Tic Disorders - Clinicals, Diagnosis, and Management

Disorders of infancy, childhood, or adolescence

Clinicals - History

Fact Explanation
Repetitive Throat clearing and shouting Most commonly seen tics are vocal tic.. Phonic (or vocal) tics can consist of any noise produced by movement of air through the nose, mouth or pharynx. Tongue clicking is, therefore, not classified as a phonic, but a motor tic. The term ‘phonic’ should be preferred over ‘vocal’, since not all sounds (For an example, sniffing) are produced by the vocal cords. Less than 5% of patients with tics have phonic tics alone without associated motor ones, but motor tics without phonic tics are very common.. Repetitive Throat clearing and shouting
Most commonly seen tics are vocal tic.. Phonic (or vocal) tics can consist of any noise produced by movement of air through the nose, mouth or pharynx. Tongue clicking is, therefore, not classified as a phonic, but a motor tic. The term ‘phonic’ should be preferred over ‘vocal’, since not all sounds (For an example, sniffing) are produced by the vocal cords. Less than 5% of patients with tics have phonic tics alone without associated motor ones, but motor tics without phonic tics are very common..
Premonitory urges Many adult patients (up to 90%), are aware of premonitory sensations preceding the tics, with a mean age of starting to become aware of 10 years. More automatic movements such as eye blinking are less often preceded by sensory urges. These sensations are experienced as unpleasant somatosensory sensations. It can be within the muscles of the upcoming tic or somewhere else in the body or the head (tiredness, itch, pressure, stabbing pain, abdominal discomfort, heat or cold) . Sometimes difficult to articulate.They are often relieved by execution of the tic. Younger children are much less aware of premonitory urges. 37% of children between 8 and 19 years are able to report on premonitory urges.And 64% of these children were able to suppress their tics. However tic awareness does not seem to be a prerequisite for the ability to suppress tics, and awareness seems to increase with age. It is closely associated with cognitive development. Premonitory urges can be bound to small localised areas, with ‘hot spots’ in the shoulder girdle, hands, feet and front of the thighs. They can also be more generalised, and described as a sense of ‘inner tension’ .. Premonitory urges
Many adult patients (up to 90%), are aware of premonitory sensations preceding the tics, with a mean age of starting to become aware of 10 years. More automatic movements such as eye blinking are less often preceded by sensory urges. These sensations are experienced as unpleasant somatosensory sensations. It can be within the muscles of the upcoming tic or somewhere else in the body or the head (tiredness, itch, pressure, stabbing pain, abdominal discomfort, heat or cold) . Sometimes difficult to articulate.They are often relieved by execution of the tic. Younger children are much less aware of premonitory urges. 37% of children between 8 and 19 years are able to report on premonitory urges.And 64% of these children were able to suppress their tics. However tic awareness does not seem to be a prerequisite for the ability to suppress tics, and awareness seems to increase with age. It is closely associated with cognitive development. Premonitory urges can be bound to small localised areas, with ‘hot spots’ in the shoulder girdle, hands, feet and front of the thighs. They can also be more generalised, and described as a sense of ‘inner tension’ ..
Repetitive thoughts A type of cognitive tic. These tics have been described in adolescents and adults with TS (Tourette Syndrome). Cognitive tics are described as repetitive thoughts that are not anxiety-driven. But it occurs as a response to the excessive urge to give in or act upon provocative auditory, visual, tactile or inner stimuli. Although exact frequencies are not known, cognitive tics encompass, echophenomena in thought, mental play, aimless counting and repetitive thoughts with sexual or aggressive content that produce no fear.. Repetitive thoughts
A type of cognitive tic. These tics have been described in adolescents and adults with TS (Tourette Syndrome). Cognitive tics are described as repetitive thoughts that are not anxiety-driven. But it occurs as a response to the excessive urge to give in or act upon provocative auditory, visual, tactile or inner stimuli. Although exact frequencies are not known, cognitive tics encompass, echophenomena in thought, mental play, aimless counting and repetitive thoughts with sexual or aggressive content that produce no fear..
Self-injurious behaviour A motor tic. Trying to wound oneself. In general complex motor tics are aimless or in response to an excessive premonitory urge. However, when the tic sequences are complex and elaborate it can be difficult to distinguish them from compulsions as seen in ‘pure’ OCD (obsessive compulsive Disorder). The latter being more cognitively driven, goal-directed and aimed at reduction of anxiety.. Self-injurious behaviour
A motor tic. Trying to wound oneself. In general complex motor tics are aimless or in response to an excessive premonitory urge. However, when the tic sequences are complex and elaborate it can be difficult to distinguish them from compulsions as seen in ‘pure’ OCD (obsessive compulsive Disorder). The latter being more cognitively driven, goal-directed and aimed at reduction of anxiety..
Echolalia Repeating others or repeating words.,. A complex phonic tic.Complex phonic tics occur when sounds are elaborate or have a semantic content, including for instance words or phrases.. Echolalia
Repeating others or repeating words.,. A complex phonic tic.Complex phonic tics occur when sounds are elaborate or have a semantic content, including for instance words or phrases..
Palilalia Repeating oneself. A complex phonic tic.. Palilalia
Repeating oneself. A complex phonic tic..
Obsessive compulsive (OC) symptoms It is generally agreed that about 50 percent of patients with TS have substantial obsessive-compulsive (OC) symptoms. OC behaviors are also commonplace in children with TS. Typically, these symptoms may include a need for things to look or feel 'just right', as well as preoccupation with symmetry, order, counting, and ritualistic repetition.. Obsessive compulsive (OC) symptoms
It is generally agreed that about 50 percent of patients with TS have substantial obsessive-compulsive (OC) symptoms. OC behaviors are also commonplace in children with TS. Typically, these symptoms may include a need for things to look or feel 'just right', as well as preoccupation with symmetry, order, counting, and ritualistic repetition..
