Tics in medicine: meaning, types, causes, diagnosis, treatment
The term ‘tics’ (also called ‘tic-like movements’) in medicine refers to all those stereotyped, purposeless and involuntary or only partly voluntary movements that fall into the large group of movement disorders or ‘dyskinesias’
Examples of widespread tics are blinking (closing one eye), throat clearing, grunting and sniffing
Repetitive movements such as compulsions caused by obsessive-compulsive disorder may appear to be tics but are not.
Tics are relatively widespread among the healthy population; much rarer, however, is Tourette’s syndrome, where multiple tics, falling into the various categories described below, are found together.
Tics can affect individuals of any gender and any age, even children and adolescents.
Some tics may persist for life, despite treatment.
Tics can appear at any age, although they mostly occur during childhood, especially between the ages of 5 and 9-10 years.
Tics can be of various types
- motor: the most common, they are rapid movements of a sudden and brief nature;
- vocal: characterised by the emission of unwanted sounds. They include grunts, words spoken without intention, etc.);
- behavioural: such as echolalia and coprolalia;
- facial: such as winks and facial grimaces;
- dystonic: a succession of coordinated movements with a non-existent but presumed purpose, e.g. jumping;
- psychic: a tic triggered by external stimulation of various kinds, e.g. auditory or light stimulation, often found in people with Tourette’s syndrome.
With regard to the involvement of one or more muscle groups, tics can be simple and complex
- simple motor tics: consisting of short, single, stereotyped movements of the face, shoulders and limbs, such as blinking, twisting the neck, shrugging the shoulders, grimacing with the face;
- complex motor tics: consisting of sequences that include several movements, such as hitting oneself, biting one’s nails (onychophagia) or pulling out one’s hair (trichotillomania).
Tics that emit sounds – as mentioned earlier – are called vocal tics, which can be distinguished into
- simple vocal tics: clearing one’s throat, coughing, sniffing, whistling;
- complex vocal tics: repeating words or sounds (echolalia), uttering socially inappropriate, obscene words (coprolalia).
With regard to duration, tics can be transient and chronic:
- transient tics: have a duration of less than a year, occur in several children with a peak age between 5 and 9 years; the body parts most affected are the eyes, face, neck, shoulders and arms.
- chronic tics: these last more than a year and may be accompanied by new tics. The age of onset is between 5 and 9 years, with a peak incidence around 7 years of age; males are affected three times more frequently than females.
Characteristics of tics
Tics are usually very rapid, sudden, repeated movements that are stereotyped, non-rhythmic, involuntary and uncontrollable or only partially controllable by the patient.
Tic-like movements have no apparent purpose, i.e. they are made without any motive or aim.
Tics disappear during sleep and sometimes decrease considerably until they almost disappear when the subject is very relaxed, engaged in a task or distracted by something.
The ‘tic-like movements’ increase when the subject is more nervous, anxious, worried or when they are in an inactive state: for example when they are in front of the television.
Simple motor tics include blinking, twisting of the neck, shrugs of the shoulders, grimacing of the face, coughing, while simple vocal tics include throat scraping, grunting, ‘sniffing’, barking.
They have the following characteristics
- they are involuntary, sometimes subject to voluntary suppression (albeit with great effort);
- they are stereotyped and repetitive, with fluctuating frequency;
- they are present in some circumstances but not in others (e.g. at home and not at school);
- they are absent when the subject is concentrated;
- they are predominantly affecting the face and neck
- are more frequent in males than in females
- they last from a few weeks to less than a year, and as such are considered transitory;
- they mainly affect children.
Complex motor tics concern movements such as miming, jumping, touching, stamping, smelling an object; complex vocal tics concern the repetition of words and phrases out of context, in the most severe cases coprolalia, i.e. the use of obscene words, and echolalia (repetition of sounds, words or phrases heard last).
Complex tics have the following peculiarities
- they are complex motor sequences that take on the meaning of gestures and involve up to three muscle groups simultaneously;
- vocal sequences that consist of the emission of elementary sounds;
- they have a tendency to become chronic and affect both children and adults.
A tic in itself is obviously not dangerous or life-threatening, but it can chronically lead to a weakening of muscles or other anatomical structures and cause an abrupt decline in the patient’s quality of life, which can also interfere with work and sports activities.
Think, for example, of people who ‘work with their image’: a repeated blinking tic is certainly not helpful and can be a big problem.
The patient’s quality of life may also decrease due to emotional issues: since tics are like a caricature of voluntary movements, they often arouse hilarity in those who witness them, especially at school age: this seriously embarrasses and humiliates the sufferer, especially if he or she is a child.
The continuous tic-like movement can stimulate parents, relatives and gamics to scold the sufferer, inviting him or her to avoid this type of movement.
Reprimands and invitations that necessarily fall on deaf ears as the execution of the tics is involuntary and being scolded through no fault of one’s own can make the child anxious, which can increase the tics and trigger actual bullying of the child by schoolmates.
