The Nervous tics Are movements, or repetitive, rapid, non-rhythmic and spasmodic vocalizations that occur in children and adults. They reproduce gestures of daily life such as blinking, coughing, winking and can occur in children and adults... They manifest involuntarily and are experienced as irresistible, although it is true that they can be temporarily suppressed voluntarily. They are also isolated, unexpected and frequent.
The definition of tics provided by the Diagnostic Manual for Mental Illness is slightly different. It defines Tic as a sudden, fast and recurrent motor movement, non-rhythmic and stereotyped.
They may appear in the form of isolated clinical signs, or may form part of psychomotor disorders of greater severity, the best known being Tourette Syndrome .
They were first described in 200 AD. By Arateus of Cappadocia. And it was not until the 19th century, when Gilles de la Tourette described a clinical picture of patients with both motor and phonological tics.
Psychomotricity and psychological factors of tics
To locate the tics it is important to mention the psychomotricity and its relation and link with the psychological factors.
We understand by psychomotricity, the reflection of the performance of the man in interaction with affective and cognitive experiences. That is, there is a nexus between external aspects (movements, gestures, postures...) and internal characteristics of the person (his psychological factors)
In our daily lives, when we meet people we form an impression of them and we do it from their gestures, postures and behavior in general.
Based on this impression we presuppose other characteristics associated with that person in relation to his personality, for example if he is cheerful, if he is a sad person, if he is rather nervous, or otherwise calm..., his emotions, his way of thinking ...
At first he mentioned the link between the psychomotor and the psychological, and this is clearly manifested when people suffer some psychopathological disorder.
With regard to the relationship that can occur in some people between psychomotor and psychopathology, the motor activity is evaluated by how it is reflected in people in attitude, gestures, mime and movements both isolated and combined, voluntary or involuntary.
Moreover, it is based on two fundamental dimensions; The expressiveness, transmitted by symbols, as a change of posture. And structuralism (nervous structural determination of movement, for example stiffness).
Biological aspects of nervous tics
It has been found that some brain structures and circuits involved in the control of psychomotor functions are the same as those involved in the modulation of cognitive and emotional aspects.
The basal ganglia and their circuits have been the most studied, considering that they not only present a modulating function of the motor functions, but also they play cognitive and affective functions.
- Circuit with projections from Paralimbic Cortex to the Nucleus Accumbens -> relationship with affective and motivational functions.
- Circuit from the Orbitofrontal cortex -> modulation of operations related to environmental context and mean inhibition of responses.
- Projections from the Dorsolateral Prefrontal Cortex to the Caudate Core , Mediatizes working memory and other executive functions.
Other findings have found interconnections between the limbic system (Involved in the emotional) and the Extrapyramidal system (Involved in the motor). And also, the involvement of the cerebellum as a modulator of cognitive and affective functions that extend beyond the modulation of motor activity.
This is reflected in the following clinical findings between motor manifestations and comorbid cognitive or emotional alterations:
- Sick of Parkinson's Which usually present associated depression. (According to studies this is between 20 and 90% of cases).
- Patients with a diagnosis of Huntington's Korea , Which present comorbid psychotic symptoms.
- Patients with Stroke Have depressive symptoms (25-30%) and the presence of concomitant episodes of mania has been reported.
- People with depression who present alterations in movement such as psychomotor retardation.
- Schizophrenics with stereotypies or Catatonia ...
Prevalence of nervous tics
Studies conducted in the general population in pediatrics, affirm that tics are the most frequent movement disorder. It is estimated that between 4 and 23% of children present tics in before puberty.
On the other hand, Zohar et al. In 1998, indicate that between 1-13% of the children and 1-11% of the girls report"frequent tics, jerks, mannerisms or spasmodic habits.
Between 7 and 11 years of age, these children have the highest prevalence rates, reaching 5%, the probability of having a tics disorder is higher than in adults.
They also affect men more than women, in a 4: 1 ratio.
