Background: Tics beginning in late adulthood often have an identifiable etiology. Psychogenic tics with onset around 60 years of age are rarely described in the literature. 

Case Report: A 67-year-old female had experienced phonic tics for 8 years. Episodes occurred without premonitory sensations and precipitant factors, and she could not suppress them. She had no history of childhood tic disorder, and secondary causes of tics were excluded. She was diagnosed with psychogenic tics and treated with quetiapine with mild improvement. 

Discussion: When physicians are faced with no identifiable cause of tics combined with certain clinical clues, a psychogenic disorder must be suspected

Knobel, Elias

Knobel, Marcos

Pedroso, Jose Luiz

Vale, Thiago Cardoso

Tremor and Other Hyperkinetic Movements

English

PubMed

Background:&nbsp;Tics beginning in late adulthood often have an identifiable etiology. Psychogenic tics with onset around 60 years of age are rarely described in the literature.&nbsp;Case Report: A 67-year-old female had experienced phonic tics for 8 years. Episodes occurred without premonitory sensations and precipitant factors, and she could not suppress them. She had no history of childhood tic disorder, and secondary causes of tics were excluded. She was diagnosed with psychogenic tics and treated with quetiapine with mild improvement.&nbsp;Discussion: When physicians are faced with no identifiable cause of tics combined with certain clinical clues, a psychogenic disorder must be suspected.&nbsp;</p

Thiago C. Vale

José L. Pedroso

Marcos Knobel

Elias Knobel

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Late-Onset Psychogenic Chronic Phonic-Tics

