Blog

Tic Tips

Written by Mary M. Moebius, MD, FAPA
Diplomat of the American Board of Psychiatry and Neurology in General and Child Psychiatry, Assistant Clinical Professor, UCLA Semel NPI, private practice Tarzana, California

Contrary to popular belief, most tics are not Tourettes Syndrome (TS). TS require a minimum of 6 months of both a motor tic and a vocal tic. The classical swearing vocalizations are rare though TS is often portrayed this way in the media.

Here are some “tic tips” I’d like to share from years of working with children, teens, and an occasional adult, with tics.

In the olden days, we thought medications that treated Attention Deficit Disorder (ADD) caused tics to develop. It turns out that tics are especially common in children with ADD and even more so in boys with the diagnosis. Because the brain has to develop to certain points before certain symptoms can present, the symptoms of ADD usually present in kids under the age of 7 while tics present around the age of 9, by which time many are already being giving medications for the ADD. If a child with ADD is not treated with medications, tics still may present. Lo and behold, the meds were not the culprit after all.

Now that that has been said, I do see tics seem to present, worsen, improve, and even disappear in individuals who receive ADD medications. Some present only to disappear about two months after starting medication. Tic “seasons” are recognized with theories as to why they occur so consistently. In the beginning of my private practice in 1991, I began to notice tics presenting at the end of November around Thanksgiving, with improvement by the end of January. Was it that a child’s schedule was defined by change from this holiday on to the next with holiday performances, celebrations, and fluctuations in school schedules?

As the years went on, it seemed that tics also came around May then left by the 4th of July or soon thereafter. Then another brief blip would present in September.

Some symptoms of manic depression and depression worsen in May and September (peak suicide seasons, contrary to popular lore that the holidays are). Neuroimmunology studies associate the almost world wide tree bloom with an abundance of pollen as the culprit of over stressing the immune system and tipping the depression “centers” over the edge. Almost certainly allergens provoke an immunological tic response. This is more clearly known in PANDAS which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep where a child has a sudden on set of tics (or obsessive compulsive symptoms) around a bout of strep throat. The body’s immune system (that is fighting the germs) begins to fight itself and in this case sets off the movement centers of the brain. My experience is that any illness may bring out or worsen tics in the right person. Some of my families are able to tell when a child is becoming sick because the tics begin as a warning!

Another pearl about tics is that something frequently begets a tic. For example, the Santa Ana winds rise up, drying the air (releasing pollen too), lips become chapped and if one has the tic “seed” in the brain, lip licking ensues and “Clown Lips” appear from the repetitive tic lip licking (say that 3 times fast!). A throat clearing tic frequently starts after a cold or hay fever reaction as do eye blinking, sniffing, and coughing. Dr. Cesar Chavarria, a local pediatric pulmonologist, sees quite a few cough tics seasonally that are in a cycle as the cough irritates the breathing tubes which causes more coughing which irritates...

Tics also have a daytime rhythm. Usually when a child is well rested in the morning, then tics are quieter. The tics may be more under the person’s control during the day, at school, with others present, and while occupied. By the time the child gets home, is tired, and with the parent the tics may become so pronounced that the parent frets (understandably so) then stresses the child by scolding or highlighting the tic so that it worsens, becoming a family issue of contention.

What’s a parent to do?

First, relax. Take a few deep breaths, after all, how many adults have noticeable tics? With time, the cycles abate and your child will likely outgrow this. As family anxiety can heighten tics, lowering it can decrease the intensity. Both “good” stress and “bad” stress may exacerbate tics. Minimize the “bad” and roll with the good.

Treat hay fever with the guidance of your pediatrician, allergist, or ENT.

If your child’s tics began or worsen during or after a streptococcal infection, tell your doctor so you can have labs done, and begin appropriate antibiotic treatment if P.A.N.D.A.S. is present. (Pediatric Autoimmune Disorders Associated with Strep)

Prevent chapped lips, cuticles, scabs, dry eyes, prolonged coughs before a cycle of licking, picking, blinking, and coughing begins. Sunglasses help eye blinking. Hypnotherapy is my favorite active treatment when the above mentioned steps are not effective enough or the social stigma becomes a problem. Children and teens tend to be able to learn the self-hypnosis techniques taught to them by the hypnotherapists quite easily. Many times, a patient of mine will stop ticking the first time they are in a hypnotic state! Hypnosis is a “tool” one may use for life. Please be reassured that people don’t really do bizarre things under hypnosis when in with a trained professional.

