Tic Disorders

Psy 610A
Gary S. Katz, Ph.D.

Tic Disorders

Tourettes Disorder
Chronic Motor or Vocal Tic Disorder
Transient Tic Disorder
Tic Disorder Not Otherwise
Specified

Tic Disorders

Tic: a sudden, rapid, recurrent, nonrhythmic,

stereotyped motor movement or vocalization.

Simple motor tics

Eye blinking, nose wrinkling, neck jerking, shoulder

shrugging, facial grimacing, abdominal tensing.
Last less than several hundred milliseconds

Complex motor tics

Hand gestures, jumping, touching, pressing, stomping,

facial contortions, repeatedly smelling an object,
squatting, deep knee bends, retracing steps, twirling
when walking, assuming/holding unusual postures
Copropraxia sudden, tic-like vulgar sexual, or obscene
gestures
Echopraxia involuntary, spontaneous mirroring of
anothers behavior.

Tic Disorders

Tic: a sudden, rapid, recurrent, nonrhythmic,

stereotyped motor movement or vocalization.

Simple vocal tics

Throat clearing, grunting, sniffing, snorting, chirping

Complex vocal tics

Involve speech or language

Sudden spontaneous expressions of single words or
phrases, speech blocking, sudden and meaningless
changes in pitch, emphasis, or volume of speech
Palilalia repeating ones own sounds or words
Echolalia repeating others sounds or words
Coprolalia sudden, inappropriate expression of a socially
unacceptable word or phrase and may include obscenities
as well as specific ethnic, racial, or religious slurs.

Found in fewer than 10% of individuals with tic disorders

Tic Disorders

Tics are generally experienced as

irresistable but can be suppressed for
periods of time, often leading to excessive
discharge later.
Many experience a premonitory urge, rising
tension prior to the tic expression and a
release of tension following the tic
expression.
Often, individuals with tic disorders
describe the tic as falling somewhere
between voluntary and involuntary behavior.

Differential Diagnosis

Abnormal movements that accompany

general medical conditions

Direct effects of a substance

Huntingtons chorea, stroke, Parkinsons

Tardive Dyskinesia

Stereotypic Movement Disorder

PDD
Compulsions (as in OCD)

OCD commonly comorbid in tic disorders

Compulsions produced in response to an
obsession, tics are more due to a perception of
physical tension

Differential Diagnosis

Tic disorders can be differentiated

from each other based upon the type
of tic and its duration.
Transient: lasts 4wks, but no longer
than 12mos
Tourettes requires multiple motor +
vocal tics

Tourettes Disorder
(307.23)
A. Both multiple motor and one or more vocal tics have been
present at some time during the illness, although not
necessarily concurrently. (A tic is a sudden, rapid, recurrent,
nonrhythmic, stereotyped motor movement or vocalization.)
B. The tics occur many times a day (usually in bouts) nearly
every day or intermittently throughout a period of more than
1 year, and during this period there was never a tic-free
period of more than 3 consecutive months.
C. The onset is before age 18 years.
D. The disturbance is not due to the direct physiological effects
of a substance (e.g., stimulants) or a general medical
condition (e.g., Huntington's disease or postviral
encephalitis).

Diagnostic Features
Tourettes

Location, number, frequency,

complexity and severity of tics can
vary over time.
About 50% of individuals with
Tourettes see a single tic as the first
symptom, usually eye blinking.
Sometimes, begins with multiple tics
at the same time.

Associated Features

Most common: obsessions and compulsions.

Hyperactivity, distractibility, and impulsivity
also common.
Social discomfort, shame, self-consciousness,
and demoralization and sadness frequently
occur.
Younger children may be unaware of their
tics as may some adults.
Tic thresholds are lowered with the use of
some psychostimulant medications. ADHD
meds can reveal underlying tic disorders.

