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40-804: A tic is a sudden, repetitive, nonrhythmic movement or sound. Tic or TIC may also refer to: Tic Tics can be invisible to the observer, such as abdominal tensing or toe crunching. Common motor and phonic tics are, respectively, eye blinking and throat clearing. Tics must be distinguished from movements of disorders such as chorea , dystonia and myoclonus ; the compulsions of obsessive–compulsive disorder (OCD) and seizure activity; and movements exhibited in stereotypic movement disorder or among autistic people (also known as stimming ). Tics are classified as either motor or phonic, and simple or complex. Motor tics are movement-based tics affecting discrete muscle groups. Phonic tics are involuntary sounds produced by moving air through

80-415: A case of klazomania accompanied by oculogyric crises , another symptom of postencephalitic Parkinsonian syndrome. Klazomania was proposed to be associated with long-term excessive use of alcohol and carbon monoxide poisoning in 1996. Bates et al. reported on a 63-year-old who was admitted to a psychiatric hospital with a two-year history of sudden episodes of shouting. The man claimed to have no memory of

120-472: A concussion or cranial fracture from the incident. Six months later, he developed oculogyric spasms, as well as dyskinesias of the mouth and tongue. At the age of 44, the patient experienced his first bout of klazomania. He remained conscious for the entire incident, while he shouted for about half an hour and appeared "crazy" for hours after the shouting ended. The next day, he felt better, though he did report being tired. The patient continued to suffer from

160-617: A longer nature. They may involve a cluster of movements and appear coordinated. Examples of complex motor tics are pulling at clothes, touching people, touching objects, echopraxia (repeating or imitating another person's actions) and copropraxia (involuntarily performing obscene or forbidden gestures). Complex phonic tics include echolalia (repeating words just spoken by someone else), palilalia (repeating one's own previously spoken words), lexilalia (repeating words after reading them), and coprolalia (the spontaneous utterance of socially objectionable or taboo words or phrases). Coprolalia

200-399: A patient with postencephalitic parkinsonism . He reported that the attacks would last for up to several hours and seemed to be outside of the patient's control. He characterized the shouting as extremely loud, noting that it could be in the form of syllables, vowels or even animal noises. In addition, he observed that while the nature of the shouting could suggest that the patient was in pain,

240-419: A peak period, followed by intermittent remissions of less intensity. Although the individual may sound like they are in pain, there does not appear to be any actual physical discomfort. The shouting can be accompanied by other symptoms, such as oculogyric crises or other involuntary movements. The presentation of klazomania has been compared to temporal lobe epilepsy , although the two can be distinguished by

280-498: A person may experience pupil dilation , tachycardia , salivation , increased blood pressure, retraction of lips, barking, grunting, and rage just as an animal would if presenting sham rage. Bates and colleagues (1996) say that neuroimaging and pathology results do not support evidence of hypothalamic involvement similar to that found in sham rage. Jankovic and Mejia describe klazomania as due to tourettism (tics having Tourette syndrome-like features but not due to TS). According to

320-424: A sharp tone, but he would inevitably return to his shouting and movements after a few seconds of stillness. The episode lasted an hour and a half and was accompanied by salivation, sweating, and tachycardia . The peak of the attack lasted 30 minutes; the intensity then started to subside, though the patient still exhibited bouts of shouting and movement after several minutes of remission. The remission periods between

360-640: A thorough history and examination may be enough to rule them out, without medical or screening tests. Although tic disorders are commonly considered to be childhood syndromes, tics occasionally develop during adulthood; adult-onset tics often have a secondary cause. Tics that begin after the age of 18 are not diagnosed as Tourette's syndrome, but may be diagnosed as an "other specified" or "unspecified" tic disorder . Tests may be ordered as necessary to rule out other conditions: For example, when diagnostic confusion between tics and seizure activity exists, an EEG may be ordered, or symptoms may indicate that an MRI

400-449: A tic disorder, such as compulsions that may resemble motor tics. "Tic-related OCD" is hypothesized to be a subgroup of OCD, distinguished from non-tic-related OCD by the content and type of obsessions and compulsions; individuals with tic-related OCD have more intrusive thoughts , and exhibit more hoarding and counting rituals than individuals with non-tic-related OCD. Tics must also be distinguished from fasciculations . Small twitches of

