Tics and Tourette syndrome: diagnosis and treatment

by Abdullah Arif · June 16, 2024

Tic disorders and Tourette syndrome are classified in the International Classification of Diseases ( ICD ) as “behavioural and emotional disorders with usual onset in childhood and adolescence”. The diagnosis is made by a (child) psychiatrist , (child) psychologist or (child) neurologist .

Medical treatment is not always necessary. However, if a tic disorder is diagnosed , it is important that the parents are also involved in the therapy .

Diagnosis

According to the ICD, tic disorders are defined as follows:

involuntary, rapid, repetitive (non-rhythmic) movements that affect certain muscle groups, e.g. blinking, shoulder shrugging and facial grimaces,
sudden sounds that are taken out of context, e.g. repetition of already spoken words, sometimes swearing (coprolalia), or involuntary repetition of one’s own syllables, words or sentences (palilalia).

Tics are further divided into transient and persistent, or also into movement ( motor ) and sound. Sometimes tics are classified as part of Tourette syndrome . From a clinical point of view, careful history taking and monitoring of tics are relevant . The use of imaging methods (e.g. magnetic resonance imaging ) or EEG is not necessary in most cases. As part of the neurological examination, it is necessary to exclude other diseases, especially those of organic origin. In addition, the doctor will find out whether the sufferer also suffers from other problems that would require treatment (e.g. obsessive compulsive disorder or ADHD ). The doctor can use special assessment scales during the diagnosis, whether they are filled out by the sufferer himself (so-called self-assessment scale) or by someone else (so-called “objective” assessment scale). Video recordings can help with difficult diagnosis.

Treatment of tic disorder

Experts recommend treatment especially in cases of severe forms of tics, and especially in cases where the tic causes considerable suffering to the sufferer, be it psychological or social. The sufferer first agrees with the attending physician on which symptoms need to be alleviated as a priority. If necessary , concomitant diseases are also treated accordingly .

Medicinal treatment

Although drugs can relieve the symptoms of a tic disorder, they have no effect on the trigger or course of the disease, nor can they completely eliminate the problem. A 50% reduction in symptoms is considered a successful treatment. In childhood, so-called second-generation neuroleptics are mainly used as first-line drugs : these drugs affect the metabolism of dopamine (see the article Neurotransmitters : messengers inside the brain ). Their active substances are aripiprazole or risperidone, which have relatively few side effects (when taken in low doses). For severe tic disorders – or if the mentioned drugs do not work – it is recommended to use pimozide, which is a slightly older neuroleptic. In adults, tic disorders are treated with aripiprazole, risperidone or sulpiride (if obsessive compulsive disorder is also present ).

If the patient does not respond to the primary treatment , the doctor can prescribe other active substances, such as clonidine, guanfacine, antidepressants that inhibit the reuptake of serotonin ( SSRI ) or muscle relaxants , i.e. muscle relaxants; in the case of tic disorders , central muscle relaxants, such as benzodiazepines or baclofen, are used. These drugs can be taken either alone or in combination, at the discretion of the doctor. If there are symptoms of ADHD or aggressive behavior, the doctor usually prescribes atomoxetine . In very exceptional cases (and only in adult patients!) the doctor may recommend cannabinoids or deep brain stimulation , where electrodes are implanted in the brain of the affected person.

Psychotherapy / behavioral therapy

Some experts have high hopes for special forms of behavioral therapy, e.g. habit reversal training ( HRT ) and comprehensive behavioral intervention for tics (CBIT) (these are relatively new methods, Czech equivalents have not yet been established). These methods have the potential not only to combat the symptoms of tic disorders, but also to favorably influence the further course of these disorders.

Habit reversal training (could be loosely translated into Czech as “habit reversal training”) is based on the following principles:

relaxation and awareness training ,
adopting alternative behavior (different movement, different voice, etc.),
transferring this behavior to situations in everyday life.

This form of therapy works with the phenomenon of “premonitions” that sufferers often mention. From around the age of 10, people with a tic disorder begin to perceive the increasing tension that immediately precedes a given tic. A “premonition” allows the sufferer to make an appropriate counter-movement in time to prevent the tic.

In the case of CBIT (could be translated into Czech as “complex behavioral intervention for tics”), the HRT method is extended by functional analysis, psychoeducation and attention training. Behavioral therapy can reduce symptoms by around 50%.

What can parents do?

If a tic disorder is diagnosed, it is important that the parents are also involved in the therapy. They can help detect and mitigate stress situations. A quality relationship between parents and child also has positive effects on the quality of life of the affected person. Parents should support the child in self-awareness of the manifestations of his disorder (in the sense of “oh, that’s just my tic!”). Sharing experiences within a self-help group can also be useful; however, make sure that the conversation does not always revolve around the tic disorder!

Who can I contact?

If you suspect a tic disorder, the best advice will be from a specialized psychiatrist or neurologist. Child psychiatrists (or child neurologists) specialize in psychiatric (or neurological) care for children and adolescents (under 18).