Culture and Gender Features

and Prevalence

Tourettes Disorder has been widely

reported in a diverse range of racial and
ethnic groups.
In clinical samples, 3x to 5x more
prevalent in males.
In community samples, 2x more
prevalent in males.
Prevalence related to age:
Children: 5-30 per 10,000
Adults: 1-2 per 10,000

Course

Age of onset can be as early as 2 years, usually

by childhood or early adolescence.
Median age for onset of motor tics is 6-7 years.
Duration may be lifelong although may have
periods of remission.
In most cases, severity diminishes during
adolescence and adulthood and may disappear in
early adulthood.
In a few cases, symptoms may worsen in
adulthood.
Predictors of course are unknown.

Familial Pattern

Tourettes Disorder appears to have

genetic transmission; the mode is not
known.
Pedigree studies suggest that there
are genes of major effect.
Not everyone who inherits the
predisposition for Tourettes will
express symptoms of a tic disorder

Could be varying levels of tic thresholds

Chronic Motor or Vocal Tic

Disorder (307.22)
A. Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent,
nonrhythmic, stereotyped motor movements or vocalizations), but not
both, have been present at some time during the illness.
B. The tics occur many times a day nearly every day or intermittently
throughout a period of more than 1 year, and during this period there
was never a tic-free period of more than 3 consecutive months.
C. The disturbance causes marked distress or significant impairment in
social, occupational, or other important areas of functioning.
D. The onset is before age 18 years.
E. The disturbance is not due to the direct physiological effects of a
substance (e.g., stimulants) or a general medical condition (e.g.,
Huntington's disease or postviral encephalitis).
F. Criteria have never been met for Tourette's Disorder.

Transient Tic Disorder

(307.21)
A. Single or multiple motor and/or vocal tics (i.e., sudden, rapid,
recurrent, nonrhythmic, stereotyped motor movements or
vocalizations)
B. The tics occur many times a day nearly every day for at least 4 weeks
but for no longer than 12 consecutive months.
C. The onset is before age 18 years.
D. The disturbance is not due to the direct physiological effects of a
substance (e.g., stimulants) or a general medical condition (e.g.,
Huntington's disease or postviral encephalitis).
E. Criteria have never been met for Tourette's Disorder or Chronic
Motor or Vocal Tic Disorder.
Specify if:
Single Episode or Recurrent

Tic Disorder Not Otherwise

Specified (307.20)
This category is for disorders
characterized by tics that do not
meet criteria for a specific Tic
Disorder. Examples include tics
lasting less than 4 weeks or tics with
an onset after age 18 years.

Case Material

Jack E. 8 year old referred because

he is having problems academically
and is significantly impulsive,
inattentive, yet perfectionistic.
Teacher reports Jack is very fidgety
at school and cannot sustain
attention in class, blurts out
answers, and is immature.

Case Material

Medical history

Delivered via c-section 4 weeks early, weighed 5lbs 12oz

No prenatal exposures
History of undereating too busy to sit down and eat
a full meal.
Developmental milestones on time, except some
continuing problems with urinary incontinence (will get
so occupied in videogames, he will wait just too long
to empty his bladder and end up wetting himself on the
way to the bathroom).

Fair social skills, becomes easily frustrated

when friends dont do exactly what he wants to
do.

Case Material

Family History

Mom has a history of anxiety disorders, treated medically and

with therapy on occasion.
Dad was described as moody.
Younger brother described as bouncy, just like Jack.

School History

Fidgety in first grade.

Second grade continued interpersonal difficulties and low
frustration tolerance.
Currently in third grade and highly distractible and
impulsive.
School observation:

Facial grimacing, repeated stretching of abdomen, some grunting

Current testing observation

See facial grimacing, soft grunting noises.

Can inhibit for a while, then they return (after 10min)

Case Material

IQ Average (VIQ: 110, PIQ: 102, FSIQ: 106)

Achievement scores all commensurate.
RCMAS (anxiety): social desirability scale
at 94th %ile, no other clinical elevations.
CPT-II numerous findings suggesting
problems with attention, vigilance, and
impulse control.
Parent and teacher CBCL checklists
indicate significant concerns with
inattention, impulsivity, and anxiety.

Diagnoses?

Diagnoses