Cognitive Behavior Therapy has also been shown to be effective. This is another “tool” one can take with them where ever they go, for life. Both hypnosis and CBT manage accompanying anxiety.

In only the most severe situations, do I recommend medications for the management of tics because the side effects and potential risks may outweigh the benefits? With that said, under supervision, these may be minimized and allow the opportunity for the less aggressive treatments to “kick in” when used together.

Clonidine and Tenex may be the first medication your doctor would use. Usually given in pill form, it may be taken once at night or up to three times a day, starting at low doses, increasing based on effects. Sometimes a child may feel sleepy at first but that usually goes away. Originally used to control high blood pressure, these medications were found to help the hyperactive component of ADHD as well as insomnia in medicated and non-medicated people with ADHD. An EKG may be done before starting these medications and about 6 weeks in to treatment. Monitoring for depression and weight gain is important too.

Catapress is the patch form of Clonidine.

Medications called Neuroleptics have been used for quite awhile to treat tics especially of the Tourettes Syndrome nature. Because of sedation, they frequently are given at night. Weight gain, Metabolic Syndrome (having labs such as fasting blood sugar, cholesterol, other lipids), abnormal body movements (not the tic itself) must be monitored closely. Other potential side effects should be explained by your doc. If a tic has a more obsessive compulsive quality to it a Selective Serotonin Reuptake Inhibitor may be tried. It’s almost hard to explain how to differentiate between some OCD behaviors and tics. It becomes a "gut" feeling so I recommend having a detailed discussion with your pediatric psychiatrist, neurologist or pediatrician.

Some nicotine and nicotine-like agents have been used but I have not felt comfortable trying them for fear of it becoming a “gateway” to cigarettes. However, if it works for your child, it may be worth trying it with a doctor experienced in its use.

I hope this article will help children, parents, siblings, and grandparents have a little more understanding as how best to ride the storm of the ever-changing weather pattern of tics.

Sports Performance and Hypnosis by Shelley Halpern, C.Ht.

You can achieve your full potential by using both your body and your mind. You might have noticed when two athletes have comparable body types and abilities and one excels at kicking a ball past the goal with amazing precision or swim faster, always defeating their competition. Have you ever noticed how a seemingly average athlete can exceed his or her potential while the athlete with more ability never reaches their goal? It is true that physical training is essential but consider how important mental training is as well. You can improve your performance, not by increasing your workouts or resorting to drugs. The most powerful tool you have is the grey matter located between your ears. Your mind is your greatest friend. Working physically and mentally are tools to help you work smarter not harder.

Mental training and imagery can help you achieve your full potential. If you want to get more out of your workouts or if you experience stress or anxiety in competition, learn how to control it and reframe it to your advantage. We all have worry and anxiety but there is a functional and dysfunctional type. There are positive parts of anxiety, the kind that prepares us for competition or when you are learning a new skill or getting “up” for a performance. Eliminate toxic worry! Worrying and stress weakens the athlete physically, spiritually and emotionally. Learn how to redefine the moderate levels of worry and anxiety.

You can learn to be a better athlete by eliminating the “stinkin thinkin,” by allowing your body to do what it was trained to do. Stop over thinking every movement and detail. Don’t become overwhelmed by the moment, your body knows what to do. Start letting go of your analytical, left brain side and allow your right side, the creative, visual side to take over.

In 2002 Johan Hedberg, the goal tender for the Pittsburgh Penguins used hypnosis and imagery to improve the mental side of his game. He was quoted as saying, “I think back on last year and I feel shame. I feel sick, I didn’t just want to work out my body to get rid of it. I wanted to work out my head as well. But Hedberg wasn’t just sick over losing – he was losing his composure.” 1

In an article written by George Smelch in Nine called “Baseball’s Mental Game,” he states that “about one-third of the players interviewed said they visualize before games. Visualization or what many sports psychologists alternatively refer to as imagery or mental rehearsal, is used to create and concentrate on the mental images of a physical act before doing it.”

Jamestown Expos pitcher Mark Larosa learned to visualize from his girlfriend’s father who is a psychiatrist and who uses hypnosis and imagery in his practice: While they are announcing the line-ups, I sit in the corner of the dugout by myself, and breathe deeply and try to relax, and I see myself on the mound going through the motions, delivering the pitch. I don’t see the batter’s face or anything, just my arm action and my ball action. Once I think I have it down, that’s it. It doesn’t take long, just three to five minutes.”