Columbia University Academic Commons

Case ReportsLate-Onset Psychogenic Chronic Phonic-TicsThiago Cardoso Vale1, Jose´ Luiz Pedroso2*, Marcos Knobel2& Elias Knobel21Department of Internal Medicine, Faculty of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Brazil, 2Hospital Israelita Albert Einstein,Sa˜o Paulo, SP, BrazilAbstractBackground: Tics beginning in late adulthood often have an identifiable etiology. Psychogenic tics with onset around 60 years of age are rarely described in theliterature.Case report: A 67-year-old female had experienced phonic tics for 8 years. Episodes occurred without premonitory sensations and precipitant factors, and shecould not suppress them. She had no history of childhood tic disorder, and secondary causes of tics were excluded. She was diagnosed with psychogenic tics andtreated with quetiapine with mild improvement.Discussion: When physicians are faced with no identifiable cause of tics combined with certain clinical clues, a psychogenic disorder must be suspected.Keywords: Tics, Tourette syndrome, idiopathic tics, phonic tics, adult ticsCitation: Vale TC, Pedroso JL, Knobel M, et al. Late-onset psychogenic chronic phonic-tics. Tremor Other Hyperkinet Mov. 2016; 6. doi: 10.7916/D88S4PWW* To whom correspondence should be addressed. E-mail: jlpedroso.neuro@gmail.comEditor: Elan D. Louis, Yale University, USAReceived: March 27, 2016 Accepted: April 20, 2016 Published: June 2, 2016Copyright: ’ 2016 Vale et al. This is an open-access article distributed under the terms of the Creative Commons Attribution–Noncommercial–No Derivatives License, which permitsthe user to copy, distribute, and transmit the work provided that the original authors and source are credited; that no commercial use is made of the work; and that the work is not alteredor transformed.Funding: None.Financial Disclosures: None.Conflict of Interest: None.Ethics Statement: All patients that appear on video have provided written informed consent; authorization for the videotaping and for publication of the videotape was provided.IntroductionTics occur predominantly in childhood and Tourette syndrome (TS)is the most common tic disorder. TS is now thought to be a continuumthat includes transient tic disorder (less than a year of symptoms),chronic single-tic disorder (motor or phonic tics, lasting more than ayear), and chronic multiple-tic disorder (motor and phonic tics, lastingmore than a year).1 According to the fifth edition of the Diagnostic andStatistical Manual of Mental Disorders (DSM-V),2 one of the criteriaof TS is its onset before the age of 18. It is unusual for tics to begin inadulthood. The DSM-V classification of tic disorders does not includea category for tic disorders that develop during adulthood, other thantic disorder ‘‘not otherwise specified.’’ In adults presenting with a ticdisorder, adult TS is a possibility, and in many cases it represents are-emergence or exacerbation of childhood-onset TS.3 In the absenceof a childhood history of tics, it is important to search for secondarycauses, such as central nervous system infection, trauma, cocaineabuse, Huntington’s disease, neuroacanthocytosis and disorders ofbrain iron accumulation and, most importantly, neuroleptic or otherdopaminergic-blocking drug exposure (tardive Tourettism).3 In theabsence of an identifiable cause, a psychogenic movement disorder(PMD) must be suspected.Psychogenic tremor, dystonia, myoclonus, and gait disorder areamong the most frequent presentations of PMDs,4 but psychogenic ticshave been rarely described in the literature.5 We describe a patientwith a chronic phonic tic disorder beginning in her late 50s withclinical clues suggestive of psychogenic origin.Case reportA 67-year-old female had complained of repetitive involuntaryvocalizations for 8 years. Initial episodes were infrequent, occurring onceor twice per week, and were characterized by involuntary grunting andsometimes shouting. However, vocalizations worsened, becoming morefrequent and more intense for 1 year. At the time of consultation, thepatient reported several episodes a day. She could not control them, evenwhen she was in public or the focus of attention, and they were notdistractible. She reported no premonitory sensations, but admitted aFreely available onlineTremor and Other Hyperkinetic Movementshttp://www.tremorjournal.orgThe Center for Digital Research and ScholarshipColumbia University Libraries/Information Services1certain relief after the episode. Episodes occurred without a clearprecipitant factor. She denied having tics or obsessive compulsive disorderduring childhood, which was confirmed after interviewing her oldersiblings. Apart from candasartan for hypertension, she was not using anymedication or illicit drugs. There was no prior history of head trauma orsurgery. She denied the use of dopamine-depleting drugs, except for thelast 2 months when she was unsuccessfully treated with metoclopramide,domperidone, and chlorpromazine for a misdiagnosis of hiccups. Acareful review of her pharmacy record showed no prescriptions ofdopamine-depleting drugs. A neurological examination showed gruntingand barking vocalizations (Video 1). The neurological examination wasotherwise normal and there were no additional abnormal involuntarymovements. A psychiatric evaluation showed no evidence of obsessivecompulsive disorder, anxiety, and depression. There was no family historyof tics or obsessive compulsive disorders. Brain magnetic resonanceimaging and magnetic resonance angiography (MRA) were normal, aswere echocardiography, pelvic, abdominal, and