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For further information, see CMDT Part 24-14: Movement Disorders
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Essentials of Diagnosis
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Multiple motor and phonic tics
Symptoms begin before age 18 years
Tics occur frequently for at least 1 year
Tics vary in number, frequency, and nature over time
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General Considerations
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The diagnosis of the disorder is often delayed for years, the tics being interpreted as psychiatric illness or some other form of abnormal movement
Patients are thus often subjected to unnecessary treatment before the disorder is recognized
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Tics are noted first in childhood, generally between the ages of 2 and 15
A family history is sometimes obtained
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Motor tics
Initial manifestation in 80% of cases
Most commonly involve the face, head, shoulders, such as sniffing, blinking, frowning, shoulder shrugging, and head thrusting
Phonic tics
Initial symptoms in 20% of cases
Commonly consist of grunts, barks, hisses, throat clearing, coughs, verbal utterances including coprolalia (obscene speech)
A combination of different motor and phonic tics ultimately develop in all patients
Echolalia (repetition of the speech of others)
Echopraxia (imitation of others' movements)
Palilalia (repetition of words or phrases)
Some tics may be self-mutilating in nature
Obsessive-compulsive disorder and attention deficit hyperactivity disorder are commonly associated and may be more disabling than the tics themselves
In addition to obsessive-compulsive behavior disorders, psychiatric disturbances may occur because of the associated cosmetic and social embarrassment
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Differential Diagnosis
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Diagnostic Procedures
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α-Adrenergic agonists are first-line therapies because of favorable side effect profile compared with typical antipsychotics
Clonidine (start 0.05 mg orally at bedtime, titrating to 0.3–0.4 mg orally daily, divided three to four times per day)
Guanfacine (start 0.5 mg orally at bedtime, titrating to a maximum of 3–4 mg orally daily, divided two times per day)
Many specialists favor use of tetrabenazine
Atypical antipsychotic risperidone (1–6 mg daily orally) is more effective than placebo in controlling tics and more effective than pimozide in improving symptoms of comorbid OCD, and may be tried before the typical antipsychotic agents
Haloperidol
Typical antipsychotic of choice
Started in a low daily dose (0.25 mg orally)
Gradually increase dose by 0.25 mg every 4 or 5 days until there is maximum benefit with a minimum of side effects ...