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Tics

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Introduction


Tics are rapid, repetitive, involuntary contractions of a group of muscles. They can occur in the form of either:

  • motor tics (bodily movements)
  • phonic or vocal tics (sounds)

Most tics are mild and infrequent and they may not even be noticeable to the person experiencing them or to others. However, some tics can be frequent and severe. Tics can also be a symptom of Tourette's syndrome (see below).

Types of tics

Motor tics can affect any part of the body, but they often involve the muscles of the face, eyes, head and neck. These produce movements such as:

  • facial twitching
  • grimacing
  • blinking
  • shrugging of the shoulders

Common phonic tics include:

  • coughing
  • grunting
  • clearing the throat
  • sniffing

Some people with tics may be able to suppress (control) a tic for a short period of time, although this is said to be like trying to hold back a sneeze. They feel increasing tension until the tic is finally released. See Tics - symptoms for more information.

Progression of tics

Most tics start during childhood. People who have them experience periods when they're better and periods when they're worse. This is often described as 'waxing and waning'. In most cases, tics improve without treatment during the teenage years or early adulthood.

Some factors can make tics worse, such as:

If you have a mild tic, you may decide that treatment isn't necessary. However, if you want to have treatment, a number of different medicines can be used, although some may cause side effects.

As well as medication, behavioural treatments can also be helpful. However, they're usually only offered in specialist centres. They include:

  • habit reversal therapy (HRT), which aims to teach you how to break the habit of the tic. See Tics - treatment for more information
  • exposure with response prevention (ERP), which aims to help you get used (habituate) to the unpleasant 'premonitory sensations' associated with tics (the overwhelming feelings that are often experienced just prior to a tic)

Tourette's syndrome

Tourette's syndrome is a condition where frequent and severe motor or phonic tics are experienced. It can also be associated with other difficulties, such as behavioural problems, attention deficit hyperactivity disorder (ADHD), sleep problems and obsessive compulsive disorder (OCD).

Tourette's syndrome affects around 1 in 100 children in the UK. Tics usually begin at around six years of age and, over time, they often become more severe. They're usually at their worst when a child is 10 to 12 years old. Tics usually start to improve during the later teenage years.

Read more about Tourette's syndrome.

If your child develops a tic

The most important thing to remember is that tics are not voluntary. Even if your child can sometimes control a tic by suppressing it, it's highly unlikely that they'll be able to control their tics all of the time.

If your child develops a tic you should:

  • not tell them off about their tic
  • not try to stop them making repetitive movements or sounds because this may cause them to become stressed, which may make the tic worse
  • wherever possible, ignore the tic because if attention is drawn to it, it may get worse
  • reassure your child that they are well, that no harm is likely to result from the tics and that there's no reason for them to feel ashamed
  • make a point of educating other children about tics so that they're aware of your child's condition; encourage them to react naturally
  • most importantly, try to reduce the levels of stress and anxiety around you and your child

Symptoms of tics


Tics are contractions of a group of muscles that either result in a movement (a motor tic) or a sound (a phonic or vocal tic). Sometimes, tics may appear to be similar to normal movements. However, tics are not voluntary and most people are unable to control them.

Motor tics

Motor tics can be either simple or complex.

Simple motor tics

Simple motor tics only involve one muscle group. They include:

  • blinking or jerking your eyes
  • wrinkling your nose
  • tongue movements, including sticking out your tongue
  • twitching or jerking your head
  • squatting and hopping
  • snapping your fingers
  • shrugging your shoulders

Complex motor tics

Complex motor tics either involve more than one muscle group or they're made up of a series of simple motor tics.

Complex motor tics are usually slower than simple motor tics. It can often appear as if you're doing the movement intentionally. They can significantly interfere with your daily life but are rarely harmful.

Complex motor tics include:

  • facial grimacing
  • bending over to touch the floor
  • smoothing your clothing
  • biting your lip
  • banging your head
  • touching other people or things
  • obscene gestures or movements

Vocal tics

As with motor tics, vocal tics can also be simple or complex.

