What are tics?
Tics are rapid, repetitive, involuntary contractions of a group of muscles.
They can occur as:
- motor tics (bodily movements) – such as facial twitching, grimacing, blinking and shrugging the shoulders
- phonic or vocal tics (sounds) – such as coughing, grunting, clearing the throat and sniffing
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.
Read more about the types of tics.
When to see your doctor
You should visit your doctor if you or your child develops a tic and they:
- occur regularly or become more frequent or severe
- are associated with emotional problems or physical discomfort
- are accompanied by other worrying moods or behaviours, such as anger, depression or self-harm
Your doctor should be able to diagnose a tic from a description of the symptoms and by observing them. Special tests aren't usually required. If possible, it can be helpful to record the movements on video so that you can show your doctor.
What causes tics?
It's not clear exactly what causes tics, although they are known to be related to the parts of the brain that control movement.
Tics often appear to run in families, so there may be a genetic reason why they develop. Tics can also be caused by certain types of medication or other health conditions, such as cerebral palsy.
There are things that can make tics worse, such as anxiety, [stress], tiredness and excitement.
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’.
For many people, tics are only temporary. They tend to improve during the late teenage years or early adulthood.
Read more about the causes of tics.
If you have a mild tic, you may decide that treatment isn't necessary. However, a number of different options are available.
Behavioural therapies are often recommended as a first choice treatment for tics. They include:
- Habit reversal therapy (HRT), which aims to help you learn 'responses' (other movements) which 'compete' with tics, meaning that the tic cannot happen at the same time. HRT teaches you to use these competing responses when you get the feeling that you need to tic, until the feeling goes away.
- Exposure with response prevention (ERP), which aims to help you get used to the overwhelming unpleasant feelings that are often experienced just before a tic.
There are also a number of medications that can improve tics in some people. In particularly severe adult cases, a new surgical treatment for tics called deep brain stimulation may be used.
Read more about treating tics.
Complications of tics
Although tics often improve over time, they can cause some problems. In particular, you or your child may find it more difficult to make friends and you may experience bullying.
Studies have also shown that having a tic can affect your performance at school or work.
Read more about the complications 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.
The severity of a tic can change over time and sometimes a tic may stop and a different one starts.
Motor tics can be either simple or complex.
Simple motor tics
Simple motor tics only involve one muscle group. They include:
- blinking or twitching 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 and it can 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 (phonic) 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:
- clearing your throat
Complex vocal tics
Complex vocal tics involve saying words, phrases or sentences. They may include:
- repeating a sound, word or phrase
- using obscene, offensive or socially unacceptable words and phrases (although this is uncommon)
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 start with a feeling of tension that builds up inside you (a premonitory urge). Some people also describe this as a hot, itchy or generally unpleasant sensation that you want to get rid of.
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 or self-conscious about your tic being noticed.
The exact cause of tics is unknown, but they are thought to be related to the connections between certain areas of the brain involved in the production and control of movements.
As tics often run in families, with several family members being affected, they are thought to be related to your genes. However, other factors may also play a role.
Your genes contain information (DNA) that controls characteristics such as the colour of your hair and eyes. It is possible that an inherited aspect of your genes is responsible for making you more susceptible to developing a tic, as it is well known that tics tend to run in families. Current research is trying to establish this genetic link through detailed family studies.
Some medicines can generate an increase in tics. For example, methylphenidate and dexamfetamine, which are used to treat attention deficit hyperactivity disorder (ADHD).
You should discuss with your doctor 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.
Sometimes, a tic may be a symptom of another condition, such as:
- cerebral palsy – a condition caused by brain damage
- Huntington's disease – an inherited condition that damages some of the nerve cells in the brain
- any disease that affects an artery within the brain or that supplies blood to the brain (cerebrovascular disease)
- a head injury – although this is very rare
Tics can also occur as a result of taking recreational drugs, such as cocaine or amphetamines, or when you stop taking drugs (as a withdrawal symptom).
Treatment for tics is not always necessary, although different treatments are available.
If your tic is mild and doesn't usually interfere with your school, work or everyday life, you may decide it doesn't need treating. The tic may improve without treatment as you get older.
If your tic needs treatment, you can try behavioural therapy, often recommended as the first approach, or there are a number of medicines you can chose from. When deciding whether you need treatment, you should bear in mind that tics tend to be better or worse at different times and often improve during later teenage years or early adulthood.
There are a number of simple things you can do that may help improve your tics, such as avoiding things which make them worse. This may involve reducing stress and trying not to become too tired or over-excited, or being aware that you may experience more tics at these times and being prepared for this.
