Tic Attacks and Tic Disorder

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Tic Attacks and Tic Disorder

THC Editorial Team July 21, 2021
La Mousmé, Vincent van Gogh, 1888, Courtesy National Gallery of Art, Washington (article on tic attacks and tic disorder)
La Mousmé, Vincent van Gogh, 1888, Courtesy National Gallery of Art, Washington

Contents

A tic is an unwanted, irregular, and often repetitive, involuntary muscle movement or vocal sound. Tics have been viewed as imperfect coping mechanisms to deal with the effects of stress.1 Many individuals experience involuntary behavioral actions similar to tics at some point during their lives. However, tics are considered problematic when they interfere with daily activities or negatively affect a person’s quality of life.

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What Are Tic Attacks?

Tics can range from mild to disabling and may encompass a small muscle or the entire body. A severe whole-body tic may resemble a seizure or cause intense writhing or shaking in the affected individual.

The term tic attack has been used to describe times when these involuntary spasms occur in distinct episodes of non-suppressible and severe tics that can span from a few minutes to hours.2 Tic attacks include both a person’s typical tics and other movements that reflect their extreme anxiety, referred to as functional tics.3

There is very little research on tic attacks, but they are described in various circles of individuals with tic disorders such as Tourette’s syndrome.4 For many, tic attacks can have an anxious, almost panic-like, component to them.4

Researchers estimate that up to 20% of school-age children experience some type of tic in their lifetime.5 Tic attacks can occur in children and adults, though they’re more frequently diagnosed in children and individuals of male biological sex.4

What Are Tic Disorders?

Tic disorders begin most frequently during early childhood. Researchers have suggested that anywhere from 4% to 18% of children in the United States may be affected.6 These conditions are more likely to occur in boys and typically peak near puberty before resolving in 65% of cases by the age of 19 or 20.7 Most children grow out of tic disorders like Tourette’s syndrome as they age; only some do not.6 However, there are cases where a tic disorder can continue into adulthood or even begin in adulthood. Tic disorders emerging in adulthood are far less researched than those in children and often result from trauma, brain inflammation, or other conditions.8

What Are the Symptoms of Tic Disorders and Tic Attacks?

Uncontrollable sounds or movements characterize tic disorders. Frequently, an affected individual experiences a premonitory urge, which is an uncomfortable sensation, or tension, relieved by the tic. In some cases, stress caused by such sensations will only be alleviated when the tic is made in a certain way or repeated a certain number of times.9

An individual may experience negative thought patterns, including anxious thoughts about whether the tic attack will occur or concerns that the oncoming tic attack will be catastrophic. Without intervention, the tic attack generally occurs.4

Motor Tics

Muscular tics are called motor tics and include the following actions:9

  • eye blinking
  • facial grimacing or nose wrinkling
  • head jerking or banging
  • shoulder shrugs
  • abdominal tensing
  • jumping
  • hand gestures
  • finger-clicking or snapping
  • touching others or objects
  • repetitive smelling of others or objects

Vocal Tics

Vocal tics are called phonic tics and include the following actions:7

  • coughing
  • sniffling
  • grunting
  • throat clearing
  • repetitive utterances of words or phrases
  • humming
  • screaming
  • barking

The Difference Between Simple Tics and Complex Tics

Simple tics are short (usually a matter of milliseconds). Simple motor tics may include blinking, shrugging, or arm-jerking. Simple vocal tics may include sniffing, grunting, and other actions.10

Complex tics are typically longer in duration and can include a combination of simple tics either simultaneously or in succession. Complex tics can also often take the form of unpleasant or seemingly obscene behavior, such as sexual gestures (copropraxia), a tic-like gesture that is in imitation of someone else (echopraxia), a repetition of sounds and words (palilalia if one’s own sounds, and echolalia if a repeat of another person’s sounds or words).10 These behaviors can make it difficult for affected individuals in social settings where their tics are particularly active.

