv Neurol. 2006;99:1–16. PMID 16536348
- American Psychiatric Association (2000). DSM-IV-TR: Tourette's Disorder. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSM-IV-TR), ISBN 0-89042-025-4. Available at BehaveNet.com Retrieved on August 10, 2009.
- Malone DA Jr, Pandya MM. "Behavioral neurosurgery". Adv Neurol. 2006;99:241–47. PMID 16536372
- Mineka S, Watson D, Clark LA (1998). "Comorbidity of anxiety and unipolar mood disorders". Annual review of psychology 49: 377–412. doi:10.1146/annurev.psych.49.1.377. PMID 9496627.
- Robertson MM. Tourette syndrome, associated conditions and the complexities of treatment. Brain. 2000 Mar;123 Pt 3:425-62. doi:10.1093/brain/123.3.425 PMID 10686169
- Singer HS. "Tourette's syndrome: from behaviour to biology". Lancet Neurol. 2005 Mar; 4(3):149–59. doi:10.1016/S1474-4422(05)01012-4 PMID 15721825
- "The Tourette Syndrome Classification Study Group. Definitions and classification of tic disorders". Arch Neurol. 1993 Oct;50(10):1013–16. PMID 8215958 Full text, archived April 26, 2006.
- Dure LS 4th, DeWolfe J. Treatment of tics. Adv Neurol. 2006;99:191-96. PMID 16536366
- National Institutes of Health (NIH). Tourette Syndrome Fact Sheet. Retrieved on March 23, 2005.
- Packer, L. Tourette Syndrome "Plus"[dead link]. Retrieved on February 12, 2006.
- Doran, Morton L. The Tourette Syndrome Association, Inc., Connecticut Chapter 1998 Educators' Conference; 1998 Nov 6; Danbury, CT.
- Sacks O. An Anthropologist on Mars. Knopf, New York, 1995.
- Cohen AJ, Leckman JF. Sensory phenomena associated with Gilles de la Tourette's syndrome. J Clin Psychiatry. 1992 Sep;53(9):319–23. PMID 1517194
- Bliss J. Sensory experiences of Gilles de la Tourette syndrome. Arch Gen Psychiatry. 1980 Dec;37(12):1343–47. PMID 6934713
- Kwak C, Dat Vuong K, Jankovic J. "Premonitory sensory phenomenon in Tourette's syndrome". Mov Disord. 2003 Dec;18(12):1530–33. PMID 14673893
- Scamvougeras, Anton. "Challenging Phenomenology in Tourette Syndrome and Obsessive–Compulsive Disorder: The Benefits of Reductionism". Canadian Psychiatric Association (February 2002). Retrieved on June 5, 2007.
- Zinner SH. Tourette disorder. Pediatr Rev. 2000 Nov;21(11):372-83. PMID 11077021
- American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 81–85. ISBN 978-0-89042-555-8.
- Neurodevelopmental disorders. American Psychiatric Association. Retrieved on December 29, 2011.
- Moran, M. "DSM-5 provides new take on neurodevelopment disorders". Psychiatric News. January 18, 2013;48(2):6–23. doi:10.1176/appi.pn.2013.1b11
- "Highlights of changes from DSM-IV-TR to DSM-5" (PDF). American Psychiatric Association. 2013. Retrieved on June 5, 2013. Archived February 3, 2013 at the Wayback Machine
- Bagheri, Kerbeshian & Burd (1999).
- Ringman JM, Jankovic J. "Occurrence of tics in Asperger's syndrome and autistic disorder". J Child Neurol. 2000 Jun;15(6):394–400. PMID 10868783
- Jankovic J, Mejia NI. "Tics associated with other disorders". Adv Neurol. 2006;99:61–8. PMID 16536352
- Freeman, RD. Tourette's Syndrome: minimizing confusion. Roger Freeman, MD, blog. Retrieved on February 8, 2006.
- Mejia NI, Jankovic J. "Secondary tics and tourettism" (PDF). Rev Bras Psiquiatr. 2005;27(1):11–17. PMID 15867978
- Adult-onset tic disorder, motor stereotypies, and behavioural disturbance associated with antibasal ganglia antibodies
- Scahill L, Erenberg G, Berlin CM Jr, Budman C, Coffey BJ, Jankovic J, Kiessling L, King RA, Kurlan R, Lang A, Mink J, Murphy T, Zinner S, Walkup J; Tourette Syndrome Association Medical Advisory Board: Practice Committee. "Contemporary assessment and pharmacotherapy of Tourette syndrome". NeuroRx. 2006 Apr;3(2):192–206. doi:10.1016/j.nurx.2006.01.009 PMID 16554257
- Hounie AG, do Rosario-Campos MC, Diniz JB, et al. "Obsessive-compulsive disorder in Tourette syndrome". Adv Neurol. 2006;99:22–38. PMID 16536350
- Freeman, R. Tourette syndrome: minimizing confusion. Retrieved on February 18, 2006.
- Black, Kevin J. Tourette Syndrome and Other Tic Disorders.
- Evidente, GH. "Is it a tic or Tourette's? Clues for differentiating simple from more complex tic disorders." PostGraduate Medicine Online. October 2000 108:5.
- Swerdlow, NR. "Tourette Syndrome: Current Controversies and the Battlefield Landscape". Curr Neurol Neurosci Rep. 2005, 5:329-331. doi:10.1007/s11910-005-0054-8 PMID 16131414
- The Tourette Syndrome Classification Study Group. "Definitions and classification of tic disorders". Arch. Neurol. 50 (10): 1013-6. PMID 8215958. Retrieved on 2005-03-22