Clinical course
The onset of tics usually occurs in infancy, around 7 years, and over 10 years, people with tics develop the capacity to be aware of the existence of premonitory impulses that precede the production of tic. It is the perception of a sensation of a particular area of the body where the tic is going to occur, for example a itch, a tickle... And a relief after the sting of tics.
This pre-tic sensation makes subjects think they are habitual and occur in response to unpleasant sensory stimuli.
Tics tend to be of short duration, rarely last more than a second, and many occur in spells, with intervals between very short tics (Peterson and Leckman, 1998). They can occur alone or together following an organization.
Usually the tics disappear, and this is related to the age of onset and duration of symptoms, the younger the subjects and the longer the symptoms, the more likely they will not disappear.
The recurrent occurrence of tics in adulthood is infrequent, when they occur, tend to be persistent childhood tics, are more symptomatic and often obey a secondary expression of some other disorder, or other events such as drug abuse, physical illnesses such as pharyngitis ...
Classification of tics
There are several classifications of tics, both motor and vocal.
On the one hand we can refer to the nature dimension, on the other to the complexity of tics. And finally, to the organic or psychological dimension of these.
Within the dimension nature of tics, we talk about Primary and secondary tics .
Within the Primary tics We talk about those hereditary and those that occur sporadically during a stage of the person's life, which may coincide with a more stressful or anxious.
The Secondary tics Are those that arise from a disease such as Huntington's Wilson's disease. Following the drugs, such as tricyclic antidepressants, anticholinergics, antiepileptics and psychostimulants. As a result of a stroke or a head injury...
With respect to complexity we find Simple and complex tics , Although it must be taken into account that the difference is not very defined.
Simple tics
Within this subgroup we can refer to phonic tics (guttural noises, hissing, clearing, coughing...) and to clonic motor tics (those that occur in a repetitive, involuntary, abrupt and explosive manner); Tonics (those that appear suddenly after a period disappeared) and dystonic (those characterized as contractures or sprains).
- Clonic: winks, blinks, sniff and inhale.
- Tonic: turn your head, lift your shoulders, close your eyelids for a few seconds.
- Distal: extension of the neck, contractures in the face.
Complex Tics
Where we find sequenced movements, which can encompass different parts of the body, are stereotyped in nature and obsessions such as compulsions are not involved. Examples of complex tics can be facial gestures such as nose and throat gestures, toilet gestures such as washing hands, shaking legs, jumping, touching something like a wall, and repeating words or phrases out of context.
In extreme cases of motor tics we find copropraxia (obscene movements) or with self-injurious movements. With regard to phonological tics in more severe cases we talk about the Coprolalia (Use of socially unacceptable, often obscene words), palilalia (repetition of own sounds or words) and echolalia (repetition of the sound, word or phrase just heard).
Psychological tics
The Psychological tics Worsen with distraction and disappear during sleep, the person can reproduce them voluntarily and also inhibit them, although this implies an increase of the anxiety and discomfort of the subject. They are not modified and the etiology is not organic.
On the other hand, Shapiro, in 1978, proposed a classification of the tics based on the aetiology of these, in their age of onset, duration and course.
He posited the existence of transient tics of childhood or simple acute tics; Simple chronic tics; Huntington's Korea; Multiple tics of childhood or adolescence and chronic multiple tic ( Gilles de la Tourette Syndrome ).
Diagnostic Classification in CIE and DSM
The manuals of diagnostic classifications of psychological disorders raise the classification of tics in the following sections:
- In the ICD (International Classification of Mental Illnesses), tic disorders are classified into behavioral disorders and emotions of usual onset in infancy and adolescence.
- In DSM-IV, tic disorders are classified in the category of motor skills disorders within the disorders usually diagnosed for the first time in childhood and adolescence.
- The DSM-5, for its part, classifies them in the category of motor disorders, within neurodevelopmental disorders. They appear next to the disorder of the development of the coordination and the disorder of stereotyped movements.