Types of Tic Disorders

According to the Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM-5), four tic disorders fall under the neurodevelopmental disorder umbrella. These are

Tourette’s syndrome, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, and other specified and unspecified tic disorders.10,11,12

Tourette’s Syndrome

Tourette’s syndrome is a disorder in which individuals experience at least two different motor tics and at least one vocal tic before the age of 18. For a diagnosis of Tourette’s syndrome to be made, tics may wax and wane in terms of frequency but must persist for more than 1 year. Additionally, the symptoms must not be better accounted for by the effects of medication, substances, or another medical condition.

Persistent (Chronic) Motor or Vocal Tic Disorder

Formerly called chronic tic disorder, persistent tic disorder occurs when symptoms begin before 18 years of age and last for more than a year. To qualify as persistent, symptoms must occur several times a day and either occur almost daily or at least on a regular and recurrent basis. People diagnosed with persistent tic disorder have either motor or vocal tics present but not both simultaneously. For a diagnosis of persistent tic disorder to be made, symptoms cannot be better explained by Tourette’s syndrome or due to the effects of medication, substances, or another medical condition.

Provisional Tic Disorder

Formerly referred to as transient tic disorder, provisional tic disorder has the same DSM-5 requirements as persistent tic disorder, but symptoms are present for less than a year. Additionally, for a provisional tic disorder diagnosis, both vocal and motor tics can be present simultaneously.

Other Specified and Unspecified Tic Disorders

Other specified tic disorder refers to the presentation of symptoms of a tic disorder that does not meet the full criteria of one of the following tic disorders: Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, or another neurodevelopmental disorder. A diagnosing clinician may refer to such a case as “other specified tic disorder,” followed by a specific reason why it is not one of the aforementioned tic disorders.10

An unspecified tic disorder differs from a specified tic disorder in that the diagnosing clinician cannot, or does not, specify why the presenting tic disorder is not one of the aforementioned tic disorders.10

Causes and Risk Factors of Tic Disorders and Tic Attacks

Although researchers have not yet identified the exact cause of tic disorders, research suggests that temperamental, environmental, genetic, and physiological factors contribute to tic disorders.10

Tic attacks generally follow a pattern as to when or where they may occur. For children, these might include “in the morning before going to school; certain lessons at school; certain social situations; at night when going to bed. This is because tic attacks often occur in the context of other sources of stress and reflect a physical expression of that stress in an individual who already has tics.”3

Temperamental

A relaxed and calm disposition can improve one’s condition with a tic disorder. Focused and relaxed activities, such as engaging schoolwork, may improve one’s symptoms. Fatigue, overstimulation, stress, and anxiety can worsen one’s symptoms.

Anxiety-related sensations, thoughts, and beliefs, along with persistent thoughts and worries about having tic attacks, can form a vicious cycle that can trigger tic attacks.4

Environmental

Seeing or hearing another person make a particular gesture or sound can trigger a person with tic disorder to experience the tic or create a similar sound or gesture. While it may seem otherwise, this reaction is usually involuntary.

Drawing attention to children with tic attacks can make them worse.3

Genetic and Physiological

Males are more likely to develop a tic disorder than females.6 A 2015 study found that in a sample of 314 children diagnosed with Tourette’s syndrome, those who had a genetic predisposition to the condition had more severe tics and symptoms than children who did not have a genetic predisposition.13

A recent review of relevant studies described several implicated pathophysiological brain areas and pathways.14 Chemicals in the brain, such as serotonin, dopamine, and glutamate, also play a role.15,16

Some tics develop due to brain injury, infections, poisoning, or stroke. In these cases, tics may qualify for a different diagnostic category, and a tic disorder may or may not be diagnosed.

How Is a Tic Disorder Diagnosed?