Simple vocal tics

Simple vocal tics involve making sounds by moving air through your nose or mouth. They include:

  • coughing
  • grunting
  • barking
  • hissing
  • sniffing
  • snorting
  • clearing your throat

Complex vocal tics

Complex vocal tics involve saying words, phrases or sentences. They may include:

  • using obscene, offensive or socially unacceptable words and phrases
  • repeating a sound, word or phrase

Complex vocal tics may interrupt your normal flow of speech, or they can sometimes occur at the beginning of a sentence in a similar way to a stutter or stammer.

When tics happen

Tics can feel like a tension that builds up inside you (a premonitory urge). The tension eventually reaches a point where you feel compelled to make the movement or sound associated with your tic in order to relieve the tension.

The sensation increases if you try to prevent the tic. After you've made the movement or sound, you may feel a sense of relief until the need to tic begins again.

Tics usually stop during sleep, although they can sometimes persist. They also tend to be less frequent when you're deeply absorbed in an activity.

Stress and anxiety can often make tics worse. They can also be worse when you are:

  • tired
  • excited
  • self-conscious about your tic being noticed

Causes of tics


The exact cause of tics is unknown, but they often run in families with several family members being affected. Tics are thought to be a genetic disorder with some environmental factors also playing a role.

Defective gene

Genes are units that contain information (DNA), which controls your characteristics, such as the colour of your hair and eyes. It's possible that a defective gene is responsible for making you develop a tic. Research is trying to establish whether this is the case.

Medicines

Some medicines can have side effects that include an increase in tics. For example, methylphenidate and dexamfetamine, which are used to treat attention deficit hyperactivity disorder (ADHD).

You should discuss with your GP whether the benefit of the medicine outweighs the problem of the tics. It may be possible to reduce your dose or change your medicine if your tics are severe.

Head injury

In very rare cases, tics may be caused by a head injury.

Other conditions and causes

Sometimes, a tic may be a symptom of another condition, such as:

  • cerebral palsy - a childhood condition that's caused by brain damage
  • Huntington's disease - an inherited condition that damages some of the nerve cells in the brain
  • Wilson's disease - an inherited disorder where copper builds up in your body
  • any disease that affects an artery within the brain or that supplies blood to the brain (cerebrovascular disease)

Tics can occur as a result of drug misuse - e.g. after taking cocaine or amphetamines. They can also sometimes occur as a withdrawal symptom after you've stopped taking drugs.


Diagnosing tics


When to see your GP

You should visit your GP if you or your child develops a tic and the tics:

  • occur regularly and are becoming more frequent or severe
  • are associated with emotional problems or physical discomfort
  • are accompanied by other worrying behaviour, such as anger, depression or self-harm

Diagnosing a tic

Your GP should be able to diagnose a tic from a description of the symptoms and by observing them. Special tests aren't usually required to diagnose tics. It's a good idea to record the movements on video so that you can show your GP.

Occasionally, your GP may recommend an electroencephalogram (EEG) to rule out seizures (fits) as the cause of the tic movements. An EEG is a painless procedure that records the electrical messages from your brain.

Read more about EEGs.


Treating tics


The treatment of tics depends on:

  • how severe the tics are
  • the distress that the tics cause you or your child
  • the effects that the tics or associated conditions have on work, school or everyday activities

If your tic is mild and doesn't usually interfere with your school, work or everyday life, you may decide that it doesn't need treatment. The tic may improve without treatment as you get older.

If you feel that your tic requires treatment, there are a number of medicines you can chose from, or you can try psychological treatments. When deciding whether you need treatment, you should remember that:

  • tics tend to be better or worse at different times
  • tics often improve during the later teenage years or early adulthood

Medicines

If you decide to use medicines to treat your tics, the choice of medicine will initially depend on several factors, including:

  • the type of symptoms that are most problematic
  • the severity of your symptoms
  • how important treatment is to you
  • the risk of possible side effects

In clinical studies, a variety of medicines have been shown to be effective in treating tics, although they can have unpleasant side effects. Some types of medicines that are used to treat tics include:

  • neuroleptics (antipsychotic medicines)
  • alpha2-adrenergic agonists
  • benzodiazepines
  • tetrabenazine

These are described below.

