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Tic Disorders

What are tics?

Good question that – what are tics? It’s a good question because for someone who has never experienced tics for themselves, it can be rather difficult to understand just how uncontrollable tics are and they might not, therefore, realise why someone is getting annoyed/upset with/fed up of their tics when it looks like they can just stop doing them. Sometimes, tics are not very noticeable to others but can be very distressing/upsetting for the one who has the tics. One without tics might think that one with tics is making a fuss about nothing. ‘Everyone has their own little habits. It’s nothing,’ is commonly heard but tics are not habits (see below). It is also upsetting for a person with tics to be told to stop, or worse, being told that they’re ‘putting it on’. Another problem is that tics are sometimes unconsciously suppressed while others are around which definitely makes people wonder why the person with the tics is ‘making such a fuss’. The person may then go to a private place eg. his or her bedroom where they might tic for hours without anyone else knowing. A person may also have highly irritating mental tics which of course cannot be seen.

This page outlines what tics are without going into the genetics and neurological side of things.

Tics aren't us

It is important to realise that tics, habits, mannerisms and spasms/twitches are not the same things. It is also important not to confuse tics with compulsions.

Tics are intermittent, involuntary, compulsive, stereotyped movements or sounds (motor/vocal tics) that may be ‘simple’ such as a cough, grunt, facial ‘twitch’ or shoulder shrug, or ‘complex’, such as a word, phrase or a stereotyped sequence of movements such as touching objects in certain ways or in certain places. Although tics appear similar to normal movement, they are not voluntary. There is often a sense of a build-up of the need to tic; this increases if the person attempts to stop the movement (the tics may be temporarily be suppressed). The tics are often preceded by a ‘foreboding’ sensation or urge; this is the feeling which builds up when trying to prevent the tics. Once the movement is made, there is often a sense of temporary relief until the sense of the need for the movement begins again. As tics do not look like spasms or spasm-like twitches, and look so much like voluntary movement, it is common for people to mistakenly believe that the person can just stop them ‘on command’. The person may incorporate the tic movement into an apparently voluntary gesture; this is done in an attempt to avoid embarrassment or to prevent drawing attention to them. Tics become worse when the person is nervous, anxious, stressed, upset or tired.

One may fulfil the criteria for Tourette’s syndrome (a.k.a. Tourette syndrome, Tourette’s disorder, Tourette disorder, Giles de la Tourette’s syndrome, TS, TD, Tourette spectrum disorder) if:
· they have multiple motor tics
· they have at least one vocal tic
· symptoms begin before the age of 21
· symptoms wax and wane over a period of more than one year with a tic-free period of no more than three consecutive months

If only motor tics are present, the disorder is referred to as ‘chronic tic disorder’ or ‘chronic motor tic disorder’. If only vocal tics are present, the disorder is referred to as ‘chronic tic disorder’ or ‘chronic vocal tic disorder’. In fact, Tourette’s syndrome is basically a different name for ‘chronic motor and vocal tic disorder’. In these cases, ‘chronic’ does not mean ‘severe’ but ‘lasting’. There is also a short-lived tic disorder called ‘transient tic disorder’. Unlike Tourette’s syndrome, in the transient and chronic tic disorders, the tics may be single or multiple.

Tics are very common. By some estimates, up to 10% of boys experience tics at some time during childhood. Tics are slightly less common in girls. Many tics resolve spontaneously and do not require treatment, unless the symptoms interfere with school or social interactions, but many tics do continue into adulthood. Even if the tics are not severe, a diagnosis may be helpful as the tics can be explained to others more easily and, therefore, with less embarrassment, should the need to explain them occur. The person would also feel less alone, knowing that they have official confirmation of a condition which so many others also have.

Tic disorders frequently occur in association with compulsions. Research suggests that tic disorders and obsessive compulsive disorder (OCD) may both be genetic and that they may also be different ways of expressing the same gene. Some people with tic disorders will be have, for example, ‘Tourette’s syndrome with obsessive compulsive behaviour’, meaning that they have the Tourette’s syndrome tic disorder with elements of OCD where these elements are too few/not serious enough to be diagnosed as actual obsessive compulsive disorder.

The severity and nature of tics change throughout life. They may wax and wane over months or permanently disappear for years.