In most cases, a mental health professional can diagnose a tic disorder based on medical history or parental or caregiver answers to questions about signs and symptoms or by witnessing tics during an appointment. If tics are not occurring during examinations with a physician, caregivers may wish to casually video record the person when tics occur without bringing too much attention to the tic.9

A physician may recommend a full blood workup or check for infections to rule out other causes of tics. However, brain imaging scans are often only done if a neurological cause, such as a stroke, is suspected.7

Treatments for Tic Disorders and Tic Attacks

When an individual’s condition is chronic or involves more severe symptoms, specialized behavioral therapies and medications have been shown to reduce the number of tics that affected individuals experience and, therefore, improve their quality of life.

Treatments for tic disorders and tic attacks can overlap. For tic attacks, it may be useful to treat the condition as an anxiety and panic-related disorder in addition to a tic disorder.3,4

Treatments for tic attacks include diverting attention away from the tic attack. Focusing attention on the person experiencing a tic attack reinforces this behavior and lengthens the attack.3 Spending time with the person one-on-one while they are not having a tic attack can reinforce the desired behaviors.

Refocusing the individual having a tic attack from what is happening internally to the world around them, such as by playing music, can help ground and bring them out of the tic attack. It is also important to learn what could trigger a tic attack to avoid such situations and environments and learn how to manage anxiety and panic that often causes tic attacks.3

Behavioral Therapies

Because most individuals experience a premonitory urge before the involuntary movement or sound, modern behavioral therapies have been designed to help clients identify this sensation and better manage the occurrence of their tics. Research has indicated that even one or two behaviorally based therapy sessions can benefit clients with tics; notably, clients were found to retain this benefit 4 weeks after the initial intervention.17

Although several types of behavioral therapy have been used to treat tic disorders, two are highly effective: Habit Reversal Training (HRT) and Comprehensive Behavioral Intervention for Tics (CBIT).18

Habit Reversal Training (HRT).

HRT is a multicomponent intervention. According to HRT, tics can be predicated by external cues, like a specific activity or environment, or internal cues, like a particular mood. It is theorized that this scenario causes someone with a tic disorder to then experience the premonitory urge. HRT helps clients identify the cues that cause their tic symptoms and challenge them with competing responses or socially undetectable actions that prevent the tic from occurring. Although an individual’s treatment may have additional components, the following are common features of HRT:18

  • Psychoeducation provides an overview of tic disorders.
  • Awareness training helps identify premonitory urges and uncomfortable sensations that precede tics.
  • Tic inconvenience ratings identify the most troublesome tics or effects on daily life. This list is reviewed and changed as needed.
  • Competing response training teaches the individual to use an incompatible, socially discreet action to replace the tic upon awareness. For example, if a client’s tic is a hand gesture, they might replace that action with putting their hands in their pockets and making fists. The actions are physically incompatible; that is, they cannot do both simultaneously.
  • Generalization training is used to make competing responses a normal part of daily life for the client to prevent tics from occurring.
  • Self-monitoring helps the client understand when tics are most likely to occur and might include three to four monitoring periods of 30 minutes each per week.
  • Social support helps monitor tic occurrence and triggers, as well as treatment progress.

More recent studies have compared the efficacy of supportive psychotherapy with HRT. A 2003 study published in the American Journal of Psychiatry indicated that HRT was more effective than supportive psychotherapy in people with Tourette’s syndrome.19 Two years later, another comparative study was published in the Journal of Behavior Research and Therapy with similar results; it found that HRT was more effective than supportive psychotherapy in reducing tic symptoms and that both HRT and supportive psychotherapy improved participants’ life satisfaction and psychosocial functioning.20

Comprehensive Behavioral Interventions for Tics (CBIT).

A more recent version of HRT, CBIT includes all of the features of HRT and places greater emphasis on the factors in clients’ lives that worsen their tic symptoms. It does so by adding the following behavioral options for a more holistic maintenance approach:18

  • Behavioral rewards are provided in connection with a point system designed by the medical care provider upon successfully following treatment parameters.
  • Relaxation exercises are incorporated, including the tensing and relaxing of muscle groups and breathing from the diaphragm.
  • Function-based assessments are utilized to monitor situations that may make tics worse.
  • Function-based interventions are then created, based on information gained from the function-based assessments, to help minimize tics and reduce their effect on daily functioning.

