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  • Writer's pictureDr Andy Raffles

Update on Tics & Mannerisms - Why have they apparently increased during pandemic associated lockdown

Do these headlines mean anything to you?

We’ve seen so many girls suffering in lockdown’: the troubling rise of tics among teenage girls Parents and clinicians are reporting an increase in the number of tic disorders and Tourette’s syndrome in teenagers – what’s behind it? Telegraph Feb 2021

Teenage girls suffer ‘explosion of tics’ in lockdown -Tourette’s symptoms of swearing, twitching and yelping made worse by publicity on social media says psychiatrist – Times March 2021

Over recent months many of us working in clinics providing care for children and young people have seen a worrying increase in the numbers of young people, particularly young women and girls aged 12-20 with either a newly observed sudden onset of motor movements, some of them quite explosive and violent, and verbal utterances – usually whole words or short sentences. Others are struggling with intermittent symptoms suggestive of such a problem. Although many of these children and young people had no previous suggestion of such tics and mannerisms, many of them had a background of anxiety, which the lockdown pandemic seems to have aggravated. In trying to understand why the frequency of such symptoms has increased by so much, lots of factors need to be taken into account.

In particular why is the age and sex distribution so different to one of the better understood conditions associated with such tics and mannerisms, namely Tourette’s syndrome? First, the age of onset is significantly older. Children with Tourette’s syndrome typically have onset of their tics at a mean age of 6. In these rapid-onset cases, the age of onset is older, between 12 and 25 years.

The sex distribution is also very different. We usually see three to four more girls than boys with the rapid onset of tics whereas with Tourette's Syndrome it is 3-4 times as many boys than girls. 95% of the cases described by clinics specialising in this condition are in girls or young women.

In the cases we have seen they are of rapid-onset, often within 48hrs and the majority of tic-like behaviours we are witnessing are complex, with big movements resulting in muscle pains, and complex vocalisations consisting of the repetition of random words. Many of the same words and phrases are in common between patients. This is in contrast to Tourette’s where the sounds are more commonly sniffing, coughing and snorting.

A relatively larger proportion of the young people with the rapid onset type of tics have a personal history of anxiety and depression, in contrast to attention-deficit/hyperactivity disorder or obsessive-compulsive disorder, which are the most frequent conditions seen in young people with Tourette syndrome. In children who do have a background of anxiety, and previously observed simple motor and vocal tics, when the rapid onset type also occurs in this group, these children and young people tend to be female and older.

We have observed many new stresses in the lives of our patients which may be associated with the onset of their symptoms, some related to pandemic lockdowns and social isolation, return to school, exam performance, or concerns related to parental acceptance of their social activities and friendship groups, sexuality or gender identity.

The level of disability experienced by young people with these rapid-onset tic-like behaviours is extremely high. For example, they may self-exclude from school and social activities, or be excluded from school due to anxiety amongst staff and potential social exclusion or bullying.

Treatment recommendations are for behavioural intervention for tics, which consists of habit-reversal therapy and a functional intervention to minimize triggers and reinforcing factors, cognitive-behavioural therapy and/or medication for associated anxiety and depression if present. These treatments will require referral to a specialised Child Psychologist, Psychotherapist or Child Psychiatrist.

It is helpful to spend time discussing functional neurologic symptoms and how these tic-like behaviours may be a physical manifestation of the extreme psychosocial stress, anxiety, social isolation, and loneliness affecting millions of people worldwide during COVID-19. One current discussion is how tic disorders can arise in otherwise perfectly healthy susceptible individuals and how social media exposure may be triggering tics.

The complicated truth about TikTok and Tourette’s syndrome

This was a letter in the British Medical Journal that suggested that TikTok or other social media may in part account for an increase in tic disorders in teenage girls. But the real story appears to be much more complex.

There are other conditions to consider, such as PANS(Paediatric Acute-onset Neuropsychiatric Syndrome) and PANDAS (Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections), which presents very commonly with new-onset tics and OCD after a recent infection – but the link to infection in these situations is essential.

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