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Tics

FIXME

  • Sudden, rapid, recurrent, nonrhythmic motor movement or vocalization that is experienced as involuntary but can often be temporarily suppressed.
  • Typical onset between ages 4–6 years and are preceded by a premonitory urge
  • Transient tics affect up to 20% of children; persistent tic disorders and Tourette syndrome are less common (0.3–1.5%)

Classification

Tics are categorized as simple or complex:

  • Simple motor tics: eye blinking, facial grimacing, shoulder shrugging, head jerking
  • Simple vocal tics: throat clearing, sniffing, grunting
  • Complex motor tics: coordinated movements appearing purposeful (e.g., simultaneous head turn and shoulder shrug), echopraxia
  • Complex vocal tics: repeating words (echolalia, palilalia), or rarely coprolalia

DSM-5 diagnostic hierarchy

  • Provisional tic disorder: motor and/or vocal tics for < 1year
  • Persistent (chronic) tic disorder: mother or vocal tics (not both) for >/= 1 year
  • Tourette syndrome >/= 2 motor tics adn >/= 1 vocal tic for >/= 1 year.

When to treat

  • Not all tics require treatment.
  • Intervention is indicated when tics cause functional impairment, physical discomfort, or psychosocial distress (embarrassment, bullying).
  • Watchful waiting with psychoeducation is appropriate for mild, non-impairing tics.

Treatment approach

Behavioral therapy (first-line)

Comprehensive Behavioral Intervention for Tics (CBIT) is the only treatment rated with high confidence for efficacy by the AAN and is recommended before pharmacotherapy.

  • Includes habit reversal training (awareness of premonitory urge + competing response),
  • Relaxation techniques
  • Functional interventions.
  • Reduces tic severity by 26–31% and treatment gains are maintained for ≥6 months in children aged ≥9 years.
  • Efficacy appears comparable to pharmacotherapy.

Pharmacotherapy (when behavioral therapy is insufficient or unavailable)

- First-line: Alpha-2 agonists — guanfacine and clonidine have moderate evidence and a favorable side-effect profile (sedation, hypotension); preferred as initial medication in children. Particularly useful when comorbid ADHD is present. - Second-line: Atypical antipsychotics — aripiprazole, risperidone, and tiapride have evidence for tic reduction but carry risks of metabolic syndrome and tardive dyskinesia. - Third-line: Typical antipsychotics — haloperidol and pimozide are effective but reserved for refractory cases due to significant adverse effects (extrapyramidal symptoms, QT prolongation).

Comorbidities are common and should be assessed: ADHD (alpha-2 agonists can treat both), OCD (SSRIs or CBT with exposure/response prevention), anxiety, and learning difficulties.

References

  1. Diagnostic and Statistical Manual of Mental Disorders. Dilip V. Jeste, Jeffrey A. Lieberman, David Fassler, et al. American Psychiatric Association (2022)
  2. Child Neurology: Simple Motor Tics Associated With Thalamic Ganglioglioma. Chen Y, You M, Zhou H. Neurology. 2024;103(12):e210101. doi:10.1212/WNL.0000000000210101
  3. Comprehensive Systematic Review Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Holler-Managan Y, Okun MS, et al. Neurology. 2019;92(19):907-915. doi:10.1212/WNL.0000000000007467
  4. Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Clinical Report. Pediatrics. 2025;155(3):e2024070334. doi:10.1542/peds.2024-070334
  5. Practice Guideline Recommendations Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Okun MS, Müller-Vahl K, et al. Neurology. 2019;92(19):896-906. doi:10.1212/WNL.0000000000007466
  6. Tourette Syndrome: Clinical Features, Pathophysiology, and Treatment. Johnson KA, Worbe Y, Foote KD, et al. The Lancet. Neurology. 2023;22(2):147-158. doi:10.1016/S1474-4422(22)00303-9
  7. Practice Guideline Recommendations Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Okun MS, Müller-Vahl K, et al. Neurology. 2019;92(19):896-906. doi:10.1212/WNL.0000000000007466
  8. Practitioner Review: Treatments for Tourette Syndrome in Children and Young People - A Systematic Review. Whittington C, Pennant M, Kendall T, et al. Journal of Child Psychology and Psychiatry, and Allied Disciplines. 2016;57(9):988-1004. doi:10.1111/jcpp.12556
  9. Child Neurology: Diagnosis and Treatment of Tourette Syndrome. Hirschtritt ME, Dy ME, Yang KG, Scharf JM. Neurology. 2016;87(7):e65-7. doi:10.1212/WNL.0000000000002977.
  10. Practice guideline recommendations summary: Treatment of tics in people with Tourette Syndrome and chronic tic disorders