If the child (or adult) tries to oppose this need, he or she usually feels a growing malaise that does not diminish in any way as long as he or she gives vent to the repressed tic movement: in this sense, the tics can be defined as partly voluntary, although incoercible.
When the subject gives vent to his or her tic, he or she has a relief that is, however, of limited duration because the malaise recurs if the next tic is repressed.
Tics, causes and risk factors
The precise causes behind tics are not yet fully known.
Underlying biological causes could be an involvement of the basal ganglia and the dopaminergic system.
Possible risk factors are family history, intake of energising drinks such as coffee, cigarette smoking and psychological causes.
The presence of tics due to involuntary muscular contractions, or ‘faulty’ swallowing and/or breathing requires careful paediatric and possibly neurological examination to rule out the presence of any organic causes, such as a tic syndrome following a common streptococcal infection.
Once organic causes have been excluded, psychological ones can be addressed.
Tic-like movements may be due to stress, fatigue, insecurity, fear, terror or anger.
In some cases, these are children who have been subjected to excessive physical and motor constraints during early childhood, or have been subjected to dietary and hygienic constraints such as early weaning and sphincter control.
In other cases, minor surgeries, injections, medical or dental treatment undergone in a particular age group, 3-5 years, may have been experienced as punitive assaults that later give rise to tics, but not all children who have experienced such things in pre-school age subsequently develop a tic disorder.
They are often very good, obedient, sometimes rather shy and awkward children; they seldom indulge in an angry outburst, reacting to insults and injustice by sulking and shutting down.
They have strict internal rules and forbid themselves to express thoughts or feelings in any other way.
It may happen that around the age of 7, when faced with stressful situations or people, previously experienced states of tension resurface in the child and the tic appears: suddenly everything disappears as it appeared and the body has given vent to its aggression.
In the self-injurious forms, the child intentionally turns the tic on himself: he gnaws his nails (onychophagia), pulls his hair to the point of creating alopecia (trichotillomania), bangs his head against the wall.
The child punishes himself either by the guilt he experiences in having contradictory feelings towards his parents or by the sense of inferiority he experiences in not meeting the expectations of particularly demanding parents.
However, one way to diagnose the cause is to ask the subject what he or she is feeling and thinking.
To reduce the severity and frequency of this abnormality, subjects are treated with a drug called haloperidol, which is effective in the majority of cases.
Psychological therapy in the treatment of tics
Simple tics generally disappear spontaneously.
However, psychological counselling involving a thorough personal and family investigation followed by a psychodiagnostic examination is useful, as information and assessment interviews and a psycho-educational intervention allow the disorder and the discomfort experienced by the child to be recognised and understood, and the situation to be managed calmly.
In most cases it is sufficient to make a few suggestions to the family, inviting them to a wait-and-see attitude.
They should be reassured that the disorder is not serious, and invited to pay little attention to the symptom, allowing the child to express himself as he wishes; where possible, voluntary suppression can be attempted, although this is not always feasible.
However, difficulties in socialising, social withdrawal, depressed moods often emerge, especially in the adolescent phase, in which meeting and confronting the peer group is fundamental for the definition of one’s identity and personality.
Tics are often accompanied by feelings of shame, frustration as a result of rejection by others, and anxiety due to the fear of manifestation in public.
In cases where the tic disorder persists for more than a year, which is especially the case in the presence of complex tics, and where there is a significant impairment of the various existential areas, a proper psychotherapeutic intervention will be carried out, to be possibly integrated with a pharmacological intervention, prescribed under strict specialist control, which involves the administration of new-generation antidepressants in association or not with low-dose antipsychotics.
Pharmacological intervention should only be reserved for the most serious and complex cases, especially if associated with behavioural disorders.
In fact, there are no specific drugs for this disorder; rather there are many drugs, even frequently used ones, that can provoke it, through hyperstimulation of the central nervous system.
Tips for tics in adults
To decrease the risk of tics in adolescents and adults, it may be helpful to
- get the right amount of sleep at night (at least 7 hours);
- avoid prolonged sleep deprivation;
- avoid chronic psycho-physical stress;
- avoid excessive sudden physical exertion;
- avoid chronic anxiety;
- avoiding drugs and stimulants;
- avoid excessive consumption or sudden cessation of caffeine and cigarette smoking;
- avoid sedentary living;
- engage in regular and appropriate physical activity;
- avoid excessively intense sports training;
- carefully regulate the sleep-wake rhythm;
- always keep active and busy;
- eat and hydrate properly.
Tips for tics in children
To reduce the risk of tics in children, one of the most important pieces of advice is not to insist that the child stops and not to scold him/her for not stopping, especially in front of his/her peers.
It is important to listen to the child and understand that at the root of the tic may be a discomfort that needs to be understood by the parent so that it can be resolved.
Especially in the age of development, it is important to try to create a serene, playful and collaborative family climate around minors, while limiting all those activities and commitments that could establish or accentuate inner anxiety.
Ultimately, the following are recommended: more sport and free play; less TV, video games, school activities and other stressful commitments.
Autogenic training exercises and psychotherapy sessions may also be helpful.