Tic Disorder:

Tics are sudden twitches, movements, or sounds that people do repeatedly. People often cannot stop their
body from doing these things. In the DSM V, recent change in categorizing Tic disorders.

Tourettes Syndrome, Chronic Motor or Vocal Tic Disorder, and Provisional Tic Disorder. The difference
between the three lies in the time period of symptoms and presence of single motor or vocal tics vs. both.

TS: both motor and vocal tics for at least 1 year of symptoms vs. Chronic where you only have one for >1 year
vs. Provisional where you have motor or vocal tics, OR BOTH, for < 1 year.

Tourette Syndrome:
- Pathogenesis
o TS is thought to be from social and environmental factors along with genetic abnormalities.
Most cases there is a strong transmission pattern from both parents. No genes have been
found for TS specifically.
o Seen as disturbance in mesolimbic (stritum, thalamus to cortex) system which leads to
disinhibition of the motor and limbic system
o Some neuroimaging studies have shown structural deficits like decreased gray matter
volumes in left frontal lobes in TS patients, but evidence is not strong
o Proposed that Group A strep infection can cause antibodies directed at the basal ganglia,
but little to no evidence that pediatric autoimmune neuropsychiatric disorder is associated
(PANDAS) with TS. – PANDAS is from group A strep antibodies to basal ganglia
- Epidemiology
o Meta-analysis of 21 population based studies showed prevalence of TS was 0.52% in general
population
o Males to Females 4:1
o Rare among African americans and sub Saharan Africans
o Linked to prenatal maternal smoking
- Clinical
o Onset is between 2-15 years old, average age is around 6 years and manifests by age 11 in
96% of patients
o Most patients have comorbid problems like ADHD and OCD.
 AHD in 60% in one study, OCD in 27%, OC behavior in 32%, learning disorder in 23%
o Tics themselves are considered involuntary but can temporarly be voluntarily suppressed
 Simple vs. Complex
 Simple include eye blinking, facial grimace, head jerking
 Complex is bizarre gait, kicking, scratching, jumping
 Characteristic feature of Tic vs. other psychogenic disorders is that patients often
have premonition or urge to perform the tic which is relieved after they perform it
o Vocal Tics: coprolalia (obscene words) in 40% cases, echolalia (repetition)
- Exam:
o Neuro exam usually normal except tics. Often finding can be increased blinking. Standard
imaging is normal but volumetric MRI has shown some changes such as decreaed volume in
Caudate.
o Ability to suppress tics temporarily and the premonitory sensations that precede tics are
main features that differente it from other disorders like chorea, dystonia, atehtosis,
myoclonus.
- Treatment
o Education to family, patient. Intervention when its effective social life, school, job.
o Need to treat comorbid conditions as well.
o For mild tics – education and counseling without any pharm
o Escalate with drugs like Tetrabenazine (unknown mechanism, depeletes Dopamine at nerve
terminals, often used in Huntingtons), Fluphenazine, and Risperidone.
o For isolated motor tics, can also use botulism toxin into the affected muscle
o Behavioral therapy with habit reversal training.