Tic disorders are not psychological, but neurological. Nor are they mental illnesses.

Compulsions are complex behaviours that respond to a psychological need. These behaviours are different from tics; the detailed movements are often not stereotyped, and there is a distinct purpose to the movements. Frequently, the person has an almost superstitious concern over the consequences of not performing the compulsion. Examples include:
· compulsive hand washing due to a fear or germs
· multiple unlocking and re-locking of a door due to concern over possible intruders
· a need for symmetrical movements or placement of objects
· counting behaviour
· fixed routines or patterns of behaviour
· obsessive thoughts

The actions feel voluntary, but the person may describe a sense of fear or impending doom if the action is not performed. Compulsions are commonly associated with obsessions and tic disorders.

Spasms/twitches are completely involuntary, usually random, unpredictable movements. Unlike tics they cannot be suppressed.

Mannerisms are the particular embellishments that people develop while performing certain movements or gestures. These mannerisms are normal voluntary phenomena; however, in some cases, they may appear abnormal, particularly if the mannerism involves unusual or unnecessary postures. An example might be the extension of the little finger while holding a teacup. This mannerism was common during the nineteenth century. However, it is important to be sure that a mannerism does not represent a ‘coving-up’ of a tic or other involuntary movement disorder.

Habits are more complex or purposeful movements. There is no sensation of a build-up of the need to move prior to performing a habit or mannerism. One can modify the movement if necessary.

It should now be clear what makes tics different from compulsions, spasms/twitches, habits and mannerisms.
In short, then, tics are movements or sounds that are repeated over and over for no reason. Not all tics are ‘rapid’ or ‘sudden’; some tics are ‘held’ movements involving freezing in a position for a few seconds or, when complex, may take a while to complete, eg. touching something.

How difficult is it to stop? Try it yourself…
(The Impossible Experiment)

An easy way to understand how difficult it is to stop a tic is to try not to blink for as long as possible. When doing this, you will notice that as soon as you take your mind off trying not to blink, you blink by mistake. Notice also that the longer your eyes are open for, the more there is a build-up of the need to blink until you become desperate and either decide to blink or your eyes blink automatically after a while. Usually, when you do blink after this time, you will not blink just once, but many times.

You could also try to imagine that it’s unusual to blink but you do it so you feel conspicuous when you are with other people. This would mean that whenever other people are around you would feel the need to prevent yourself from blinking (remember how difficult that is). At the same time, you would need to try to carry on doing everything else as normal. It would make you very tense and annoyed after a while and you would not be able to concentrate fully on everything else that’s going on around you at the same time.

What do tics look like?

So what sort of movements and sounds are tics usually? Tics can be just about any movement or sound. Below is a table of some examples.

MOTOR abdominal jerking
ankle flexing
arm flailing
arm flapping
arm flexing
arm jerking
arm squeezing
eye blinking
eye rolling
facial contortions
foot dragging
foot shaking
foot tapping
hair tossing
head jerking
knee bending
knee knocking
leg jerking
lip smacking
mouth opening
nose twitching
tongue thrusting
body jerking
body slamming
chewing clothes
hair twisting
pulling clothes
smelling things
stepping backwards
tearing things
throwing things
twirling in circles
walking on toes
VOCAL belching
guttural sounds
misc. noises
noisy breathing
throat clearing
‘tsk’, ‘pft’ etc.
amplitude of speech
animal sounds
barely audible muttering
calling out
‘hey’, ‘wow’ etc.
repeating parts of words
repeating phrases
repeating words
talking to oneself

*Copropraxia: making obscene gestures.
*Echopraxia: mimicking movements that others made.
*Coprolalia: vocalising obscene or other socially unacceptable words or phrases.
*Echolalia: repeating what someone else just said.
*Palilalia: repeating your own words over and over again.

The five tic senses

Visual tics are any sudden, repetitive, stereotyped, uncontrollable desire or need to look at certain objects.

Auditory tics are any need to hear a certain thing. Common auditory tics are the need to hear a certain sound repeated, and a need to hear sounds correctly. For example, a person with auditory tics might insist that a friend repeat the phrase they had just said in different ways until it sounded right.