How does imagery work in sports performance? Imagery is seeing something in the back of your mind’s eye (in the back of the eyelids) but it uses sensory recruitment as well. This includes using all of the senses; sight, sound, smell, taste, touch and emotions. By training physically and mentally you will enhance your performance. Words create images and the brain learns through images. There are two hemispheres of the brain, the right and the left side. We use both hemispheres all of the time but often times, one side is dominant. The left side is the logical analytical side. The right side is responsible for imagination and making pictures. By using both hemispheres of the brain you are using all of the mental tools available to the athlete. Imagery allows you to mentally rehearse your athletic performance, enables you to connect with your own inner resources and affects you physiologically. When you are in hypnosis you are in homeostasis, your mind and body are in balance. Your body doesn’t discriminate between real and imagined events. So you are actually practicing and pre-training for your sport, you are rehearsing for your physical activity.

Mental training and imagery allows the athlete to merge the physical and the mental side of the game. If you want to get more out of your workouts, learn to control and conquer your fear and enhance your performance during competition, learn the tools and strategies to help you be the best you can be. The athlete cannot rely solely on physical training. Enhance your sports performance by unlocking your potential and tapping into the body and the mind.

1 ESPN.com Wednesday, August 28, 2002

Trichotillomania-Compulsive Hair-Pulling by Shelley Halpern

Certified Hypnotherapist
Tarzana, CA
818-205-7271
www.shelleyhalpern.com

Most people don’t know that it has a name! Trichotillomania (TTM) is a disorder of shame and embarrassment. Oftentimes, people go to great lengths to hide this behavior for fear of how others might perceive them. It affects an estimated 8-11 million people, and this number might even be underestimated, due to the secretiveness of this disorder.

Trichotillomania is an impulse disorder, whereby a person pulls their hair from their body, particularly the scalp, eyebrows, and eyelashes. It frequently begins in pre-or early adolescence, the average age being around 12 years old. Prior to pulling out the hair, a person notices an increase in tension and then a feeling of pleasure or relief after the hair is pulled.

Trying to understand the etiology of trichotillomania is very difficult and complex, and health professionals are often in disagreement as to its cause. Some believe it is a type of obsessive-compulsive disorder and is a result of feelings of loss or perceived threats. Others contend that it is because of neurobiological factors and is similar in nature to Tourette Syndrome, as they are both repetitive behaviors. Still others feel that it is a coping mechanism, in response to stress and anxiety, or it could be self-injurious behavior.

Hair-pulling is an anxiety reduction process, whereby the person associates the behavior with relaxation. When assessing a client with trichotillomania, I go into great detail in the interview process with regard to the history of their hair-pulling. I ask them when it started, how it occurs, what their behaviors are, if there have been times when they have been free of hair-pulling, how often they do it, what they feel the cause is, how strong their desire is to stop, and much more. I will consider the severity, and if there is any concern regarding infections or self-mutilation, I will immediately refer the client to their doctor.

Hypnosis and imagery can be effective modalities to reduce and eliminate symptoms, by teaching the client to identify what the triggers are and to teach them stress-relief tools. It is followed up by giving the client positive replacement strategies. Oftentimes, people with trichotillomania suffer from additional problems, such as, depression which need to be addressed by a medical professional.

Sports Performance and Hypnosis by Shelley Halpern, C.Ht.

Using your body and your mind in sports can help you achieve your full potential! Have you ever wondered when there are two athletes with similar body types and capabilities and one can throw a ball with stunning accuracy or swim faster, always out performing their competitor? Why does an average athlete excel, while the person with greater potential never achieves their goal? There is no doubt that physical training is crucial but have you ever thought that the mental game might be just as important?

Mental training and imagery can help you achieve your full potential. If you want to get more out of your workouts or if you experience stress or anxiety in competition, learn how to control it and re-frame it to your advantage. We all have worry and anxiety but there is an functional and dysfunctional type. There are positive parts of anxiety, the kind that prepares us for competition or when you are learning a new skill or getting “up” for a performance. Eliminate toxic worry! Worrying and stress weakens the athlete physically, spiritually and emotionally. Learn how to redefine the moderate levels of worry and anxiety.

