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tics [2026/08/05 13:21] – [Tics] Scott Larsontics [2026/08/06 20:54] (current) – Scott Larson
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 ====== Tics ====== ====== Tics ======
-FIXME 
- 
   * Sudden, rapid, recurrent, nonrhythmic motor movement or vocalization that is experienced as involuntary but can often be temporarily suppressed.    * Sudden, rapid, recurrent, nonrhythmic motor movement or vocalization that is experienced as involuntary but can often be temporarily suppressed. 
   * Typical onset between ages **4–6 years** and are preceded by a premonitory urge   * Typical onset between ages **4–6 years** and are preceded by a premonitory urge
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 ====Classification=== ====Classification===
  
-Tics are categorized as **simple** or **complex**:[1]+Tics are categorized as **simple** or **complex**:
  
-- **Simple motor tics**: eye blinking, facial grimacing, shoulder shrugging, head jerking +  * **Simple motor tics**: eye blinking, facial grimacing, shoulder shrugging, head jerking 
-- **Simple vocal tics**: throat clearing, sniffing, grunting +  * **Simple vocal tics**: throat clearing, sniffing, grunting 
-- **Complex motor tics**: coordinated movements appearing purposeful (e.g., simultaneous head turn and shoulder shrug), echopraxia +  * **Complex motor tics**: coordinated movements appearing purposeful (e.g., simultaneous head turn and shoulder shrug), echopraxia 
-- **Complex vocal tics**: repeating words (echolalia, palilalia), or rarely coprolalia+  * **Complex vocal tics**: repeating words (echolalia, palilalia), or rarely coprolalia
  
 ===DSM-5 diagnostic hierarchy=== ===DSM-5 diagnostic hierarchy===
  
-- **Provisional tic disorder**: motor and/or vocal tics for [4][5] Watchful waiting with psychoeducation is appropriate for mild, non-impairing tics.+  * **Provisional tic disorder**: motor and/or vocal tics for < 1year 
 +  * **Persistent (chronic) tic disorder**: motor or vocal tics (not both) for >/= 1 year 
 +  * **Tourette syndrome** >/= 2 motor tics adn >/= 1 vocal tic for >/= 1 year.   
 + 
 +====When to treat==== 
 + 
 +  * Not all tics require treatment.  
 +  * Intervention is indicated when tics cause functional impairment, physical discomfort, or psychosocial distress (embarrassment, bullying).  
 +  * Watchful waiting with psychoeducation is appropriate for mild, non-impairing tics.
  
 ====Treatment approach==== ====Treatment approach====
  
 ===Behavioral therapy (first-line)==  ===Behavioral therapy (first-line)== 
-**Comprehensive Behavioral Intervention for Tics (CBIT)** is the only treatment rated with high confidence for efficacy by the AAN and is recommended before pharmacotherapy.[6][5] CBIT includes habit reversal training (awareness of premonitory urge + competing response), relaxation techniques, and functional interventions. It reduces tic severity by **26–31%** and treatment gains are maintained for ≥6 months in children aged ≥9 years.[6][5] Efficacy appears comparable to pharmacotherapy.[6]+**Comprehensive Behavioral Intervention for Tics (CBIT)** is the only treatment rated with high confidence for efficacy by the AAN and is recommended before pharmacotherapy.  
 +  * Includes habit reversal training (awareness of premonitory urge + competing response),  
 +  * Relaxation techniques 
 +  * Functional interventions.  
 +  * Reduces tic severity by **26–31%** and treatment gains are maintained for ≥6 months in children aged ≥9 years. 
 +  * Efficacy appears comparable to pharmacotherapy.
  
 ===Pharmacotherapy (when behavioral therapy is insufficient or unavailable)=== ===Pharmacotherapy (when behavioral therapy is insufficient or unavailable)===
  
-- **First-line: Alpha-2 agonists** — **guanfacine** and **clonidine** have moderate evidence and a favorable side-effect profile (sedation, hypotension); preferred as initial medication in children. Particularly useful when comorbid **ADHD** is present.[8][4][9][6] +  * **First-line: Alpha-2 agonists** — **guanfacine** and **clonidine** have moderate evidence and a favorable side-effect profile (sedation, hypotension); preferred as initial medication in children. Particularly useful when comorbid **ADHD** is present. 
-- **Second-line: Atypical antipsychotics** — **aripiprazole**, **risperidone**, and tiapride have evidence for tic reduction but carry risks of metabolic syndrome and tardive dyskinesia.[6][9] +  * **Second-line: Atypical antipsychotics** — **aripiprazole**, **risperidone**, and tiapride have evidence for tic reduction but carry risks of metabolic syndrome and tardive dyskinesia. 
-- **Third-line: Typical antipsychotics** — haloperidol and pimozide are effective but reserved for refractory cases due to significant adverse effects (extrapyramidal symptoms, QT prolongation).[9]+  * **Third-line: Typical antipsychotics** — haloperidol and pimozide are effective but reserved for refractory cases due to significant adverse effects (extrapyramidal symptoms, QT prolongation).
  