Gustatory tics are any sudden, repetitive, stereotyped, uncontrollable desire to taste or touch the tongue to something. This can include:
· foodstuffs
· household objects
· toxic items such as soap and bleach
This can be a very strong and quite distressing tic. Many people are afraid they will poison themselves accidentally.

Olfactory tics are the sudden, repetitive, stereotyped, uncontrollable need or want to smell something. This often accompanies an Obsessive Compulsive trigger. For example, a lady repeatedly smells her fingertips after being exposed to dirt. She then washes under her nails until she can only smell soap.

These are pretty much part of the typical motor tic spectrum. The need to touch things including:
· things that others have just touched
· things that you have just touched previously
· things that you really don't want to touch
· things that are dangerous to touch
It is also the need to touch certain types of thing. For example, a need to touch every piece of denim one comes across in one’s life, although this example has a stronger link with OCD.

Sometimes things must be touched until they ‘feel right’. Objects sometimes have to be touched in special spots. Frequent targets for touching are the edges or corners of things, or any surface irregularities such as bumps, cracks or rough spots. Sometimes stains, spots or marks are also singled out. Other common events which can become incorporated into a person’s touching tics are the opening and closing of drawers, bottles or boxes. Picking up objects and then setting them down in certain ways is also a variation on this type of behaviour.

Rarely, motor tics may be provoked by a mental projection of sensory impressions to other persons or objects and are relieved by touching or scratching that person or object. These are known as phantom tics.

There are also some recently discovered tic types:

Mental tics

The existence of mental tics has only recently been recognised by the Tourette’s Society and other medical institutions. Not much is known about them, however, and very little is publicised in literature or on the web.

Mental tics are any conscious thought process or pattern that one feels a compulsion to perform. The word ‘compulsion’ is used here because mental tics are not quite the same as physical tics and cannot be defined as ‘involuntary, rapid or sudden’. They are involuntary, but seem to only come in complex form. They are therefore similar to compulsions, although not in the OCD sense. In OCD, obsessions are repetitive thoughts about danger. Examples may be: “I’ve left the gas on, we’re all going to suffocate.” or the less logical “If I don’t tap this doorway three times every time I walk through it, my wife will die in a car crash.” This thought then stays prominent in the mind until the corresponding compulsion is performed. Mental tics are obsessions, but not in an OCD way; they are any conscious thought sequence or pattern that must be completed correctly (in the same way a motor or vocal tic must). Distraction tends to be the best way of dealing with mental tics, but not in all cases, for example when they are less compulsion-like and more tic-like.

Probably the best way of demonstrating mental tics is to give examples:
(Since there are not yet any technical medical terms for mental tics, the prefix is shown here followed by an apostrophe).

The mental form of echolalia. Those affected will hear the last few words spoken by another echoed in their minds. Echo’ also happens with music or any other sound heard. Echo’ appears to be a very common mental tic.

The mental form of coprolalia. Copro’ is immeasurably less disruptive than coprolalia. The thinking of socially unacceptable phrases is mildly frustrating (worse when combined with pali’), but often sparks worries of a progression to coprolalia. Sometimes copro’ can only be controlled by a motor tic of the mouth. Sometimes copro’ is classed as part of coprolalia.

The mental form of Palilalia. The repetition of one’s own conscious thoughts or spoken words. Pali’ can make reasoning and coherent conscious thought difficult. It can grab hold of a phrase or single word and repeat it many times before you can move on to complete the sentence, then take you back to the beginning and make you rephrase the sentence using different stresses.

Counting, listing, or reciting
Similar to having a tune stuck in your head and being unable to get it out. In this mental tic the tune will usually be completely stuck, but for some people, there is one way to get it out; if you mentally sing the song all the way through, with rests, major accompaniment etc. it will stop playing. But you have to get it exactly correct – one small mistake and your brain takes you right back to the start. A lot of people get tunes stuck in their head, but this is an obsessional need to take it all the way through. This tic also happens for poems or lists such as numbers, letters, colours or a repeating string of nonsense words. A person may need to count, for example in twos to two hundred, putting exactly the same emphasis on each number and mentally saying each number the same distance apart.

