A Clear Practical Approach for the Parents.
Dr. Grossmann has provided this page as a clear and practical resource for patients and their families who live with tic disorders. Please click on the highlighted, underlined words of the questions or topics you are interested in.
Tics are involuntary twitches that may involve any voluntary muscle groups. Tics may be partially controlled, usually for a short duration during which a person makes a strong effort to control them. Later, however, the tics will reoccur and may be stronger due to the compensation attempt. Tics may consist of eye blinking, facial grimacing, nasal flaring, or mouth opening. To best understand how a person with a tic disorder feels, one may try to refrain from blinking his own eyes for a long period of time. This will be easy initially, but after about 30 seconds the blinking will occur almost automatically. This is how a person with a tic disorder feels constantly. Tics become worse when people are under stressful situations. Usually presenting for the first time when a family emergency or a move from a safe environment occurs.
Tics usually fluctuate in intensity and if they occur only temporarily, they do not qualify for any specific tic disorder.
Tics may be motor or vocal; the vocal tics include humming, grunting, or saying actual words, usually in an explosive, spastic fashion, (the words may be curses).
Tics may be simple or complex. A simple tic is purposeless, such as an eye blink, any other muscle twitch, a grunt, or a production of a noise. A complex tic consists of a muscle movement with a purpose, such as scratching, throwing, or chewing. A vocal complex tic is one that actually produces a word, not just a sound.
The most complicated and concerning tic disorder is Tourette's disorder. This disorder requires the presence of tics for at least 1 year. The tics must be motor and vocal in nature. The tics must be frequent, never stopping for a period of longer than 2 months. They also must be causing a significant impairment. Tourette's disorder is a combination of multiple tics, AD/HD like symptoms, and obsessive-compulsive difficulties.
This is a disorder of a combination of both vocal and motor tics. It should be considered a part of a behavioral disorder spectrum that consists of tics, obsessive-compulsive behavior, and attention deficit hyperactivity disorder. In order to qualify for the diagnosis of Tourette's disorder the tics must be present for over 1 year and never resolve for a period longer than 2 months. The natural course of the disorder is fluctuating. The fluctuations of the symptoms may or may not be related to stress factors.
The origin of the disorder is genetic, believed to be transmitted in an autosominal dominant manner, but other genetic factors may play a role, including gene amplification (worsening with consecutive generations) and genetic imprinting (having a different presentation in inherited from the mother's or father's chromosomes). The usual presentation of Tourette's disorder is with some increasing hyperactivity and irritability. At this time some kids may be diagnosed with AD/HD and started on stimulant medication, to be later discontinued as tics develop. The tics usually evolve initially involving motor tics in the face area, such as eye blinking, facial grimacing, hair fixing, mouth opening, nasal flaring, and neck jerking. The tics then evolve to the shoulders and extremities. Usually the vocal tics develop later and frequently consist of throat clearing. Other vocal tics may consist of humming sounds, grunting, high-pitched noises, yelling, and actual words, usually curses.
The vocal and motor tics may occur concomitantly but don't have to in order to qualify for the diagnosis of Tourette's.
Obsessive-compulsive behavior, anxiety, and depression may be associated with the disorder and usually develop later into the course of the disorder.
The full-blown condition may be extremely disruptive and living with it may be difficult. Treatment may be helpful to various degrees.
Tics may be caused by extreme stress, some medications including Ritalin, Dexedrine, and Adderall (stimulants), or Tegretol may cause them. On rare occasions, some infections that involve the brain (encephalitis) may be associated with tics. Other genetic and metabolic disorders, mostly those that affect the basal ganglia may be associated with tics or with tic-like phenomenon. Also viral infections may rarely cause tics. Streptococcal infections have been associated with the development of tics and obsessive-compulsive behaviors. PANDAS or pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, is a known entity in which the antibodies to the streptococcal bacteria attack the basal ganglia causing the above-mentioned symptoms.
Tics must be differentiated from chorea. Chorea is a movement disorder that unlike tics, cannot be reproduced by an observer, is more difficult to suppress, and is incorporated into voluntary movements. Rarely some seizures may be brief and rapid imitating tic disorders.
Most children with tics do not require treatment. The fluctuating course of the disorder makes waiting a prudent choice; it also makes it difficult to clearly assess response to the medications, since a regular fluctuation rather than medication effects may cause worsening or improvements. When treatment is considered, different neurologists may have some slightly different approaches.
Clondine (Catapress) may be used as the first line of therapy by some. The advantage is that it is available in a patch form that may be replaced once per week, not requiring a daily ingestion of tablets. Like Guanephezine (Tenex) it is a centrally acting blood pressure medication that may benefit tics and calm down the hyperactive behavior. In some, especially with Tenex, parents report an improvement in attention span and school performance.
Other tic suppressing medications included pimozide, fluphenazine, and haloperidol. These are highly effective, but may be associated with some serious side effects, including liver and blood clot dysfunctions, weight gain, allergic reactions, dystonic reactions, and tardive dyskinesia. Tardive dyskinesia is a potentially irreversible movement disorder that involves the mouth, tongue, and extremities. Other medications helpful in this situation include the SSRI's (selective serotonin reuptake inhibitors); these include Prozac, Zoloft, Paxil, Luvox, and Celexa. These medications may reduce anxiety and improve obsessive-compulsive inclination and behavior. Their primary indication is as antidepressants. Depression plays an active role in late Tourette's disorder patients.
Other treatments include psychological counseling, behavioral modification, support groups, and biofeedback with limited results.
The natural course and outcome of this disorder is variable and in many situations as the individual matures the degree of the tics and the disorder tunes down gradually, regardless to the medications effects.
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