Attention deficit hyperactivity disorder (ADHD) ADHD is frequently diagnosed in children with TS. The prevalence as high as 70 percent. This comorbidity is associated with disruptive behaviors, such as aggression, inappropriate expression of anger, low frustration tolerance, and noncompliance. Disruptive behavior in TS patients may occur with a wide frequency range of 26 to 75 percent.They often add considerable burdens to affected patients, including academic problems, peer rejection, and family conflict.. Attention deficit hyperactivity disorder (ADHD)
ADHD is frequently diagnosed in children with TS. The prevalence as high as 70 percent. This comorbidity is associated with disruptive behaviors, such as aggression, inappropriate expression of anger, low frustration tolerance, and noncompliance. Disruptive behavior in TS patients may occur with a wide frequency range of 26 to 75 percent.They often add considerable burdens to affected patients, including academic problems, peer rejection, and family conflict..
Poor attention and impaired school works Children with TS tend to have difficulties with attention, perseverance, and the ability to keep themselves focused and their work organized. Many have poor penmanship.Schoolwork may also be impaired by a variety of compulsions, such as the need to scratch out words or return to the beginning of a sentence. So the child with TS requires a careful assessment of cognitive functioning and school achievement.. Frequent phonic tics can impair fluency of speech and thus conversations. Moreover, children can expend mental energy in the classroom to suppress their tics, thus reducing their attention to schoolwork and interfering with their academic performance.. Poor attention and impaired school works
Children with TS tend to have difficulties with attention, perseverance, and the ability to keep themselves focused and their work organized. Many have poor penmanship.Schoolwork may also be impaired by a variety of compulsions, such as the need to scratch out words or return to the beginning of a sentence. So the child with TS requires a careful assessment of cognitive functioning and school achievement.. Frequent phonic tics can impair fluency of speech and thus conversations. Moreover, children can expend mental energy in the classroom to suppress their tics, thus reducing their attention to schoolwork and interfering with their academic performance..
Sleep disturbances Sleep studies have repeatedly described insomnia and inefficient sleep, parasomnias (sleep walking, sleep terrors), and agitated sleep in TS.Tics may be seen during sleep. Studies on the impact of sleep problems in children are rare. However, a recent study suggest that sleep deprivation can have a profound impact on children’s behaviour and academic achievement. It suggests that improving sleep quality in TS may improve symptom. Sleep disturbances
Sleep studies have repeatedly described insomnia and inefficient sleep, parasomnias (sleep walking, sleep terrors), and agitated sleep in TS.Tics may be seen during sleep. Studies on the impact of sleep problems in children are rare. However, a recent study suggest that sleep deprivation can have a profound impact on children’s behaviour and academic achievement. It suggests that improving sleep quality in TS may improve symptom.
Restless legs Restless legs syndrome (RLS) is an urge to move a limb, usually one or both legs, associated with focal dysesthesia, which is increased by rest, reduced by movement, mostly in the evening. There is an increased RLS symptoms, seen in children with TS (10%).There may be parallels between premonitory urges, relieved by tics and the dysesthesia/urge to move relieved by leg movements in RLS.. Restless legs
Restless legs syndrome (RLS) is an urge to move a limb, usually one or both legs, associated with focal dysesthesia, which is increased by rest, reduced by movement, mostly in the evening. There is an increased RLS symptoms, seen in children with TS (10%).There may be parallels between premonitory urges, relieved by tics and the dysesthesia/urge to move relieved by leg movements in RLS..
Pain Pain in TS may arise from the actual performance of frequent or intense tics causing discomfort by sudden or repeated extreme exertion (e.g. with head or neck). This kind of pain is usually musculoskeletal, although rare examples of neuropathic pain may occur.Additionally, some patients obtain relief from tics while experiencing pain, to such an extent that they will deliberately provoke pain to obtain benefit. A smaller number of patients complain of pain associated with the irresistible urge to tic or with aggravating premonitory urges during voluntary efforts to suppress their tics.. Pain
Pain in TS may arise from the actual performance of frequent or intense tics causing discomfort by sudden or repeated extreme exertion (e.g. with head or neck). This kind of pain is usually musculoskeletal, although rare examples of neuropathic pain may occur.Additionally, some patients obtain relief from tics while experiencing pain, to such an extent that they will deliberately provoke pain to obtain benefit. A smaller number of patients complain of pain associated with the irresistible urge to tic or with aggravating premonitory urges during voluntary efforts to suppress their tics..
Socially Isolation Persistent complex motor tics and loud phonic tics can cause social problems. Tics may cause isolation, bullying, or social stigmatization.loud phonic tics may result in the child being put out of the classroom.In higher school classes, bullying and social stigmatization due to tics becomes more common. After proper psychoeducation, many children and adolescents will accept their tic symptoms and await the natural remission.. Socially Isolation
Persistent complex motor tics and loud phonic tics can cause social problems. Tics may cause isolation, bullying, or social stigmatization.loud phonic tics may result in the child being put out of the classroom.In higher school classes, bullying and social stigmatization due to tics becomes more common. After proper psychoeducation, many children and adolescents will accept their tic symptoms and await the natural remission..
Social and emotional problems Tics can cause social and emotional problems for the patient. Sustained social problems, consequent to negative reactions of the social environment, some patients develop depressive and anxious symptom, low self-esteem, and/or social withdrawal. . Social and emotional problems
Tics can cause social and emotional problems for the patient. Sustained social problems, consequent to negative reactions of the social environment, some patients develop depressive and anxious symptom, low self-esteem, and/or social withdrawal. .