Mental manipulations
All tics have a sensory stimulus that triggers the need to tic, like an itch. In mental manipulations the stimulus is in a discreet area (like a ball) but is not on a part of the body, it is floating through the air. The mind has control (within certain limitations) over the movement of this “ball of itchiness”. Sometimes the need is to guide the “ball” through a specific pattern. Other times the “ball” is already moving, say in a circle or swinging like a pendulum, and the object is to stop the movement. It’s not as easy as it sounds; it’s like trying to stop a grandfather clock’s pendulum by tilting the clock from side to side. Another tic is when you need to push the “ball” away from the body in a straight line.

Breathing tics

Breathing tics are any sudden, rapid, recurrent, stereotyped control of breath. They are sometimes classed as vocal tics.

Examples of breathing tics:

Pacing breaths
When the person hears someone else breathing loudly, or there is a strong rhythmic sound (e.g. the bass in pop music) their lungs get confused and they must consciously match the beat with their own breathing in order to breathe comfortably.

Holding of breath with another tic
A person will hold their breath while performing a complex motor tic. Until the motor tic is completed properly, the breath cannot be released. Sometimes the person will breathe in and in and in while performing a tic. Sometimes this is done jerkily and sometimes smoothly. This probably starts as a way of concentrating on correctly performing the motor tic, but becomes ingrained as part of the tic.

Independent breath holding
The person will only realize he is holding his breath when he begins to choke. He must then remind himself to breathe, usually in a desperate gasp for oxygen. This can be scary; the autonomic nervous system is supposed to keep you breathing even when you’re unconscious, which is why you can’t commit suicide by holding your breath. But some people worry that because the tic will occasionally stop them from breathing, and some tic in their sleep, they may suffocate themselves. However, it can’t happen, the autonomic nervous system is incredibly strong and will cause their breathing to restart and may possibly wake them up.

More notes

Sometimes one’s tics may vary slightly from their usual ones. For example, one who often touches things may suddenly find that they need to lick something instead because there’s such a strong urge that touching it just isn’t adequate. Also, some people find that they have a certain extra tic during certain activities. For example, a tic involving the legs may occur only when watching a film.

It is also known that tics are ‘contagious’ and that they can be started or worsened just by mentioning them.

Listed below are some symptoms which are commonly found in people with tic disorders (especially Tourette’s syndrome).

Polydipsia – Excessive fluid intake
Some people with polydipsia drink about 15 bottles of water a day. Toilet trips are very frequent.

Sensitivity to heat
With this symptom, the person is almost always warm. In hot weather the person boils, in cold weather they wear much less heavy clothing than would be expected.

Tactile hypersensitivity
Some with this symptom can't stand the feel of hair on their skin. Most cannot wear synthetic material or wool. Pure cotton undergarments seem to be the only acceptable alternative and a couple of women go bra-less because they are too uncomfortable otherwise. There seems a higher than normal level of allergies to things like detergents and cheap metal jewellery. Even the thought of touching chalk makes some of them squirm. Often a person with this symptom will feel suddenly itchy all over, for no discernable reason. This itchiness can be triggered by watching/seeing a biting insect, seeing someone else scratch, and even talking about scratching or itches.

Co-morbid conditions
Co-morbid conditions are syndromes, disorders, illnesses etc. that are not part of the existing syndrome/disorder, but are more likely in people with that syndrome/disorder. In some cases, there may only be a slight tendency towards the co-morbid conditions of a syndrome/disorder/illness.

o obsessive compulsive disorder (OCD)
o addictive disorders
    · alcoholism
    · compulsive eating
    · compulsive shopping
    · drug abuse
    · pathological gambling
o anxiety
    · generalised panic disorders
    · panic attacks
    · phobias (especially agoraphobia and social phobia)
o attention problems
    · attention deficit disorder (ADD)
    · attention deficit hyperactivity disorder (ADHD)
o conduct disorders
o depression
    · uni-polar depression (basic depression)
    · bi-polar depression (manic depression)
o gastric troubles
    · irritable bowel syndrome (IBS)
    · reflux
    · ulcers
o inappropriate or abnormal sexual behaviours
o learning disorders
    · dyslexia
    · poor handwriting
    · poor spelling
    · trouble with maths or reading
o sleep problems
    · bed wetting
    · night terrors
    · sleep apnoea
o speech problems/abnormalities
    · delayed speech
    · hesitancy
    · stuttering
    · talking too loud or too fast


