'Ticcing' and Tourette's: An investigation of a growing phenomenon among young women
COVID-19 related increase in childhood tics and tic-like attacks
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- COVID-19
- kid psychiatry
- neurology
Explosion of tics
Since the onset of the COVID-19 pandemic, paediatricians and child mental health practitioners accept noticed an increase in tic symptoms in some children and adolescents already diagnosed with tic disorders.1 Interestingly, clinicians accept also seen a marked increment in presentations of sudden and new onset of severe tics and 'tic-like' attacks.
There is an urgent need to collate systematic information on this grouping as this is a rare and unusual subtype of tics and Tourette syndrome, differing in age and blazon of onset and expected patterns of tics. Typically, babyhood tics start around 5–7 years and show a waxing and waning form of predominantly motor tics, more normally affecting boys in a ratio of iv:ane. The new surge of referrals consists of adolescent girls with sudden onset of motor and phonic tics of a complex and bizarre nature. In London, UK specialist tic clinics at each of the 2 children's hospitals, each centre received four to vi referrals per yr (out of a full of approximately 200 in 2019/2020), which were acute onset tics in teenage girls. In the last 3 months (end of 2020–January 2021), both centres take been receiving three to four referrals per calendar week of this nature which, if it continues, would corporeality to 150–200 cases per year and effectively double the referral charge per unit.
Initial impressions are that these adolescent girls fall into two groups: the first nowadays with explosive functional tic-like movements on a groundwork of diagnosis of, or vulnerability to, motor and phonic tics. The 2d group comprises florid, completely new onset tic-like disorder that appears functional in nature. Both groups may have undiagnosed neurodevelopmental impairment, autism spectrum disorder (ASD), specific learning difficulties and attention arrears hyperactivity disorder (ADHD). Distinguishing these ii subtypes can be challenging; however, the likelihood is that in either case the precipitating cistron for symptomatology and harm is anxiety (probably in part COVID-xix related), and importantly, the same management strategies are suggested for both of these groups.
Case example: 14-yr-former girl, AB
AB developed explosive onset of motor and phonic tics in November 2020. On careful history taking, this occurred the day after the announcement of another COVID-19 lockdown period. The tics mostly occurred in school and resulted in her being sent home. They included complex head turns with cervix thrusting and flailing movements of the hands, together with some coprolalia and yelping noises. There was no premonitory urge reported. In that location was an associated indifference to the phonic tics without evidence of embarrassment, which is unusual in tic disorders. A history of childhood tics was absent-minded. AB described herself every bit a shy kid, broken-hearted in social situations and she identified herself as having autistic traits although she had not been assessed for autism. AB admitted to searching diverse media sites and reading about Tourette disorder and uploading videos of her tics on TikTok.
There was a family history of autism, ADHD and Tourette syndrome.
On examination, at that place were many florid tics, some which exacerbated on action and interfered with the motor examination and that were incongruous with usual motor tics. In that location were positive examination features of a functional diagnosis and an intermittent tremor that could be entrained. The formulation in this example was of functional tic-like episodes occurring in a girl with a probable tic predisposition and with some traits of ASD. We provided reassurance and psychoeducation with suggestions for selective attention strategies that resulted in a positive issue. A referral was made for further evaluation of anxiety and ASD.
Functional tic-similar set on disorder
The clinical impression is that these florid presentations of tics in teenagers has at least a partial component of functional neurological disorder that have been identified equally functional tics and tic-similar attacks.ii 3 Neurological examination reveals no focal abnormalities, and investigation is unremarkable, as is the case in Tourette syndrome. The adolescents present acutely, and they and their families are invariably distressed and frightened, may have presented to emergency services and sought multiple opinions well-nigh the new symptoms. Information technology is hypothesised that this unusual presentation is related to lockdown, alter in usual structure and routine, social media related events/bullying and pandemic-related stress in vulnerable adolescents. Stress may be unmasking a tic predisposition in some, while in others compounding existing vulnerability to anxiety, for example, underlying neurodevelopmental or emotional difficulties to the signal of becoming overwhelming.
Careful cess, diagnosis and reassurance together with a sharing of the presumed diagnosis of tic-like functional symptoms is recommended. At that place is increasing show that personal, family and professional anxiety serves to exacerbate and prolong episodes, while clear caption, reassuring and calm management can reduce or fifty-fifty eliminate occurrences.iii Equally in other functional neurological disorders, the child may be unable or unwilling to clear stress or emotional symptoms. More than in-depth discussion with the young person, with careful evaluation and questioning of carers, reveals a meaning and upsetting change to routine, with adverse impact on socialisation, education, and emotional and behavioural functioning in the context of the COVID-nineteen pandemic and lockdown.
Management includes psychoeducation about functional symptoms and tic-like attacks. This explanation in itself can event in a dramatic resolution of symptoms. It is important to annotation that these young people show little or no response to the usual medications for tics, and nosotros would not recommend prescription.
Function of social media?
There is some business concern that social media and websites such as TikTok that promote the sharing of videos of influencers with symptoms may have a part to play. These sites announced to have exploded in popularity; for example, the site TikTok #tourettes (https://vm.tiktok.com/ZMe8e62aS/ accessed 12 February 2021) has ii.5 billion views, having approximately doubled in viewing in the last month (January–Feb 2021). Some teenage girls written report increased consumption of such videos prior to symptom onset, while others take posted videos and information nearly their movements and sounds on social media sites. They report that they proceeds peer support, recognition and a sense of belonging from this exposure. This attending and support may be inadvertently reinforcing and maintaining symptoms. The part of social media needs further exploration, specially the potential for 'contamination' and the maladaptive gains that might unintentionally arise from this peer identification.
Functional symptoms every bit a role of an overall increase in mental wellness disorders during the COVID-19 pandemic
The adverse impact of the COVID-19 pandemic on adult and child mental wellness is becoming increasingly evident.iv 5 Rates of mental health problems in children and young people were 10.eight% in the 2017 United kingdom mental health survey. Re-evaluation in July 2020, half dozen months into the pandemic and later the first UK lockdown, showed that incidence had risen to 16.0%.6
It appears that children presenting with functional symptoms, including functional tics and 'tic-like attacks', may be one of the many increases in stress-related difficulties seen in the context of the COVID-19 pandemic. It is important to consider this diagnosis every bit role of the diagnostic evaluation and investigation of motility disorder presentations, which should include the usual range of examinations and investigations to explore alternatives such every bit the paroxysmal dyskinesias that tin also exacerbate at times of stress. At that place is a need for collaboration between paediatric and mental wellness services. One time a positive diagnosis of functional tic-like attacks has been made, optimum management is likely to include integration of paediatric and mental healthcare7 and ensuring children and families sympathise the diagnosis and the usefulness of behavioural/psychological intervention.viii There are new information showing that referrals to child mental health services in September 2020 were 72% higher than in September 2019.9 It will be important that functional and mental health aspects are considered in the likely increase of physical presentations associated with long COVID in the coming yr.
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Source: https://adc.bmj.com/content/106/5/420
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