Clinicals - Examination

Fact Explanation
Repetitive eye blinking It is a common type of motor tic.Tics are repetitive, sudden, rapid, nonrhythmic, stereotyped movements which usually occur in response to a sensation or an urge and often occur in bouts. Motor tics usually manifest first in the head and face and then migrate to more distal regions..Motor tics arise in the voluntary musculature and involve discrete muscles or muscle groups. Tics can be seen as fragments of normal motor movements that appear out of context . The most frequent tic is eye blinking.Examples of Other simple motor tics include,nose twitching, tongue protrusion, head jerks and shoulder shrugs,. Tic disorders are classified as TS [Tourette Syndrome], chronic motor or vocal tic disorder, or transient tic disorder.. In TS, motor tics often begin between the age of 3 and 8, several years before the appearance of vocal tics.. Repetitive eye blinking
It is a common type of motor tic.Tics are repetitive, sudden, rapid, nonrhythmic, stereotyped movements which usually occur in response to a sensation or an urge and often occur in bouts. Motor tics usually manifest first in the head and face and then migrate to more distal regions..Motor tics arise in the voluntary musculature and involve discrete muscles or muscle groups. Tics can be seen as fragments of normal motor movements that appear out of context . The most frequent tic is eye blinking.Examples of Other simple motor tics include,nose twitching, tongue protrusion, head jerks and shoulder shrugs,. Tic disorders are classified as TS [Tourette Syndrome], chronic motor or vocal tic disorder, or transient tic disorder.. In TS, motor tics often begin between the age of 3 and 8, several years before the appearance of vocal tics..
Copropraxia So called repetitive obscene movements. It is a complex motor tic. Complex motor tics often have a repetitive and/or compulsive nature. Other examples include repetitive touching of objects or people, making elaborate sequences of movements.. Copropraxia
So called repetitive obscene movements. It is a complex motor tic. Complex motor tics often have a repetitive and/or compulsive nature. Other examples include repetitive touching of objects or people, making elaborate sequences of movements..
Echopraxia It Means mimicking others or imitating actions.,. It is also a complex motor tic.. Echopraxia
It Means mimicking others or imitating actions.,. It is also a complex motor tic..
Coprolalia It is an involuntary verbalization of obscene or scatological words. Appears only within a minority of subjects and it is often a temporary manifestation.. It is a Complex phonic tic.. Coprolalia
It is an involuntary verbalization of obscene or scatological words. Appears only within a minority of subjects and it is often a temporary manifestation.. It is a Complex phonic tic..