agoraphobia Morbid dread of open spaces. Literally ‘fear of the market place’.
alcoholism Continual heavy drinking of alcoholic liquor; diseased condition resulting from this.
apnoea Cessation of breathing.
attention deficit disorder A disorder with the main symptoms being inattention and impulsivity – difficulty in keeping one’s attention focused on one thing and being susceptible to a broad range of distractions. Other symptoms include: difficulty in remembering oral instructions; lack of organisation; poor handwriting skills etc. Often abbreviated to ADD.
attention deficit hyperactivity disorder The same as attention deficit disorder but including hyperactivity (the inability to sit still) and impulsivity (doing or saying things without thinking, blurting out). Often abbreviated to ADHD.
auditory Concerned with hearing; received by the ear.
autonomic Functioning involuntarily.
breathing tic Any sudden, rapid, recurrent, stereotyped control of breath.
chronic Lingering, lasting.
co-morbid condition A co-morbid condition of a syndrome, disorder or illness is a condition which is commonly found with that syndrome, illness or disorder but is not actually a part of it.
complex tic A motor tic which involves more than one muscle group or vocal tic which involves sounds of more than one syllable.
compulsion An action one feels compelled to make, often in a ritualistic fashion. Quite often these rituals are gone through despite the fact that one does not really want to do them and despite wanting to resist them.
compulsive Contrary to one’s conscious wishes; irresistible; having compulsions.
conscious Aware, knowing; with mental faculties awake; realised by the doer; aware of, concerned with.
copro- Obscene; socially inappropriate, socially unacceptable.
disorder Disturbance of normal state of body, organ etc., ailment, disease.
dyslexia Word blindness’; a disorder in which the sufferer has difficulty reading and writing.
echo- To repeat; to mimic.
genetics Study of heredity and variation in animals and plants.
gustatory Taste.
habit Settled tendency or practice; automatic reaction to a specific situation. Habits are complex, purposeful movements.
hypersensitivity The state of being abnormally or excessively sensitive.
illness Unhealthy condition of body, state of being ill.
involuntary Unintentional; not controlled by the will.
irritable bowel syndrome A condition in which the sufferer has alternating constipation and diarrhoea, abdominal pains that disappear when you go to the toilet and a feeling of never feeling quite empty. Commonly abbreviated to IBS.
-lalia From the Greek laleo meaning literally ‘to talk babble’
mannerism The particular embellishments that people develop while performing certain movements or gestures.
mental tic Any conscious thought process or pattern that one feels a compulsion to perform or which occurs unwillingly in one’s head although not an actual obsession.
motor tic Any tic involving movement of the muscles other than the diaphragm.
neurological Of or concerning the neurons in the brain.
obsession Obsessing or being obsessed; unreasonably persistent idea in the mind; condition in which such ideas are present.
obsessive Having obsessions.
olfactory Concerned with smelling.
pali- From the Greek palai meaning ‘hence/not long ago/just now’.
panic attack A sudden attack of panic and intense fear not always with an obvious trigger, usually including hyperventilating, shortness of breath, chest pains, dizziness, shaking, feeling very hot, sweating, increased heartbeat, small blackouts, nausea, intense feeling of dying or as though it is the end of the world. Sometimes accompanied by feelings of disassociation (feeling as if one is not actually there) or depersonalisation (feeling as if one is not inside one’s body).
phantom tics Motor tics provoked by a mental projection of sensory impressions to other persons or objects which are relieved by touching or scratching that person or object.
phobia Morbid fear or aversion.
polydipsia Excessive fluid intake.
-praxia From the Greek praxis ‘doing/action in drama/exhibited in actual life’.
psychological Of the mind.
reflux A gastric disorder.
sensory Of sensation or the senses.

All the information in this page should have provided you with a simple yet detailed outline of tics. Obviously not everyone has tics severe enough to warrant medication, but all tics can be annoying and can make one self-conscious even if the tics are barely noticeable. The person who’s going to notice the tics the most is the person with the tics. The greater the number of people who know about tics and tic disorders and the more those people know about them, the better.

Below are the diagnosis sheets for the three tic disorders from the DSM IV (DSM: Diagnostic service manual; the diagnostic service manual commonly used in the USA). Parts of it will explain briefly what has already been described above.

