Post-traumatic stress disorder (PTSD) and tic disorders are two distinct conditions that sometimes co-occur. PTSD involves a set of symptoms that develop after experiencing a traumatic event, while tic disorders cause involuntary movements or vocalizations called tics. Though the two conditions are separate, their symptoms can interact and exacerbate one another. This article will examine the relationship between PTSD and tics and discuss whether tics should be considered part of the cluster of symptoms of PTSD.
What are PTSD and tic disorders?
PTSD is a mental health condition triggered by experiencing or witnessing a terrifying or deeply distressing event. Symptoms of PTSD include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the trauma. These symptoms can be so severe that they interfere with an individual’s ability to function at work, maintain close relationships, or even perform daily tasks.
Tic disorders result in sudden, repetitive movements or vocalizations called tics. Tics can be simple or complex. Simple motor tics involve brief movements like eye blinking or shoulder shrugging. Simple vocal tics may include throat clearing, sniffing, or grunting. Complex tics are more elaborate and purposeful-looking but are not intended. An example is a sudden jumping, bending, or twirling. Coprolalia is a complex vocal tic involving the utterance of obscene words or phrases.
The most common tic disorders are Tourette syndrome, chronic motor or vocal tic disorder, and provisional tic disorder. Tourette syndrome begins in childhood and involves multiple motor and vocal tics over the course of more than one year. Chronic tic disorders involve either motor or vocal tics, but not both, lasting for over a year. Provisional tic disorder occurs when tics have been present for less than one year.
The relationship between PTSD and tics
Studies have uncovered connections between PTSD and tics, though specifics about their relationship remain unclear. Here are some key points about what we know so far about how PTSD and tic disorders interact:
– Comorbidity rates between PTSD and tic disorders have been documented. For example, a study of children exposed to trauma found that 73% of those with chronic tics also had PTSD symptoms. And 48% of youth being treated for tic disorders also had PTSD.
– The onset of tics can be triggered by psychological trauma or extreme stress. Tics may manifest for the first time after a child or adult experiences a traumatic event. Increased tic severity has also been linked to times of heightened stress.
– Both PTSD and tic disorders are linked to changes in brain functioning. Neuroimaging studies show that areas of the brain related to inhibition, anxiety, and repetitive behaviors are impacted in both PTSD and tic disorders. This suggests a biological mechanism may underlie some of their interactions.
– Anxiety is a hallmark of PTSD and can exacerbate tics. The presence of PTSD correlates to more severe tics. Treating PTSD anxiety symptoms may alleviate tics.
– Medications used for PTSD like antidepressants may also help lessen tics.
– Cognitive behavioral therapy for PTSD focuses on processing trauma, managing anxiety, and correcting unhelpful thought patterns. These same techniques may aid in tic management.
Should tics be part of the PTSD criteria?
The diagnostic criteria for PTSD are outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association. The DSM-5 criteria describe the cluster of symptoms that must be present to warrant a PTSD diagnosis. Key symptom clusters include:
– Re-experiencing symptoms like intrusive memories or flashbacks
– Avoidance of trauma reminders
– Negative changes in thinking and mood
– Changes in arousal like hypervigilance or a startle reaction
Tics are not currently part of the diagnostic criteria for PTSD. However, some experts have proposed that tics should be added as an additional symptom cluster of PTSD, given the documented associations between the two conditions.
There are reasonable arguments on both sides of this issue:
Reasons to add tics as a PTSD criterion
– Acknowledges the strong link between trauma and onset of tics
– May lead to improved screening and diagnosis when tics and PTSD symptoms co-occur
– Reflects our evolving understanding of how trauma impacts brain areas linked to tics
– Results in more comprehensive treatment plans that address both tic and PTSD symptoms
Reasons against adding tics to PTSD criteria
– Tics have biological roots and causes outside of trauma
– The majority of tic disorder cases are not linked to PTSD
– The DSM aims to define separate conditions, not blended syndromes
– More research on trauma-induced tics is still needed before amending criteria
– Adding new criteria may lead to overdiagnosis of PTSD
Expert opinions on revising the PTSD criteria
There is some division among experts regarding whether or not tics should be added as a diagnostic criterion for PTSD. Here are some opinions from leading researchers and clinicians:
– “I do not believe there is sufficient data to warrant inclusion of tics as a defining feature of PTSD in the next iteration of DSM.” – Dr. Murray Stein, UCSD School of Medicine
– “Tics are likely best conceptualized as a sequela of PTSD rather than part of its defining clinical features. The optimal approach is monitoring tics during PTSD treatment.” – Dr. Brigette Ritschel, University of North Carolina
– “In children, especially, a sudden onset or worsening of tics in the context of trauma exposure warrants screening for PTSD.” – Dr. Tanya Murphy, University of Toronto
– “Revising the PTSD criteria to recognize trauma-induced tics would reduce unnecessary treatment delays for vulnerable youth.” – Dr. Rebecca Hedlund, Baylor College of Medicine
How are PTSD-related tics treated?