Diagnostic Criteria Tics Disorders (DSM-5)
Criterion A. Multiple motor tics and one or more vocal tics have been present at some point during the disease, although not necessarily concurrently.
Criterion B. Tics may appear intermittently in frequency but persist for more than a year since the appearance of the first tick.
Criterion C. It starts before the age of 18.
Criterion D. The disorder can not be attributed to the physiological effects of a substance (eg cocaine) or other medical condition (eg, Huntington's disease, post-viral encephalitis).
Persistent (chronic) motor or vocal tics disorder
Criterion A. Single or multiple motor or vocal tics have been present during the disease, but not both at the same time.
Criterion B. Tics may appear intermittently in frequency but persist for more than a year since the appearance of the first tick.
Criterion C. It starts before the age of 18.
Criterion D. The disorder can not be attributed to the physiological effects of a substance (eg cocaine) or other medical condition (eg, Huntington's disease, post-viral encephalitis).
Criterion E. The criteria for Tourette's disorder have never been met.
Specify if:
"Only with motor tics."
-Only with vocal tics.
Chronic motor or vocal tics disorder is present in some children with developmental difficulties and children with ADHD . Sometimes a set of symptoms can occur because of an increased period of stress or fatigue in the subject.
Transient tics disorder
Criterion A. Single or multiple motor and / or vocal tics.
Criterion B. Tics have been present for less than a year since the appearance of the first tic.
Criterion C. It starts before the age of 18.
Criterion D. The disorder can not be attributed to the physiological effects of a substance (eg cocaine) or other medical condition (eg, Huntington's disease, post-viral encephalitis).
Criterion E. The criteria for Tourette's disorder or persistent (chronic) motor or vocal tics disorder have never been met.
Transient tics disorder is the most common form among 4 or 5 years of age, and usually take the form of winking, grimacing or neck jerking, ie, they are limited to eyes, face, neck or extremities Higher.
Treatment of tics
Although we currently have effective techniques for the reduction of tics and nervous habits, it should be made clear that tics are rarely completely eradicated and that there is no ideal anti-tics treatment.
The criterion of improvement in these people is governed by the decrease in the percentage of these behaviors, rather than by their complete disappearance. When a low frequency is reached, interference in the person's daily life is greatly reduced.
There are different psychological and pharmacological treatments for tics and nervous habits.
Of the pharmacological treatments, the most used are the Antipsychotics .
Historically, classic antipsychotics have been used but atypicals are currently being used because they have a wider action involving more neurotransmitters and less side effects (especially extrapyramidal).
As for psychological treatments, those that come from behavior therapy predominate. But depending on the response to treatment and other Factors (comorbidity with other disorders, specific patient situations, etc.), it may be necessary to use other different behavioral techniques, treatments Psychosocial or combined treatments when symptoms are very severe and do not refer to specific behavioral techniques.
The most commonly used behavioral technique is habit inversion, which is not limited to a specific technique, but rather represents a complex intervention program. The most important components are:
- Training in increasing awareness of the occurrence of tics.
- Practice a competitive response contingent on its appearance, such as relaxation, tension the muscles opposed to those that trigger the tic, or make a response incompatible with such maladaptive behavior.
These components have proven to be effective both together and separately and as
A single applied technique.
Bibliography
- AMERICAN PSYCHIATRIC ASSOCIATION (APA). (2002). Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR . [Links]
- AMERICAN PSYCHIATRIC ASSOCIATION (APA). (2014). Diagnostic and Statistical Manual of Mental Disorders DSM-5 . [Links]
- ICD-10 (1992). Mental and behavioral disorders. London: Oxford University Press.
- Vallejo Ruiloba, J. (2011) Introduction to psychopathology and psychiatry . Elsevier España S.L. Barcelona.
- Tijero-Merino, B., Gómez-Esteban, J.C., Zarranz, J.J. Tics and Gilles de la Tourette syndrome. (2009). Neurological Review , 48. S17-S20.
- Perez Alvarez, M. (2006). Guide to effective psychological treatments: childhood and adolescence. Pyramid.