Investigations - Diagnosis

Fact Explanation
EEG Usually Tic disorders are clinically diagnosed on the basis of a detailed history and a neurological and psychiatric examination. Further diagnostic evaluation is only rarely needed.. However in case of atypical features such as apparent adult onset or severe deterioration or progression in symptoms should always lead to detailed consideration and investigation to include EEG and neuroimaging.Sometimes EEG in a typical tic disorder is mistaken for epilepsy or myoclonus. So it is worthwhile seeking expert opinion if doubt exists about the extent of investigation to pursue.. EEG
Usually Tic disorders are clinically diagnosed on the basis of a detailed history and a neurological and psychiatric examination. Further diagnostic evaluation is only rarely needed.. However in case of atypical features such as apparent adult onset or severe deterioration or progression in symptoms should always lead to detailed consideration and investigation to include EEG and neuroimaging.Sometimes EEG in a typical tic disorder is mistaken for epilepsy or myoclonus. So it is worthwhile seeking expert opinion if doubt exists about the extent of investigation to pursue..
MRI scanning Additional investigation with the aid of MRI scanning is rarely indicated except in those cases where the presentation is not typical in terms of either the semiology of the movement disorder or the presence of features suggestive of differential diagnoses.MRI studies with different techniques and electrophysiological investigations on neuronal inhibition have identified alterations in brain areas of the cortico-striato-thalamo-cortical (CSTC) circuits.. MRI scanning
Additional investigation with the aid of MRI scanning is rarely indicated except in those cases where the presentation is not typical in terms of either the semiology of the movement disorder or the presence of features suggestive of differential diagnoses.MRI studies with different techniques and electrophysiological investigations on neuronal inhibition have identified alterations in brain areas of the cortico-striato-thalamo-cortical (CSTC) circuits..
Videotape recording A considerable difficulty in assessing and quantifying tics is caused by the spontaneous variations of tics in an individual over time, large variability in impact of a given level of physical tic severity on an individual or their family and , the tendency of patients to suppress their tics, especially when in the office with the clinician.Therefore, it is advisable when assessing tics, to use multi informant data. One of the way is collecting video data. Videotape tic monitoring might enhance capturing the whole tic repertoire of the patient.. Videotape recording
A considerable difficulty in assessing and quantifying tics is caused by the spontaneous variations of tics in an individual over time, large variability in impact of a given level of physical tic severity on an individual or their family and , the tendency of patients to suppress their tics, especially when in the office with the clinician.Therefore, it is advisable when assessing tics, to use multi informant data. One of the way is collecting video data. Videotape tic monitoring might enhance capturing the whole tic repertoire of the patient..
PET studies PET raclopride studies using amphetamine challenge to study D2 receptor availability in striatal circuits in TS patients have revealed increased phasic dopamine release in ventral striatal areas in TS patients after amphetamine challenge. PET studies
PET raclopride studies using amphetamine challenge to study D2 receptor availability in striatal circuits in TS patients have revealed increased phasic dopamine release in ventral striatal areas in TS patients after amphetamine challenge.

