Surge in New-Onset Tics in Adults Tied to COVID-19 Stress

Daniel M. Keller, PhD

September 21, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

An unusual surge of new-onset tics in patients with no prior history of these disorders, has been tied to the psychological stress associated with the COVID-19 pandemic, new research suggests.

Results from a large, single-center study show several cases of tic-like movements and vocalizations with abrupt onset among older adolescents and adults during the pandemic. None had a previous diagnosis of a tic disorder. Among 10 patients, two were diagnosed with a purely functional movement disorder, four with an organic tic disorder, and four with both.

"Within our movement disorders clinic specifically...we've been seeing an increased number of patients with an almost explosive onset of these tic-like movements and vocalizations later in life later than what is typically seen with organic tic disorders and Tourette syndrome, which is typically in school-aged children," said study investigator Caroline Olvera, MD, Rush University Medical Center, Chicago.

"Abrupt onset of symptoms can be seen in patients with tic disorders although this is typically quoted as less than 10%, or even 5% is more characteristic of functional neurological disorders in general and also with psychogenic tics," she added.

The findings were presented at the virtual International Congress of Parkinson's Disease and Movement Disorders (MDS) 2021.

Anxiety, Other Psychiatric Conditions

Tic disorders typically start in childhood. However, the researchers observed an increase in the number of patients with abrupt onset of tic-like movements and vocalizations later in life, which is more often characteristic of functional neurological disorders.

To examine the profile, associated conditions, and risk factors in this population the investigators conducted a thorough chart review of patients attending movement disorders clinics between March 2020, when the COVID pandemic was officially declared, and March 2021.

Patients with acute onset of tics were identified using the International Classification of Diseases codes for behavioral tics, tic vocalizations, and Tourette syndrome.

The charts were then narrowed down to patients with no previous diagnosis of these conditions. Most patients were videotaped for assessment by the rest of the movement disorder neurologists in the practice. Since the end of the study inclusion period in March 2021, Olvera estimates that the clinic experienced a doubling or tripling of the number of similar patients.

In the study cohort of 10 patients, the median age at presentation was 19 years (range, 15 - 41 years), nine were female, the gender of the other one was unknown, and the duration of tics was 8 weeks (range, 1 - 24 weeks) by the time they were first seen in the clinic. Four patients reported having COVID infection before tic onset.

All exhibited motor tics and nine had vocal tics. Two were diagnosed with a purely functional neurologic disorder, four with only an organic tic disorder, and four with organic tics with a functional overlay.

"All patients, including those with organic tic disorders, had a history of anxiety and also reported worsening anxiety in the setting of the COVID pandemic," Olvera said.

The majority of patients were on a psychotropic medication prior to coming to the clinic, and these were primarily for anxiety and depression. Three patients had a history of suicidality, often very severe and leading to hospitalization, she noted.

"In terms of our conclusions from the project, so we feel that this phenotype of acute explosive onset of tic-like movements and vocalizations in this older population of adults, compared to typical organic tic disorders and Tourette's syndrome, appears novel to the pandemic," she said.

She cautioned that functional and organic tics share many characteristics and therefore may be difficult to differentiate.

COVID Stress

Commenting on the findings for Medscape Medical News, Michele Tagliati, MD, director of the movement disorders program at Cedars-Sinai Medical Center, Los Angeles, said the research highlights how clinicians' understanding of particular diseases can be challenged during extraordinary events such as COVID-19 and the heightened stress it causes.

"I'm not surprised that these [disorders] might have had a spike during a stressful time as COVID," he said.

Patients are "really scared and really anxious, they're afraid to die, and they're afraid that their life will be over. So they might express their psychological difficulty, their discomfort, with these calls for help that look like tics. But they're not what we consider physiological or organic things," he added.

Tagliati added that he doesn't believe rapid tic onset in adults is a complication of the coronavirus infection, but rather a consequence of psychological pressure brought on by the pandemic.

Treating underlying anxiety may be a useful approach, possibly with the support of psychiatrists, which in many cases is enough to relieve the conditions and overcome the symptoms, he noted.

However, at other times, it's not that simple, he added. Sometimes patients "fall through the cracks between neurology and psychiatry," Tagliati said. "Between 'you really have a disease, and you don't really have a disease,' and they can be very disabled."

Olvera and Tagliati have disclosed no relevant financial relationships.

International Congress of Parkinson's Disease and Movement Disorders (MDS) 2021: Abstract #1331. Presented September 17-22, 2021.

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