Neuroleptics

Neuroleptics, also known as antipsychotic medicines, are a type of medicine that are sometimes used to treat psychosis (a mental condition where a person can't distinguish between reality and their imagination). In much lower doses, neuroleptics have also been shown to be very effective at treating tics.

Neuroleptics work by altering the effects of dopamine on the brain. Dopamine is a naturally occurring chemical in the brain that helps to control and co-ordinate your body's movements.

There are several different neuroleptics, but haloperidol and pimozide may be particularly effective in suppressing (controlling) tics. Haloperidol is associated with more side effects than pimozide.

Other possible neuroleptics include:

  • risperidone
  • olanzepine
  • clozapine
  • quetiapine
  • aripiprazole
  • sulpiride
  • fluphenazine
  • trifluoperazine

As neuroleptics can cause side effects, the initial dose that will be prescribed is likely to be low to minimise any adverse reactions. Possible side effects of neuroleptics include:

  • tremor (shaking)
  • restlessness and involuntary movements
  • slow movements and muscle stiffness
  • drowsiness
  • weight gain
  • dry mouth
  • blurred vision

See the patient information leaflet that comes with your medicine for a full list of the possible side effects. Speak to your GP if side effects are troubling you.

Pimozide can affect the rhythm of your heart, so you may need to have an electrocardiograph (ECG) before you start treatment and once a year while you're taking pimozide.

An ECG measures the electrical activity of your heart. Every time your heart beats, it produces tiny electrical signals. An ECG machine records these signals onto paper, enabling your doctor to see how well your heart is functioning.

An ECG is painless and takes about five minutes to perform. During the test, electrodes (flat metal discs) will be attached to your arms, legs and chest. Wires from the electrodes will be connected to the ECG machine, which records the electrical impulses.

Alpha2-adrenergic agonists

Alpha2-adrenergic agonists, such as clonidine, have been shown to be effective in suppressing tics, as well as treating the symptoms of attention deficit hyperactivity disorder (ADHD).

Alpha2-adrenergic agonists have less adverse side effects and have been shown to benefit some people. Possible side effects of clonidone include:

  • drowsiness
  • constipation
  • dry mouth
  • feeling sick

Benzodiazepines

Benzodiazepines, such as clonazepam, have been shown to reduce the severity of tics in some people. Benzodiazepines aren't as effective as neuroleptics in suppressing tics and they may have side effects. It's also possible to become addicted to benzodiazepines. However, they can be useful for the short-term treatment of tics.

Tetrabenazine

Tetrabenazine is a medicine that's used to treat conditions that affect movement. Some studies have found that tetrabenazine improved tics in 8 out of 10 people. It can cause side effects, such as drowsiness, feeling sick and depression. However, it's less likely to cause weight gain than some of the other medicines.

Botulinum toxin

Botulinum toxin type A is a powerful poison that's clinically safe when used in minute doses. A tiny amount of botulinum toxin can be injected into the muscles that are involved in a particular tic. It can also be injected into the muscles of your voice box to treat vocal tics.

As well as improving the tic, botulinum toxin can reduce the feeling of building tension that often comes before a tic. When it's used for vocal tics, you may have a weak or soft voice afterwards as a possible side effect.

Deep brain stimulation

Deep brain stimulation is a type of surgery that's been used to treat a few severe cases of Tourette's syndrome. Its effectiveness and the best methods are still being studied.

Deep brain stimulation involves placing one or more electrodes (small metallic discs) in an area of your brain that's known to be associated with Tourette's syndrome. The electrodes are placed in the brain by inserting fine needles through small holes in your skull. This is done under general anaesthetic, while you're put to sleep.

Thin wires run from the electrodes to a pulse generator (a device that's similar to a pacemaker), which is implanted under the skin somewhere in your chest. The generator gives out an electric current to help regulate your brainwaves and control your symptoms.

