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ALL ABOUT TICS
What is a tic? What movements may be confused with tics? How are the tics of Tourette's disorder defined and classified? What are some common tics of Tourette syndrome?
The word tic is often misspelled as tick. Ticks are creepy little beasts which suck blood and carry Lyme disease: people with Tourette’s syndrome have tics, also misspelled at times as tixs.
"Tics are brief movements (motor tics) or sounds (vocal tics) that occur intermittently and unpredictably out of a background of normal motor activity." Definitions and classifications of tic disorders, TSA
Tics typically begin at about 6 or 7 years of age, initially presenting in midline body regions where there are many muscles: the head, neck and facial region. Movement-based tics are called motor tics. Involuntary sounds produced by moving air through the nose, mouth, or throat are alternately called verbal tics, vocal tics, or phonic tics. Some diagnosticians prefer the term phonic tics, because the vocal cords are not involved in all tics that produce sound.
Tics can be temporarily suppressible for some people, but suppression of tics can result in an increased burst of tics later. Tics are often described as unvoluntary, because they can be perceived by the person ticcing as a semi-voluntary response to an urge to relieve a sensation or feeling that precedes the tic. Adults or mature children may be more aware of this premonitory urge -- a general feeling which precedes the tic and can be described like the feeling before a sneeze, or the need to scratch an itch. The unvoluntary nature of tics, capacity for suppression, and presence of a premonitory sensation, along with waxing and waning (tics that change over time in frequency, anatomical location, severity, and number) are the main characteristics that help distinguish Tourette's syndrome from other movement disorders. Children are typically less aware of premonitory sensations, and less able to suppress tics, than adults.
"Tics are a curious assemblage of abrupt, repetitive movements and sounds. ... Tics are often more easily recognized than precisely defined. They are isolated disinhibited fragments of normal motor or vocal behaviors. Said another way, tics are sudden, repetitive, stereotyped motor movements or phonic productions that involve discrete muscle groups. They can be easily mimicked and are often confused with normal coordinated movements or vocalizations. ... The observed range of motor tics is extraordinary, so that virtually any voluntary motor movement can emerge as a motor tic.
Motor tics may be described as simple or complex. Simple motor tics are sudden, brief (usually less than 1 second in duration), meaningless movements. Common examples include eye blinking, facial grimacing, mouth movements, head jerks, shoulder shrugs, and arm and leg jerks. Younger patients often are totally unaware of their simple motor tics.
Over time, many patients develop complex motor tics, which are sudden, more purposive-appearing, stereotyped movements of longer duration. Examples are myriad. Facial gestures and grooming-like movements such as brushing hair back are commonplace. Gyrating, bending and more dystonic-appearing movements of the head and torso are also seen. These complex motor tics rarely are seen in the absence of simple motor tics.
Simple phonic tics are fast, meaningless sounds or noises that can be characterized by their frequency, duration, volume intensity, and potential for disrupting speech. Complex phonic tics are quite diverse and can include syllables, words, or phrases, as well as odd patterns of speech in which there are sudden changes in rate, volume, and/or rhythm. Complex phonic tics are rarely if ever present in the absence of simple phonic tics and motor tics of one sort or another.
In summary, tics present as fragments of innate behavioral routines that are expressed in a disinhibited fashion." From Chapter 2, pp. 24 - 26, of Tourette's Syndrome : Tics, Obsessions, Compulsions : Developmental Psychopathology and Clinical Care, by James F. Leckman, Donald J. Cohen, John Wiley & Sons; November 1998.
From Table 2.1, page 25, of Tourette's Syndrome : Tics, Obsessions, Compulsions:
Simple Motor Tics
Sudden, brief, meaningless movements
Eye blinking, eye movements, grimacing, nose twitching, mouth movements, lip pouting, head jerks, shoulder shrugs, arm jerks, abdominal tensing, kicks, finger movements, jaw snaps, tooth clicking, rapid jerking of any part of the body.
Complex Motor Tics
Slower, longer, more purposeful movements
Sustained looks, facial gestures, biting, touching objects or self, throwing, banging, thrusting arms, gestures with hands, gyrating and bending, dystonic postures, copropraxia (obscene gestures).
Simple Phonic Tics
Sudden, meaningless sounds or noises
Throat clearing, coughing, sniffling, spitting, screeching, barking, grunting, gurgling, clacking, hissing, sucking and innumerable other sounds.
Complex Phonic Tics
Sudden, more meaningful utterances
Syllables, words, phrases, statements such as "shut up," "stop that," "oh, okay," "I've got to," "okay honey," "what makes me do this," "how about it," or "now you've seen it," speech atypicalities (usually rhythms, tone, accents, intensity of speech); echo phenomenon (immediate repetition of one's own or another's words or phrases); and coprolalia (obscene, inappropriate, and aggressive words and statements).
