Dear Therapist:
Thank you for your informative and insightful column. I am reaching out for guidance regarding my 15-year-old daughter, who has been experiencing motor tics for several years. The tics have followed a fluctuating course, typically appearing for a period of time and then resolving for several months. There have been intervals of up to six months without any symptoms, followed by sudden recurrences, often in connection with identifiable stressors.
In recent months, however, the tics have been persistent and ongoing, with some variation in frequency and intensity throughout the day.
I have observed that episodes of anxiety such as before a challenging exam or during perceived social difficulties consistently exacerbate her tics. She is a bright, conscientious, and perfectionistic child who displays certain traits that appear consistent with obsessive or compulsive tendencies.
Given this background, I would appreciate your guidance regarding the most appropriate next steps. Would it be advisable to consult a child psychiatrist, or might an experienced therapist specializing in anxiety and behavioral interventions be sufficient at this stage? In your experience, does effective management of underlying anxiety typically lead to improvement in tic symptoms? Additionally, are medications for anxiety commonly recommended in cases such as this?
Thank you for your time and for providing valuable direction to parents navigating complex situations such as ours.
Response:
You’ve done an excellent job observing the relationship between your daughter’s anxiety and her tics. As a non-prescriber, I cannot speak to medication use, but I can share some insight into the diagnostic and treatment process. As far as cause is concerned, this is likely a matter of ruling things out, rather than finding the specialist who can give you a definitive diagnosis and treatment.
As you mentioned, there are connecting and exacerbating factors. You noted her obsessive and compulsive tendencies. Without going into detail, tics are common in people who are obsessive-compulsive. Because obsessions and compulsions are closely related to anxiety, it makes sense that her tics worsen in stressful situations.
Various medical and lifestyle factors can contribute to motor tics—including genetics, Tourette syndrome, certain medications, and sleep deprivation. Often, several of these interact to trigger or intensify symptoms.
I would advise that your daughter be seen by a neurologist, a psychiatrist, and a therapist, possibly (though not necessarily) in that order. The goal is to identify and rule out possible causes and contributing factors.
It also sounds like your daughter has issues other than the tics that should be addressed in therapy. If she is not already seeing a therapist, this would be an important step. Aside from the goal of reducing anxiety, obsessions, and compulsions, therapy can help determine to what degree her tics are emotionally driven.
An experienced therapist may be able to help your daughter with her anxiety, obsessions, and compulsions—but the only way to know whether that will significantly reduce her motor tics is to see how her symptoms respond over time.
If you want to work on the tics as a possibly separate issue, a neurologist is the place to begin. If she does see a neurologist, make sure they are aware of all the exacerbating factors—anxiety, OCD symptoms, and so on. Also, be sure to understand their rationale for any diagnosis. For instance, if they diagnose her with Tourette syndrome, ask them to explain the examination findings or test results that led to that conclusion.
By working with the right professionals and maintaining open communication among them, you’ll be best positioned to understand what’s driving her symptoms and how to help her manage them effectively.
-Yehuda Lieberman, LCSW
psychotherapist in private practice
Woodmere, NY
adjunct professor at Touro University
Graduate School of Social Work
author of Self-Esteem: A Primer
www.ylcsw.com / 516-218-4200
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