Tic Disorders

Tic disorders belong to the group of extrapyramidal motor hyperkinesias. This means that they involve excessive movements. These can be simple muscle twitches as well as complex sequences of movements. Verbal exclamations may also occur. Although it is a rare tic disorder, Gilles-de-la-Tourette syndrome (or "Tourette syndrome") is well known in the general population. In this manifestation, there are multiple motor and vocal tics, but they do not necessarily occur at the same time.

In childhood, tic disorders are very common and in most cases are not a cause for concern. About a quarter of all children develop tics, which disappear spontaneously within a few days to weeks. Therapy is not necessary in this case.

In addition to genetic predisposition, pregnancy also plays a role in the development of tic disorders. Studies have shown a connection with smoking, alcohol consumption, medication, drugs and stress during pregnancy. Infections with certain bacteria could also trigger the development of a tic disorder, for example after a middle ear infection, scarlet fever or tonsillitis.

A tic is a rapid, involuntary movement or sound production that is repeated but not rhythmically executed. Although they cannot be controlled directly, they can be suppressed for individually varying periods of time. Stress can intensify them, but they also occur in relaxed situations. Tics do not occur during sleep. The symptoms can fluctuate greatly and even disappear completely for a time before they reappear. A distinction can be made between simple and complex tics, and between motor and vocal tics.

Examples of simple motor tics include:

• Head movements
• Blinking, squinting eyes
• Shoulder shrugging
• Grimacing

Examples of complex motor tics include:

• Bouncing
• Body contortions
• Echopraxia: imitating other people's movements

Examples of simple vocal tics include:

• Clearing throat
• Animal sounds (e.g., barking)
• Smacking

Examples of complex vocal tics include:

• Echolalia: repeating other people's words and phrases
• Coprolalia: exclaiming fecal language or obscene terms.

In the beginning, the tics are often not noticed by the affected children. In most cases, parents or teachers are the first to notice the strange behavior. Later, those affected often have a premonition just before a tic occurs. In addition, there is often a sense of suffering due to the exclamations and movements that are perceived as inappropriate. It is not uncommon for those affected to encounter incomprehension, indignation or rejection. In particular, coprolalia, i.e. the exclamation of obscene words, can lead to conflicts with fellow human beings. Although it is the best-known symptom, coprolalia is not that common. In Tourette's sufferers, it is only about 10 to 20 percent.

In most cases, the diagnosis is made at a late stage. It is mainly made by taking the symptoms (anamnesis). The extent of the tics, their course, suppressibility and sense of foreboding are particularly important. In this way, a tic disorder can be distinguished from other movement disorders or obsessive-compulsive disorders. Since affected children often do not notice all tics, it can help to involve the parents. Risk factors such as tic disorders in the family (family history) and recent infectious diseases should also be collected. The Yale Global Tic Severity Scale (YGTSS) questionnaire can be used to assess the severity of the disorder.

Other syndromes must also be considered, for example:

• Blepharospasm: spasms in the eyelid muscles, usually bilateral.
• Oromandibular dystonia: repetitive muscle spasms in the mouth region
• Spasmus hemifacialis: unilateral painless muscle twitching, usually with onset around the eye

Imaging by MRI or measurement of brain activity by EEG is usually not required, but may rule out other disorders in certain cases.

Tic disorders are usually only treated with medication if they cause pain, sleep problems, reduced performance or psychological stress. Unfortunately, there is no causal treatment, but there are drugs that achieve symptomatic improvement. This leads to an alleviation of the symptoms, which reduces the stress. However, a complete suppression of the tics is usually not possible. The principle of therapy is based on dopamine blockers, which balance the excess of dopamine in the basal ganglia.

Typical drugs would be

• Tiapride (Delpral®), sulpiride
• Pimozide
• Haloperidol (Haldol®)
• risperidone (Risperdal®)
• tetrabenazine, topiramate, THC

The substance class of dopamine blockers can often cause hormonal disturbances, which can manifest themselves, for example, in loss of menstruation, orgasmic disturbances, breast pain and breast swelling, breast growth in men (gynecomastia), milk production and potency disorders. These side effects are usually reversible after discontinuation.

Furthermore, Parkinson's-like symptoms may occur, such as hand tremors, muscle stiffness, lack of movement, and increased salivation.

Other side effects include.

• drowsiness, listlessness, lack of strength
• restlessness, insomnia
• confusion, hallucinations
• dizziness, headache

Irrespective of drug treatment, psychoeducation of those affected and their relatives is particularly important. Through counseling and education, the disease can be better understood and thus the psychological and social burden can be reduced. Often, this measure alone can lead to sufficient coping with the disease. In more severe cases, additional behavioral therapy methods can be used. Habit Reversal Training" (HRT) strengthens the early recognition of tics so that they can be counteracted, for example, by muscle tension. Exposure and Response Prevention Training" (ERPT), i.e. reaction avoidance training, attempts to break through the tic reaction to the unpleasant pre-existing sensation.

Other approaches rely on relaxation techniques. In Jakobsen's progressive muscle relaxation, for example, various muscle groups are tensed and then relaxed again, ultimately relaxing the person psychologically. For all psychotherapeutic methods, it is important to consider the age of the person affected. Especially when the disease begins in childhood, it can happen that the children are still too young to implement the therapeutic approaches.

In very rare cases, neurosurgical treatment by deep brain stimulation can be used.

It is also important to treat comorbidities, or co-occurring disorders. These include ADHD or obsessive-compulsive disorder, both of which can be treated using various psychotherapeutic approaches. Psychostimulant drugs are also available for ADHD symptoms, such as methylphenidate (Ritalin®, Concerta®). Antidepressants are used for obsessive-compulsive disorders.

Tic disorders are often chronic. Symptoms usually begin in childhood before the age of 10 and may persist into adulthood. However, 20 to 70% become symptom-free again. Tics often occur together with disorders such as ADHD, Asperger's autism, obsessive-compulsive disorder, or other psychological complaints.

There is no specific prophylaxis to prevent tic disorders. Since there is evidence of a connection with substance abuse during pregnancy, especially for tobacco smoke and alcohol, these addictive substances should be avoided during pregnancy.