Tics or persistent, intermittent muscle twitches or spasms
Tics are persistent, intermittent muscle twitches or spasms that are usually limited to a localized muscle group. A person with a tic cannot control the movement or sounds. Tics are either transient, with a duration of less than 12 consecutive months, or chronic, with a course that lasts more than a year. Common simple tics are eye blinking, shoulder jerking, picking movements, grunting, sniffing and barking. Complex tics include facial grimacing, arm flapping and echolalia (repeating another’s words or phases). As many as one in five children have had a tic at some point in the first 10 years of life. Tics are often worse when a person is stressed, tired or anxious. Some medications make tics worse. An important note to remember is that children who have tics are usually “normal”, bright, and sensitive.
Tourette’s disorder is a type of tic disorder. Children with Tourette’s disorder have both body and vocal tics. The Tourette’s syndrome have both repetitive movements and sounds, but they may not always occur together. Several different tics can happen at the same time. Children with this disorder may have problems with attention and concentration. They may act impulsively or they may develop obsessions and compulsions. Children usually see their worst symptoms between 9 and 13 years of age. About one half of all children with Tourette’s syndrome also have ADHD. About one third also have obsessive-compulsive disorder.
One hypothesis of Tics is that they believe there is a tripartite dysfunction in the central nervous system. A second source of abnormality is the thought that there is an inappropriate regulation of neurotransmitters, especially dopamine. A third hypothesis is a dysfunction in a neurophysiologic deficit secondary to neurotransmitter abnormalities, resulting in failure of inhibition of the frontal-subcortical motor circuts. Stress and anxiety may neurochemically intensify this inhibitory deficit. They truly have no idea what causes tics.
Alan, a 10 year-old boy, is brought for a consultation by his mother because of “sever compulsions.” The mother reports that the child at various times has to run and clear his throat, touch the doorknob twice before entering any door, tilt his head from side to side, rapidly blink his eyes, and suddenly touch the ground with his hands by flexing his whole body. These “compulsions” began 2 years ago. The first was the eye blinking, and then the others followed, with a waxing and waning course. The movements occur more frequently when he is anxious or under stress. The last symptom to appear was the repetitive touching of the doorknobs. The consultation was scheduled after the child began to make the middle finger sign while saying “fuck.”
When examined, Alan reported that most of the time he did not know in advance when the movements were going to occur except for the touching of doorknobs. Upon questioning, he said that before he felt he had to touch the doorknob, he got the thought of doing it and tried to push it out of his head, but he couldn’t because it kept coming back until he touched the doorknob several times; then he felt better. When asked what would happen if someone did not let him touch the doorknob, he said he would just get mad; once his father had tried to stop him and Alan had had a temper tantrum. Alan explained that the touching of the doorknobs didn’t really bother him – what did was all the “other stuff” that he couldn’t control.
During the interview the child grunted, cleared his throat, turned his head, and rapidly blinked his eyes several times. At times he tried to make it appear as if he had voluntarily been trying to perform these movements.
Personal history and physical and neurological examination were totally unremarkable except for the abnormal movements and sounds. The mother reported that her youngest uncle had had similar symptoms when he was an adolescent, but she could not elaborate any further. She stated that she and her husband had always been “very compulsive,” by which she meant only that they were quite well organized and stuck to routines.
The DSM-v would diagnosis Alan with Tourette’s Disorder.
Alan is most disturbed by his motor tics (example tilting his head from side to side, blinking his eyes, flexing his whole body) and by his verbal tics (example clearing throat, saying “fuck”). Because the motor tics involve a series of coordinated movements, they are considered “complex motor tics.” The combination of motor and verbal tics with a duration of over 1 year establishes the diagnosis of Tourette’s Disorder (DSM-IV, p. 103).
It is sometimes difficult to distinguish a complex motor tic from a compulsion because the observed behavior can be similar. A tic is an involuntary, sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization. In contrast, a compulsion is an intentional voluntary act that is either performed in response to an obsession or according to rules that must be applied rigidly. Alan, like many patients with Tourette’s Disorder, also has obsessions and compulsions, even if not sufficiently impairing to warrant the additional diagnosis of Obsessive-Compulsive Disorder.
Between 5 and 10 percent of patients continue to have unchanged or worsening symptoms in to adolescence and adulthood. In this percentage, the likelihood of tics continuing for decades is very small. Patients in between seventy and ninety years old may have tics that have been present since childhood. In most older patients, the tics tend to become quite stable over time, although occasionally new tics will a peer. There is no reliable way to predict which children will have an easy time extinguishing the tic to those who will never be able to.
They have found that behavior treatment has been the most beneficial. Positive reinforcement programs appear to be most helpful in the management of tic disorders. Target behaviors may be categorized into two groups: areas that initially require concentration to build social and academic skills, and in areas which the goal is to help the patient decrease the frequency of these behaviors.
They also have found that pharmaceuticals decrease tics to a level at which they are no longer noticeable. The goal in tic control is to use the lowest dosage of medication that will enhance the patient’s functioning to an acceptable level.