Tic Disorders and Tourette Syndrome
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Direct answer
Tic disorders are sudden, rapid, recurrent movements or vocalisations that can be briefly suppressed and are often preceded by an urge. Tourette syndrome requires both multiple motor tics and at least one vocal tic, present for more than a year, with onset before age 18. Behavioural therapy such as habit reversal training is first-line, and alpha-2 agonists or antipsychotics are reserved for disabling symptoms.
What you must remember
- Motor tics: eye blinking, grimacing, head jerks and shoulder shrugs; vocal tics include throat clearing, sniffing and grunting.
- Duration rules: a tic disorder lasting under a year is transient or provisional, a motor or vocal tic disorder lasting over a year is persistent, and Tourette syndrome needs both motor and vocal tics over a year.
- Course: tics usually begin in early school age, peak around 10 to 12 years and often improve in late adolescence.
- Premonitory urge: many children describe a sensory build-up relieved by the tic, which is the basis of habit reversal training.
- Comorbidity: ADHD, obsessive-compulsive disorder, anxiety and learning difficulties commonly coexist and often cause more impairment than the tics.
- PANDAS: a proposed post-streptococcal autoimmune link, but the evidence is contested and guidance differs, so it should not be assumed.
- Behavioural first line: comprehensive behavioural intervention for tics and habit reversal training, which teaches awareness and a competing response, are preferred.
- Pharmacotherapy: alpha-2 agonists such as clonidine or guanfacine, and aripiprazole or other antipsychotics for disabling tics, with metabolic and movement side effects monitored.
A pathway for a child with tics
A 9-year-old has eye blinking and throat clearing for eight months, and the teacher reports classroom disruption. The steps below guide the assessment.
- Take the history: note the onset age, tic type, premonitory urge and whether symptoms worsen with stress or improve with sleep.
- Apply the duration rule: under a year suggests a transient or provisional tic disorder, while Tourette syndrome needs over a year of both motor and vocal tics.
- Screen for comorbidity: ask about attention, obsessions and anxiety, since ADHD and OCD change management.
- Exclude secondary causes: check for drugs such as stimulants, and look for neurological signs when tics are new in an adult or atypical.
- Offer psychoeducation and behavioural therapy: explain the condition to the family and school, then start habit reversal training.
- Treat disabling symptoms: alpha-2 agonists first, then antipsychotics such as aripiprazole if tics remain impairing.
- Review periodically: most tics wax and wane and many improve by late adolescence, so reassess before escalating treatment.
Where the exam tries to catch you
Tic questions usually hinge on the duration rule and on resisting the urge to start medication first.
- Trap: calling tics a psychiatric illness that needs antipsychotics first. Correct: habit reversal training is first-line, and drugs are reserved for disabling symptoms.
- Trap: diagnosing Tourette syndrome after a single brief tic episode. Correct: Tourette syndrome needs both motor and vocal tics for more than a year, so a short course is provisional.
- Trap: accepting PANDAS as established and giving antibiotics for tics. Correct: the streptococcal link is contested, so antibiotics are not a routine tic treatment.
Frequently asked questions
What duration distinguishes Tourette syndrome from a transient tic disorder?
Tourette syndrome requires both multiple motor tics and one or more vocal tics, present for more than one year, with onset before age 18. A transient tic disorder lasts less than a year, so the duration rule separates the two.
Is habit reversal training effective for tic disorders in children?
Habit reversal training is a first-line behavioural treatment for tic disorders in children. It teaches awareness of premonitory urges and a competing response, and drugs are reserved for tics that cause functional impairment.
What is PANDAS and why is it controversial?
PANDAS is a proposed syndrome of paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection, linked to abrupt tic or obsessive-compulsive onset. Its diagnostic criteria and the autoimmune link remain contested, so routine antibiotics are not recommended for tics.
Which drugs treat disabling tics in children?
Alpha-2 agonists such as clonidine and guanfacine are typically tried first for disabling tics in children. Antipsychotics such as aripiprazole are reserved for persisting symptoms, and their metabolic and movement side effects need monitoring.