Summary
Tic disorders are neurological conditions characterized by sudden and rapid movements and/or vocalizations. Primary tic disorders begin in childhood and include Tourette syndrome, persistent (chronic) motor or vocal tic disorder, and provisional tic disorder. Primary tic disorders are often associated with other conditions, including attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). The diagnosis is clinical and confirmed using DSM-5-TR diagnostic criteria. The degree of functional impairment should be determined to guide management. Patients without functional impairment may be managed expectantly. Comprehensive behavioral intervention for tics (CBIT) is recommended for all patients with functional impairment. Depending on the response to CBIT, comorbidities, and the severity of symptoms, additional treatment options may be considered, including pharmacological treatment (e.g., alpha-2 receptor agonists, dopamine antagonists) and advanced treatments (e.g., botulinum toxin injection, deep brain stimulation).
Epidemiology
- Sex: ♂ > ♀ [1]
- Age of onset: usually 4–6 years of age (tics are most severe between 10–12 years of age and then decline during adolescence) [1]
Epidemiological data refers to the US, unless otherwise specified.
Etiology
- Hypothesized to be a combination of environmental, social, psychological, and genetic factors
- Associated conditions
- ADHD and/or OCD (most common)
- Learning disabilities
- Sleep disorders
- Conduct disorder and oppositional defiant disorder
- Mood and anxiety disorders
Clinical features
-
Tic: sudden and rapid movements or vocalizations that are intermittent, nonrhythmic, and without any recognizable purpose [1][2]
- Usually involuntary but may be temporarily suppressible
- Premonitory urge: An urge or sensation preceding the tic is relieved by its onset.
- Exacerbated by factors such as fatigue and excitement [2]
- Tic types [1]
| Common features of vocal and motor tics [1] | ||
|---|---|---|
| Simple | Complex | |
| Vocal tics |
|
|
| Motor tics |
|
|
Diagnosis
Primary tic disorders are clinical diagnoses confirmed with DSM-5-TR criteria. [1]
DSM-5-TR diagnostic criteria for Tourette syndrome [1]
The patient must meet all the following criteria:
- Onset < 18 years of age
- ≥ 2 motor tics and ≥ 1 vocal tic
- Symptoms persist for > 1 year (can wax and wane in frequency).
- Not explained by substance use or other medical conditions (see “Differential diagnoses”)
DSM-5-TR diagnostic criteria for persistent (chronic) motor or vocal tic disorder [1]
The patient must meet all the following criteria:
- Onset < 18 years of age
- ≥ 1 motor or vocal tics
- Symptoms occur for > 1 year and can wax and wane in frequency.
- Criteria for Tourette syndrome are not met.
- Not explained by substance use or other medical conditions (see “Differential diagnoses”)
DSM-5-TR diagnostic criteria for provisional tic disorder [1]
The patient must meet all the following criteria:
Differential diagnoses
-
Adult-onset tics [3][4]
- Onset of tics after the age of 18 years
- Primary tics (idiopathic): not explained by other medical conditions or substance use (e.g., cocaine); very rare
- Secondary tics: due to a medical condition (e.g., brain lesions, brain injury, neurodegenerative disease) or substance use; much more common
-
Stereotypic movement disorder
- Stereotypic, uncontrolled, repetitive movements lasting ≥ 4 weeks
- More common in children, especially boys, with neurological disorders and developmental delay
- Includes rocking movements, hair pulling, hair twisting, and self-destructive behavior (e.g., head banging, picking at skin, hitting oneself) [5][6]
- Tardive dyskinesia
- Huntington disease
- Sydenham chorea in rheumatic fever
- Spasmus nutans (nodding spasm)
- Myoclonus
- Oromandibular dystonia
- Blepharospasm
- Hemifacial spasm
The differential diagnoses listed here are not exhaustive.
Management
In patients with chronic tic disorders, treatment is aimed at improving symptoms and quality of life. [7][8]
Approach [7][8]
- All patients
-
Patients with no functional impairment
- Consider expectant management.
- Refer for CBIT, if interested.
-
Patients with functional impairment [2][8];
- Behavioral therapy is the preferred initial treatment option.
- Pharmacological treatment or advanced treatments may be used depending on any of the following; consult a specialist:
- Degree of impairment
- Presence of comorbidities
- Behavioral therapy is ineffective or unavailable.
Tic disorders can have a waxing and waning course; regularly assess the treatment regimens to determine the need for treatment escalation or tapering. [7]
Closely monitor patients for suicidal ideation and start management of suicidal behavior if necessary. [7]
Behavioral therapy [7]
-
Comprehensive behavioral intervention for tics (CBIT)
- Indication: all patients with tic disorders and functional impairment
- Components [2]
- Habit reversal training: to identify premonitory urges and train patients to suppress tics
- Functional assessment and intervention: to identify and change environmental situations that worsen tics
- Relaxation training (e.g., diaphragmatic breathing): to reduce anxiety
- Alternative options such as exposure and response prevention can be used if CBIT is not available.
Pharmacological treatment [7]
There is no consensus on a preferred drug; use shared decision-making and consider factors such as the risks and benefits of therapy and comorbid conditions.
- Alpha-2 receptor agonists; (off-label): e.g., clonidine, guanfacine; can also be used for the treatment of ADHD
- Dopamine antagonists: e.g., aripiprazole, haloperidol, risperidone (off-label), pimozide
- Additional options with limited evidence include:
- Topiramate (off-label)
- Vesicular monoamine transporter-2 inhibitors such as tetrabenazine (off-label)
- Cannabis (off-label)
Advanced treatments [7]
- Botulinum toxin injection: for focal motor tics or disabling vocal tics in adults and adolescents
- Deep brain stimulation: for severe tics (e.g., causing harm to the patient) or tics refractory to other treatment modalities
Prognosis
- Symptoms improve during adolescence. [9]
- May resolve spontaneously by 18 years of age (50% of cases) [10]