Tics -CEW

This page is read only. You can view the source, but not change it. Ask your administrator if you think this is wrong.
====== Tics ======
  * 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
  * Transient tics affect up to 20% of children; persistent tic disorders and Tourette syndrome are less common (0.3–1.5%)

====Classification===

Tics are categorized as **simple** or **complex**:

  * **Simple motor tics**: eye blinking, facial grimacing, shoulder shrugging, head jerking
  * **Simple vocal tics**: throat clearing, sniffing, grunting
  * **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

===DSM-5 diagnostic hierarchy===

  * **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====

===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. 
  * 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)===

  * **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.
  * **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.

====References====

  - [[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)]]
  - [[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]]
  - [[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]]
  - [[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.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}}
  - [[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]]
  - [[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]]
  - [[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]]
  - [[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]]