2. CONTENTS
• Definition
• History
• Epidemiology
• Etiopathogenesis
• Classification
• Clinical features
• Diagnostic Criteria
• Approach
• DD &Comorbid conditions
• Course and prognosis
• Management
3. INTRODUCTION
• Tics: rapid, non rhythmic, recurring, involuntary or semi
voluntary, sudden onset, motor movements or vocalizations.
• Complex, heterogenous, neurodevelopmental disorders.
4. HISTORY
• Itard (1825) : first clinical description of
Tourette syndrome on Marquise de
Dampierre.
• Georges Edouard Albert Brutus Gilles de la
Tourette (1885) : described in 9 patients,
coined term coprolalia
• Charcot : believed in Heriditary
degenerative disorder.
Gilles de la
Tourette
5. EPIDEMIOLOGY
Tic
disorder
overall
prevalence
6.5%
Typical age 3-8yrs
Avg age 6yrs
M>F by 3-4 times
Provisional Tic D/o (MC)
20% prevalence in school age
Persistent tic d/o
2-4% prevalence
Tourette disorder 0.77% prevalence
• 79% comorbid
Mental health/
Neurodevelopment
condition.
• 60-70% comorbid
ADHD
• 50% comorbid OCD.
7. Genetic factors
• Twin studies: High concordance in MZ (50-90%)
• Multigene loci with environmental factors.
• Linkage study by TSAICG: linkage region on Chr 2p, duplication
of long arm Chr 7
• Balanced transloction Chr 6 and 8
• Candidate gene SLITRK1 on Chr 13Q31.1
• Functional mutation of HDC encoding l-histidine decarboxylase.
• Dopamine receptor gene, transporter gene, noradrenegic
genes, serotonergic genes.
15. CLINICAL
FEATURES
• Occurs in bouts.
• Change in frequency, anatomical
site, number, complexity, severity.
• May persist during sleep
• Can be suppressed.
• Associated with sensory
phenomenon.
16. • Premonitary urges: uncomfortable sensation preceding tics, need to
itch, sneeze, restlessness…Mounting tension.
• 82-92% of adults and adolescent reports PU.
• warning sign : can be utilized in CBT.
• Execution of a tic till it feels good : “Just right phenomenon”
• Somatic hypersensitivity: deficit in sensorimotor gating in TS and
Schizophrenia.
• Prepulse inhibition: startle response to low intensity stimulus prevents
startle response to high intensity stimulus of same kind; impaired in TS.
17. Exacerbating and relieving factors.
Exacerbating
• Tic related conversation.
• Overt observation
• Stress
• Anxiety
• Public commenting
Relieving
• Relaxation
• Mental or Physical task
• Rewarding tic free
period.
18. PANDAS
• Paediatric Autoimmune
Neuropsychiatric Disorder
Associated with Stretococcus
• Gp A betahaemolytic streptococci.
• Molecular mimicry
• Multiple streptococcal infection in
preceding 12 months : high risk.
• Evaluation of Tic/ OCD for
pharyngitis/ Strep exposure; throat
culture, ASO, anti-DNAse B titres.
• Antibiotics
Diagnostic Features
• OCD & tic symptom
• Pre pubertal onset
• Episodic course
• Sudden explosive onset
• Exacerbation and
remissions
• Temporal relation with
GABHS infection.
19. Diagnostic Criteria
• DSM 5
Neurodevelopmental disorders
• Tourette Disorder:
Both multiple motor and vocal tics
>1 yr since first tic onset
Onset before 18yrs
• Persistent (Chronic) Motor or
Vocal Tic Disorder
Single or multiple motor or vocal
tic, not both.
• Provisional Tic disorder
Motor and/or vocal tics
<1 yr since onset.
• Other specified & Unspecified
Tic Disorders.
• ICD 10
Disorders of Childhood and
Adolesence
F95 Tic disorders
• F95.0 Transient Tic Disorder :
<12 months
• F95.1 Chronic Motor or Vocal Tic
Disorder.
• F 95.2 Combined vocal and
multiple motor tic disorder (de
la Tourette’s syndrome)
• Other tic disorders( F95.8) and
unspecified(F95.9)
20. ICD 11
• Chapter 8 : Diseases
of Nervous System
• Primary & Secondary
21. Adult onset tic disorder
• True Prevalance not known
• ~55% recurrence of childhood tic disorder
• Of New adult onset tics, 50% has precipitating factors.
• Often involve face, neck and shoulders.
• Inciting event: head injury, local infection, cocaine binge,
neuroleptic drugs.
• Many unaware, unnoticed tics in childhood and family
members.
• Comorbid OC symptoms.
22. Approach to Tic disorders.
1. History :
• Present illness: Onset, course, severity, pattern, burden on
emotional, social, family, academic function ,ability to supress,
premonitory urges, aggrevating/ allevating factors, comorbidities,
medications/ substances.
• Developmental history, medical history.
• All child cases should be screened for unusual movements/
vocalizations.
2. Physical examination( including neurology) Ht, Wt, dysmorphic
features, posture, gait, reflex.
• AIMS
• Videotaped interviews
23. • Investigations: to r/o infectious etiology, Huntington disease, Wilson
disease.
• Specific neurological finding : Neuroimaging, genetic workup, EEG.