When tics occur along with PTSD, an integrated treatment approach addressing both conditions together is recommended. Treatment generally involves a combination of psychotherapy focused on processing trauma, reducing anxiety, and modifying cognitive distortions plus medication to reduce tic severity as needed.
Psychotherapy
Cognitive behavioral therapy (CBT) is considered the gold standard psychosocial treatment for both PTSD and chronic tic disorders. For PTSD, CBT aims to help the individual process their memories of the trauma in a healthy way and develop coping skills for managing fear, anxiety, and upsetting flashback or thoughts. CBT for tics teaches techniques to become more aware of tic triggers, recognize premonitory urges, and voluntarily suppress tics. Relaxation exercises are included to reduce anxiety that exacerbates tics.
Exposure therapy is also used in PTSD treatment to help the individual face trauma-related memories and situations in a safe, controlled way to overcome avoidance and fear. A similar approach called Habit Reversal Training is applied to tics, gradually exposing the person to tic-triggering situations so they can practice applying CBT skills to minimize tics.
Medication
Anti-anxiety medications, antidepressants, and alpha-agonists may be prescribed to help control tics. Examples include clonidine, guanfacine, clonazepam, and selective serotonin reuptake inhibitors (SSRIs). Psychostimulants like methylphenidate may also reduce tics for individuals with comorbid ADHD alongside PTSD.
BOTOX injections directly into affected muscles have been approved to treat chronic motor tics and may provide temporary relief lasting about 3 months.
Supportive therapy and lifestyle changes
Additional supportive therapy can aid PTSD and tic management. Family therapy educates loved ones about both disorders to foster a supportive home environment. Individual and group therapy help enhance emotional regulation skills and resilience. Stress management and relaxation techniques such as meditation, yoga, massage, or tai chi can reduce anxiety that often worsens tics. Avoiding stimulants like caffeine, nicotine, and amphetamines may also minimize tic severity.
Prognosis for PTSD-related tics
With proper diagnosis and a comprehensive treatment plan, the prognosis for concurrent PTSD and tic disorder is generally positive. Here are some factors that influence outlook and recovery:
– Younger age at onset of symptoms tends to correlate with better long-term tic improvement.
– Comorbid conditions like OCD or ADHD alongside PTSD and tics require additional monitoring and treatment.
– Ongoing stress or trauma exposure may exacerbate symptoms. A stable, supportive environment aids recovery.
– Treatment is most effective when started quickly after tic onset rather than delaying intervention.
– Adherence to CBT therapy homework optimizes tic reduction and PTSD symptom management.
– Most children see a significant decline in tics by early adulthood even without treatment.
– Medications can provide temporary tic relief though not a permanent cure.
– Residual or intermittent tics may remain for some patients, requiring occasional booster therapy.
– Relapse is possible, especially during times of high stress. Having a response plan helps minimize setbacks.
Overall, with prompt detection and access to evidence-based treatment combining psychotherapy, lifestyle changes, medication, and support, the majority of individuals experiencing tics related to PTSD will get substantial symptom relief and improve their quality of life.
Conclusion
The link between psychological trauma and the onset or worsening of tic disorders has become increasingly clear. At the same time, there is still uncertainty and debate among experts regarding whether tics warrant inclusion as a diagnostic criterion for PTSD. While there are reasonable arguments on both sides, the two conditions can be viewed as related yet distinct disorders.
Regardless of the diagnostic classification, it is vitally important to recognize when tics and PTSD symptoms occur together. Evidence-based integrated treatment addressing trauma reactions and tic management should be made easily accessible. Ongoing research to better understand tic-PTSD connections and refine therapies will further improve quality of life for affected individuals. A collaborative, patient-centered approach that is responsive to emerging evidence represents the ideal strategy for serving the needs of this vulnerable population.