440-401: A tic increase (for instance, watching television or using a computer), while concentration on an absorbing activity often leads to a decrease in tics. Neurologist and writer Oliver Sacks described a physician with severe Tourette syndrome (Canadian Mort Doran, M.D., a pilot and surgeon in real life, although a pseudonym was used in the book), whose tics remitted almost completely while he

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480-423: Is a highly publicized symptom of Tourette syndrome ; however, only about 10% of TS patients exhibit coprolalia. Martino, et al. have argued that tics may be considered physiological, or developmentally typical. Tics are described as semi-voluntary or unvoluntary , because they are not strictly involuntary —they may be experienced as a voluntary response to a premonitory urge (a sensory phenomenon that

520-472: Is an inner sensation of mounting tension). A unique aspect of tics, relative to other movement disorders, is that they are suppressible yet irresistible; they are experienced as an irresistible urge that must eventually be expressed. Tics may increase as a result of stress , fatigue, boredom, or high-energy emotions, which can include negative emotions, such as anxiety , as well as positive emotions, such as excitement or anticipation. Relaxation may result in

560-467: Is caused by an irritating lesion in the mesencephalon and a malfunction in the control of the motor circuit from the substantia nigra in the mesencephalon to the globus pallidus in the striatum (mesostraital pathway). This circuit becomes overstimulated during a mesencephalic "fit". In a 1996 report of one case, Bates et al. postulated that klazomania is similar to the vocal tics of Tourette syndrome , although patients with klazomania may not have

600-548: Is generally used to treat seizures, while Artane is used to treat involuntary movements in Parkinson's disease ; however, this combination was found to have no beneficial effect in treating klazomania. Klazomania does not respond to anti-epileptic medications. The word klazomania comes from the Greek κλάζω ("klazo"), meaning "to scream". The term was coined by L. Benedek in 1925 when he witnessed bouts of compulsive shouting in

640-585: Is needed to rule out brain abnormalities. TSH levels can be measured to rule out hypothyroidism , which can be a cause of tics. Brain imaging studies are not usually warranted. In teenagers and adults presenting with a sudden onset of tics and other behavioral symptoms, a urine drug screen for cocaine and stimulants might be necessary. If a family history of liver disease is present, serum copper and ceruloplasmin levels can rule out Wilson's disease . Individuals with obsessive–compulsive disorder (OCD) may present with features typically associated with

680-522: Is no loss of consciousness during klazomania and that individuals may remain fully aware of their surroundings. One of the first instances in which an infectious disease was associated with klazomania was the notable pandemic of the encephalitis lethargica from 1916 to 1927. This pandemic also gave rise to observations of other tics that came to be associated with encephalitis lethargica such as complex vocalizations of blocking, echolalia, palilalia, and oculogyric crises. In 1961, Wohlfart et al. reported

720-793: The differential diagnosis . Conditions besides Tourette syndrome that may manifest tics or stereotyped movements include developmental disorders , autism spectrum disorders , and stereotypic movement disorder ; Sydenham's chorea ; idiopathic dystonia; and genetic conditions such as Huntington's disease , neuroacanthocytosis , pantothenate kinase-associated neurodegeneration , Duchenne muscular dystrophy , Wilson's disease, and tuberous sclerosis . Other possibilities include chromosomal disorders such as Down syndrome , Klinefelter syndrome , XYY syndrome , and fragile X syndrome . Acquired causes of tics include drug-induced tics, head trauma, encephalitis , stroke , and carbon monoxide poisoning . Most of these conditions are rarer than tic disorders, and

760-400: The 1917 to 1926 encephalitis lethargica pandemic revealed "neurofibrillary tangles and neuronal loss in the globus pallidus , hypothalamus , midbrain tegmentum , periaqueductal gray matter, striatum , and the substantia nigra ". Wohlfart et al hypothesized that klazomania originates in the periaqueductal gray matter in the mesencephalon. The vocalizing center in animals is located in

