Chronic Vocal Tic Disorder

What vocal tics are

A tic is a sudden, rapid, repeated, non-rhythmic movement or sound. Vocal (phonic) tics produce sounds:

• simple vocal tics: throat clearing, sniffing, coughing, grunting, snorting, humming, squeaking, barking
• complex vocal tics: words, phrases, repeating others' words (echolalia), or repeating one's own words (palilalia). Swearing (coprolalia) is uncommon.

Many people feel an uncomfortable urge or sensation before a tic (a premonitory urge), which the tic briefly relieves. Tics can often be held back for a short time, but the urge builds up. Tics typically worsen with stress, excitement, tiredness or illness, and lessen during focused activities and sleep.

How it differs from other tic disorders

Tics in all these conditions start before age 18 and are not due to a medicine or another medical condition. Chronic vocal tic disorder alone is less common than chronic motor tic disorder.

Causes

The exact cause is unknown. Tic disorders involve differences in brain circuits linking the basal ganglia and frontal cortex, and the chemical messenger dopamine. Contributing factors:

• genetics: tic disorders run in families
• male sex: boys are affected about 3 to 4 times more often
• prenatal and birth factors, such as maternal smoking and low birth weight, in some studies
• infections: a controversial link with streptococcal infections (PANDAS) has been proposed for a sudden-onset subset

Tics are not caused by bad parenting or emotional problems, and they are not done on purpose.

Conditions that often occur alongside

• ADHD
• Obsessive-compulsive disorder and obsessive-compulsive behaviors
• Anxiety and depression
• learning difficulties

These co-occurring conditions often cause more difficulty than the tics themselves and need their own treatment.

Vocal tics that are mistaken for other problems

Throat clearing, sniffing and coughing tics are frequently mistaken for allergies, asthma, reflux or a lingering cold. Clues that a sound is a tic include:

• it changes over time (sniffing for months, then throat clearing)
• it stops during sleep
• the child can hold it back briefly
• it worsens with stress or excitement
• allergy, asthma or reflux treatments do not help

A chronic "habit cough" that stops during sleep can also be a tic or a functional cough.

Diagnosis

There is no laboratory test. A pediatrician, neurologist or psychiatrist makes the diagnosis based on:

• a history of vocal tics lasting more than 1 year
• onset before age 18
• no motor tics
• ruling out other causes such as medicines, stimulant drugs or other neurological conditions

Videos recorded at home are helpful because tics may not appear during the appointment. Doctors also screen for ADHD, OCD and anxiety.

Treatment

Education and reassurance

Many children have mild tics that do not need treatment. Explaining tics to the child, family and school reduces stress and teasing. Ignoring tics, rather than asking the child to stop, usually helps.

Behavioral therapy

Comprehensive Behavioral Intervention for Tics (CBIT), which includes habit reversal training, is the recommended first-line treatment for tics that cause distress or impairment. People learn to recognize the premonitory urge and perform a competing response, such as slow, controlled breathing through the nose, that makes the tic difficult. It typically involves 8 to 10 sessions and works for many children and adults.

Medicines

For tics that are severe or do not respond to behavioral therapy:

• alpha-2 agonists (guanfacine, clonidine), often helpful when ADHD is also present
• antipsychotics such as aripiprazole, which is FDA-approved for Tourette syndrome, with monitoring for weight gain and other side effects
• topiramate in some cases

Treating co-occurring conditions

Treating ADHD, OCD or anxiety often improves overall wellbeing and can reduce tics.

Outlook

Tics typically peak around ages 10 to 12, then improve. Many people have significantly fewer tics, or none, by adulthood. A minority continue to have tics as adults. Most people with chronic vocal tic disorder lead full, normal lives.

Frequently asked questions

What is chronic vocal tic disorder?

It is a tic disorder in which a person has one or more vocal tics, such as throat clearing, sniffing or grunting, that persist for more than a year, start before age 18, and occur without motor tics. If motor tics are also present, it may be Tourette syndrome.

Is a throat-clearing habit a vocal tic?

It can be. Persistent throat clearing that changes over time, stops during sleep, worsens with stress and does not respond to allergy or reflux treatment is often a vocal tic. A doctor can help distinguish a tic from medical causes.

Do vocal tics go away?

Often they improve. Tics usually peak in late childhood and decrease in the teen years, and many people have few or no tics as adults. Behavioral therapy can reduce tics in the meantime.

How do you treat vocal tics?

First-line treatment is behavioral therapy called CBIT, which teaches awareness of the urge and a competing response. Education and a supportive environment help. Medicines such as guanfacine or aripiprazole are used for severe tics.