Included below is a more extensive list of tics which may occur in people with Tourette Syndrome. Before reviewing the list of tics, please keep in mind that other movements might be confused with tics. The list below is only intended to give you an idea of what movements *may* be tics. When reviewing the list, please keep in mind:
1. Tics can be invisible to the untrained (or even trained) observer. Some examples of this are tensing of abdominal muscles, contracting of leg muscles, or breathing tics.
2. Not All That Tics is Tourette’s. There are many secondary causes of tic disorders -- referred to as “tourettism” -- as well as other conditions which include movements that are often confused with tics (such as the stims and stereotypies of the autism spectrum, or Stereotypic Movement Disorder). It is important to rule out other causes of stereotyped or repetitive movements before conferring a diagnosis of Tourette’s Disorder. One of the important hallmarks of Tourette's tics is that they are ever-changing in number, frequency, severity and anatomical location.
3. You may encounter some literature or laypersons referring to “mental tics.” This term, often employed by laypersons, seems to be due to a blurring of the already fuzzy line between tics, obsessions and compulsions. Since a subset of obsessive-compulsive disorder is thought to be genetically related to Tourette's, and an alternate expression of the Tourette's syndrome gene(s), there is some blurring of the lines between what is considered a tic and what is considered an obsessive-compulsive behavior. Here is an excerpt from a paper, The Benefits of Reductionism, explaining the definitions endorsed by the Tourette's Syndrome Study Group:
"A tic is a rapid and nonrhythmic repetitive movement. It is preceded by a physical sensation (a sensory premonitory phenomenon) in more than 80 per cent of patients. There is no associated cognition or anxiety. A compulsion, in contrast, is a stereotyped and intentional movement that is performed in response to an obsession (an intrusive thought that is perceived to be senseless to the affected individual). There is a mental anxiety present prior to the compulsion, with temporary relief after the act. There is no associated sensory phenomenon. Patients who suffer both of these pure forms are often eloquent in their ability to differentiate the phenomena as being respectively 'physical' and 'mental.'
Tics, however, can also consist of coordinated patterns of sequential movements, in which case they are called 'complex tics' and may be challenging to differentiate from compulsions.
In the clinical setting, a reductionistic approach makes most sense. Describe the action as accurately as possible, calling complex behaviours 'intentional repetitive behaviours' if they are not definite pure forms." Challenging Phenomenology in Tourette Syndrome and Obsessive–Compulsive Disorder: The Benefits of Reductionism
Although the list (below) includes some movements which may actually be compulsions in some people, the author of this website adheres to the belief in the benefits of reductionism. Several of the movements listed could be found in persons on the autism spectrum, and/or could be better described as obsessive-compulsive behaviors. So, please note that, in any person with additional diagnoses of autism spectrum disorders, Obsessive-Compulsive Disorder (OCD) or Attention Deficit Hyperactivity Disorder (ADHD), behaviors or movements might not necessarily be tics, and could have alternate explanations. This is best sorted out with professional input from experts in tic disorders and comorbid conditions. Please do not assume something is a tic because you see it on this list : consult with trained professionals in cases of diagnostic confusion.
4. You may have encountered the term “full-blown Tourette’s.” It is not always clear what authors or layperson are referring to when they use this term, since a person either meets the diagnostic criterion for Tourette's disorder or not. Some people use the term to refer to very severe, frequent or disruptive tics, while others use it to refer to cases which include coprophenomena and echophenomena. Most people fulfilling the criterion for a diagnosis of Tourette’s disorder probably have milder symptoms, and many people with more severe symptoms don’t necessarily have the more complex or socially stigmatizing tics, so the intent and usefulness of the term “full-blown Tourette’s” is unclear. At any rate, this is a good time to include a definition of the copro and echo phenomena found in a minority of people with Tourette's syndrome.
uttering socially unacceptable or obscene phrases
Copropraxia -- performing obscene or forbidden gestures
Echopraxia -- imitating movements just seen
Echolalia -- repeating words, phrases, sounds that were just heard
Palilalia -- repeating one's own words, phrases, sounds
Coprolalia is estimated to occur in less than 15% of patients with Tourette’s syndrome. The actual percentage may be even lower if we account for the large number of people in the broader population with milder symptoms who are likely to escape diagnosis and never come to clinical attention. Studies show that coprolalia is more likely as the number of comorbid diagnoses increases (for example, a person with ADHD plus OCD plus tics plus a mood disorder is much more likely to have coprolalia than a person with tics only).
