Persistent (Chronic) Motor or Vocal Tic Disorder DSM-5 307.22 (F95.1)

Persistent (Chronic) Motor or Vocal Tic Disorder DSM-5 307.22 (F95.1)

DSM-5 Category: Tic Disorders

Introduction

Tics are described as sudden, repeated sounds, movements or twitches. If a patient is experiencing tics, there is nothing that they can do to stop these involuntary actions. An example of motor tic is repeated blinking, while an example of a vocal tic is an involuntary throat clearing sound. Of the three tic disorders described in DSM-5, one example is defined as persistent (chronic) motor or vocal tic disorder. Patients with persistent motor or vocal tic disorders have had the tic symptoms for a minimum of one year. If the symptoms have existed for less than a year, they can be defined as provisional tic disorders. The term provisional tic disorder is a DSM-5 update: previously the term “transient” was used to describe patients with symptoms of less than one year. Also in DSM-IV, the diagnosis of persistent (chronic) motor or vocal tic disorder required the absence of any tic-free periods of 3 months or greater (CDC 2014).

Diagnostic criteria for persistent (chronic) motor or vocal tic disorder include all of the following features:

  • Presence of at least one motor or vocal tics, but not both;
  • Presence of tics that have commenced prior to the 18th birthday;
  • Tics that occur many times throughout the course of the day, almost every day, or occur on or off over a period of greater than one year;
  • The tic symptoms must not be a result of taking medications or drugs, or be the result of a medical condition, for example, encephalitis, Huntington’s disease or epileptic seizures;
  • Patient must not be diagnosed with Tourette’s syndrome (CDC 2014).

Symptoms of Persistent (Chronic) Motor or Vocal Tic Disorder

Motor and vocal tics are either simple or complex:

Simple motor tics involve only one muscle group and they may include:

  • Twitching or blinking of the eyes;
  • Nose wrinkling;
  • Tongue movements;
  • Hopping or squatting;
  • Snapping of fingers;
  • Shoulder shrugging (NHS 2013).
Complex motor tics are a series of simple motor tics, or involve more than one muscle group. Examples include:

  • Facial grimacing;
  • Bending to touch the floor;
  • Smoothing of clothing;
  • Lip biting;
  • Head banging;
  • Touching people or things;
  • Obscene gestures (NHS 2013).

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

  • Grunting;
  • Coughing;
  • Hissing;
  • Barking;
  • Sniffing;
  • Throat clearing;
  • Snorting (NHS 2013).

Complex vocal tics involve the vocalization of words, phrases or sentences. They are capable of interrupting normal flows of speech, similar to a stutter or stammer. Examples include:

  • Repetition of phrases, sounds or words;
  • The use of socially unacceptable, offensive or obscene words or phrases (NHS 2013).

Onset

Persistent (chronic) motor or vocal tics usually are first noted between the ages of 5 and 6 years, and typically progressively worsen until about age 12. In most cases, the tics improve by the time the patient reaches adulthood (MedlinePlus 2013).

Prevalence

The estimation of the prevalence of tic disorders is much more complicated than originally thought. In the past, it was thought that tic disorders were quite rare. Currently, though, tics are thought to be the most common movement disorder in children, with between 0.2 to 46% of school age children experiencing them during their lifetime. The reason for the wide range of prevalence estimates include the multi-faceted nature of tics, as well as their heterogeneous presentation (Cubo 2012).

Comorbidities

The most frequently reported conditions associated with tics are attention deficit hyperactivity disorders (ADHD) in roughly 20% of cases, obsessive compulsive disorder (OCD), self-injurious behavior, anxiety, depression, personality disorder, oppositional defiant disorder and conduct disorders (Cubo 2012).

Treatment for Persistent (Chronic) Motor or Vocal Tic Disorder

In many cases, tics do not significantly interfere with daily life, so treatment is not required. In fact, many patients never even seek medical advice (Roessner, et al 2011).

European treatment guidelines for children and adolescents with tic disorders include behavioural and psychosocial interventions (BPI). Verdellen, et al, conducted an extensive literature search designed to characterize the efficacy of such BPI. It appears that behavioral treatments are the most vigorously researched psychological interventions. A total of 8 separate tic behavioral treatments were identified, including:

  • Massed (negative) practice (MP): oldest intervention. Of limited efficacy;
  • Habit reversal (HR): most extensively researched, awareness + competing response. Effective and durable;
  • Self-monitoring (SM): goal is to identify occurrence. Usually temporary improvement;
  • Contingency management/function based interventions (FBI): tic-free intervals rewarded. Typically part of a multi-faceted treatment, so hard to assess.
  • Relaxation training (RT)/hypnosis: stress causes tics, so this approach reduces stress. No evidence of long-term efficacy, may be useful in short term.
  • Exposure/response prevention (ER): basis is that tics are a conditioned response to premonitory stimuli. Treatment, then, is habituation to stimuli. Preliminary results are positive, need confirmation;
  • Cognitive-behavioral treatment (CBT): re-structuring expectations and actions in high risk situations related to ticking behavior. Preliminary studies show no efficacy;
  • Bio(neuro) feedback (NF): self-directed modulation of brain electrical activity. Preliminary data is positive, confirmatory work is needed (Verdellen, et al 2011).

European clinical treatment guidelines include the following psychosocial interventions:

  • Psychoeducation- designed to provide support and resolve the misunderstanding/uncertainty felt by patients and family members;
  • Group work- is focused on providing tic management, anger management as well as providing information on bullying, effect on school and self-esteem;
  • Support organizations- serve as vehicle for sharing information regarding tic disorders (Verdellen, et al 2011).

Although not a mainstay of therapy, a variety of medications may reduce the frequency of tics by blocking dopamine in the brain of affected patients (Child Mind Institute 2014).

References

Centers for Disease Control and Prevention 2014. Diagnosing Tic Disorders. CDC.gov. Retrieved 22 February 2014 from http://www.cdc.gov/ncbddd/tourette/diagnosis.html#persistent

Child Mind Institute (2014). Mental Health Guide: Chronic motor or vocal tic disorder. Childmind.org. Retrieved 22 February 2014 from http://www.childmind.org/en/health/disorder-guide/chronic-motor-or-vocal-tic-disorder

Cubo, E 2012. Review of prevalence studies of tic disorders: methodological caveats. Temor and other hyperkinetic movements. 2, 1-8.

Roessner, V., Plessen, K.J., Rothenberger A., Ludolph A.G., Rizzo, R., Skov, L., et al 2011. European clinical guidelines for Tourette Syndrome and other tic disorders. Part II: pharmacological treatment. European Child & Adolescent Psychiatry. 20, 173-196.

UK National Health Service (NHS) Choices (2013). Different types of tics. NHS.uk. Retrieved 22 February 2014 from http://www.nhs.uk/Conditions/Tics/Pages/Symptoms.aspx

U.S. National Library of Medicine, National Institutes of Health, MedlinePlus 2013. Chronic motor tic disorder. Retrieved 22 February 2014 from http://www.nlm.nih.gov/medlineplus/ency/article/000745.htm

Verdellen, C., van de Griendt, J., Hartmann, A., Murphy, T. 2011. European clinical guidelines for Tourette Syndrome and other tic disorders. Part III: Behavioural and psychosocial interventions. European Child & Adolescent Psychiatry. 20, 197-207.


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