Mrs. Maria Kyriazi, a Pediatrician and Developmental specialist, delves into the world of tics, categorising them, linking them to possible difficulties that patients may face, and providing useful information about the available therapeutic pathways.
Tics are a common neurodevelopmental disorder treated by paediatricians, child neurologists-developmentalists, and child psychiatrists. They are sudden, rapid, repetitive, non-rhythmic movements or vocalisations that usually fluctuate in frequency, intensity, and type.
Typically, tics are defined as motor if they manifest as detectable movements in body parts, while as vocal if they manifest with the utterance of audible sounds. Motor tics are simple when they consist of short, meaningless, abrupt motor elements (e.g. eye blinking), while complex when they are longer and involve more muscle groups, with a more targeted character (e.g. scratching, chewing).
On the other hand, vocal tics are simple when they consist of rapid, meaningless sounds or noises (e.g. snorting, throat clearing, moaning, barking), while complex when they include syllables, words, phrases, strange speech patterns, echolalia (involuntary repetition or imitation of another person's gestures or expressions), palilalia (repetition of one's own phrases and actions), and coprolalia (uncontrolled expression of socially unacceptable words).
The onset of tics occurs between the ages of 5 and 8 in most patients. The first tics are simple, while complex ones appear later, during the course of the disease. In addition, their anatomical distribution is impressive, with the first tics usually involving the muscle groups of the skull and neck (eye-opening and closing, movements of the eyes, face and nose, head and shoulders), with the involvement of the muscles of the trunk and limbs later.
Studies also indicate that vocal tics begin at an older age than motor tics. When multiple motors and one or more vocal tics are present, but these persist for more than a year from their first onset, then it is Tourette syndrome.
The most common misconception about Tourette's syndrome, mainly as portrayed in the movies, is that the main feature of tics is profanity, which, in the medical term, we call coprolalia. In fact, only 1 in 10 people with Tourette syndrome experience coprolalia. Therefore, the occurrence of tics ranges from simple transient tics, lasting from a few weeks to months, to multiple tics of a long duration.
As highlighted, therefore, tics can be mild, going unnoticed, or severe, causing difficulties in the daily life of individuals. Tics are involuntary but difficult to control or suppress. Changes in the frequency and intensity of tics may depend on environmental factors.
Clinical studies support that exposure to psychosocial stressors can worsen the severity of tics in the short term. Tics also disappear during deep sleep. When people try to suppress their tics, it creates stress, making them worse.
Many patients compare tics to the feeling of wanting to scratch or sneeze, which temporarily improves until the urge returns. The most relevant and best characterised of these sensory phenomena is the “presensory aura,” which can be defined as the unpleasant bodily sensation that typically intensifies just before the tics and momentarily diminishes after the tics resolve.
It appears that children begin to recognise this warning sensory aura from around the age of 10. In the majority of patients, the severity of tics reaches a zenith between the ages of 10 and 13, then gradually diminishes over time, with a substantial decrease in severity as they move into adulthood.
Although tics can be confused with other hyperactivity disorders, most clinicians can differentially diagnose tics based on the history, clinical examination, ability to suppress tics (even temporarily), and presence of a presensory aura.
According to the practice parameters for evaluating children with tic disorders, as described in the Journal of the American Academy of Child & Adolescent Psychiatry, parents and children should be asked about habitual movements or vocalisations at the initial assessment and family history of tic disorders.
Many families are unaware that frequent sneezing, coughing, or eye blinking are indicative of tics, attributing these behaviours to allergies or eye problems. If the clinician's screening is positive for the diagnosis of tics, a more systematic assessment of tics is required, including age of onset, type, factors that reduce or exacerbate them, and family history.
Again, in keeping with the practical parameters of treating children with tic disorders, treatment of chronic tic disorders should be guided by the level of harm and distress they cause, as well as any comorbid conditions. If the tics are mild in severity, there is no need for intervention after providing psychological support.
Psychological interventions for chronic tic disorders should be in the therapeutic quiver when tics cause harm, are moderate in severity, or if psychiatric comorbidities, amenable to behavioural therapies, are present.
In the same context, the American guidelines point out that medication for chronic tic disorders should be considered a treatment option if the tics are moderate or severe and cause serious impairment in quality of life or if there are co-existing psychiatric disorders that respond to medication—treatment, which will target both tic symptoms and comorbid conditions.
Although many people with chronic tic disorders report that they resolve the issue early in adulthood, tics often do not go away completely, and at least some children must endure them for many years. Thus, youth with chronic tic disorders must develop effective tic coping strategies even when receiving evidence-based treatments. Targeted interventions will mitigate the harm caused by tics, positively impact the quality of life in childhood and adolescence, and reduce social difficulties in adulthood.
* Maria Kyriazi is a pediatrician—developmental Specialist, A΄ΕΙΝΙΙ Curator, and a member of the 1st Pediatric Clinic of A.ΟΥ. of the Hippocrates Hospital of Thessaloniki. Translated by Paul Antonopoulos.
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