Medications

The use of medications is often reserved for those who have more chronic tic disorders or whose symptoms interfere with the quality of life.9

The most common types of medication that are effective for reducing the symptoms of tic disorders are as follows:21

  • antipsychotics
  • atypical antipsychotics
  • alpha-2 agonists

While medication does not completely eradicate tics, it can improve the quality of life of people with a tic disorder.22

The US Food and Drug Administration (FDA) has approved three medications to treat tics: haloperidol (Haldol), pimozide (Orap), and aripiprazole (Abilify).23

Some off-label medications, including the alpha-adrenergic agonists guanfacine or clonidine, have shown effectiveness in treating tics. While these medicines are approved to treat blood pressure but not tic disorder, clinicians sometimes start with these due to better general tolerability.23

Some anti-anxiety medications may be considered by a physician when tic attacks are prevelant.3,4

Complementary Approaches

The most effective management of a tic disorder likely includes a combination of treatments that best suit the client. Some additional techniques include the following:

Parent training.

Learning from professionals how to parent a child with a tic disorder can be a useful intervention.22

Education.

When people know more about tic disorders, they can better understand and accommodate others who have tics.22

Distraction techniques.

People can pick up on indirect cues of worry and attention in part by others’ body language. As such, redirecting focus away from the tic or tic attack can be a helpful form of distraction and can reduce the duration or intensity of a tic attack.3

Mindfulness training.

Grounding techniques may help with the management of tic attacks.3

Reduction of stress and anxiety.

High-stress situations can more easily trigger tics and make them harder to manage. One way to avoid this is to get involved in a relaxing hobby.9 Stress-management and reduction activities can help with the management of tic attacks.3

Prioritization of rest.

Tiredness can also make tics occur more easily. Avoid becoming overtired by being sure to get a good night’s rest.9

Practicing tolerance.

Current recommendations suggest that scolding someone for their tics is counterproductive and that dwelling on tics and calling attention to them may only make them worse.9

Reassurance, support, and comfort.

It is helpful to teach people that their tics are nothing to be embarrassed about, even if they happen in public or in front of others. Support can be provided at home, at school, and in other environments.9

Development of self-confidence, resilience, and social or emotional skills.

These important skills are even more imperative for children with tic disorders, as psychosocial stressors can exacerbate tics.24

Deep brain stimulation (DBS) surgery.

In cases with severe and potentially dangerous tics, a physician might recommend DBS surgery. This procedure targets certain areas of the brain thought to be implicated in tic symptoms, and there is some evidence that it might reduce both motor and phonic tics.24,25

Transcranial magnetic stimulation (TMS).

TMS targets overactive motor cortical regions to reduce tics. Some research has demonstrated that participants treated with repetitive, low-frequency TMS showed an improvement in tic symptoms.26