Categorisation : types,
dominant one, associated
features, DDs
Sudden onset ,severe
tics, atypical tics, mental
status abnormalities :
organic process : detailed
investigation.
24. Rating Scales
Yales Global Tic Severity Scale (YGTSS): assess number, frequency,
complexity, intensity, interference of vocal and motor tics. (Clinician
rated)
Tic Symptom Self Report
Tourette Syndrome Diagnostic confidence index (TSDCI)
Shapiro TS Severity Scale
TS Symptom list(TSSL)
Motor tic, Obsession and compulsion, vocal tic evaluation survey
(MOVES)
Clinical Global Impression Scale
27. ADHD
AND
TICS
50-75% have
ADHD
10/-30% OF
ADHD have tics
Low frustration
tolerance, over
aggression, Self
injurious
behaviour
Poor treatment
adherence
Inability to
delay
gratification.
Academic
difficulty
Peer
rejection
Poor
outcome
28. OCD
AND
TICS
20-40 %
meet
criteria for
OCD
Differ in
subjective
experience
of
Cognition,
Anxiety
and
Sensory
phenomen
on.
90%
subthreshold
symptoms:
repetitive
counting,
touching,
symmetry.
Share similar
Neurobiology:
overlap of
symptoms.
More severe
tics,
depressive
anxiety
symptoms
Comorbid
Trichotillomania,
BDD,Social
Phobia
29. Course and Prognosis
6-7 yrs
• Motor tics
• Rostrocaudal progression
• 94.8% eye tics
8-9 yrs
• Vocal tics
• Simple to complex
11-12 yrs
• OC symptoms
•Waxing-waning course
•Improve mid adolesence to adulthood;
65%
•19.3% coprophenomenon.
Course of Tourette Syndrome
34. Behavioural Interventions
• First line treatment :
Cognitive
Behavioural
Intervention
• Habit Reversal
Training (HRT) forms
essence of
Comprehensive
Behavioural
Intervention for Tics
(CBIT)
• Exposure and
Response
Prevention.
Competing
response training
Relaxation
training
Awareness
training
Contingency
management
Social support and
relapse prevention
35. At Home
Argumentati
ve :123
technique
time out
Coprolalia:
more
acceptable
words
Reward
acceptable
behaviour
Address
Sibling
concerns.
Me time”
for
caretaker
Screen time;
sleep
hygiene.
Addressing
public
comments
Responsible
behaviour
After school
bursts:
Relaxation
techniques,
sport
activities
Be
consistent,
clear &
specific
36. At School
• Parent-Teacher communication
• Avoiding , Critical /Negetive comments
• Rewarding good behaviour: Token system; Good
behaviour Diary
• Proper seating arrangements; permission to leave
classroom.
• Breaking activities to small chunks; using visual cues
• Extra time at exam/ worksheet with minimum writing
requirement.
• Public performance :not compelling
• Address peer bullying
• Building Self esteem
37. Medications
• Individualised planning: Addressing Comorbidities (OCD,
ADHD, Mood disorders)
• Initial work up: Blood parameters; ECG;FLP
• Lowest dose; gradual titration
• Monotherapy
Indication
Moderate-severe tics/ interfering
all functional areas
Psychotherapeutic options
unavailable/ not beneficial
43. • Surgical Interventions:
DBS, TMS
• DBS: Severe, treatment
resistant, Self injurious
tics/cervical tics
Regions stimulated:
Centromedian Nucleus of
Thalamus, Gp interna , Gp
externa, STN, ventral
striatum, NA.
Botulinum Toxin Inj : Onabotulinum
Toxin A
For vocal tics
Last 12-16 weeks
Hypophonia
44. CONCLUSION
• Tics are Neurodevelopmental Disorders with Multiple
Etiopathogenesis.
• Classified as Motor and Vocal, Categorized again on severity
basis.
• Clinical features; Premonitary Urges, Sensory phenomenon
distinguishing features.
• Most common comorbid conditions are ADHD and OCD.
• Approach and evaluation to arrive at a diagnosis.
• Most require only Psychoeducation. First line management:
Behavioural Interventions.
• Medication only in selected cases, Individualized approach.
45. REFERENCE
• 1. Kaplan and Sadock Comprehensive Text Book of Psychiatry 10th edition.
• 2.Practice parameters for asessment and treatment children and adolescent
with Tic disorders AACAP guidelines.
• 3.Tics and Tourette Syndrome ; Continuum on Movement Disorders, 2019.
• 4.The Clinical approach to movement disorders; Abdo .W. F et al;Nature
Neurology 2010.
• 5.Tourette Syndrome ;Roseli et al ; Psychiatric clinics of North America.
• 6.Practice guidelines: The treatment of tics in people with Tourette
Syndrome and Chronic Tic Disorder; AANP 2019
• 7.Clinical Asessment of Tourette Syndrome and Tic Disorder; Stephanie et al;
Neuroscience Behaviour Rev. 2013
• 8.Adult onset Tic disorder; Sylvian Chouinard; J Neurol Neurosurg Psychiatry.
• 9.Tics and Tourette Syndrome ; A handbook for Parents and Professionals;
Uttom Chowdhury
• 10. Tic Disorders: Neural Circuits, Neurochemistry,Neuroimmunology; Haris
et al , Jcn.sagepub.