800-467: The absence of simple tics. Tics "may be challenging to differentiate from compulsions", as in the case of klazomania (compulsive shouting). Tic disorders occur along a spectrum, ranging from mild (transient or chronic tics) to more severe; Tourette syndrome is the more severe expression of a spectrum of tic disorders, which are thought to be due to the same genetic vulnerability. Nevertheless, most cases of Tourette syndrome are not severe. Management for

840-530: The attacks for the next few years before coming under observation of Wohlfart and colleagues. He subsequently served as a model to describe klazomania from beginning to end. According to Wohlfart's account of one patient, onset is sometimes characterized by absentmindedness: the patient K.R. stared straight ahead and only responded in monosyllables in the minutes leading up to the incident. An oculogyric spasm then developed, during which he demonstrated echolalia . After 15 minutes, further motor symptoms arose, with

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880-430: The attacks, which he could anticipate by a few seconds. The episodes were characterized by shouting of "aagh" or "help" and he was reported to appear angry during the incidents. At the end of the outbursts he would appear surprised, though he was able to continue a conversation. The patient remained fully oriented between attacks. The episodes themselves occurred at a frequency of one or two a month, generally taking place in

920-519: The definition of tic to better distinguish between stereotypies and tics, replaced transient tic disorder with provisional tic disorder, removed the criterion that tics must occur nearly every day, and removed the criterion that previously had excluded long tic-free periods (months) from counting towards the year needed to diagnose Tourette's or Persistent (Chronic) tic disorders. Dystonias , paroxysmal dyskinesias, chorea , other genetic conditions, and secondary causes of tics should be ruled out in

960-501: The diagnosis is based on history and symptoms. According to Bates (1996), electroencephalography (EEG) abnormalities are not observed during klazomania, and a link between klazomania and seizures is not likely. In large doses, atropine sulfate helped control the involuntary movements associated with klazomania in one patient; attempts to treat with a combination of phenobarbital and trihexyphenidyl (also known as Artane) were also made. Phenobarbital acts as an anticonvulsant and

1000-439: The duration of the attack and the fact that the patient experiencing klazomania appears to retain consciousness. A 1961 report by Wohlfart described a postman known as K.R. who contracted encephalitis lethargica at the age of 12. While he reported no significant ill effects from the disease, he was irritable and complained of fatigue for years after recovering. At 22, the patient received a head injury, though he did not sustain

1040-409: The motor tics necessary for a diagnosis of TS. Bates and colleagues observed a case where alcohol use disorder and encephalitis were accompanied by vocal tics and occasionally klazomania. They hypothesized that the cause of klazomania is linked to the combined effects of brain damage due to alcohol use disorder or encephalitis. Jankovic and Mejia's 2006 review indicated that autopsies of victims of

1080-795: The nose, mouth, or throat. They may be alternately referred to as verbal tics or vocal tics , but most diagnosticians prefer the term phonic tics to reflect the notion that the vocal cords are not involved in all tics that produce sound. Simple motor tics are typically sudden, brief, meaningless movements that usually involve only one group of muscles, such as eye blinking, head jerking, or shoulder shrugging. Motor tics can be of an endless variety and may include such movements as hand clapping, neck stretching, mouth movements, head, arm or leg jerks, and facial grimacing. A simple phonic tic can be almost any sound or noise, with common phonic tics being throat clearing, sniffing, or grunting. Complex motor tics are typically more purposeful-appearing and of

1120-444: The overall presentation. Two of Benedek’s colleagues, E. Von Thurzó and T. Katona, recorded two further instances of klazomania in 1927. They expanded upon Benedek’s earlier observations, describing the angry flushed face of one patient, as well as extreme restlessness and agitation. They noted that afterwards the patient apologized for the incident, suggesting awareness of the behavior. From this, Thurzó and Katona proposed that there

1160-438: The patient making small jerky motions with his arms that developed into larger, circular movements. At 20 minutes, the attack reached its peak, with the patient becoming bright red and making large compulsive movements with his arms and kicking his legs. He began swearing, shouting, screaming, grunting and barking loudly, with intermittent bouts of heavy panting. He remarked upon the people present, with his comments being related to