Investigations - Management

Fact Explanation
Genetic testing The physical examination includes careful examination for dysmorphic features to identify any indication of genetic syndromes. Unusual features may prompt specific genetic testing by consulting a clinical geneticist. Further, in the presence of additional learning difficulties or autism spectrum diagnosis, it might be advisable to consult a clinical geneticist as well.In some cases this high resolution array might reveal a rare genetic aetiology of these heterogeneous disorders.. Genetic testing
The physical examination includes careful examination for dysmorphic features to identify any indication of genetic syndromes. Unusual features may prompt specific genetic testing by consulting a clinical geneticist. Further, in the presence of additional learning difficulties or autism spectrum diagnosis, it might be advisable to consult a clinical geneticist as well.In some cases this high resolution array might reveal a rare genetic aetiology of these heterogeneous disorders..

Management - Supportive

Fact Explanation
Reduction of stress and lifestyle modification Acute and chronic stress can exacerbate tics. So an attempt to reduce the stress of patients is reasonable. Psychotherapy sessions may be useful to improve self-esteem, social coping, family strain, and school adjustment. But it is unclear if they directly affect tic severity. Regular appointments with the same clinical team, who can help the patient deal with the changing manifestations of the disorder through the years, are highly recommended. Regular contact via telephone or e mail may also be helpful. Participation in regular school and extracurricular activities is encouraged.The impact of physical exercise on tic symptoms has not been systematically studied. But though a regular program of exercise can be beneficial by reducing stress, increasing the child's sense of mastery, and contributing to overall well being.. Reduction of stress and lifestyle modification
Acute and chronic stress can exacerbate tics. So an attempt to reduce the stress of patients is reasonable. Psychotherapy sessions may be useful to improve self-esteem, social coping, family strain, and school adjustment. But it is unclear if they directly affect tic severity. Regular appointments with the same clinical team, who can help the patient deal with the changing manifestations of the disorder through the years, are highly recommended. Regular contact via telephone or e mail may also be helpful. Participation in regular school and extracurricular activities is encouraged.The impact of physical exercise on tic symptoms has not been systematically studied. But though a regular program of exercise can be beneficial by reducing stress, increasing the child's sense of mastery, and contributing to overall well being..
Reduce caffeine Caffeine should be minimized as it may exacerbate tics in some children.. Reduce caffeine
Caffeine should be minimized as it may exacerbate tics in some children..
Thorough patient education Psychoeducation should always be the first step of treatment.Many patients and their families, the diagnosis itself brings considerable relief. If the patient is a child, it is important that his or her teachers and other significant adults should also understand the nature of the condition. Thorough patient education should include not only information about the cause and future course of the disease, but also counseling on social issues such as the various types of compensatory aid that are available, how to request certification as a disabled or severely disabled person, the issue of driving, and the choice of an occupation. It is not at all rare for patients to feel stress as a result of their tic disorder for no other reason than the way others respond to it.. Thorough patient education
Psychoeducation should always be the first step of treatment.Many patients and their families, the diagnosis itself brings considerable relief. If the patient is a child, it is important that his or her teachers and other significant adults should also understand the nature of the condition. Thorough patient education should include not only information about the cause and future course of the disease, but also counseling on social issues such as the various types of compensatory aid that are available, how to request certification as a disabled or severely disabled person, the issue of driving, and the choice of an occupation. It is not at all rare for patients to feel stress as a result of their tic disorder for no other reason than the way others respond to it..
Behavioral therapy Habit reversal training (HRT) was recently introduced as an alternative to drug therapy for tics. In HRT, the patient prevents the occurrence of a tic by performing a previously learned alternative behavior instead.This method lessens the frequency of tics by about 30% .Comparable results can be obtained with exposure and response prevention (ERP), a strategy for interrupting the automatism described by many patients in which a premonitory urge is necessarily followed by a tic. A European expert commission recently recommended that behavior therapy (if available) should always be tried before drug treatment. Behavior therapy often fails because of inadequate motivation, particularly in children.. Behavioral therapy