-**Comorbidities** are common and should be assessed: **ADHD** (alpha-2 agonists can treat both), **OCD** (SSRIs or CBT with exposure/response prevention), anxiety, and learning difficulties.[2][6]+**Comorbidities** are common and should be assessed: **ADHD** (alpha-2 agonists can treat both), **OCD** (SSRIs or CBT with exposure/response prevention), anxiety, and learning difficulties.
  
 ====References==== ====References====
  
-  - Diagnostic and Statistical Manual of Mental Disorders. Dilip V. Jeste, Jeffrey A. Lieberman, David Fassler, et al. American Psychiatric Association (2022) +  - [[https://docs.eyefixer.org/Manuals/DSM%205.pdf|Diagnostic and Statistical Manual of Mental Disorders. Dilip V. Jeste, Jeffrey A. Lieberman, David Fassler, et al. American Psychiatric Association (2022)]] 
-  - Child Neurology: Simple Motor Tics Associated With Thalamic Ganglioglioma. Chen Y, You M, Zhou H. Neurology. 2024;103(12):e210101. doi:10.1212/WNL.0000000000210101 +  - [[https://www.neurology.org/doi/10.1212/WNL.0000000000210101|Child Neurology: Simple Motor Tics Associated With Thalamic Ganglioglioma. Chen Y, You M, Zhou H. Neurology. 2024;103(12):e210101]] 
-  - Comprehensive Systematic Review Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Holler-Managan Y, Okun MS, et al. Neurology. 2019;92(19):907-915. doi:10.1212/WNL.0000000000007467 +  - [[https://pubmed.ncbi.nlm.nih.gov/31061209/|Comprehensive Systematic Review Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Holler-Managan Y, Okun MS, et al. Neurology. 2019;92(19):907-915]] 
-  - Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Clinical Report. Pediatrics. 2025;155(3):e2024070334. doi:10.1542/peds.2024-070334 +  - [[https://publications.aap.org/pediatrics/article/155/3/e2024070334/200384/Pediatric-Acute-Onset-Neuropsychiatric-Syndrome?autologincheck=redirected|Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Clinical Report. Pediatrics. 2025;155(3):e2024070334]] 
-  - Practice Guideline Recommendations Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Okun MS, Müller-Vahl K, et al. Neurology. 2019;92(19):896-906. doi:10.1212/WNL.0000000000007466 +  - {{::practice_guideline_recommendations_summary_treatment_of_tics_in_people_with_tourette_syndrome_and_chronic_tic_disorders.pdf |Practice Guideline Recommendations Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Okun MS, Müller-Vahl K, et al. Neurology. 2019;92(19):896-906}} 
-  - Tourette Syndrome: Clinical Features, Pathophysiology, and Treatment. Johnson KA, Worbe Y, Foote KD, et al. The Lancet. Neurology. 2023;22(2):147-158. doi:10.1016/S1474-4422(22)00303-9 +  - [[https://pubmed.ncbi.nlm.nih.gov/36354027/|Tourette Syndrome: Clinical Features, Pathophysiology, and Treatment. Johnson KA, Worbe Y, Foote KD, et al. The Lancet. Neurology. 2023;22(2):147-158]] 
-  - Practice Guideline Recommendations Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Okun MS, Müller-Vahl K, et al. Neurology. 2019;92(19):896-906. doi:10.1212/WNL.0000000000007466 +  - [[https://pubmed.ncbi.nlm.nih.gov/31061208/|Practice Guideline Recommendations Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Okun MS, Müller-Vahl K, et al. Neurology. 2019;92(19):896-906]] 
-  - Practitioner Review: Treatments for Tourette Syndrome in Children and Young People - A Systematic Review. Whittington C, Pennant M, Kendall T, et al. Journal of Child Psychology and Psychiatry, and Allied Disciplines. 2016;57(9):988-1004. doi:10.1111/jcpp.12556 +  - [[https://acamh.onlinelibrary.wiley.com/doi/abs/10.1111/jcpp.12556|Practitioner Review: Treatments for Tourette Syndrome in Children and Young People - A Systematic Review. Whittington C, Pennant M, Kendall T, et al. Journal of Child Psychology and Psychiatry, and Allied Disciplines. 2016;57(9):988-1004]] 
-  - Child Neurology: Diagnosis and Treatment of Tourette Syndrome. Hirschtritt ME, Dy ME, Yang KG, Scharf JM. Neurology. 2016;87(7):e65-7. doi:10.1212/WNL.0000000000002977.+  - [[https://pubmed.ncbi.nlm.nih.gov/27527544/|Child Neurology: Diagnosis and Treatment of Tourette Syndrome. Hirschtritt ME, Dy ME, Yang KG, Scharf JM. Neurology. 2016;87(7):e65-7]]