Some studies have reported good results from deep brain stimulation, with tics being reduced by at least a fifth or, in some cases, almost disappearing. Possible side effects include drowsiness, reduced energy and changes in your sexual behaviour. As with all types of surgery, deep brain stimulation carries other risks such as infection. It's not recommended for use in children.

Psychological treatment

Psychological treatment, including behavioural therapies, cognitive behavioural therapy (CBT), counselling or relaxation training, are possible treatment options if you have particularly frequent or severe tics that affect your emotional wellbeing.

Psychological treatments aim to teach you to change your behaviour - for example, by thinking about your feelings or what triggers the tic. Over time, you may learn to control your tic so that it's no longer a problem.

The type of psychological treatment that's most suitable for you will depend on the nature and severity of your tics. You may be referred to a specialist psychological treatment service where staff can advise you about an appropriate treatment plan.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a form of psychological therapy that aims to change your behaviour by changing the way you think about a situation. CBT encourages you to talk about:

  • how you think about yourself, the world and other people
  • how your thoughts affect your feelings and behaviour

By talking about these things, cognitive behavioural therapy can help you to change how you think ('cognitive') and what you do ('behaviour'), which may help your tics.

Read more about cognitive behavioural therapy.

Habit reversal therapy (HRT)

Habit reversal therapy (HRT) is another treatment option that aims to teach you to change your behaviour. HRT aims to:

  • educate you about your condition and how it is treated
  • make you more aware of when you tic and identify the urges you feel - for example, you may tic during stressful situations
  • teach you a new response to carry out when you feel the urge to tic - for example, if your tic is usually involves shrugging your shoulders, you may be taught to stretch out your arms if you feel the urge to tic

Studies have found that HRT can improve the severity of symptoms in around 50% of people.

Exposure with response prevention (ERP)

Exposure with response prevention (ERP) involves delaying your tic for as long as possible by suppressing the growing feeling that you need to tic (premonitory urge). Eventually, the need to tic should go down, much like resisting scratching an itch, resulting in the itchy feeling eventually going down.

ERP is a new behavioural approach, but evidence suggests that it's probably at least as effective as HRT in treating tics.

Self help

Tics are difficult to control and prevent because they're involuntary muscle contractions. However, it might be possible to reduce the frequency and severity of some tics by:

  • avoiding stressful situations
  • taking time to enjoy relaxing activities
  • avoiding becoming tired or over-excited

Complications of tics


Although tics generally improve over time, they can cause a number of complications.

Social problems

Tics can be associated with social problems, such as difficulty making friends and other people not understanding your condition. This can have a significant impact on your quality of life.

If your child has a tic, it may be helpful to develop ways for them to explain their tics to other children who ask about them. This may help your child to deal with their tics and reduce any stress and anxiety that they're feeling.

In some cases, someone with a tic may be bullied. See the Live Well section for advice about bullying if you're being bullied.

Problems at school or work

Tics can also affect your performance at school or at work. A small UK-based study found that half of the young people questioned said their tics had a significant impact on their performance at school. Some children with tics also have other, specific learning needs.

Tics can often develop at school when your child is studying for exams and is under extra pressure. This type of stressful situation can make your child's tics worse.

If your child is finding work difficult because of their tic, you should talk to their teacher about possible ways of dealing with it. For example, you could speak to your child's teacher about the possibility of your child being allowed to leave the classroom when their tics are particularly bad.

Similarly, if you have a tic that's making things difficult for you at work, speak to your employer to find out whether any additional help and support is available.


The materials in this website are provided by Medicine Chest and NHS Choices.  Neither Co-operative Group Limited or Co-operative Healthcare Limited (trading as The Co-operative Pharmacy or otherwise) shall be in any way responsible or liable for its content.

The materials in this website are in no way intended to replace the professional medical care, advice, diagnosis or treatment of a doctor.  The website does not have answers to all problems and answers to specific problems may not apply to everyone.  If you notice medical symptoms or feel unwell, you should consult your doctor.  For further information, consult the terms and conditions.

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