NB: The next DSM (DSM V) is not expected out until 2006, but there has been a revision called DSM IV-TR. DSM IV-TR does not include the criteria marked with an asterisk as it has been decided that a diagnosis can still be made without them. DSM III listed the age of onset as before 21. It is expected that DSM V will return to this figure.

Transient Tic Disorder

A tic is a problem in which part of the body moves repeatedly, quickly, suddenly and uncontrollably. Tics can occur in any body part, such as the face, shoulders, hands or legs.

Sounds that are made involuntarily (such as throat clearing) are called vocal tics. Most tics are mild and hardly noticeable. However, in some cases they are frequent and can affect many areas of a person’s life.

· The patient has vocal or motor tics or both. They can be single or multiple.
· For at least 4 weeks but no longer than 12 consecutive months, these tics have occurred many times each day, nearly every day.
· These symptoms cause marked distress or materially impair work, social or personal functioning.*
· They began before age 18.
· The symptoms are not directly caused by a general medical condition (such as Huntington’s disease or a postviral encephalitis) or to substance use (such as a CNS stimulant).
· The patient has never fulfilled criteria for Tourette’s Disorder or Chronic Motor or Vocal Tic Disorder.

Transient Tic Disorder is common in children. Five to twenty four percent of all school age children have had tics at some stage during this period. The cause of transient tic disorder or short-lived, temporary tic, is either organic or psychogenic. The child may have facial tics or tics involving movement of the arms, legs, or other areas. Tics appear to get worse with emotional stress and are absent while sleeping.

Chronic Motor or Vocal Tic Disorder

This disorder is characterised either by rapid, recurrent, uncontrollable movements or by vocal outbursts, but not both, that have been present nearly daily for more than a year without a period free of the problem longer than three months. These repeated uncontrollable bursts of activity or speech are called tics.

This tic disorder is diagnosed when the patient has either motor (rapid, recurrent, movement of the arms, legs or other areas) or vocal (vocalisations) grunts, abdominal or diaphragmatic contractions but not both – see Tourette’s. Tics (sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalisation) are experienced persistently.

· Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalisations), but not both, have been present at some time during the illness.
· The tics may occur many times a day nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
· The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.*
· The onset is before age 18 years.
· The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington’s disease or postviral encephalitis).
· Criteria have never been met for Tourette’s Disorder.

There may be other symptoms, such as mental coprolalia – sudden, intrusive, senseless thoughts of socially unacceptable or obscene words, phrases, or sentences that differ from true obsessions in that no attempt is made to ignore, suppress or neutralise the thoughts, obsessions, and compulsions.

The incidence of chronic motor or vocal tic disorder is more common than the better-known Tourette’s syndrome. The incidence of Chronic Motor or Vocal Tic Disorder ranges from 1 to 2%. It is, however, rare compared with the common short-lived childhood tic (transient tic disorder). Tics appear to get worse during emotional stress and are absent during sleep. It is thought that chronic tics are a variant of Tourette’s syndrome and have an underlying genetic cause.

Tourette’s Disorder

This is a rare disorder characterised by repetitive muscle movements and vocal outbursts. The main diagnostic criteria are as follows:

· At some time during the illness, though not necessarily at the same time, the patient has had both of:
At least one vocal tic (a tic is a motor movement or vocalisation that is nonrhythmic, rapid, repeated, stereotyped and sudden) and
Multiple motor tics:
For longer than 1 year, these tics have occurred many times each day, nearly every day or at intervals.
· During this time, the patient never goes longer than 3 months without the tics.
· These symptoms cause marked distress or materially impair work, social or personal functioning.*
· The symptoms begin before age 18.
· The symptoms are not directly caused by the effects of a general medical condition (such as Huntington’s disease or a postviral encephalitis) or substance use (such as a CNS stimulant).

There may be other symptoms, such a mental coprolalia, obsessions, and compulsions.

Approximately 1% of mainstream schoolchildren may be affected. Onset usually occurs with motor tics followed by vocal tics. The cause of Tourette’s Disorder is genetic in most cases. It occurs most often in boys, and may begin around age 7 or 8 but may not appear until the child is in his or her late teens or early twenties. It may run in families. The tics are worse during emotional stress and are absent during sleep.

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