1200-447: The periaqueductal gray matter and a klazomania-like episode involving grunts and animal sounds can be evoked by electrical stimulation of this region. Wohlfart and colleagues hypothesized that the stimulation of the autonomic nervous system by the posterior hypothalamus is involved in klazomania, adding that klazomania resembles sham rage in animals, which is controlled by stimulation of the sympathetic nervous system . During klazomania,

1240-488: The revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV-TR ), Tourette's may be diagnosed when the other diagnostic criteria are met and symptoms cannot be attributed to another general medical condition. Hence, other medical conditions that include tics or tic-like movements—such as tourettism —must be ruled out before a TS diagnosis can be conferred. There are no specific tests;

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1280-497: The shoulders, leading to the need to clear one's throat or shrug the shoulders. The actual tic may be felt as relieving this tension or sensation, similar to scratching an itch. Another example is blinking to relieve an uncomfortable sensation in the eye. Some people with tics may not be aware of the premonitory urge. Children may be less aware of the premonitory urge associated with tics than are adults, but their awareness tends to increase with maturity. Complex tics are rarely seen in

1320-451: The shouting episodes became longer, until the entire attack was over in about an hour and a half. Although the cause of klazomania is unknown, it is considered to be associated with encephalitis lethargica; a 2006 journal review by Jankovic and Mejia attributes klazomania to tourettism (tics not due to Tourette syndrome), widely seen after the encephalitic lethargica pandemic of 1916 to 1927. Wohlfart (1961) hypothesized that klazomania

1360-401: The situation in question. He attempted at times to excuse his behavior. Afterwards the patient was able to provide an account of what had happened. Wohlfart et al. concluded that the patient was aware of his surroundings during the attack, with the patient even expressing concern over missing a scheduled appointment; the patient demonstrated some ability to control his behavior when spoken to in

1400-406: The sounds themselves were unrelated to any physical discomfort. He stated that the patient appeared to have the ability to anticipate an incident and could even prevent it through deep and rapid breathing. However, he noted that the effort required to suppress klazomania could be even more tiring than enduring it. He said that though anxiety could increase the frequency of klazomania, it did not affect

1440-458: The spectrum of tic disorders is similar to the management of Tourette syndrome . Tic disorders are defined based on symptoms and duration. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ), published in May 2013, reclassified Tourette's and tic disorders as motor disorders listed in the neurodevelopmental disorder category, removed the word "stereotyped" from

1480-533: The upper or lower eyelid, for example, are not tics, because they do not involve a whole muscle, rather are twitches of a few muscle fibre bundles, that are not suppressible. Klazomania Klazomania (from the Greek κλάζω ("klazo")—to scream) refers to compulsive shouting; it has features resembling the complex tics such as echolalia , palilalia and coprolalia seen in tic disorders , but has been seen in people with encephalitis lethargica , alcohol use disorder , and carbon monoxide poisoning . It

1520-413: Was a vocal tic. Klazomania is similar to other complex tics including echolalia , palilalia and coprolalia . It is defined as compulsive shouting, which can be in the form of swearing, grunting or barking. The subject may appear flushed, and klazomania can occur with increasing frequency if the person is agitated. The duration of the incident depends on the individual, but it can be characterized by

1560-526: Was first reported by L. Benedek in 1925 in a patient with postencephalitic parkinsonism . Little is known about the condition, and few cases have been reported. Klazomania shares some features with vocal tics seen in tic disorders including Tourette syndrome (TS). Klazomania was described in a 2006 journal review as a cause of tics differentiated from TS ( tourettism ), attributed to infectious processes (encephalitis) rather than TS. A 1996 case report on one patient by Bates et al suggested klazomania

1600-417: Was performing surgery. Immediately preceding tic onset, most individuals are aware of an urge that is similar to the need to yawn, sneeze, blink, or scratch an itch. Individuals describe the need to tic as a buildup of tension that they consciously choose to release, as if they "had to do it". Examples of this premonitory urge are the feeling of having something in one's throat or a localized discomfort in

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