Tics and Tic‐Like Phenomena as Compulsive Acts

The association of tics with obsessive thoughts and other intrusive, repetitive cognitions has been long established,1 but the phenomenological spectrum of associated motor phenomena has not been fully acknowledged and video material is scarce. We detail six cases to illustrate the variety of compulsive tics and tic-like behaviors associated with obsessive thoughts and other complex cognitions. A 19-year-old woman (case 1) and a 17-year-old boy (case 2) had childhood-onset motor tics. Case 1 was later diagnosed with anxiety and obsessive-compulsive disorder (OCD), and case 2 with schizoaffective disorder, OCD, and substance abuse. They both reported that their tics were a result of a “need to do” instead of a physical “urge,” often linked to symmetry, counting, or specific number of repetitions (Video 1A,B). Case 3 describes a 45-year-old man with facial tics since childhood, next to anxiety, OCD, and recurring intrusive thoughts (fear of dying) over 20 years that compel him to turn his head to the left to mitigate their impact (Video 1C). Aripiprazole (10 mg) and escitalopram (20 mg) led to an improvement in the intrusive thoughts and associated head turning but had little effect on his motor tics. Case 4 is a 33-year-old man with chronic motor tics, OCD, and possibly a history of paranoid thoughts. He suffers from intrusive, ego-dystonic violent thoughts and images, prompting him to hold his breath, followed by body jerking, to briefly alleviate the experienced distress (Video 2A). These symptoms improved significantly with escitalopram (30 mg). His motor tics remained unchanged. Case 5 is a 38-year-old man with a diagnosis of OCD, anxiety, depression, and autism spectrum disorder. He experiences unwanted movement patterns triggered by reading difficult texts. Over the past 10 years, he feels compelled to squint, close his left eye, and briefly turn his neck to the left (Video 2B). Case 6 is a 65-year-old woman with a 10-year history of repetitive, short-lasting head and trunk jerks triggered by unpleasant cognitions, including flashbacks of past trauma and possibly auditory hallucinations. She has been diagnosed with post-traumatic stress disorder with obsessive-compulsive and psychotic features (Video 2C). These cases illustrate compulsive, repetitive motor behaviors that occur in response to intrusive, ego-dystonic thoughts, including (1) patterned and repetitive movements as a “need to do” an action, or to symmetrically match actions along a body axis2; (2) motor maneuvers to ameliorate the impact of unpleasant cognitions, images, or auditory hallucinations; and (3) specific motor sequences to initiate a particular action. Although these motor manifestations phenomenologically fall under the rubric of tics and tic-like movements, they are not preceded by somatic sensations but cognitions, and they occur in the context of significant anxiety. Despite their similarity with typical tics, there are important treatment implications. For instance, exposure-response prevention in conjunction with pharmacotherapy for OCD would be a first-line approach for compulsive tics and tic-like actions, whereas Comprehensive Behavioral Intervention for Tics (CBIT) and antipsychotics are recommended for idiopathic tics.3 However, there is significant therapeutic overlap; for example, augmentation with antipsychotics is used to enhance selective serotonin reuptake inhibitor (SSRI) efficacy in treating OCD symptoms, including tic-like compulsions.4, 5 Importantly, response patterns can inform etiology. In cases 3 and 4, SSRI treatment (with or without antipsychotic augmentation) reduced compulsive motor behaviors, whereas idiopathic tics persisted, highlighting the distinct pathophysiology and treatment responsiveness of these motor symptoms. Careful history taking is therefore essential to ensure capturing the entire spectrum of relevant psychiatric disorders. Overall, these cases demonstrate a wide range of brief repetitive motor acts as compulsions and reinforce the need for careful etiological distinction between similar phenomena to guide treatment. (1) Research project: A. Conception, B. Organization, C. Execution; (2) Analysis: A. Design, B. Execution, C. Review and critique; (3) Manuscript: A. Writing of the first draft, B. Review and critique. T.G.: 1A, 1C, 2C, 3A J.C.-Y.C.: 1C, 2B, 3A A.B.: 1B, 2B, 3A N.G.D.R.: 1A, 1C, 1B, 3A P.S.: 1A, 2C, 3B A.E.L.: 1A, 2C, 3B C.G.: 1A, 1B, 2B, 2C, 3B We thank all the patients for allowing publication of their cases and videos for educational purposes. Ethical Compliance Statement: We confirm that we have read the journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. We confirm that the study was approved by the University Health Network Research Ethics Board (reference number 24-5646) and that written consent was obtained from the patients. Funding Sources and Conflicts of Interest: . This work was supported by the Wolf Chair, a joint Hospital-University Named Chair between the University of Toronto, UHN, and UHN Foundation, held by Dr. Ganos. The authors declare that there are no conflicts of interest relevant to this work. Financial Disclosures for the Previous 12 Months: T.G., J.C.-Y.C., A.B., N.G.D.R., and P.S., report no relevant funding sources in the past 12 months. A.E.L reports unrelated disclosures including that he serves as advisor for Abbvie and Sunivon; received grants from Brain Canada, Canadian Innstitute of Health Research, Edmond J Safra Philanthropic Foundation, Michael J. Fox Foundation, Parkinson Foundation, Parkinson Canada, and the Garfield Weston Foundation. C.G reports no other relevant funding sources in the previous 12 months. The data that support the findings of this study are available from the corresponding author upon reasonable request.

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