5. Arbitrariness of the Definition of Tourette’s Disorder. Many people wonder if a Tourette’s diagnosis is appropriate, because of confusion over the distinction between vocal and motor tics, or the requirements for timing and the number of vocal and/or motor tics for a Tourette’s diagnosis. It is important to keep in mind that the definition of Tourette’s at any given time is man-made and arbitrary. Here are some discussions of the arbitrariness of those man-made definitions:
SUMMARIZING: the definition of Tourette’s syndrome is arbitrary, man-made, and changes over time; the distinction between vocal and motor tics may be moot, since a vocal tic is just a motor tic using a specific set of muscles that produce sound; “not all that tics is Tourette’s;” some complex tics may actually be compulsions in some people, and many of the movements below could be explained by an alternate diagnosis. Please use this list only as a guide.
Chart of Tics (and/or
of Tourette Syndrome, Tourette’s syndrome, Tourette’s Disorder
Abdominal jerking, abdominal tensing
Adjusting crotch area, adjusting wedgie
Arm extending, arm flapping, arm rotating, arm touching, arm flailing,
arm flexing, arm jerking, arm squeezing
Banging things, banging parts of the body against something else
Bending at the waist, bending at the knees, bending
Bite mouth, bite arm
Biting self or biting others, biting nails
Blocking, Freezing (on movement)
Body jerking, body slamming
Brushing hair out of eyes
Chewing clothes, chewing fingers, chewing fingernails, chewing toes, chewing things
Clothes pulling, clothes tearing, clothes chewing
Cracking knuckles, cracking jaw
Cuticle picking, cuticle chewing
Elbow – touching together behind back
Extending arms, extending neck
Eye blinking, eye rolling, eyes toward ceiling, eyes bulging, eye squinting, winking
Facial grimaces, facial contortions, facial grimacing
Finger smelling, finger pulling, finger snapping, finger movements
Flexing ankles, flexing wrists, flexing arms, flexing knees, flexing toes
Foot dragging, foot flexing, foot tapping, foot shaking
Grimacing – mouth, facial
Hair brushing out of eyes, hair tossing, hair twisting, hair pulling
Hand fiddling, hand flexing, hand snapping
Head toss, head jerk, head turn, head shaking, head banging
Hitting self or hitting others
Jaw snapping, jaw thrusting, jaw cracking
Jerking head, jerking neck, jerking body
Knee bending, deep knee bends, knee knocking, knee extending
Knocking things, knocking body parts
Leg tensing, leg jerking, leg extending
Lip-licking, lip popping, lip smacking, lip pouting
Mouth opening, mouth pouting, mouth grimacing
Neck twisting, neck extending, neck pulling, neck stretching
Nose twitching, nose touching
Opening mouth, opening eyes
Picking skin, picking scabs, picking at lint, picking lips, picking cuticles
Pulling clothes, pulling fingers, pulling hair
Rolling eyes, rolling shoulders
Shaking head, shaking feet, shaking arms, shaking legs, shaking hands
Shoulder shrugs, shoulder lifts, shoulder rolls
Smelling fingers, smelling objects, smelling hands
Snapping fingers, snapping jaw
Tearing clothes, tearing things
Tensing abdominals, tensing gluts, tensing legs, tensing muscle groups
Thrusting movements, thrusting tongue, thrusting jaw
Toe walking, toe flexing, toe scrunching
Torso thrusting, torso twisting
Tossing hair out of eyes, tossing head
Touching elbows behind back, touching palms, touching chin,
touching nose, touching people, touching objects (haphemania)
Twirling, Twirling around, Twirling hair
Twisting neck, twisting torso
Walking on toes, walking backwards
VOCAL TICS, PHONIC TICS, or VERBAL TICS
Animal sounds, animal noises, animal-like sounds
(dog, cow, cat, pig, duck, frog,
barking, chirping, quacking, meowing, oinking, braying)
Blocking tic (unable to get sound out)
Blowing on fingers, self, objects, others
Coprolalia - speaking obscenities or socially taboo or inappropriate phrases
Echolalia - repeating other's words
Guttural sounds from back of throat
Making unintelligible noises
Palilalia - repeating one's own words
Repeating phrases, repeating words, repeating parts of words
Talking to oneself
Throat clearing, throat clicking, guttural sounds in back of throat
Voice – change in pitch, change in volume, change in intonation
(Just a note: this website was
designed for newcomers to Tourette's syndrome, to be read through in page order.
Strengths and advantages associated with Tourette's syndrome
Growing up with Tourette's
Syndrome: Information for Kids
HBO Documentary on Tourette's Syndrome
Syndrome Research Article Summary
Tourette's Syndrome - Now What?
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