Tic, stim or compulsion?

Many of the associated symptoms present in individuals with Tourette syndrome can look very similar and can be confused with one another. For some people, it may not be necessary to distinguish between different symptoms, but some people feel that it is needed to determine which treatment option may be the most effective if a particular symptom is causing distress or just for clarification or to rule out any co-occurring conditions or a differential diagnosis.

Tics are the symptom that is most frequently associated with Tourette syndrome as tics are needed for a diagnosis, but other symptoms are usually present as well. Compulsions are usually associated with OCD or sometimes Tourettic OCD if it is a tic-like compulsion, and stimming (also known as self-stimulatory behaviour) can include movements such as jumping, hand flapping, rocking backwards and forwards, swaying side to side, spinning, eye tapping, leg jiggling and more, vocal stims such as humming can also be present. People with Tourette’s my stim due to sensory processing issues or due to co-occurring ADHD or Autism.

Tics:

  • Tics are uncontrollable movements and vocalisations that can range from very mild to severely disabling.

  • Almost any movement or vocalisation that the body can physically do can be a tic.

  • Tics often change over time and can be replaced by another within hours, days, weeks or years of it first appearing. Sometimes, when you develop a new tic, it can be quite anxiety provoking as you have no idea how long it is going to last, but the likelihood is that it will eventually pass and be replaced by other tics as time goes by.

  • Tics can be simple or complex. Vocal tics can range from a subtle throat clearing tic to a full sentence with linguistic meaning that may be in context, but it’s vital to know that there is no intention behind it as we don’t mean what we tic and it does not reflect our opinions as we don’t choose our tics. Motor tics can range from a nose twitch to full body movements and repetitive ritualistic movements that must be performed in a specific order or until it ‘feels right’.

  • For some people, tics often come with a strong, uncomfortable and distressing sensation beforehand, this is termed a ‘premonitory urge’. This sensation can feel different for everyone, some people describe it as an itch, tension, pressure or ‘itchy blood’. For some people it may feel like there is something stuck on their skin or something stuck inside their throat or chest, and some people may feel the urge as a surge of electricity shooting up their spine or into their limbs. Different tics usually have different sensations, and the urge may be felt in a different part of the body from where the tic physically occurs, some people may experience phantom tics which are out of body sensations which precede a tic or tic-like compulsion, these urges are called phantom tics but they are relatively rare. Some people may not experience premonitory urges, and some people may not be aware that they are experiencing them until an older age and some people are aware of the urges since their symptom onset, especially if the urges are very prominent and distressing.

  • Tics often ‘wax and wane’ over time meaning that they can fluctuate in frequency and intensity, the periods of worsened tics may have a trigger such as certain dietary allergens, food additive sensitivities, sensory overload, exposure to electronic screens and fluorescent lights (photosensitivity), stress, excitement and anxiety.

  • Some people can suppress and hold in their tics for certain periods of time, but this can cause a lot of physical discomfort and can lead to rebound where the symptoms come out worse later on.

  • Tics are the main symptom present for a diagnosis of Tourette’s to be made.

Stimming:

  • Stimming is also known as ‘self-stimulatory behaviours’ and the most common stims can include rocking back and forth, swaying side to side, jumping up and down, hand flapping and hand wringing. Some people may have vocal stims as well.

  • Stimming is usually very repetitive and not necessarily as complex as tics.

  • Stims can change over time, but usually not as much as tics can. Stimming often involves common repetitive actions that may occur in spurts.

  • Stimming usually happens when an individual is excited, when we are daydreaming about something that brings us joy, or listening to a piece of music that we love, we may feel a sudden burst of energy that comes out as stimming such as hand flapping or jumping up and down.

  • Stimming can also help an individual to keep calm, a person may start stimming more when anxious or being overstimulated by sensory input, stims such as rocking back and forth can sometimes help people to stay calm.

  • Stimming doesn’t usually have a premonitory urge before it, it is possible to stop stimming but we should never be asked or encouraged to stop as it helps us to express and manage our emotions and regulate sensory input, being told to stop stimming may trigger meltdowns as we are unable to let out our extra energy.

  • Stimming can release beta-endorphins that can be beneficial to a person’s wellbeing.

  • Stimming is usually associated with Autism (ASD) but can also occur in people with sensory processing issues, anxiety, Tourette’s, ADHD and more.

  • Some people may not realise they are stimming as it can be almost automatic, but sometimes a tic has a bit more effort behind it to satisfy the premonitory urge.

  • Stimming can feel pleasant, whereas tics may not feel pleasant due to the premonitory urge.

  • Stimming may sometimes be initiated voluntarily as it may feel good, whereas people are unlikely to be able to initiate their tics voluntarily and do not typically get a feeling of joy or regulation from their tics.

Compulsions:

  • Compulsions are usually associated with OCD.

  • Compulsions can include hand washing, tapping, touching, turning light switches on and off, opening and closing doors, checking, straightening objects and long complex rituals.

  • The complex rituals can include multiple stages and may focus on specific numbers (some people may feel that certain numbers are ‘good’ or ‘bad’).

  • Compulsions can occur when doing specific daily tasks, some people may have certain rituals for toileting, walking up the stairs, dressing, turning the lights off, going to bed, eating etc.

  • Classic OCD compulsions are usually preceded by intrusive thoughts and anxiety , someone may perform a ritual in attempt to eliminate these thoughts and this can usually be helped with CBT (cognitive behavioural therapy). However, for a smaller percentage of people, these complex rituals may be more tic like as they are preceded by a physical sensation (premonitory urge) rather than a thought or emotion based fear – this is Tourettic OCD as its more sensation and tic based, these rituals can look virtually identical to classic OCD compulsions to the observer, but its important to distinguish what is preceding the ritual as CBT isn’t usually as effective for Tourettic OCD as the suppression of these rituals can cause the premonitory urge to accumulate and explode as more intense issues later on.

  • Compulsions may happen when a certain activity is performed such as dressing, or certain compulsions may occur at specific times of the day, for example some people have night-time rituals that they have to do before bed.

  • When compulsions are prevented, there is not usually a rebound of symptoms (unless it is Tourettic OCD) but people can experience very high levels of anxiety.

  • Rituals are often very time consuming.






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