You can learn to be a better athlete by eliminating the “stinkin thinkin,” by allowing your body to do what it was trained to do. Stop instructing yourself through every movement. Start letting go of your analytical, left brain side and let your right side take over, allow the creative, visual side to take over.

Prior to the 1980 Olympics, the Soviets did a study with their elite athletes. They divided them into four training groups. The first group worked solely on their physical training. The second group worked 75% on the physical training and 25% on the mental training. The third group worked on 50% physical and 50% mental training. The last group worked on 25% on physical training and 75% on mental training. Which group proved to be the most successful? The last group showed the most improvement. The group that showed the least improvement was the group that physically trained 100%. Keep in mind that these athletes were comparable in their ability.

How does imagery work in sports performance? Imagery is seeing something in the back of your mind’s eye (in the back of the eyelids) but it uses sensory recruitment as well. This includes using all of the senses; sight, sound, smell, taste, touch and emotions. By training physically and mentally you will enhance
your performance. Words create images and the brain learns through images. There are two hemispheres of the brain, the right and the left side. We use both hemispheres all of the time but often times, one side is dominant. The left side is the logical analytical side. The right side is responsible for imagination and making pictures. By using both hemispheres of the brain you are using all of the mental tools available to the athlete. Imagery allows you to mentally rehearse your athletic performance, enables you to connect with your own inner resources and affects you physiologically. When you are in hypnosis you are in homeostasis, your mind and body are in balance. Your body doesn’t discriminate between real and imagined events. So you are actually practicing and pre-training for your sport, you are rehearsing for your physical activity.

Prior to the 1980 Winter Olympics, the Soviets did a study with their elite athletes. They divided them into four training groups. The first group worked solely on their physical training. The second group worked 75% on the physical training and 25% on the mental training. The third group worked on 50% physical and 50% mental training. The last group worked 25% on physical training and 75% on mental training. Which group proved to be the most successful? The last group showed the most improvement. The group that showed the least improvement was the group that physically trained 100%. Keep in mind that these athletes were comparable in their athletic ability.

Tic Tips

Revised 2/16

By Mary M. Moebius, MD, FAPADiplomat of the American Board of Psychiatry and Neurology in General and Child
Psychiatry, Assistant Clinical Professor, UCLA Semel NPI, private practice Tarzana, California

Fleeting motor tics are quite common in childhood and may not even be noticed as such.
However, a passing tic can be quite distressing, usually for parents more so than for the
child. The range I have seen has been from what I call the “ticky picky” behaviors to cartwheels, vomiting tics, and one I’ll never forget,”Dr. Mary Dr.Mary Dr. Mary”!Contrary to popular belief, most tics are not Tourettes Syndrome. TS require a minimum of 6 months of both a motor tic and a vocal tic. The classical swearing vocalizations are
rare even if they are the best known.

Here are some “tic tips” I’d like to share from years of working with children, teens, and

an occasional adult, with tics.

In the olden days, we thought medications that treated attention deficit disorder caused

tics to develop. It turns out that tics are especially common in children with ADD and

even more so in boys with the diagnosis. Because the brain has to develop to certain

points before certain symptoms can present, the symptoms of ADD usually present in

kids under the age of 7 while tics present around the age of 9, by which time many are

already being giving medications for the ADD. If a child with ADD is not treated with

medications, tics still may present. Lo and behold, the meds were not the culprit after all.

Now that that has been said, I do see tics seem to present, worsen, improve, and even

disappear in individuals who receive ADD medications. Some present only to disappear

about two months after starting medication.

Tics “seasons” are recognized with theories as to why they occur so consistently. In the

beginning of my private practice in 1991, I began to notice tics presenting end of

November around Thanksgiving, with improvement by the end of January. Was it that a

child’s schedule was defined by change from this holiday on to the next with holiday

performances, celebrations, and fluctuations in school schedules?

As the years went on, it seemed that tics also came around May then left by the 4th of July

or soon thereafter. Then another brief blip would present in September.