While tic attacks can be extremely distressful, they are treatable.3,4

References

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    https://doi.org/10.1016/j.neubiorev.2016.10.003
  2. Collicott, N. J., Stern, J. S., Williams, D., Grabecki, K., Simmons, H., & Robertson, M. M. (2013). Tic attacks in Tourette syndrome. Journal of Neurology, Neurosurgery & Psychiatry, 84(11), 168.
    http://dx.doi.org/10.1136/jnnp-2013-306573.168
  3. Tourettes Action. (2021). Tic attacks and how to cope with them. [Fact sheet].
    https://www.tourettes-action.org.uk/storage/downloads/1615388654_Factsheet---Tic-Attacks.pdf
  4. Robinson, S., & Hedderly, T. (2016). Novel psychological formulation and treatment of “tic attacks” in Tourette syndrome. Frontiers in Pediatrics, 4(46).
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    https://doi.org/10.1016/j.jocrd.2014.06.002
  6. Kapalka, G. M. (2010). Nutritional and herbal therapies for children and adolescents.
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    https://www.chp.edu/-/media/chp/healthcare-professionals/documents/tips/tic-disorders.pdf?la=en
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    https://doi.org/10.1177/0883073814538668
  14. Yael, D., Vinner, E., & Bar-Gad, I. (2015). Pathophysiology of tic disorders. Movement Disorders Mini‐Series: Advances in Tics and Tourette’s Syndrome, 30(9), 1171–1178.
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  15. Fox, S. H., & Steeves, S. D. L. (2008). Neurological basis of serotonin-dopamine antagonists in the treatment of Gilles de la Tourette syndrome. Progress in Brain Research, 172, 495¬¬–513.
    https://doi.org/10.1016/S0079-6123(08)00924-2
  16. Bestha, D. P., Jeevarakshagan, S., & Madaan, V. (2010). Management of tics and Tourette’s disorder: An update. Expert Opinion on Pharmacotherapy, 11(11), 1813–1822.
    https://doi.org/10.1517/14656566.2010.486402
  17. Bennet, S. M., Keller, A. E., & Walkup, J. T. (2013). The future of tic disorder treatment. Annals of the New York Academy of Sciences, 1304(1), 32–39.
    https://doi.org/10.1111/nyas.12296
  18. McGuire, J. F., Ricketts, E. J., Piacentini, J., Murphy, T. K., Storch, E. A., & Lewin, A. B. (2015). Behavior therapy for tic disorders: An evidenced-based review and new directions for treatment research. Current Developmental Disorders Reports, 2, 309–17.
    https://doi.org/10.1007/s40474-015-0063-5
  19. Baer, L., Bohne, A., Coffey, B. J., Deckersbach, T., Peterson, A. L., & Wilhelm, S. (2003). Habit reversal versus supportive psychotherapy for Tourette’s disorder: A randomized controlled trial. American Journal of Psychiatry, 160(6), 1175–1177.
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  20. Buhlmann, U., Deckersbach, T., Rauch, S., & Wilhelm, S. (2005). Habit reversal versus supportive psychotherapy in Tourette’s disorder: A randomized controlled trial and predictors of treatment response. Behavior Research and Therapy, 44(8), 1079–1090.
    https://doi.org/10.1016/j.brat.2005.08.007
  21. Weisman, H., Qureshi, I., Leckman, J. F., & Bloch, M. H. (2013). Systematic review: Pharmacological treatment of tic disorders—Efficacy of antipsychotic and alpha-2 adrenergic agonist agents. Neuroscience & Biobehavioral Reviews, 37(6), 1162–1171.
    https://doi.org/10.1016/j.neubiorev.2012.09.008
  22. Centers for Disease Control and Prevention. (2021, April 20). Tourette syndrome (TS): Tourette syndrome treatments. US Department of Health and Human Services.
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  23. Tourette Association of America. (n.d.). Tourette Association of America. Retrieved July 2, 2021, from
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  24. Kurlan, R., & Shprecher, D. (2009). The management of tics. Movement Disorder Journal, 24(1), 15–24.
    https://doi.org/10.1002/mds.22378
  25. Pringsheim, T., Okun, M. S., Müller-Vahl, K., Martino, D., Jankovic, J., Cavanna, A. E., Woods, D. W., Robinson, M., Jarvie, E., Roessner, V., Oskoui, M., Holler-Managan, Y., & Piacentini, J. (2019). Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology, 92(19), 896–906.
    https://doi.org/10.1212/WNL.0000000000007466
  26. Castrogiovanni, P., Lisanby, S. H., Mantovani, A., Pieraccini, F., Rossi, S., & Ulivelli, M. (2006). Repetitive transcranial magnetic stimulation (rTMS) in the treatment of obsessive-compulsive disorder (OCD) and Tourette’s syndrome (TS). International Journal of Neuropsychopharmacology, 9(1), 95–100.
    https://doi.org/10.1017/S1461145705005729

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