A tic is a sudden, short-lasting, nonrhythmic movement or vocalization. These sounds or movements occur suddenly during what is otherwise normal behavior. Tics are usually repeated; a person could do several of the same tic in a row or might find themselves doing the same tic hours or days apart. Tics are considered semi-voluntary. While many people with tics can temporarily hold-in their tics, doing this can be quite uncomfortable (imagine trying not to blink or trying not to scratch a mosquito bite), and might not be possible for all of their tics.
Movement-based tics (called motor tics) can include excessive, repeated or forceful blinking or eye movements, nose or mouth movements, head jerks or turning, shoulder shrugging or any other movement a person can do with their body. Motor tics are called complex when they involve more than one group of muscles, such as a facial tic involving eyes, nose, mouth and jaw, or short series of movements performed in the same order. Sound-making tics (called vocal tics or phonic tics) can include sniffing, throat clearing, coughing, humming, or any other sound a person can make. Vocal tics are considered complex when they involve language (such as syllables, words, phrases or animal sounds) or repeating of some sort. Some tics can be invisible to the observer, such as abdominal tensing, toe crunching inside shoes or ear popping.
A person can have tics without having a tic disorder. It is estimated that up to 25% of children have tics at some point in their development, as a normal part of development, but not all of these will develop a tic disorder. When tics start before the age of 18 and continue for more than a year (even if they seemed to disappear for a period of time), a person may have a tic disorder such Chronic Tic Disorder (if only motor tics or only vocal tics occur) or Tourette Disorder (when both motor and tics have occurred). A diagnosis of Tourette is not more severe than a diagnosis of chronic tic disorder, it simply means that both types of tics have occurred at some point. A core feature of chronic tic disorder and Tourette Disorder is that tics evolve or change over time. They “wax and wane” in frequency, number and intensity, meaning they can vary widely in these respects. The localization (where in the body or which sound) also tends to evolve or change over time. In Tourette Disorder, the nature (motor or vocal) of the tics may also evolve or change over time, with periods characterized by relatively more or less severe motor or vocal tics, periods where both are prominent, and periods where both are milder.
Tic disorders are quite common. A recent global study showed that approximately 1 in a hundred (1%) children or adults will have a tic disorder. To put this into perspective, this statistic represents up to 17,500 Montrealers, 81,000 persons across Québec or 375,000 Canadians!
Despite their prevalence, tic disorders often go undetected. One reason may be that tic disorders can be easy to miss, for example:
- if tics are of mild severity;
- if tics are disguised as voluntary movements or perceived by others as “quirks”;
- if the person regularly holds in their tics around other people; or
- if the person with tics also has other, more noticeable/severe difficulties that may overshadow the tics in the minds of parents, teachers, spouses or other important people in their lives.
For these and other reasons, many people with tic disorders go undiagnosed for years, or even for their entire lifetime. Unaware of the medical and nonmedical treatments that exist, many may struggle to hide more severe tics and feel resigned to suffer in silence.
Most tic disorders will not require any treatment. Tics are considered to warrant treatment if they are painful or dangerous, if they begin to interfere with the ability to function at home, at school, at work or in social relationships, or if they have a negative impact on well-being and quality of life, including feelings of anxiety or depression. Even if tics don’t require treatment, specialized psychological treatment for tics can help a person manage their tics differently, to feel more comfortable with them and to feel more in control.
Behavioral Treatment
The global consensus is that a recommended first-line treatment for tics is specialized behavioral therapy for tics, which can be done with both children and adults. What makes behavior therapy for tics so great?
- Behavior therapy for tics is effective, reducing tics in the majority who have tried it
- Behavior therapy for tics is brief, typically lasting 10-14 sessions
- Behavior therapy for tics (unlike medication), teaches children and adults concrete skills that they can use every day to manage their tics for the rest of their lifetimes
- Behavior therapy for tics was shown in a study published in 2018 to be as effective at improving tics as some of the most effective medications (Abilify, Risperdal)
- Behavior therapy for tics has been shown to be effective at improving tic severity among persons already taking medication for their tics.
- Behavior therapy for tics has not been associated with substantial side effects
We offer two types of behavior therapy for tics:
- Comprehensive Behavioral Intervention for Tics, or CBIT. The main component of CBIT is a type of therapy called Habit Reversal Therapy (HRT, the most widely studied specialized therapy for tics). The majority of people studied have shown improvement in tic severity (such as the number, complexity, frequency, and intensity of tics) using CBIT.
- A second, innovative approach called Cognitive PsychophysioloicalIntervention for Tics, or CoPs, has shown strong preliminary results, with up to 80% of adults and children studied showing improvements in their tics.
Medical Treatment
Tic disorders may also be treated with medications, although there are no approved medications to date that have been created specifically for the treatment of tics. Most medications approved for treating tics fall into one of two main categories:
- Alpha-2 agonist (antihypertensive) medications (such as clonidine and guanfacine/Intuniv);
- Antipsychotic medications (such as aripriprazole/Ability and risperizone/Risperdal).
While these and other medical treatments for tics may be beneficial for improving tics, they aren’t appropriate in all cases and may be associated with important possible side effects. Nevertheless, medical treatment of tics is an important option that many clients count on. Discussion with your tic specialist can help you to determine whether this option might be helpful for you. Careful exploration with a neurologist, psychiatrist or family doctor of the potential benefits and drawbacks of medications and other medical treatments for tics is also recommended.
Combination Treatment
Many persons with tics who found only partial relief with medications or behavior therapy have found the mixture of the two approaches to be the winning combination for them. Similarly, clients who have found only partial relief form one type of behavior therapy may find that combining skills from both CoPs and CBIT works well for them.
Both CBIT and CoPs are available at our clinic. Dr. Cartwright is a certified CBIT Therapist with the Tourette Syndrome Behavioral Therapy Institute (TS-BTI) of the Tourette Association of America. She has also completed advanced training in CoPs at the Centre for the Study of Obsessive-Compulsive Disorders & Tics (CETOCT) in Montreal, Canada. Dr. Cartwright feels privileged to have received training under international experts Dr. Douglas Woods, Dr. Keiron O’Connor and Dr. Julie Leclerc.