Also, try to make time for activities that are relaxing and enjoyable.
If your child develops a tic, there are several things you can do that may help them. For example:
- don't tell them off about their tic
- don't try to stop them making repetitive movements or sounds because this may cause them to become stressed, which may make the tic worse
- try to ignore the tic because drawing attention to it may make it worse
- reassure your child that they are well and there's no reason for them to feel ashamed
- make a point of educating other children about tics so they're aware of your child’s condition; encourage them to react naturally
Most importantly, you should try to reduce the levels of stress and anxiety around you and your child.
Behavioural therapies are often recommended as one of the first treatments for tics. Behavioural therapy is a type of psychotherapy designed to change the pattern of your behaviour.
The type of therapy most suitable for you will depend on the nature and severity of your tics. Often several different techniques are used together.
You may be referred to a specialist psychological treatment service where staff can advise about an appropriate treatment plan.
One of the main types of behavioural therapy used to treat tics is called habit reversal therapy (HRT). 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
- teach you a new response to carry out when you feel the urge to tic – for example, if your tic usually involves shrugging your shoulders, you may be taught to stretch out your arms if you feel the urge to tic, until the urge subsides
Behavioural therapy for tics may also include a technique called exposure and response prevention (ERP). ERP aims to help you learn to suppress the growing feeling that you need to tic (premonitory urge) until this feeling subsides.
The idea is that over time you will get used to the feeling of this premonitory urge (habituation) and the need to tic in response will lessen.
Studies have shown that both HRT and ERP can improve tics in around half the people using them. These techniques are more likely to be successful if practiced regularly.
If you decide to use medicines to treat your tics, the choice of medicine will initially depend on several things, 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 of these are described below.
Neuroleptics, also known as antipsychotic medicines, are a type of medicine used to treat psychosis. In much lower doses, they have also been shown to be 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.
Examples of neuroleptics include haloperidol, pimozide and risperidone. However, haloperidol is rarely prescribed nowadays due to the potential side effects (see below).
Neuroleptics can be divided into two main groups:
- typical neuroleptics – the first generation of neuroleptics, developed in the 1950s
- atypical neuroleptics – a newer generation of neuroleptics, developed in the 1990s
The newer, atypical neuroleptics tend to have milder side effects.
Side effects of both typical and atypical neuroleptics include:
- weight gain
- blurred vision
- a dry mouth
However, typical neuroleptics can also cause:
- muscle twitches
Studies have found that neuroleptics can improve tics in about seven out of every 10 people.
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 relatively mild side effects, including:
- dry mouth
- feeling sick
Studies have shown that alpha2-adrenergic agonists can reduce the frequency of tics in about half the people who are prescribed them.
Benzodiazepines, such as clonazepam, have been shown to reduce the severity of tics in some people. They work by altering the way certain chemicals transmit messages in the brain.
Benzodiazepines aren't as effective as neuroleptics in suppressing tics and it's possible to become addicted to them if they're used for a long time. However, they can be useful for the short-term treatment of tics.
Tetrabenazine is a medicine used to treat conditions that affect movement. Some studies have found that tetrabenazine improved tics in eight out of every 10 people and some people experienced a long term improvement in their symptoms.
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 type A is a powerful poison that's safe when used in small doses. A tiny amount of botulinum toxin can be injected into the muscles involved in a particular tic to relax them. For example, it can be injected into the muscles of your voice box to treat vocal tics.
As well as reducing tics, botulinum toxin can reduce the feeling of building tension that often comes before a tic.
However, the effect of botulinum toxin injections only lasts about three months, so further injections may be necessary. It can also cause a temporarily weak or soft voice when used to treat vocal tics.
Deep brain stimulation
Deep brain stimulation is a type of surgery that's been used to treat severe cases of Tourette's syndrome. It's a relatively new treatment for the condition, so it's still being studied.
Deep brain stimulation involves placing one or more electrodes (small metallic discs) in an area of your brain associated with tics. The electrodes are placed in the brain by inserting fine needles through small holes in your skull. This is done under general anaesthetic.
Thin wires run from the electrodes to a pulse generator (a device 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 tics.
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.
Due to the uncertainty surrounding this treatment for tics, deep brain stimulation is currently only recommended for adults who have severe tics that have not responded to other treatment.
Although many tics improve over time, they can cause a number of problems.
Some of these are outlined below.
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 [advice about bullying] for help 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 emerge as a problem at a time when your child is studying for exams at school 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 if their tics are particularly bad or if they have been suppressing their tics and need a break to release them to help them concentrate more in class.
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.