Habit reversal training (HRT) was recently introduced as an alternative to drug therapy for tics. In HRT, the patient prevents the occurrence of a tic by performing a previously learned alternative behavior instead.This method lessens the frequency of tics by about 30% .Comparable results can be obtained with exposure and response prevention (ERP), a strategy for interrupting the automatism described by many patients in which a premonitory urge is necessarily followed by a tic. A European expert commission recently recommended that behavior therapy (if available) should always be tried before drug treatment. Behavior therapy often fails because of inadequate motivation, particularly in children..
Dopamine Modulating Agents Traditionally dopamine-blockers have been the first line treatment for tics and have the most compelling evidence for effectiveness in double-blind controlled studies.The three most studied agents are haloperidol, pimozide and risperidone. Starting doses of haloperidol and pimozide are 0.25–0.5 mg/day and 0.5–1 mg/day respectively, with usual maintenance doses ranging between 1–4 mg/day and 2–8 mg/day. Dopamine modulators have important but variable side effects such as weight gain, sedation, anxiety, electrographic changes (tachycardia and QTc prolongation) and extrapyramidal symptoms.Because of their presumed lower long-term side effects profile, atypical neuroleptics such as risperidone (0.5–4 mg) or olanzapine (2.5–10 mg) are preferred.Tetrabenazine (given as 12.5–25 mg TID) is a monoamine depletion which operates mainly by inhibiting dopamine liberation. This drug may be effective for the treatment of tics and unlike neuroleptics, does not pose any major risk of tardive dyskinesia at lower doses.. Dopamine Modulating Agents
Traditionally dopamine-blockers have been the first line treatment for tics and have the most compelling evidence for effectiveness in double-blind controlled studies.The three most studied agents are haloperidol, pimozide and risperidone. Starting doses of haloperidol and pimozide are 0.25–0.5 mg/day and 0.5–1 mg/day respectively, with usual maintenance doses ranging between 1–4 mg/day and 2–8 mg/day. Dopamine modulators have important but variable side effects such as weight gain, sedation, anxiety, electrographic changes (tachycardia and QTc prolongation) and extrapyramidal symptoms.Because of their presumed lower long-term side effects profile, atypical neuroleptics such as risperidone (0.5–4 mg) or olanzapine (2.5–10 mg) are preferred.Tetrabenazine (given as 12.5–25 mg TID) is a monoamine depletion which operates mainly by inhibiting dopamine liberation. This drug may be effective for the treatment of tics and unlike neuroleptics, does not pose any major risk of tardive dyskinesia at lower doses..
Alpha-2-Adrenergic Agonists Because of contradictory results, the role of alpha-2-adrenergic agents (clonidine and guanfacine) in the treatment of tics is debatable. However, in practice, because of a better side effect profile and no long term potential risk, they are often a first line treatment option especially in patients with comorbid symptoms of ADHD..Clonidine is used preferentially in English-speaking countries, even though its tic-suppressing effect is rather weak in comparison to most of the neuroleptics.. Alpha-2-Adrenergic Agonists
Because of contradictory results, the role of alpha-2-adrenergic agents (clonidine and guanfacine) in the treatment of tics is debatable. However, in practice, because of a better side effect profile and no long term potential risk, they are often a first line treatment option especially in patients with comorbid symptoms of ADHD..Clonidine is used preferentially in English-speaking countries, even though its tic-suppressing effect is rather weak in comparison to most of the neuroleptics..
Botulinum toxin Botulinum toxin may be a good treatment for highly-localized motor tics. But some patients treated with botulinum toxin for a single focal tic notice spread of the tic to an adjacent non-injected muscle.. Botulinum toxin
Botulinum toxin may be a good treatment for highly-localized motor tics. But some patients treated with botulinum toxin for a single focal tic notice spread of the tic to an adjacent non-injected muscle..

Management - Specific

Fact Explanation
Neurosurgical Treatment Multiple neurosurgical procedures including frontal lobe bimedial frontal leucotomy and pre-frontal lobotomy, limbic system anterior cingulotomy and limbic leucotomy, have been tried in patients with severe tics with variable results. None of these procedures have been studied in a large control case studies. More recently, because of a lower side effect profile and potential access to deeper regions, deep brain stimulation has been advocated as an alternative for cases with severe uncontrolled tics.. Very severely affected adult patients with medically intractable Tourette syndrome may benefit from deep brain stimulation.. Neurosurgical Treatment
Multiple neurosurgical procedures including frontal lobe bimedial frontal leucotomy and pre-frontal lobotomy, limbic system anterior cingulotomy and limbic leucotomy, have been tried in patients with severe tics with variable results. None of these procedures have been studied in a large control case studies. More recently, because of a lower side effect profile and potential access to deeper regions, deep brain stimulation has been advocated as an alternative for cases with severe uncontrolled tics.. Very severely affected adult patients with medically intractable Tourette syndrome may benefit from deep brain stimulation..

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