Some symptoms of manic depression and depression worsen in May and September

(peak suicide seasons, contrary to popular lore that the holidays are). Neuroimmunology

studies associate the almost world wide tree bloom with an abundance of pollen as the

culprit of over stressing the immune system and tipping the depression “centers” over the

edge. Almost certainly allergens provoke an immunological tic response. The disorder

known as PANDAS which stands for Pediatric Autoimmune Neuropsychiatric Disorders

Associated with Strep (now called PANS- Pediatric Acute-onset Neuropsychiatric

Syndrome) where a child has a sudden onset of tics (or obsessive compulsive symptoms)

around a bout of strep throat has come into question of late (2011). Previously it was

thought that the body’s immune system (that is fighting the germs) began to fight itself,

setting off the movement centers of the brain. My experience is that any illness may

bring out or worsen tics in the right person. Some of my families are able to tell when a

child is becoming sick because the tics begin as a warning!

Another pearl about tics is that something frequently begets a tic. For example, the Santa

Ana winds rise up, drying the air (releasing pollen too), lips become chapped and if one

has the tic “seed” in the brain, lip licking ensues and “Clown Lips” appear from the

repetitive tic lip licking (say that 3 times fast!). A throat clearing tic frequently starts

after a cold or hay fever reaction as do eye blinking, sniffing, and coughing. Dr. Cesar

Chavarria, a local pediatric pulmonologist, sees quite a few cough tics seasonally that are

in a cycle as the cough irritates the breathing tubes which causes more coughing which

irritates...

Tics also have a daytime rhythm. Usually when a child is well rested in the morning,

then tics are quieter. The tics may be more under the person’s control during the day, at

school, with others present, and while occupied. By the time the child gets home, is tired,

and with the parent the tics may become so pronounced that the parent frets

(understandably so) then stresses the child by scolding or highlighting the tic so that it

worsens, becoming a family issue of contention.

What’s a parent to do?

First, relax. Take a few deep breaths, after all, how many adults have noticeable tics?

With time, the cycles abate and your child will likely outgrow this. As family anxiety

can heighten tics, lowering it, can decrease the intensity. Both “good” stress and “bad”

stress may exacerbate tics. Minimize the “bad” and roll with the good.

Treat hay fever with the guidance of your pediatrician, allergist, or ENT.

Prevent chapped lips, cuticles, scabs, dry eyes, prolonged coughs before a cycle of

licking, picking, blinking, and coughing begins.

Sunglasses help eye blinking.

Hypnotherapy is my treatment when the above mentioned steps are not effective enough

or the social stigma becomes a problem. Children and teens tend to be able to learn the

self-hypnosis techniques taught to them by the hypnotherapist quite easily. Many times,

a patient of mine will stop ticking the first time they are in a hypnotic state! Hypnosis is

a “tool” one may use for life. Please be reassured that people don’t really do bizarre

things under hypnosis when in with a trained professional.

Cognitive Behavior Therapy has also been shown to be effective. This is another “tool”

one can take with them where ever they go, for life. Both hypnosis and CBT manage

accompanying anxiety.

In only the most severe situations, do I recommend medications for the management of

tics because the side effects and potential risks may outweigh the benefits. With that

said, under supervision, these may be minimized and allow the opportunity for the less

aggressive treatments to “kick in” when used together.

Clonidine (Kapvay) and Tenex (Intuniv) may be the first medication your doctor would

use. Usually given in pill form, starting at low doses and increasing based on effects.

Sometimes a child may feel sleepy at first but that usually goes away. Originally used to

control high blood pressure, these medications were found to help the hyperactive

component of ADHD as well as insomnia in medicated and non-medicated people with

ADHD.

Medications called Neuroleptics have been used for quite awhile to treat tics especially of

the Tourettes Syndrome nature. Because of sedation, they frequently are given at night.

Weight gain, Metabolic Syndrome (having labs such as fasting blood sugar, cholesterol,

other lipids), abnormal body movements (not the tic itself) must be monitored closely.

Other potential side effects should be explained by your doc.

If a tic has a more obsessive compulsive quality to it a Selective Serotonin Reuptake

Inhibitor may be tried. It’s almost hard to explain how to differentiate between some

OCD behaviors and tics. It becomes a "gut” feeling so I recommend having a detailed

discussion with your pediatric psychiatrist or neurologist or pediatrician.

I hope this article will help those children, parents, siblings, and grandparents have a little

more understanding as how best to ride the storm of the ever-changing weather pattern of

tics.

Tic Tips

Sports Performance and Hypnosis by Shelley Halpern, C.Ht.

Trichotillomania-Compulsive Hair-Pulling by Shelley Halpern