thoracic computedtomography. The patient was diagnosed with a psychogenic adult-onsetchronic single-tic disorder with phonic tics. She was treated withquetiapine 25 mg/day with mild improvement. She did not adhere topsychotherapy sessions, although we had stressed its importance.DiscussionBaizabal-Carvallo and Jankovic4 reported on nine cases ofpsychogenic tics, representing only 4.9% of all patients evaluatedfor PMD. The mean age of onset in their series was 34.1 years andthey found that the lack of premonitory sensations, the absence of ticsin childhood and no family history of tics, the inability to suppressmovements, and coexistence with other PMDs and pseudoseizureswere common in their patients. In their series, two cases started inlate adulthood and there was one case in an elderly patient. Thesewere motor tics and they were combined with other PMDs. Ourpatient had only vocal tics, and they had started at the age of 59years; after 8 years no other PMDs had occurred. Similarly to theirfindings, our patient presented with a lack of premonitory sensationsand an inability to suppress the movements, which strongly supportsa psychogenic origin. The premonitory sensation is considered ahallmark feature of organic tics, and it is reported in about 90% ofTS patients.6 Although characteristic of organic tics, premonitorysensations have been reported in patients with presumed psychogenicmovements.7 Likewise, patients with TS are usually able totransiently suppress their movements, a feature not consistentlypresent in psychogenic tics.Some features of our case, taken together, raised suspicion of aPMD: the consistent pattern and severity of the barking sounds; thefact that they have remained the same over many years withoutchanging or waxing/waning; the strained appearance of the patientwhen vocalizations happen; the fact that there are no other tics, inparticular no facial grimacing and no increased eye blinking; the lackof premonitory sensations; and the inability to suppress movements.However, in our case, the patient had no history of psychiatriccomorbidity and the tics did not coexist with other PMDs.Additionally, the vocalizations were not suppressible with distractionmaneuvers, a characteristic feature of PMD. One might postulatethat it is idiopathic instead of psychogenic. Indeed, there are fewdescriptions of idiopathic adult-onset tics in the literature. InChouinard and Ford’s8 series of 411 patients with tic disorders,22 patients presented for the first time with tic disorders after the age of 21.Seven patients (33.3%) were classified as idiopathic adult-onset ticdisorder. A chronic single-tic disorder with phonic tics, as in our case,occurred in only one of their series. Sethi9 has reported seven malepatients with adult-onset tic disorders: three of them were idiopathic.In their original reports, they do not consider the possibility of apsychogenic origin for the movements.In conclusion, psychogenic tics are rare and usually a matter ofdebate. This case is unique in its late adulthood onset of only phonicVideo 1. Video Segment 1. Vocalizations with mixed barking and tossing sounds. Video Segment 2. Phonic tics during talking. Video Segment 3. Bouts of phonictics while talking.Vale TC, Pedroso JL, Knobel M, et al. Late-onset Psychogenic TicsTremor and Other Hyperkinetic Movementshttp://www.tremorjournal.orgThe Center for Digital Research and ScholarshipColumbia University Libraries/Information Services2tics without other PMDs. The absence of childhood and familialhistory of tics, the exclusion of secondary causes, and the clinical cluessuch as inability to suppress the movements and lack of premonitorysensations led us to suspect of a psychogenic origin.AcknowledgmentsWe are thankful to Prof. Kapil Sethi for carefully reviewing ourpaper and suggesting improvements.References1. Jankovic J. Tics and Tourette syndrome. In: Jankovic J, Tolosa E, editors.Parkinson’s disease & movement disorders. Philadelphia: Wolters Kluwer,2015. p 328–341.2. American Psychiatric Association. Diagnostic and statistical manual of mentaldisorders (DSM-V). 5th ed. American Psychiatric Association. Washington, DC:American Psychiatric Publishing; 2013.3. Goetz CG, Tanner CM, Stebbins GT, Leipzig G, Carr WC. Adult tics inGilles de la Tourette’s syndrome: description and risk factors. Neurology 1992;42:784–788. doi: 10.1212/WNL.42.4.7844. Baizabal-Carvallo JF, Jankovic J. The clinical features of psychogenicmovement disorders resembling tics. J Neurol Neurosurg Psychiatr 2014;85:573–575. doi: 10.1136/jnnp-2013-3055945. Edwards MJ, Bhatia KP. Functional (psychogenic) movement disorders:merging mind and brain. Lancet Neurol 2012;50:250–260. doi: 10.1016/S1474-4422(11)70310-66. Kwak C, Dat Vuong K, Jankovic J. Premonitory sensory phenomenonin Tourette’s syndrome. Mov Disord 2003;18:1530–1533. doi: 10.1002/mds.106187. Van der Salm SM, Koelman JH, Henneke S, van Rootselaar AF, Tijssen MA.Axial jerks: a clinical spectrum ranging from propriospinal to psychogenic myoclonus.J Neurol 2010;257:1349–1355. doi: 10.1007/s00415-010-5531-68. Chouinard S, Ford B. Adult onset tic disorders. J Neurol Neurosurg Psychiatry2000;68:738–743. doi: 10.1136/jnnp.68.6.7389. Sethi KD. Adult-onset tic disorder. Neurology 1991;41(S1):227.Late-onset Psychogenic Tics Vale TC, Pedroso JL, Knobel M, et al.Tremor and Other Hyperkinetic Movementshttp://www.tremorjournal.orgThe Center for Digital Research and ScholarshipColumbia University Libraries/Information Services3

Late-Onset Psychogenic Chronic Phonic-Tics

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